Background of diabetes

• A high blood glucose level indicates glucose cannot get into cells to provide energy and cannot be properly stored.
• A chronic condition in which the pancreas produces little (the initial stage of DM-II) or no insulin (DM type I or late-stage DM-II – must convert from oral meds to insulin injection, or). Signs and symptoms: 3-Ps (polyphagia, polyuria, polydipsia), hyperglycemia.
• The pancreas has exocrine and endocrine functions. The exocrine functions to help with digesting food (e.g: amylase, lipase enzymes are secreted to break down dietary proteins and fats into usable sources of energy for the body). The endocrine secrets 2 main pancreatic hormones: Insulin (by beta-cells to ↓ blood glucose), glucagon (by alpha cells to ↑ blood glucose).
• Insulin: signal the liver to convert glucose to glycogen (stored glucose for later on use); assist in glucose uptake by muscle cells; regulate fat store, convert excessive glucose to fat, and prevent fat breakdown for energy.
• Type I DM: autoimmune destruction of beta cells in the pancreas, insulin cannot be produced. Usually in younger, thinner patients. Type II DM: due to insulin resistance or deficiency, strongly associated with inactivity, family history, obesity.
• DM complications: Microvascular (affects tiny vessels and nerves): retinopathy, nephropathy, and neuropathy, autonomic neuropathy (ED, gastroparesis, loss of bladder control); Macrovascular (all heart related): coronary artery disease (MI, chronic angina), cerebrovascular (TIA/stroke), peripheral artery disease.

Regulation of glycolysis (glucose break down) and gluconeogenesis (glucose formation)

• Insulin: ↑ cell uptake of glucose and glycolysis, suppress glucagon = ↓ blood sugar.
• Glucagon: ↓ glycolysis (break down of glucose to utilize its energy), ↑ gluconeogenesis = ↑ blood sugar.
• Epinephrine (Epi-pen): ↑ both glycolysis (muscle) and gluconeogenesis (release glucose into the blood and use it in muscle) = fight or flight.

 

Drug-induced hyperglycemia

• Corticosteroid (a prominent SE), protease inhibitors (recall metabolic abnormalities such as hyperglycemia), thiazide/loop diuretics (a well-known SE), atypical antipsychotics (recall metabolic abnormalities), beta-blockers (inhibits catecholamines, one of which is epinephrine which can cause hyper/hypoglycemia).
• Others: niacin, pentamidine (Nebupent, PCP prophylaxis, may cause QT prolongation), tacrolimus (Prograf, has a BBW of post-transplant diabetes)
• Cortisol: a stress hormone, increases gluconeogenesis and blood sugar.

Drug-induced hypoglycemia:

• Fluoroquinolones, linezolid, pentamidine
• Beta-blockers
• lorcaserin (Belviq) - weight loss drug

 

Classification

	Pre-prandial	Post-prandial
Pre-diabetes	100-125	140-199
Diabetes	126	>200
Goal (ADA)	80-130	<180
Goal (AACE)	<110	<140

**A1C of 7% is 155mg/dL, with every 1% change in A1C is about 30mg/dL change in estimated average glucose level

• Gestational DM: Goal <6.5% A1C to reduce birth defect; Drug of choice: glyburide, metformin

Treatment Goal

• ADA guideline goals: Pre-prandial: 80-130 mg/dL, postprandial: <180, A1C <7%, BP < 130/80 mmHg.
• Individualized A1C goals: 
• < 7%: Recommend for most type 2 with few comorbidities (reduce MICROvascular complications, but lowering A1C doesn’t seem to reduce MACROvascular events). 
• < 6.5%: more aggressive goal for healthier and younger individuals who can safely reach it with metformin alone, and pregnant women.
• < 8%: For advanced age, long-standing diabetes, many chronic conditions or diabetes complications, risk of hypoglycemia.
• Patients with diabetes are at increased risk for developing hypertension (Both HTN and DM are risk factors for CV events). Reducing blood pressure reduces MICROvascular and MACROvascular risks in patients with diabetes. Goal: mostly 130/80 mmHg, especially for high-risk CV diseases; (140/90 in multiple comorbidities, elderly unable to tolerate a strong reduction in BP, neuropathy - nerve damage unable to tolerate a significant reduction). 
• LDL: <100 w/ CVD, TG: <150, HDL > 40 in men, >50 in women.
• Annual urine test for albumin
• Microalbuminuria: 30-300mg.
• Macroalbuminuria: >300, indicates worsening renal function.
• Immunizations: influenza (>6 mo), pneumococcal (>2 yo, repeat if >65 or longer than 5 years since 1st vaccine), hepatitis B, Tdap x1 & Td every 10 years.

