JB is a 59-year-old male who comes to the clinic after a recent hospitalization for a heart failure exacerbation. He states that he is feeling much better at today’s visit.
Past Medical History: dyslipidemia, hypertension, New York Heart Association (NYHA) class III heart failure, type 2 diabetes mellitus
Allergies: amoxicillin (rash)
Medications:
Atorvastatin 80 mg PO daily
Carvedilol 50 mg PO BID
Furosemide 40 mg PO QAM
Metformin 1,000 mg PO BID
Sacubitril/valsartan 97 mg/103 mg PO BID
Spironolactone 25 mg PO daily
Vital Signs: BP 116/72 mmHg, HR 60 bpm, Ht 5′ 10″, Wt 210 lbs
Laboratory Tests (Fasting, Taken in Office):
Sodium 142 mEq/L
Potassium 4.8 mEq/L
Chloride 102 mEq/L
Bicarbonate 26 mEq/L
Blood urea nitrogen 30 mg/dL
Creatinine 1.4 mg/dL
eGFR 68 mL/min/1.73 m2
Glucose 191 mg/dL
Hemoglobin A1C 8.2%
The primary care provider wants to add a drug to treat JB’s diabetes mellitus. Which of the following medications should be avoided?
A. Dapagliflozin
B. Glimepritide
C. Insulin glargine
D. Liraglutide
E. Pioglitazone
E. Pioglitazone
When selecting medications for type 2 diabetes mellitus (T2DM), coexisting conditions should be evaluated to avoid drug-disease interactions. In patients with heart failure, two classes of T2DM medications should be avoided:
Dipeptidyl peptidase 4 (DPP-4) inhibitors
Thiazolidinediones (TZDs)
DPP-4 inhibitors have a warning for heart failure due to an increased risk seen with alogliptin and saxagliptin; these two drugs should be avoided in patients with heart failure. TZDs (eg, pioglitazone) are contraindicated in patients with New York Heart Association (NYHA) class III or IV heart failure and have a boxed warning for causing or exacerbating heart failure. TZDs increase sodium reabsorption, resulting in edema. The excess fluid puts more strain on the heart, causing or worsening heart failure.
(Choice A) Sodium-glucose cotransporter 2 (SGLT2) inhibitors (eg, dapagliflozin) are recommended in patients with heart failure, with or without diabetes, because they improve morbidity and mortality. SGLT2 inhibitors are avoided in patients with recurrent vaginal candidiasis or urinary tract infections.
(Choice B) Sulfonylureas (eg, glimepiride) are not contraindicated in heart failure. These drugs should be used cautiously in patients who are at increased risk for hypoglycemia, such as the elderly.
(Choice C) Insulin (eg, glargine) is ultimately required in many patients with T2DM. There are no absolute contraindications to insulin therapy except for true hypersensitivity reactions.
(Choice D) Glucagon-like peptide 1 (GLP-1) agonists (eg, liraglutide) are beneficial in patients with a history of or at high risk for atherosclerotic cardiovascular disease. GLP-1 agonists should be avoided in patients with gastroparesis, pancreatitis, or a history of thyroid cancer.
Things to remember:
Thiazolidinediones have a boxed warning for causing or worsening heart failure and are contraindicated in patients with New York Heart Association class III or IV heart failure
An 11-year-old female is brought to the office due to recent weight loss, frequent urination, and thirst. Her blood glucose in the office is 389 mg/dL, hemoglobin A1C is 10.4%, and C-peptide is 0.1 ng/mL. She has a normal BMI for her age. Which of the following medication regimens would be appropriate to start?
E. Humalog + Lantus
Type 1 diabetes mellitus (T1DM) is characterized by insulin deficiency due to autoimmune destruction of the pancreatic beta-cells. Therefore, patients with T1DM require consistent insulin administration, typically as a basal plus bolus regimen.
Basal insulin is usually long-acting insulin given once daily (eg, glargine) or intermediate-acting insulin given twice daily (eg, NPH).
Bolus insulin is usually rapid-acting insulin (eg, lispro, aspart), and is given before meals.
Noninsulin medications [eg, metformin, sodium-glucose cotransporter 2 (SGLT2) inhibitors] are used in type 2 diabetes mellitus (T2DM) to control blood glucose when endogenous insulin is present. These medications are occasionally used to treat T1DM but only in addition to insulin; they offer limited benefits in T1DM since endogenous insulin production is deficient and long-term safety has not been established.
(Choice A) Thiazolidinediones [eg, pioglitazone (Actos)] increase insulin sensitivity. Dipeptidyl peptidase 4 inhibitors [eg, sitagliptin (Januvia)] increase insulin secretion with food, among other mechanisms. Because endogenous insulin is not present, these medications would not be beneficial.
(Choices B and C) Metformin (Glucophage) decreases gluconeogenesis, increases insulin sensitivity, and decreases intestinal glucose absorption. SGLT2 inhibitors [eg, dapagliflozin (Farxiga)] increase glucose excretion in the urine. Glucagon-like peptide 1 agonists [eg, liraglutide (Victoza)] increase insulin secretion with food, among other mechanisms. Since endogenous insulin is not present, these medications alone are insufficient.
(Choice D) Sulfonylureas [eg, glipizide (Glucotrol)] increase insulin release from the pancreas. They would be ineffective if endogenous insulin production is insufficient. Furthermore, use of sulfonylureas with insulin increases the risk of hypoglycemia.
Things to remember:
Type 1 diabetes mellitus is a result of autoimmune beta-cell destruction of the pancreas. Since the pancreas is unable to produce enough insulin, exogenous insulin is the primary form of therapy.
AMis a 19-year-old male ( 5’11”, 176 lbs) who was just diagnosed with type 1 diabetes. He eats 3 meals per day. The physician writes for an initial daily dose of insulin of 0.6 units/kg/day. Using a basal-bolus dosing strategy, calculate the amount of Lantus and the amount of HumalogAMshould take.
C. Lantus 24 units at bedtime and Humalog 8 units before meals
When using a basal and mealtime (also called bolus) insulin dosing strategy, it is initiated by taking the total daily dose of insulin and giving 50% of the insulin as the basal dose and 50% as the bolus, or mealtime, dose. The bolus dose will then need to be divided up by the number of meals the patient eats (in this case, AM eats 3 meals).
