BCACP Ambulatory Diabetes Management 2 — Questions and Answers
Question 1: A patient with T2DM and an eGFR of 38 mL/min/1.73m² is currently on metformin 1000 mg twice daily. What is the most appropriate action?
- Continue metformin at current dose
- Reduce metformin dose to 500 mg twice daily
- Discontinue metformin (Correct answer)
- Switch to metformin XR 2000 mg daily
Correct answer: Discontinue metformin
Metformin is contraindicated when eGFR falls below 30 and should be discontinued at eGFR <30; at eGFR 30-45 it should be used with caution at reduced doses, but eGFR 38 warrants discontinuation per many guidelines.
Question 2: Which GLP-1 receptor agonist is FDA-approved for once-weekly subcutaneous injection and has demonstrated cardiovascular outcome benefits in the LEADER trial?
- Exenatide extended-release
- Liraglutide (Correct answer)
- Semaglutide
- Dulaglutide
Correct answer: Liraglutide
Liraglutide (Victoza) was studied in the LEADER trial, demonstrating significant reduction in major adverse cardiovascular events in high-risk T2DM patients.
Question 3: A patient with T2DM develops recurrent genital mycotic infections after starting empagliflozin. What is the mechanism behind this adverse effect?
- Increased urinary glucose promotes fungal growth (Correct answer)
- Immune suppression from glucosuria
- Direct antifungal resistance induction
- Increased urinary pH favoring Candida
Correct answer: Increased urinary glucose promotes fungal growth
SGLT2 inhibitors increase urinary glucose excretion (glucosuria), creating an environment that promotes Candida and other fungal infections of the genitourinary tract.
Question 4: For a patient with T2DM and established ASCVD, which medication class has the strongest evidence for reducing cardiovascular mortality as a first add-on to metformin?
- DPP-4 inhibitors
- Sulfonylureas
- GLP-1 receptor agonists or SGLT2 inhibitors (Correct answer)
- Thiazolidinediones
Correct answer: GLP-1 receptor agonists or SGLT2 inhibitors
ADA guidelines recommend GLP-1 receptor agonists or SGLT2 inhibitors with proven cardiovascular benefit as preferred add-ons to metformin in patients with established ASCVD.
Question 5: A pharmacist is counseling a patient starting insulin glargine. Which statement about insulin glargine storage is correct?
- Opened vials must be discarded after 14 days
- Unopened pens can be stored at room temperature indefinitely
- Once opened, insulin glargine can be kept at room temperature for up to 28 days (Correct answer)
- Insulin glargine must always be refrigerated, even after opening
Correct answer: Once opened, insulin glargine can be kept at room temperature for up to 28 days
Once opened (in-use), insulin glargine vials and pens can be stored at room temperature (below 86°F/30°C) for up to 28 days.
Question 6: Which of the following best describes the mechanism of action of pioglitazone in T2DM?
- Inhibits hepatic glucose production via AMPK activation
- Activates PPAR-gamma to improve insulin sensitivity in peripheral tissues (Correct answer)
- Stimulates pancreatic beta-cell insulin secretion
- Inhibits intestinal glucose absorption
Correct answer: Activates PPAR-gamma to improve insulin sensitivity in peripheral tissues
Pioglitazone is a thiazolidinedione that activates peroxisome proliferator-activated receptor gamma (PPAR-γ), improving insulin sensitivity in muscle, fat, and liver.
Question 7: A patient with T2DM has an A1C of 9.2% and is asymptomatic. According to ADA standards, what is the most appropriate initial pharmacotherapy approach?
- Start lifestyle changes alone for 3 months
- Start metformin monotherapy
- Start dual combination therapy (Correct answer)
- Initiate insulin immediately
Correct answer: Start dual combination therapy
ADA recommends considering dual combination therapy from the start when A1C is ≥1.5% above the patient's goal, which 9.2% typically satisfies.
BCACP Ambulatory Diabetes Management 2
A patient with T2DM and an eGFR of 38 mL/min/1.73m² is currently on metformin 1000 mg twice daily.
What is the most appropriate action?