 

Pharmacotherapy

• Metformin is the first-line therapy which means all other classes are the second line.
• ACEI/ARB 1st line therapy to manage BP, or CCB for African Americans. Add thiazide (CrCl >30) or loop (CrCl < 30) if BP not at goal.
• ASA (Plavix as alternative if CI) to prevent CV in men >50, women >60 with one major risk factor (family history, HTN, smoking, dyslipidemia, albuminuria), or in pregnant women to prevent preeclampsia.
• ↓ASCVD (atherosclerotic cardiovascular disease) to reduce mortality and morbidity: SGLT inhibitors (e.g., empagliflozin), GLP-1 agonists (e.g., liraglutide).
• Drug class-related SEs.
  • higher cardiovascular risk - TZDs due to water retention, avoid use in patients with CV risks.
  • Pancreatitis - GLP-1 agonists, DPP-4 inhibitors.
  • Bladder cancer - pioglitazone (Actos).
  • Thyroid cancer - GLP-1 agonists.

 

Summary of MOA

• Insulin secretagogues: insulin, SFU, meglitinides (this should prompt you to think about the highest hypoglycemic risk).
• ↓ hepatic glucose production: metformin.
• ↑ insulin sensitivity: metformin, TZDs.
• ↓ glucagon (which ↓ glucose production): GLP agonists, pramlintide.
• ↑ glucose excretion: SGLT2 inhibitors.
• ↑ Work in the gut (Slows gastric emptying via targeting incretin or amylin, may help improve postprandial hyperglycemia): GLP agonists, DPP4 inhibitors, pramlintide, alpha-glucosidase inhibitors.

 

Metformin

• Drugs: Metformin (Glucophage, Glumetza, Fortamet), Riomet (solution 500mg/5ml)
• Combos: + glipizide (Metaglip), + glyburide (Glocovance), + sitaliptin (Janumet), + saxagliptin (Kombiglyze XR), + repaglinide (PrandiMet), + pioglitazone (Actoplus), + rosiglitazone (Avandamet).
• MOA: decrease hepatic glucose output (production).

• SE: diarrhea (weight neutral, take with meal), ↓ folate and B-12 absorption (lead to neuropathic damage, supplement with B12, cyanocobalamin), safe in terms of hypoglycemic risk.
• Caution: CHF (hold dose if HF is acute or worsening), lactic acidosis with dehydration or hypoxic state.
• Lactic acidosis: rare, an indication that the body undergoes anaerobic metabolism. Hypo-perfusion can lead to hypoxia/acute renal failure, finally, lactic acidosis (LA); Renal/cardiac diseases, alcohol and iodinated contrast dye may ↑ the risk of LA.
• CI: Renal dysfunction (CrCl < 30).  Hypoxia (decompensated HF, respiratory failure, sepsis).
• Fortamet: may see a shell of medicine in the stool (extended-release), counsel patient that no need to freak.

 

Thiazolidinediones (TZD)

• Drugs: pioglitazone (Actos), rosiglitazone (Avandia: restricted prescribing - REMS).
• MOA: Increase insulin sensitivity. (PPARγ agonist)
• BBW:  bladder cancer(pioglitazone), ↑ risk of MI (rosiglitazone).
• SE: peripheral edema/weight gain (water gain can be treated by aldosterone antagonist) /macular edema/CHF, increase fracture risk, liver damage (monitor liver enzymes), pioglitazone has benefits in lipids (↑HDL, ↓LDL).
• Signs and symptoms of liver damage: dark-colored urine, pale stools, lethargy, eye whites become yellow.

Insulin secretagogues

• SFUs and meglitinides. They should never be used together or used with insulin due to ↑ the risk of hypoglycemia.
• Meglitinide has a faster onset, and shorter duration compared to SF.