KH is a 34-year-old female who comes to the pharmacy with a new prescription for a glucometer kit, test strips, and lancets. She states that she was recently diagnosed with gestational diabetes and has never used a glucometer. Which of the following counseling points should the pharmacist provide to the patient?
A. Blood sample from the side of the fingerand not on the finger pad
B. Recalibrate the device prior to each use
C. Test strips can be removed from canister and stored in pocket of glucometer kit
D. The thigh can be used when hypoglycemia is expected
E. Used test strips should be disposed of in a sharps container
BGM frequency ranges from as needed (eg, in someone with type 2 diabetes mellitus well-controlled with lifestyle modifications) to multiple daily tests (eg, in someone with gestational diabetes or with multiple daily injections of insulin).
General counseling points apply to the majority of glucometers, although slight differences exist between devices (eg, calibration). BGM includes the following steps:
Wash hands and dry thoroughly; water will dilute the sample.
Insert a new test strip into the glucometer.
Prick the side of the finger (less painful than the finger pad) using a lancet/lancing device.
Apply a drop of blood to the test strip.
Record the reading.
(Choice B) Some devices require calibration to verify accuracy with each new container of test strips (not prior to each use) or with device concerns (eg, exposure to extreme temperatures, inconsistent readings).
(Choice C) Test strips must be stored in the original container to protect them from light and moisture. Do not use test strips after the expiration date.
(Choice D) Alternate testing sites (eg, forearm, palm, thigh) can be used with some devices. They are not recommended when blood glucose is changing (eg, after exercise or eating) or when hypoglycemia is suspected because the result may be approximately 20 minutes old compared to fingertip testing.
(Choice E) After testing, dispose of the lancet in a sharps container. The test strip does not require special disposal.
Things to remember:
Blood glucose is usually monitored by pricking the side of the finger. Some devices allow for use of alternate testing sites (eg, forearm, thigh) but only if the blood glucose is steady (ie, hypoglycemia not expected)
A 46-year-old female with type 2 diabetes mellitus is currently taking metformin 1,000 mg orally twice daily. Although the patient is adherent to metformin, her hemoglobin A1C is 7.7%. Her healthcare provider is adding Amaryl to her medication regimen. What is the primary mechanism of action of Amaryl?
E. stimulates insulin secretion from the pancreas
Sulfonylureas [eg, glimepiride (Amaryl)] and meglitinides are known as insulin secretagogues because they work in the pancreas to increase insulin secretion by blocking ATP-sensitive potassium channels on the beta cells. Therefore, secretagogues are effective only if the patient has some remaining beta cell function; if not, insulin injections may be needed for blood glucose control.
Secretagogues work independently of the blood glucose level. They stimulate insulin release whether the blood sugar is elevated or not, leading to an increased risk of hypoglycemia. For this reason, secretagogues must be taken with food or shortly before the start of a meal (ie, within 30 minutes before eating). Sulfonylureas are often taken daily whereas meglitinides have a faster onset and shorter duration of action and are taken before each meal.
(Choice A) Reducing hepatic glucose output is the primary mechanism of metformin. Thiazolidinediones (TZDs) also work in this manner but to a lesser extent.
(Choice B) Improving insulin sensitivity in fat and muscle cells is a mechanism of the TZDs and metformin.
(Choice C) Sodium-glucose cotransporter 2 (SGLT2) inhibitors reduce renal glucose reabsorption and increase glucose excretion in the urine.
(Choice D) The primary mechanism of sulfonylureas is not related to glucagon secretion. Dipeptidyl peptidase 4 (DPP-4) inhibitors work in this manner; they prevent the breakdown of natural incretins (eg, glucagon-like peptide 1), which increases glucose-dependent insulin release from the pancreas and reduces hepatic glucagon secretion.
Things to remember:
Sulfonylureas and meglitinides work primarily in the pancreas, where they increase insulin secretion from the beta cells. This mechanism of action lowers blood glucose but also increases the risk of hypoglycemia.
AR is a 51-year-old female who comes to the primary care clinic for her six-month follow-up visit. She states that she has been experiencing “tingling” and “numbness” in her legs and feet recently. She has also had trouble sleeping and is worried because she is becoming “forgetful.”
Past Medical History:
Hypertension
Gastroesophageal reflux disease
Type 2 diabetes mellitus
Dyslipidemia
Stage 3 chronic kidney disease
Social History: vegetarian diet × 2 years, former cigarette smoker (quit 5 years ago), sedentary lifestyle
Allergies: NKDA
Medications:
Metformin 1,000 mg PO BID
Crestor 40 mg PO daily
Enalapril 20 mg PO daily
Amlodipine 10 mg PO daily
Pantoprazole 40 mg PO daily
Lantus 10 units SQ HS
Vital Signs: BP 122/80 mmHg, HR 70 bpm, Ht 5′ 4″, Wt 140 lbs
Laboratory Tests:
eGFR 58 mL/min/1.73 m2
Glucose 131 mg/dL
Hemoglobin A1C 7.2%
Which of the following tests should be ordered based on the patient’s symptoms?
E. Vit B
Metformin reduces vitamin B12 intestinal absorption in up to 30% of patients, which can lead to deficiency with long-term treatment (ie, ≥ 5 years). For this reason, metformin-treated patients should have vitamin B12levels monitored periodically (eg, every 1–2 years), especially when additional risk factors exist (eg, vegan or vegetarian diet) or when symptoms of deficiency are present.
Vitamin B12 is required for myelin sheath formation, which is why neurological symptoms such as peripheral neuropathy, symmetric paresthesias of the lower extremities, and cognitive impairment (eg, insomnia, forgetfulness) can precede other clinical manifestations (eg, macrocytic anemia).
(Choice A) Dual-energy x-ray absorptiometry is a diagnostic tool used to assess bone mineral density and risk or presence of osteopenia or osteoporosis. This patient does not meet the criteria for screening (eg, age ≥ 65 years, history of fragility fracture).
(Choice B) Serum b-type natriuretic peptide is released from myocardial cells to promote sodium and water excretion in response to fluid overload. A level would be warranted if the patient had symptoms of heart failure (eg, peripheral edema, shortness of breath).
(Choice C) Because folic acid is added to many foods (eg, pasta, cereal, rice), deficiencies are rare in the absence of other risk factors, such as alcohol use disorder, malabsorption, or use of certain medications (eg, methotrexate).
(Choice D) Lipase is often elevated in acute pancreatitis, the symptoms of which include acute, persistent abdominal pain, nausea, and vomiting.
Things to remember:
Long-term use of metformin can result in vitamin B12 deficiency. Vitamin B12 levels should be monitored periodically (eg, annually) or when concerning symptoms develop (eg, peripheral neuropathy, neurocognitive changes)
A patient injects 52 units of Novolin N in the morning and 36 units at bedtime using a vial and syringes. Which of the following syringe sizes are the most appropriate for this regimen?
E. 1mL for morning and 0.5 mL for bedtime dose
When using insulin vials, selecting the appropriate syringe size improves measurement accuracy and helps reduce dosing errors. Most insulin is supplied in a concentration of 100 units/mL. Higher insulin doses (larger volumes) require a larger syringe than smaller doses (smaller volumes), which require a smaller syringe. Commonly used syringe sizes include:
0.3 mL, used for ≤ 30 units, marked in 1-unit increments
0.5 mL, used for 31–50 units, marked in 1-unit increments
1 mL, used for 51–100 units, marked in 2-unit increments
U-500 (for regular insulin U-500 only), used for ≤ 250 units, marked in 5-unit increments
This patient’s morning dose is 0.52 mL (52 units × 1 mL/100 units = 0.52 mL). Therefore, a 1 mL syringe is needed; the other sizes are too small. The 0.3 mL syringe is too small for the evening dose (0.36 mL). The 0.5 mL and 1 mL syringes are large enough, but the smallest syringe that holds the number of units needed should be selected, making a 0.5 mL syringe the appropriate choice.
(Choice A) The 0.3 mL syringe is too small to hold either the patient’s morning or evening dose.
(Choice B) The 0.5 mL syringe is too small for the morning dose, and the 0.3 mL syringe is too small for the evening dose.
(Choice C) The 0.5 mL syringe is large enough for the evening dose but too small for the morning dose.
(Choice D) The 1 mL syringe is appropriate for the morning dose, but the 0.3 mL syringe is too small for the evening dose.
Things to remember:
Select the smallest insulin syringe that will hold the required dose to improve dosing accuracy and reduce error risk
A pharmacist is counseling a patient on a new prescription of exenatide (Byetta).
Glucagon-like peptide 1 (GLP-1) agonists come as pen injections for subcutaneous administration. Patients require counseling on proper handling and storage. General counseling points are applicable to all GLP-1 agonist injectables, although subtle differences exist for each (eg, priming, stability).
Exenatide immediate release (Byetta) is administered twice daily within 60 minutes before meals. One Byetta pen will last 30 days, after which it should be thrown away. New pens require a one-time setup (eg, inspecting the cartridge, priming). Administration includes the following:
Wash hands.
Attach a new pen needle with each injection. Remove the outer and inner needle shields, keeping the outer shield for later use (Choice A).
Dial the pen to the dose.
Insert the needle at 90 degrees in the abdomen, thigh, or upper arm. Rotate injection sites (Choice C).
Press and hold the injection button while counting slowly to five (Choice D).
After use, replace the outer shield and remove the pen needle. Never store a pen with a needle attached (Choice E).
Discard used needles in a sharps disposal container (Choice B).
Replace the pen cap before storing. The pen in use can be stored at room temperature, while unused pens should be stored in the refrigerator (Choice F).
Key counseling points for injectable glucagon-like peptide 1 agonists include the following: attaching a new pen needle with each injection; inserting the needle at 90 degrees in the subcutaneous tissue of the abdomen, thigh, or upper arm; pressing and holding the injection button for five seconds; removing the used pen needle and discarding it in a sharps disposal container; and storing the pen with the pen cap in place.
FM is a 68-year-old female with type 2 diabetes mellitus. She is in the office today for a follow-up appointment and does not report any symptoms. The patient takes metformin 1,000 mg BID, Lantus 30 units at bedtime, and Humalog 6 units TID with meals. Below is her self-monitored blood glucose log from the past week.
Based on these blood glucose readings, which adjustment to her medications is most appropriate?
A. Decrease breakfast, lunch, and dinner Humalog to 4 units
B. Decrease Lantus to 26 units at bedtime
C. Increase breakfast Humalog to 8 units
D. Increase dinner Humalog to 8 units
E. Increase Lantus to 34 units at bedtime
B. Decrease Lantus to 26 units at bedtime
The goals of treatment for diabetes mellitus are to maintain blood glucose (BG) levels in the target range (while avoiding hypoglycemia) and to reduce complications. In nonpregnant adults, the goal preprandial BG level is between 80–130 mg/dL. Hyperglycemia can lead to long-term complications, whereas hypoglycemia can lead to immediate morbidity/mortality. Hypoglycemia (BG < 70 mg/dL) is a common adverse effect of insulin treatment.
For patients on a basal/bolus insulin regimen, fasting plasma glucose (FPG) is most impacted by basal insulin. If FPG is trending low, the basal insulin dose should be decreased; for high trends, the dose should be increased. In this case, the patient’s BG readings are all within the target range except for FPG. Decreasing the dose of basal insulin [eg, insulin glargine (Lantus)] would be best to prevent hypoglycemia.
(Choices A, C, and D) BG level trends before lunch and dinner or at bedtime are usually reflective of the bolus insulin (eg, regular or rapid-acting) dose prior to that reading. For example, an elevated BG reading before dinner reflects that the bolus insulin dose before lunch was not adequate for control. In this case, the patient’s BG readings before lunch and dinner and at bedtime are all within normal range; therefore, insulin lispro (Humalog) does not require adjustment.
(Choice E) Increasing the basal insulin dose would further decrease FPG, putting the patient at an even higher risk of hypoglycemic events.