 

Sulfonylureas (SFU)

• Drugs: Glipizide (Glucotrol) + metformin (Metaglip), Glimepiride (Amaryl) + pioglitazone (Duetact), + rosiglitazone (Avandaryl), Glyburide (Diabeta, Micronase) + metformin (Glucovance)

• MOA: Stimulates insulin secretion from the pancreas, do not use with meglitinides due to similar MOA. Drug of choice in renal insufficiency or at high risk of hypoglycemia
• SE: hypoglycemia, weight gain (real gain), no benefit in lowering CV risk; Caution with drugs cause hypoglycemia (insulin, SFU, meglitinide), disulfiram-like reaction (flushing, chest pain, low BP, vertigo) with alcohol.
• Expect SFU to lose efficacy as the pancreas produces less insulin (nothing to stimulate).
• Take with breakfast (except glipizide 15-30 mins before meal). Remind patients on sulfonylureas to avoid skipping meals (↑ risk of hypoglycemia), if skip a meal skip a dose.
• Educate about symptoms of hypoglycemia and check blood sugar if these occur: Shaking, dizziness, sweating, anxiety, hunger, etc).
• Glyburide is on Beers Criteria, no longer recommended due to long half-life (↑ hypoglycemia and weight gain), avoid in renal impairment and elderly. 3mg micronized (better absorption) glyburide=5mg glyburide.
• 1st generation SFU (Chlorpropamide (Diabinese), acetohexamide (Dymelor)), no longer used due to prolonged hypoglycemia, and disulfiram-like reaction.

 

Meglitinides

• Drugs: Prandin (repaglinide), Starlix (nataglinide)
• MOA similar to SFU: stimulates insulin secretion (avoid taking together with sulfonylurea).
• SE: weight gain and hypoglycemia.
• Dosing: TID 15 min AC.

 

SGLT2 inhibitors (flozin)

• Drugs: Empagliflozin (Jardiance), canagliflozin (Invokana), dapagliflozin (Farxiga + meformin = Xigduo XR)

• MOA: Sodium-Glucose cotransporter inhibitor, blocks SGLT2 in proximal renal tubule resulting in the elimination of glucose in the urine (Reduce reabsorption of glucose).
• Pros: Lower CV risk (empagliflozin), may decrease BP (due to volume depletion and osmolarity), moderate weight loss, QD dosing.

• Cons: ↑urinary and thirst, ↑ risk of UTI infection (more sugar in the urine, more food for the bugs), ↑ risk of amputation (canagliflozin: due to neuropathy, foot ulcer, peripheral vascular disease), ketoacidosis (risk factor: dehydration), bladder cancer(dapagliflozin), hyperkalemia (canagliflozin), acute kidney injury (risk increases with other drugs affect kidney: diuretics, RAAS inhibitors are mostly renal-protective however can worsen renal due to stenosis, NSAIDs due to vasoconstrictive effects).

 

DPP4-inhibitors (dipeptidyl peptidase 4)

• Drugs: sitagliptin (Januvia), saxagliptin (Onglyza), linagliptin (Tradjenta), alogliptin (Nesina)
• MOA: prevent the breakdown of incretin (hormone released by the intestine in response to meals, stimulate insulin release, and decrease liver glucose production). Work in the gut.
• The use of gliptin has been increasingly prevalent in practice due to its favorable SE profile.
• SE: well-tolerated, no hypoglycemia or weight gain.
• Warning: may cause pancreatitis, arthralgia, risk of HF.
• Counseling: Once daily AM, with or without food.
• Most require dose adjustment in renal impairment (Trick: if a drug requires renal dose adjustment, it is most likely renal metabolism) except Tradjenta.

 

Other oral anti-glycemic

 

α-glucosidase inhibitors

• Drugs: acarbose (Precose), miglitol (Glyset)
• MOA: Inhibits alpha-glucosidase, prevents the breakdown of complex carbohydrates in the GI tract, resulting in delayed glucose absorption
• SE: high incidence of GI (flatulence/diarrhea/abdominal pain, no surprise because this drug works in the gut, thereby caution in IBS), ↑ hepatic enzymes, increase HDL, and decrease TG & LDL (good!).
• Take with food, if skip a meal skip a dose. Dosed three times per day, just like our mealtime.