Things to remember:
Fasting plasma glucose highs or lows should be addressed by adjusting the basal insulin dose for patients on a basal/bolus insulin regimen.
A patient is going to convert from his U-100 regular insulin to U-500 insulin. He currently uses 100 units of U-100 regular insulin with his evening meal. How many mL of U-500 insulin will he need with his evening meal to get the same dose? (Answer must be numeric; no units or commas; include a leading zero when the answer is less than 1; round the final answer to the nearest TENTH.)
U-500 insulin (500 units/mL) is five times as concentrated as regular insulin (100 units/mL), so 1/5 the volume of U-100 is required to provide the same number of units of U-500 insulin.
The patient was using 100 units (1 mL) of U-100 regular insulin.
500 units/mL = 100 units/X mL
X = 0.2 mL of U-500 provides 100 units of insulin
Alternatively, 1 mL x 1/5 = 0.2 mL of U-500
Where within the kidney does Invokana exert its mechanism of action?
A. Ascending limb of the loop of Henle
B. Collecting duct
C. Distal convoluted tubule
D. Efferent arteriole
E. Proximal tubule
E. Proximal tubule
Sodium-glucose cotransporter 2 (SGLT2) is found in the proximal tubule of the nephron, where it is responsible for glucose and sodium reabsorption. Inhibiting SGLT2 lowers the amount of glucose reabsorbed into the bloodstream, increasing urinary glucose for excretion. This mechanism is glucose-dependent: more glucose is eliminated when blood glucose levels are elevated, and as blood glucose levels fall less glucose is excreted, resulting in a low risk of hypoglycemia.
SGLT2 inhibitors [eg, canagliflozin (Invokana)] increase glucose and sodium in the urine, causing water to remain within the nephron and increasing urination (called osmotic diuresis and natriuresis). The diuretic effect of SGLT2 inhibitors can lead to volume depletion, which can cause hypotension and acute kidney injury. Excess glucose in the urine increases the risk of urinary tract and genital mycotic (fungal) infections.
(Choice A) Loop diuretics (eg, furosemide) exert their action in the ascending limb of the loop of Henle, where they inhibit sodium reabsorption. This results in excess water remaining in the filtrate, causing diuresis.
(Choice B) Aldosterone antagonists (eg, spironolactone) block aldosterone receptors in the collecting duct, increasing sodium and water excretion and reducing potassium elimination.
(Choice C) Thiazide diuretics (eg, hydrochlorothiazide) inhibit the sodium-chloride pump in the distal convoluted tubule, causing diuresis due to extra sodium and water remaining within the filtrate.
(Choice D) Angiotensin-converting enzyme (ACE) inhibitors (eg, lisinopril) and angiotensin receptor blockers (ARBs) lower pressure within the glomerulus by dilating the efferent arterioles, slowing the progression of kidney disease in patients with albuminuria.
Things to remember:
Sodium-glucose cotransporter 2 (SGLT2) inhibitors act in the proximal tubule to increase urinary glucose excretion, which leads to decreased blood glucose concentrations and other beneficial effects (eg, diuresis)
A 37-year-old female is seen in the clinic for follow-up of type 2 diabetes mellitus. She was diagnosed with diabetes 10 months ago and started metformin at that time. Her point-of-care hemoglobin A1C is 8.2%. The prescriber would like to start her on Trulicity. Which of the following is the correct route and frequency for this new medication?
A. Administer subcutaneously once daily
B. Administer subcutaneously once weekly
C. Administer subcutaneously twice daily
D. Take by mouth once daily in the morning
E. Take by mouth twice daily before meals
B. Administer subcutaneously once weekly
Dulaglutide (Trulicity) is a glucagon-like peptide 1 (GLP-1) agonist used for the treatment of type 2 diabetes mellitus (T2DM). It is administered by subcutaneous injection via a prefilled pen, like other medications in this class (except for an oral formulation of semaglutide).
Because these medications require self-injection, a fear of needles can be a barrier for some individuals. However, select GLP-1 agonists are injected weekly (eg, dulaglutide) to decrease the number of injections and improve patient adherence. Others in the class are dosed daily or twice daily. The agents given as weekly injections come with pen needles.
(Choices A and C) Shorter-acting GLP-1 agonists are administered daily [eg, liraglutide (Victoza)] or twice daily [ie, exenatide immediate-release (Byetta)]. GLP-1 agonists with higher-frequency dosing (daily or twice daily) require needles to be purchased separately.
(Choice D) Semaglutide is available as an oral GLP-1 agonist (Rybelsus) administered once daily at least 30 minutes before the first meal of the day. These same dosing instructions apply to another class of medications for T2DM, the sodium-glucose cotransporter 2 (SGLT2) inhibitors. Dipeptidyl peptidase 4 (DPP-4) inhibitors and thiazolidinediones are administered once daily without regard to meals.
(Choice E) None of the GLP-1 agonists are administered orally twice daily, but other medications for T2DM may have these instructions. Metformin is administered once or twice daily with meals to reduce adverse gastrointestinal effects. Sulfonylureas and meglitinides are administered 1–3 times daily before meals to reduce postprandial hyperglycemia and hypoglycemia risk.
Things to remember:
Most glucagon-like peptide 1 (GLP-1) agonists are administered as subcutaneous self-injections. The dosing frequency depends on the medication and can range from twice daily to weekly
MK is a 42-year-old female who currently takes semaglutide and metformin for type 2 diabetes mellitus. At initial diagnosis, her hemoglobin A1C was 9.5%. Two years later, her hemoglobin A1C is now 10.6% despite adherence to her current medications. The health care provider decides to initiate insulin therapy. Which of the following insulin options would be the best choice?
A. Humalog, administered via an insulin pump
B. Humalog, taken with meals and carbohydrate-heavy snacks
C. Lantus, taken with meals and carbohydrate-heavy snacks
D. Lantus, taken at bedtime
E. Novolin 70/30, dosed TID
Many patients with type 2 diabetes mellitus (T2DM) will not achieve adequate blood glucose control on oral medications alone. Glucagon-like peptide 1 agonists are typically recommended as the initial injectable medication. If these are not tolerated or do not provide adequate control, insulin should be started.
In T2DM, insulin can be added gradually because some pancreatic beta-cell function remains. Basal insulin [eg, insulin glargine(Lantus)] should be initiated first and given once daily. If basal insulin alone does not control blood glucose, prandial insulin [eg, insulin lispro (Humalog)] can be added before meals, starting with the largest meal of the day.
(Choice A) Insulin pumps are used for highly motivated patients who have been previously controlled on multiple daily injections. They are not first-line for insulin initiation in T2DM.
(Choice B) Rapid-acting insulins [eg, insulin lispro (Humalog)] are appropriate for prandial control in combination with basal insulin. In general, these would not be the first insulin started in a patient with T2DM.
(Choice C) Long-acting insulins [eg, insulin glargine (Lantus)] are given once (sometimes twice) daily as basal insulin (ie, to provide consistent insulin throughout the day). They should not be administered more than twice daily nor as prandial insulin.
(Choice E) Mixed insulin regimens containing intermediate-acting insulin and short- or rapid-acting insulin (eg, premixed Novolin 70/30) are dosed twice daily before meals. They are not preferred due to a higher incidence of hypoglycemia but may be used if barriers to a basal/bolus regimen exist (eg, cost, nonadherence due to frequent injections).
Things to remember:
Basal insulin is recommended as the first-line insulin for patients with type 2 diabetes mellitus
ML is a 53-year-old male who comes to the office for follow-up of chronic medical conditions and smoking cessation. He reports symptoms of frequent thirst and fatigue.
Past Medical History: alcohol use disorder, chronic pancreatitis, tobacco use disorder, type 2 diabetes mellitus
Medications:
Acetaminophen 500 mg PO every 4–6 hours PRN
Metformin ER 1,000 mg PO BID
Naltrexone 380 mg IM every 4 weeks
Varenicline 1 mg PO BID
Laboratory Tests:
Hemoglobin A1C 8.2%
Which of the following medications should be avoided in this patient? (Select ALL that apply)
A. Exenatide
B. Glipizide
C. Invokana
D. Janumet
E. Linagliptin
A. Exenatide
D. Janumet
E. Linagliptin
Acute pancreatitis is commonly due to chronic alcohol use, gallstones, hypertriglyceridemia, and, sometimes, medications. It can present with sudden severe upper abdominal pain, nausea, and vomiting. Persistent alcohol use and the resulting acute pancreatitis can progress to chronic pancreatitis, which can cause lasting damage to the pancreatic insulin-producing cells.
Drug-induced pancreatitis is uncommon but can develop within weeks or months of beginning a drug. Dipeptidyl peptidase 4 (DPP-4) inhibitors (eg, linagliptin) and glucagon-like peptide 1 (GLP-1) agonists (eg, exenatide) have been associated with acute pancreatitis (Choices A and E). Metformin/sitagliptin (Janumet) should be avoided due to the DPP-4 inhibitor component (and, in this patient, would also result in a duplication of therapy with metformin) (Choice D). Medications associated with pancreatitis should be avoided in patients with current signs of or a history of pancreatitis.
(Choice B) Sulfonylureas (eg, glipizide) can be added to metformin and are not associated with pancreatitis. They should be used with caution in patients with a high risk for hypoglycemia or sulfa allergies.
(Choice C) Sodium-glucose cotransporter 2 (SGLT2) inhibitors [eg, canagliflozin (Invokana)] are appropriate metformin add-on treatments. They are not associated with pancreatitis but should be used with caution in those with risks associated with SGLT2 inhibitors (eg, recurrent urinary tract infections).
Things to remember:
Dipeptidyl peptidase 4 (DPP-4) inhibitors and glucagon-like peptide 1(GLP-1) agonists have been associated with an increased risk of pancreatitis, and therefore should be avoided in patients with pancreatitis (current or past).
KT is a 15-year-old female brought to the emergency department by her father, who found her in the bathroom vomiting and unable to stand without assistance. The patient is drowsy but arousable. She states that she has had a sore throat and nasal congestion for the past week, as well as increased urination and thirst for the past 2 months. She now reports 4 episodes of vomiting in the past 24 hours and abdominal pain.
Past Medical History: none
Current Medications: multivitamin once daily
Vital Signs: BP 100/66 mmHg, HR 120 bpm, RR 28 bpm, T 98.8°F (37.1°C), Ht 5’7”, Wt 120 lbs
Laboratory Tests:
Sodium 140 mEq/L
Potassium 5.3 mEq/L
Chloride 100 mEq/L
Bicarbonate 16 mEq/L
Blood urea nitrogen 28 mg/dL
Serum creatinine 0.8 mg/dL
Calcium 9.2 mg/dL
Glucose 420 mg/dL
Hemoglobin A1C 10.1%
Urine albumin negative
Urine ketones positive
Urine beta-hCG negative
A. Dextrose 5% in water infusion
B. Metformin
C. Normal saline infusion
D. Oral potassium replacement
E. Subcutaneous insulin glargine
C. Normal saline infusion
Polyuria, polydipsia, vomiting, and abdominal pain are concerning for diabetic ketoacidosis (DKA), a hyperglycemic crisis common in type 1 diabetes mellitus. Clinical findings of hyperglycemia, ketonuria, metabolic acidosis, and dehydration (ie, hypovolemia caused by hyperglycemia and subsequent osmotic diuresis) further support a DKA diagnosis.
DKA treatment includes:
IV normal saline (ie, an isotonic fluid) to expand intravascular volume
IV regular insulin infusion to lower blood glucose
Potassium monitoring and replacement to maintain serum concentrations of 4–5 mEq/L
Acid-base monitoring and correction with sodium bicarbonate if pH ≤ 6.9
(Choice A) Dextrose 5% in water does not provide adequate intravascular fluid resuscitation and can worsen hyperglycemia. Dextrose-containing fluid (eg, dextrose 5% with 0.45% sodium chloride) is recommended once blood glucose is < 200 mg/dL to prevent hypoglycemia from insulin administration.