 

Bile acid-binding resin

• Drug: Colesevelam (Welchol)
• MOA: binds bile (produced from cholesterol), blocks reabsorption; Take with food.
• Approved for DM2, and for lipids.
• SE: constipation, increase TG.
• Decrease absorption of other drugs – a lot of GI symptoms as that is the primary site of drug action, thereby avoid in bowel obstruction, TG > 500, or history of TG-induced pancreatitis
• Drug interactions
  • Phenytoin, levothyroxine, glyburide, oral contraceptive, warfarin (can decrease INR), Niaspan (despite taking at night), fenofibrate.
  • Supplement with multivitamins due to possible decreased levels of fat-soluble vitamins: A, D, E, K.

Bromocriptine (Cycloset)

• MOA: Dopamine (DA) agonist; Adjunct to improve glycemic control by working in CNS to reset circadian rhythm & decrease insulin resistance.
• SE: risk of psychiatric symptoms (increased DA), Orthostasis (slow dose titration).
• Starting dose: 0.8mg within 2-hrs of waking up in AM with food to decrease nausea.
• Drug interaction:
  • CYP 3A4 substrate: caution with inducers, inhibitors
  • Do not use with other DA agonists (increase DA).

 

Injectables

Glucagon-Like Peptide receptor agonists (GLP-1 agonist)

• Drugs: exenatide (Byetta, Bydureon ER), liraglutide (Victoza, or Saxenda - weight loss), dulaglutide (Trulicity), lixisenatide (Adlyxin), semaglutide (Ozempic, or Rybelsus oral tablet)
• MOA: Analog of incretin hormone: GLP-1 (similar to DPP4 inhibitors).
• SE: nausea (primary side effect), weight loss (significant, an advantage that they can be used in weight loss!). Adequate fluid intake if vomit or diarrhea.
• BBW: pancreatitis  (avoid use in gallstone, alcoholism, high TG, MedGuide required), thyroid carcinoma (not Byetta), renal failure (cannot use in CrCl < 30).
• Strong A1C reduction, a shining star in DM management, decreases CV events (Trulicity), and can be an add-on to almost any other class of diabetic meds. (EXCEPT DPP4 inhibitors, also works to increase incretin release)
• Mostly come in SC injection. Exenatide (Byetta) is BID vs. liraglutide (Victoza) once daily; weekly (Trulicity, Bydureon) without regard to meals. Notice how the frequency moved from BID, to QD to Q-weekly, much more convenient.
• New approved combo with a basal insulin: Insulin degludec + liraglutide = IDegLira, lixisenatide + insulin glargine (Soliqua), lixisenatide + insulin glargine (iGlarLixi).
• Exenatide: 5mcg BID 1-hr before breakfast and dinner, then increase to 10mcg when nausea is manageable. Never inject after a meal due to the risk of hypoglycemia.
• Liraglutide (Victoza): Inject with regard to meals: 0.6mg (1week) -> 1.2mg (1wk) -> 1.8mg SC QD >18yo.

Pramlintide (Symlin)

• MOA: Analog of amylin (produced by pancreatic beta cells, which aid in PPG, slow gastric emptying, and suppress glucagon).
• SE: Nausea, anorexia, CI in gastroparesis, hypoglycemia unawareness.
• Inject before meals, use in DM1 (15U TID AC) & 2 (60U TID AC). Do not use if skip a meal

 

Insulin

• SE: hypoglycemia/weight gain, hypokalemia (drive K intracellularly), local skin reactions (rotate site on abdomen/upper arms/thighs where there is more fat, injection site pain due to acidic pH), pregnancy category C.
• Routes are IV/SC (except regular insulin IM). Do not shake insulin suspension, gently roll in the palm to mix suspension. Pens are easier to use than vials for patients with dexterity problems (arthritis).
• Rapid-acting and regular insulins are typically given before meals to control the rise in glucose after a meal; intermediate and long-acting insulins are given once or twice daily to provide basal coverage, to prevent rise between meals and overnight. Recommends basal & rapid-acting insulin and avoids the use of regular insulin R and N if possible (unpredictable time).
• Insulin is initiated in severe hyperglycemia (random BG≥ 300 mg/dL or A1C ≥ 10% or FBG>250) or when 3 oral drug combinations have failed.
• Storage: do not use the insulin that has been frozen, opened vials and pens may be left in room temp up to 28 days.
• All rapid, short-acting, and NPH can be sold without an Rx. (but not long-acting)