(Choice B) Metformin has a boxed warning for lactic acidosis and is contraindicated in patients with metabolic acidosis caused by DKA. In addition, it is not appropriate for management of a hyperglycemic crisis due to its slower onset of action.
(Choice D) Potassium replacement is indicated in patients with a low potassium level (ie, < 5mEq/L) to overcome insulin-induced hypokalemia.
(Choice E) Regular insulin is preferred in the early management of DKA because it has a quick onset and can be administered IV. Subcutaneous long-acting insulin (eg, glargine) is appropriate when ketoacidosis has resolved and the IV insulin infusion is ready to be discontinued.
Things to remember:
A diabetic ketoacidosis presentation includes dehydration, blood glucose between 250–800 mg/dL, ketones in the urine or blood, and anion gap metabolic acidosis. Treatment includes IV normal saline, IV regular insulin, and correction of potassium and acid-base imbalances
A 56-year-old female is picking up a new prescription of Actos from her community pharmacy. Which of the following are possible risks with this prescription? (Select ALL that apply)
A. Fluid retention
B. Gastroparesis
C. Pancreatitis
D. Urinary tract infection
E. Weight gain
Thiazolidinediones (TZDs) (eg, pioglitazone) activate peroxisome proliferator-activated receptor-gamma (PPARγ) found in muscle, liver, and fat. This leads to decreased insulin resistance by increasing the uptake and utilization of glucose, ultimately lowering blood glucose. TZDs may benefit those with high insulin resistance or hypoglycemia risk, and pioglitazone has additional beneficial effects (eg, reduced inflammation, reduced steatosis) in nonalcoholic steatohepatitis (NASH).
TZDs are not the preferred treatment for type 2 diabetes mellitus because of limited efficacy, slow effect (ie, weeks or months), lack of cardiovascular benefit, and safety issues. Primary adverse effects include fluid retention due to sodium reabsorption in the collecting tubule of the kidney, which can cause or worsen heart failure, and weight gain, mainly due to fluid retention and increased adipose tissue (Choices A and E). TZDs should be used with caution in patients with osteoporosis due to risk of fractures.
(Choice B) Use caution or avoid drugs that can delay gastric emptying, such as glucagon-like peptide 1 (GLP-1) agonists and the amylin analog pramlintide, in severe gastrointestinal disease (eg, gastroparesis).
(Choice C) Dipeptidyl peptidase 4 (DPP-4) inhibitors and GLP-1 agonists should be avoided in patients with signs of pancreatitis (eg, severe abdominal pain) or a history of pancreatitis.
(Choice D) Sodium-glucose cotransporter 2 (SGLT2) inhibitors should be used with caution in patients with recurrent urinary tract infections.
Things to remember:
Thiazolidinediones (eg, pioglitazone) are not the preferred treatment for type 2 diabetes mellitus because of safety issues such as fracture risk, weight gain, and fluid retention (which can cause or worsen heart failure).
LJ is a 41-year-old male who comes to the pharmacy to fill a new prescription. His hemoglobin A1C is 9.2% and his healthcare provider is starting him on Lantus 10 units daily at bedtime.
Past Medical History: asthma, type 2 diabetes mellitus, gastroesophageal reflux disease, obesity, generalized anxiety disorder
Allergies: penicillin (rash)
Medications:
-Metformin 1,000 mg PO BID
-Advair Diskus 250/50 mcg 1 inhalation PO BID
-Escitalopram 20 mg PO daily
-Farxiga 10 mg PO daily
-Proventil HFA 90 mcg 2 inhalations PO Q4–6H PRN SOB
-Pantoprazole 40 mg PO QAM
Which of the following counseling points about Lantus should the pharmacist provide? (Select ALL that apply)
A. Blood tests will be needed because Lantus can lower sodium levels
B. Monitor asthma symptoms because Lantus can worsen breathing problems
C. Monitor your weight because Lantus can cause weight loss
D. Rotate your injection sites to prevent skin abnormalities, such as redistribution of fat
E. Watch for sweating, hunger, and confusion; these are symptoms of low blood sugar
D. Rotate your injection sites to prevent skin abnormalities, such as redistribution of fat
E. Watch for sweating, hunger, and confusion; these are symptoms of low blood sugar
A patient with type 2 diabetes injects herself with 30 units of NPH BID and 15 units of regular insulin BID before meals each day. Determine how many grams of carbohydrates are covered per 1 unit of insulin. (Answer must be numeric; no units or commas; round the final answer to the nearest WHOLE number.)
450/90 = 5
The ICR is calculated with the Rule of 450 because the patient is administering regular insulin
A 42-year-old female is picking up a new prescription of Farxiga from her community pharmacy. Which of the following are possible risks with this prescription? (Select ALL that apply)
A. Hypertension
B. Urinary tract infection
C. Vaginal yeast infection
D. Weight gain
E. Worsening heart failure
B. Urinary tract infection
C. Vaginal yeast infection
Sodium-glucose cotransporter 2 (SGLT2) inhibitors [eg, dapagliflozin (Farxiga)] block the reabsorption of glucose, along with sodium, in the proximal tubule of the kidney, thereby decreasing blood glucose levels. The resulting excess glucose is excreted through the urine. The glucose in the urine also causes extra water to collect in the urine, increasing urination in a process called osmotic diuresis.
Increased urinary glucose levels provide a favorable environment for bacteria and fungi, resulting in increased risk for:
Urinary tract infections (Choice B).
Genitourinary (eg, vaginal) yeast infections (Choice C).
(Choice A) Due to their diuretic effect, SGLT2 inhibitors can lead to volume depletion. Orthostatic hypotension may result, especially in patients with a higher risk (eg, older age, concurrent use of diuretics).
(Choice D) SGLT2 inhibitors can lead to weight loss and, along with glucagon-like peptide 1 (GLP-1) agonists, are preferred agents when weight loss is desired in patients who are overweight or obese. Other medications used for type 2 diabetes mellitus treatment (ie, insulin, meglitinides, sulfonylureas, thiazolidinediones) can lead to weight gain.
(Choice E) SGLT2 inhibitors have demonstrated benefits in heart failure (eg, reduced heart failure hospitalizations), likely due to their diuretic effect.