 

Rapid-acting insulin

• Lispro (Humalog, Admelog, also comes as KiwikPen or SoloStar a bit cheaper), aspart (Novolog), glulisine (Apidra, rarely used now)
• Up to 15 mins before eating, chosen for the amount of carbs in a meal.
• Clear color and can be mixed with other insulins (except long-acting).
• Afreeza: inhalation powder, caution on bronchospasm.

 

 Short-acting Regular insulin

• Humulin R, Novolin R
• Usually given as mixture with longer-acting NPH (N), 30 mins before breakfast and dinner (they take 30 mins to work).
• No injection is required at lunchtime, because the regular may leave mid-day and NPH will be in effect, which lasts 4-6 hrs.
• Drug of choice in insulin pumps and for sliding scales in hospitals (as are rapid-acting), available without an Rx.
• Humalog 75/25 contains 75% lispro protamine (N) and 25% insulin lispro (R).

 

NPH (intermediate insulin)

• Humulin N, Novolin N
• Can last up to 24-hrs, peaks 4-14-hrs may cause hypoglycemia in mid-afternoon, therefore AACE prefers basal insulin for long-term control.
• Regular insulin is drawn up first (clear), NPH (cloudy) drawn up second.

 

Basal insulin

• Insulin glargine (Lantus/Toujeo SoloStar, Basaglar KwikPen), insulin detemir (Levemir- onset 4-hrs, can crystalize, duration 12-24-hrs), insulin degludec (Tresiba 100 or 200 U/ml)
• Onset about 1-hr, duration 24-hrs. Once or twice daily, usually @ HS; avoid mixing with other insulins.
• Does not peak, insulin level remains plateau: that is why basal coverage is very important because insulin peak can cause hypoglycemia.

 

Insulin calculation

• Dosage in general: 0.5 – 1 unit/kg/day, 50% basal, 50% bolus (short acting). DM type I: 0.6 u/kg/day on total body weight, rapid and long acting are preferred. DM type II: starting dose 10 u/day (or 0.1-0.2 u/kg/day) of basal insulin.
• Conversions of insulin dose are generally 1:1, the new dose is the same as the old total daily dose. A 20% dose reduction is recommended when switching to another insulin to reduce cross-tolerance (similar to opioid conversion). It’s easier to add more insulin than overdose and deal with hypoglycemia. However, 2 exceptions when we use 80% TDD:

1. 1. NPH BID -> long-acting Lantus or degludec QD: use 80% of the NPH dose. e.g: NPH 20 units BID (TDD = 40 units) = 40 x 0.8 = 32 units of Lantus daily.
2. 2. Toujeo (300U) -> Lantus or Basaglar: use 80% of the Toujeo dose.

• Correction dose: [(blood glucose now) – (target blood glucose)] / correction factor

• 1800 rule (rapid-acting insulin): 1800/TDD
• 1500 rule (regular insulin): 1500/TDD.

• Insulin-to-carbohydrate ratio (ICR) = g of carb covered by 1 U insulin.

• Rule of 500 (rapid-acting): 500/ TDD
• Rule of 450 (regular insulin): 450/TDD

• Insulin U500: more concentrated thus less injection volume for patients needs larger dose which can mean multiple injections. Only indicated for patients on >200 units/day. (e.g: a patient on 400 units of basal insulin needs 4 separate injections), because the max a regular insulin syringe can hold is 100 units; a smaller injection volume = better absorption and less pain.
• Humulin R U-500 is a concentrated (5X more concentrated) regular insulin used for basal coverage, while U-100 is for prandial coverage. Only Humulin R comes as U-500, only use tuberculin syringes (has a green cap) for correct dosing.
• Practice: the patient is on 400 units of U-100 basal insulin per day, about to be switched to U-500 Humulin R, what is the injection volume of the U500 insulin?