Things to remember:
Sodium-glucose cotransporter 2 (SGLT2) inhibitors increase urinary glucose excretion, which decreases blood glucose levels but also increases the risk for urinary tract infections and genitourinary (eg, vaginal) yeast infections
CP is a 62-year-old female who was discharged from the hospital two days ago after experiencing an ischemic stroke. She is at her primary care provider’s office today for a follow-up appointment post-discharge. She was also newly diagnosed with type 2 diabetes mellitus while hospitalized.
Past Medical History: hypertension, tobacco use, chronic obstructive pulmonary disease
Allergies: NKDA
Discharge Medications:
Plavix 75 mg PO daily
Aspirin 81 mg PO daily
Lipitor 80 mg PO daily
Humulin N 6 units SQ BID
Hydrochlorothiazide 25 mg PO daily
Valsartan 80 mg PO daily
Spiriva Respimat 2.5 mcg/actuation inhale 2 puffs once daily
Vital Signs: BP 150/86 mmHg, HR 78 bpm, RR 18 bpm, O₂ sat 96% on room air, T 97.8°F (37.4°C), Ht 5’6”, Wt 178 lbs
Laboratory Tests (Fasting):
Sodium 140 mEq/L
Potassium 4.1 mEq/L
Chloride 102 mEq/L
Bicarbonate 25 mEq/L
Blood urea nitrogen 11 mg/dL
Serum creatinine 0.87 mg/dL
Glucose 171 mg/dL
Hemoglobin A1C 8.7%
Plan: Discontinue Humulin N. Start dual therapy for type 2 diabetes mellitus to include metformin. Consult clinical pharmacist for further recommendations. Continue all other discharge medications.
Which of the following medications should be added to the patient’s regimen to provide mortality benefit?
A. Amaryl
B. Januvia
C. Lantus
D. Repaglinide
E. Trulicity
E. Trulicity
Atherosclerotic cardiovascular disease (ASCVD), including coronary artery disease, peripheral artery disease, and cerebral vascular disease (stroke, transient ischemic attack), is the most common cause of death among patients with type 2 diabetes mellitus (T2DM). To reduce cardiovascular morbidity and mortality, glucagon-like peptide 1 (GLP-1) agonists [eg, Trulicity (dulaglutide)] and sodium-glucose cotransporter 2 (SGLT2) inhibitors are recommended first-line treatments for patients with T2DM and preexisting ASCVD or high ASCVD risk.
A GLP-1 agonist or SGLT2 inhibitor is recommended even when the hemoglobin A1C is at goal. More commonly, the hemoglobin A1C is above goal, and these drugs are used in combination with other glucose-lowering therapies (eg, metformin).
(Choices A, B, C, and D) Sulfonylureas [eg, Amaryl (glimepiride)], dipeptidyl peptidase 4 (DPP-4) inhibitors [eg, Januvia (sitagliptin)], insulin [eg, Lantus (insulin glargine)], and meglitinides (eg, repaglinide) do not provide cardiovascular benefits. In this patient with preexisting ASCVD, these drugs can be considered if additional glycemic control is needed after a GLP-1 agonist and/or SGLT2 inhibitor have been added to the patient’s regimen. Patient-specific safety issues, such as hypoglycemic risk with the secretagogues and insulin or heart failure risk with DDP-4 inhibitors, should be evaluated before use.
Things to remember:
A glucagon-like peptide 1 agonist or sodium-glucose cotransporter 2 inhibitor is recommended for patients with type 2 diabetes mellitus and preexisting atherosclerotic cardiovascular disease (ASCVD) or high ASCVD risk
Which of the following are macrovascular complications of diabetes mellitus? (Select ALL that apply)
A. Cerebrovascular accident
B. Gastroparesis
C. Myocardial infarction
D. Nephropathy
E. Peripheral artery disease
F. Peripheral neuropathy
G. Retinopathy
A, C, E
Poorly controlled diabetes mellitus (DM) can cause several long-term complications that can be broadly divided into two categories: microvascular and macrovascular disease. Macrovascular complications result from damage to large blood vessels (eg, atherosclerosis) and encompass the same conditions that define atherosclerotic cardiovascular disease (ASCVD). These include:
Cerebrovascular accident (ie, stroke) and transient ischemic attack (Choice A).
Coronary artery disease, such as myocardial infarction or angina (Choice C).
Peripheral artery disease (Choice E).
The macrovascular complications of DM are a leading cause of death; prevention of complications with glycemic control and diabetes comprehensive care (eg, management of blood pressure, dyslipidemia) is critical.
(Choices B, D, F, and G) Gastroparesis, nephropathy, peripheral neuropathy, and retinopathy are all examples of microvascular complications. These and other autonomic neuropathies, such as erectile dysfunction and urinary incontinence, occur due to damage to small blood vessels. Microvascular complications are strongly correlated with poor blood glucose control and therefore are best prevented by achieving tight glucose control.
Things to remember:
Macrovascular complications of diabetes mellitus arise from damage to large blood vessels and include coronary artery disease, cerebrovascular disease, and peripheral artery disease. Management of contributing risk factors (eg, blood pressure, lipid control) and achieving glycemic targets can help minimize complications
AS is a 58-year-old male who comes to the clinic for an evaluation of his blood pressure. He monitors his fasting blood glucose daily (range: 122–180 mg/dL) and blood pressure occasionally (range: 134–142/86–90 mmHg) at home. His 10-year cardiovascular disease (CVD) risk, according to the PREVENT calculator, is 11%.
Past Medical History: dyslipidemia, type 2 diabetes mellitus
Medications:
Atorvastatin 10 mg PO daily
Dapagliflozin 5 mg PO QAM
Metformin ER 2,000 mg PO daily
Vitamin B12 1,000 mcg PO daily
Vital Signs: BP 138/86 mmHg, HR 82 bpm, Ht 5’9”, Wt 200 lbs
Laboratory Tests:
eGFR 70 mL/min/1.73 m²
Hemoglobin A1C 7.6%
Urine albumin-to-creatinine ratio 22 mg/g
Which treatment is most appropriate to manage this patient’s blood pressure?