• 400/100u/ml = 4ml (of U-100), 400 / 500 units/ml = 0.8ml (of U-500).

 

Summary of drug treatments

 

Manage Hypoglycemia

• It is important to educate patients to recognize the symptoms of hypoglycemia (<70) and prevent recurrence: sweating, hunger (beta-blocker cannot mask), shakiness, palpitation.
• Rule of 15: use glucose tablets/gel 15-20 g (rapidly absorbed carbs: juice, soda, sugar/honey, hard candy) and recheck BG 15 mins later. Do not use a protein bar or food high in fat, which takes longer to elevate BG.
• Glucagon (1mg) Sub-Q or IV dextrose is used only if a patient is unconscious.

 

Hyperglycemia

• Hyperglycemia can lead to diabetic ketoacidosis (DKA, more often in type 1 DM) or hyperosmolar hyperglycemic syndrome (HHS, more commonly in type 2 diabetes), AKA nonketotic hyperosmolar state.
• In both DKA and HHS, dehydration often occurs due to osmotic diuresis (excess glucose causes water to leave the body), which also depletes other electrolytes (Na, K, etc.).

Diabetic ketoacidosis (DKA)

• In an acute illness (infection, myocardial infection, stroke, etc.), there isn’t enough insulin produced for muscle/ fat cells, and the liver to utilize glucose in the blood (glucose cannot enter the cell without insulin). Since they can’t use glucose for fuel, the body breaks down fat for energy instead, producing ketones (fat metabolism for fuel) and acidosis DKA; high-level ketone may lead to coma.
•  hyperglycemia, metabolic acidosis (fruity breath, dyspnea), dehydration (due to high levels of glucose and ketone drawing water from the cell into the bloodstream), Kussmaul respirations (deep and rapid breathing for the body to get rid of excessive H+) to compensate for metabolic acidosis.
• Labs: glucose > 250, ↑ ketones, pH <7.3 (acidic) / anion gap>12, ↑ WBC.
• Treatment: hydration (NS), insulin infusion (transfer BG from the blood to cell), replace electrolytes to prevent cardiovascular mortality (insulin shifts K+ intracellularly, do not rapidly lower glucose because of K shift), Na bicarb (raise pH), and give more glucose when BG < 250.

Hyperglycemia hyperosmolar state (HHS)

• Typically without ketone (type 2 patients still produce a small amout of insulin, the body won’t just yet break down fat to ketone for energy needs), but extreme hyperglycemia is present. 
• Signs and symptoms: BG>600, high osmolality (basically means the proteins/substances/molecules content in the blood e.g., glucose >320), extreme dehydration/altered mental consciousness, pH>7.3 & bicarbonate >18 (non-acidic).
• Treatment: Normal saline and insulin.

 

Diabetic Neuropathy

• Most meds have limited evidence. Advise switching if the first med doesn't help after a few weeks. Suggest trying a combo: Tricyclic/ SNRI + Pregabalin/Gabapentin.
• TCA: Use agents with fewer anticholinergic side effects; TCA is on Beers List (potentially risky meds for elderly), try to avoid them in patients with cardiovascular disease or the elderly.
• SNRI (duloxetine, etc.): Consider for patients who are also depressed.
• Pregabalin (Lyrica is C-V) Vs. gabapentin: Gabapentin takes longer to titrate, use titration instructions to help minimize side effects. Caution about CNS effects: Sedation, dizziness, blurred vision, etc.; Both at higher doses can cause euphoria.
• Medical food Metanx: vitamin B supplement, contains folic acid, vitamin B6, vitamin B12, and etc. The rationale is based on B vitamins' role in improving microvascular function and reducing oxidative stress.

Continuous Glucose Monitoring (CGM) devices

• Continuously track glucose levels and monitor the trend so that the readings will differ from those of a traditional BG meter. Most evidence in Type I, e.g.: hypoglycemia keeps them from reaching A1C goals, or hypoglycemia unawareness. A prescription is required.
• A sensor is embedded under the skin (arm, or stomach) and measures the interstitial glucose level (NOT blood glucose levels from a traditional BG meter). A transmitter snaps into the sensor pod and sends glucose data to a receiver/smart device. Sensors can be worn while bathing or swimming but cannot go through a metal detector. Pull off the sensor like a bandage, rotating sites to avoid irritation. 
• Dexcom G6: Can integrate with an automated insulin delivery system. Rx must include a receiver, wireless transmitter, and a 3-pack of sensors.
• FreeStyle Libre: It does not connect to a pump, and the sensor must be scanned with a reader to view results.