A. Atenolol/chlorthalidone
B. Lifestyle modifications only
C. Metoprolol
D. Valsartan
E. Verapamil
Hypertension is a common comorbid condition in individuals with diabetes mellitus, and treatment to a blood pressure goal of < 130/80 mmHg decreases the risk of atherosclerotic cardiovascular disease (ASCVD) and microvascular complications (eg, chronic kidney disease).
The presence of select comorbidities guides antihypertensive drug selection. Angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) are recommended in individuals with coronary artery disease (CAD) or albuminuria (eg, urine albumin-to-creatinine ratio ≥ 30 mg/g). The preferred drug classes for hypertension without albuminuria or CAD include:
ACE inhibitors (eg, lisinopril) or ARBs (eg, valsartan)
Dihydropyridine calcium channel blockers (eg, amlodipine)
Thiazide diuretics (eg, chlorthalidone)
(Choices A and C) Beta-blockers (eg, atenolol, metoprolol) are recommended first line when certain comorbid conditions (eg, myocardial infarction) are present. Although chlorthalidone is appropriate, initiating two drugs at baseline is recommended only when systolic blood pressure is ≥ 140 mmHg and diastolic blood pressure is ≥ 90 mmHg; dual therapy should include agents from the preferred drug classes.
(Choice B) Lifestyle modifications (eg, dietary salt restriction) are recommended in all individuals with hypertension, but drug treatment should also be initiated for stage 2 hypertension (ie, blood pressure ≥ 140/90 mmHg) or stage 1 hypertension (ie, blood pressure ≥ 130/80 mmHg) with added risk (eg, ASCVD, diabetes mellitus, chronic kidney disease, 10-year cardiovascular disease risk ≥ 7.5%).
(Choice E) Nondihydropyridine calcium channel blockers (eg, verapamil) are not preferred for hypertension. These are used primarily for heart rate control in atrial fibrillation and angina (eg, chest pain).
Things to remember:
Angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), dihydropyridine calcium channel blockers, and thiazide diuretics are the preferred antihypertensive drugs to treat hypertension without albuminuria or coronary artery disease
What diabetes medications are at a higher risk for hypoglycemia?
A. Empagliflozin
B. Glimepiride
C. Hydrochlorothiazide
D. Lisinopril
E. Metformin
B. Glimepiride
Hypoglycemia initially presents with symptoms such as anxiety, tremor, and sweating primarily due to activation of the sympathetic nervous system. As hypoglycemia worsens, life-threatening symptoms can develop including confusion, loss of consciousness, and seizures. Hypoglycemia risk increases with age, certain diabetes medications (eg, insulin, sulfonylureas, meglitinides), use of multiple diabetes medications, exercise, or inconsistent eating patterns (eg, skipping meals).
Sulfonylureas (eg, glimepiride) and meglitinides stimulate insulin release from the pancreas independent of blood glucose levels and food intake; therefore, they have a high risk for hypoglycemia. Longer-acting sulfonylureas (eg, glimepiride, glyburide) are more likely to cause hypoglycemia and are not preferred drugs in older individuals. They are on the American Geriatric Society Beers Criteria for Potentially Inappropriate Medication Use in Older Adults (ie, Beers Criteria) due to the risk for severe, prolonged hypoglycemia.
(Choices A and E) Diabetes medications such as metformin and sodium-glucose cotransporter 2 (SGLT2) inhibitors (eg, empagliflozin) have a lower risk for hypoglycemia when used alone. However, the risk increases when multiple blood glucose–lowering medications are combined.
(Choices C and D) Hypotension can present with dizziness, lightheadedness, and syncope and is an adverse effect of antihypertensive medications (eg, hydrochlorothiazide, lisinopril). Nausea, tremor, and sweating are not common symptoms of hypotension.
Things to remember:
Insulin and insulin secretagogues (ie, sulfonylureas, meglitinides) have a higher risk for hypoglycemia compared to other diabetes medication classes.
A 54-year-old male with type 2 diabetes mellitus has a hemoglobin A1C of 8.1%. Metformin therapy is initiated. What is the mechanism of action of this drug?
A. Decreased intestinal carbohydrate digestion
B. Delayed gastric emptying
C. Increased beta-cell insulin secretion
D. Increased insulin uptake by muscles
E. Inhibition of hepatic gluconeogenesis
Type 2 diabetes mellitus (T2DM) is characterized by insulin resistance and progressive insulin deficiency. Insulin resistance is when cells cannot effectively use insulin and therefore do not allow glucose entry from the bloodstream. This condition plus a decrease in insulin production from the pancreas leads to elevated blood glucose levels. Medications target these and other mechanisms that contribute to hyperglycemia.
Metformin decreases hepatic glucose production (ie, gluconeogenesis), increases insulin sensitivity in muscle and fat (ie, increased uptake and utilization of glucose), and, to a lesser extent, decreases intestinal absorption of glucose. These three mechanisms make metformin highly efficacious at treating T2DM without causing hypoglycemia.
(Choice A) Alpha-glucosidase inhibitors (eg, acarbose) slow the hydrolysis, or breakdown, of carbohydrates and disaccharides (eg, sucrose) in the small intestine. This slows glucose absorption, thereby decreasing postprandial blood glucose levels.
(Choice B) Dipeptidyl peptidase 4 (DPP-4) inhibitors (eg, sitagliptin), glucagon-like peptide 1 (GLP-1) agonists (eg, liraglutide), and the amylin analog (pramlintide) delay gastric emptying (ie, slow movement of food from the stomach to the intestines), among other mechanisms. This decreases carbohydrate absorption, thereby reducing postprandial blood glucose levels.
(Choice C) Sulfonylureas (eg, glipizide) and meglitinides (eg, repaglinide) are known as insulin secretagogues and stimulate the beta-cells in the pancreas to release insulin.
(Choice D) Muscles do not uptake insulin; therefore, no medications increase insulin uptake by the muscles. Medications that increase insulin sensitivity (eg, thiazolidinediones, metformin) increase the uptake of glucose into muscle and fat cells.
Things to remember:
Metformin decreases glucose production from the liver, increases peripheral insulin sensitivity, and decreases intestinal glucose absorption