 

Quiz

1. A pharmacist is reviewing a new prescription, which reads: Precose 25mg PO TID x 30 day, # 90 5 refills. Which of the following acts done by the pharmacist is the most appropriate? 
   1. Fill as it is. 
   2. Call the prescriber to verify the Precose dose. 
   3. Call the prescriber to verify the number of refills. 
   4. Add an auxiliary label: "Take with meals". 
   5. Counsel the patient that this drug may cause "Severe Constipation".

 

2. A 55-year-old female patient comes to the pharmacy for a medication therapy management consult. The patient is currently taking metformin 1,000 mg twice daily and apixaban 5 mg for her nonvalvular atrial fibrillation. Review of the patient’ s self-management blood glucose log shows that her blood sugars have been above 180 mg/dL for the last two months. Which of the following medications would be the most appropriate to add on to the patient’ s regimen for her diabetes?
   1. Nateglinide
   2. Glipizide
   3. Canagliflozin 
   4. Sitagliptin

 

3. How many days can Humalog stay out of the refrigerator and be considered safe to administer?
   1. 1 day
   2. 28 days
   3. 42 days
   4. 90 days

 

4. A 65-year-old woman (5′ 3″, 190 lb) with type 2 diabetes, history of medullary thyroid carcinoma, osteopenia, and stage 3 chronic kidney disease (CrCl = 45 mL/min) presents for routine follow-up. Current medications include metformin 500g BID, lisinopril 10 mg PO daily, calcium carbonate/vitamin D 600/400 BID, and aspirin 81 mg PO daily. Labs today include A1c 7.6%, AST 20 IU/L, ALT 22 IU/L and K 4.2 mEq/L. Which of the following is the most appropriate recommendation?
   1. Initiate pioglitazone 30mg PO QD.
   2. Initiate insulin glargine 30 units SC QD.
   3. Initiate sitagliptin 50mg QD.
   4. Initiate Bydureon 0.5mg SC weekly.

     5. Which of the following medications is contraindicated in a patient with heart failure?

1. Sitagliptin
2. Exenatide
3. Glimepiride
4. Pioglitazone

 

6. Which of the following medications is most likely to cause hypoglycemia?
   1. Metformin
   2. Sitagliptin
   3. Glyburide
   4. Liraglutide 

 

7. Which of the following mechanisms most accurately describes the action of exenatide?
   1. Inhibits gluconeogenesis in the liver
   2. Mimics glucagon-like peptide-1
   3. Inhibits the dipeptidyl peptidase IV enzyme
   4. Increases periphery insulin sensitivity

 

8. A 65-year-old woman (5′ 3″, 186 lb) with hypertension, heart failure (NHYA Class I), and history of pancreatitis is newly diagnosed with type 2 diabetes. Medications include lisinopril 20 mg PO daily, carvedilol 3.125 mg PO BID, and aspirin 81 mg PO daily. Serum laboratory results today include A1c 8.3%, creatinine 1.6 mg/dL, ALT 35 IU/L, and BNP 20 pg/mL. A prescription is written for metformin. Which of the following statements is the best evaluation of this therapy?
   1. Appropriate drug; no contraindications present
   2. Inappropriate drug; contraindicated due to renal function
   3. Inappropriate drug; contraindicated due to heart failure
   4. Inappropriate drug; contraindicated due to pancreatitis

 

9. FDA has recently approved Insulin Human Inhalation Powder, a rapid-acting inhaled insulin to improve glycemic control in adults with diabetes mellitus. It is available under the trade name: 
   1. Afrezza
   2. Vazculep 
   3. Sivextro 
   4. Bunavail 
   5. Beleodaq 

 

10. A pharmacist receives a prescription for Bydureon. Which of the following statements are correct regarding Bydureon? (Select ALL that apply.)
    1. A patient needs to be started on Byetta first before beginning on Bydureon.
    2. Bydureon is administered once per week.
    3. Patients can expect a weight loss of 2-6 pounds
    4. The reconstituted solution can be stored up to 8 hours prior to injection.
    5. Bydureon has a black box warning for thyroid cancer.

 

11. Andrea is a 19 yo female (5'3", 100 lbs) who has just been diagnosed with type 1 diabetes. She eats 2 meals per day. The physician writes for an initial daily dose of insulin of 0.6 units/kg/day. Using an NPH-regular insulin dosing strategy, calculate the amount of NPH insulin and the amount of regular insulin Andrea should take.
    1. Take NPH 18 units BID and Regular 9 units BID before meals
    2. Take NPH 9 units BID and Regular 18 units BID before meals
    3. Take NPH 9 units BID and Regular 4 units BID before meals
    4. Take NPH 22 units BID and Regular 5 units BID before meals
    5. Take NPH 15 units BID and Regular 3 units BID before meals

 

12. Tammy is beginning insulin therapy. Proper advice on injection techniques should include: (Select ALL that apply.)
    1. The abdomen is the preferred site for injection.
    2. All insulins require a prescription
    3. The injection site should be cleansed with soap and water prior to injection.
    4. The injection site should be rotated.
    5. Unused insulin vials or cartridges should be kept refrigerated; once in use can be kept at room temperature for up to 28 days.

 

13. Jessica is a patient with type 1 diabetes who takes NPH 12 units BID and regular insulin 10 units BID. She likes to stay controlled and uses her glucometer often. She is at a wedding and just tested her blood glucose. Her glucometer shows 220 mg/dL. Jessica's target BG is 120 mg/dL and her correction factor is 50. Calculate Jessica's correction dose.
    1. 10 units
    2. 6 units
    3. 5 units
    4. 4 units
    5. 2 units

 

14. Adrian is a 19 yo male (5'11", 176 lbs) who was just diagnosed with DM-I. Adrian eats 3 meals a 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 Humalog Adrian should take.
    1. Lantus 32 units HS , Humalog 5 units before meals
    2. Lantus 24 units at HS , Humalog 8 units before meals
    3. Lantus 5 units at HS , Humalog 32 units before meals
    4. Lantus 16 units at HS , Humalog 10 units before meals
    5. Lantus 8 units at bedtime, Humalog 24 units before meals 

 

15. What is the estimated average glucose (eAG) of a patient with a hemoglobin A1C value of 9%?
    1. 130 mg/dL
    2. 126 mg/dL
    3. 366 mg/dL
    4. 212 mg/dL
    5. 278 mg/dL

 

16. A patient is taking propranolol for hypertension. He has just begun therapy with glipizide. The patient may not be able to recognize the following symptoms of hypoglycemia: (Select ALL that apply.)
    1. Shakiness
    2. Anxiety
    3. Hunger
    4. Sweating
    5. Palpitations

 

17. Metformin therapy is contraindicated in the following clinical situations:
    1. A patient who will receive non-iodinated IV radio-contrast dye
    2. NYHA Class I heart failure
    3. Serum creatinine of 1.7 mg/dL
    4. Pregnancy
    5. Children 10 - 16 years old

 

18. A patient is taking Humalog 75/25, 10 units BID. How many units of insulin lispro does the patient inject in the morning?
    1. 12 units
    2. 6.5 units
    3. 3 units
    4. 2.5 units

 

19. Charles is taking pioglitazone for his diabetes management. Which of the following are possible risks can happen when taking this medication? (Select ALL that apply.)
    1. Pancreatitis
    2. Weight gain
    3. Edema
    4. Fractures
    5. Bladder cancer

  

20. Frank is a 50 yo white male with DM. His BP reads 140-152/88-93 mmHg. He has a SCr of 2.8 mg/dL and BUN: 5 mg/dL. Which of the following would be appropriate to treat his HTN according to the JNC 8 guidelines? (Select ALL that apply.)
    1. Enalapril
    2. Losartan
    3. Amlodipine
    4. Begin lifestyle modification
    5. He does not require any intervention at this time.

 

Answers (Click to expand)

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