Meglitinide Works by Stimulating The Release of Insulin in The Presence of Glucose

Diabetes
A patient with type 2 diabetes is beginning therapy with pramlintide. Choose the correct
statement:
The mealtime insulin dose should be decreased by 50% when beginning pramlinitide.
Pramlintide has a boxed warning for severe hypoglycemia; the mealtime insulin dose must be
decreased by 50% when starting therapy.
Pramlintide (Symlin) is an injectable amylin analogue drug for diabetes (both type 1
and 2) for patients who blood glucose is not controlled by mealtime insulin.
Symlin suppresses the release of glucagon, a hormone that tells your liver to
release sugar into the bloodstream.
Symlin slows the rate food moves from the stomach into the small intestine.
Protect unopened pens from light and store in the refridgerator. Store opened pens
in the refrig. Or room temp for 30 days then dispose.
A physician wants to prescribe exenatide to his patient. He calls the pharmacy to ask if there are
any precautions to the use of this medication. The pharmacist should relay that the drug may not
be safe to use in the following situations: (Select ALL that apply.)
Exenatide (Byetta)- can be used to treat type 2 diabetes- glucagon-like peptide-1
agonist (GLP-1 agonist) medication- belonging to the group of incretin mimetics.
SubQ injection. Acts to increase the amount of insulin release by the pancreas.
CI- thyroid cancer, multiple endocrine neoplasia syndrome type 2, DKA, Severe
kindey or stomach, bowel problems.
Creatinine clearance less than 30 mL/min
History of pancreatitis
Exenatide's warnings include the risk of pancreatitis, use is not recommended in
severe renal impairment (CrCl < 30 mL/min) and use is not recommended in severe
GI disease (such as gastroparesis).
BP is picking up a new prescription for repaglinide. What is a possible side effect
from this medication?
Repaglinide (Prandin)- belongs to the meglitinides.- promotes insulin release from
the B-islet cells of the pancreas.
Do not take if taking gemfibrozil or NPH insulin
Take 15 to 30 minutes before each meal. If you skip a meal, do not take the dose for
the skipped meal. If you add an extra meal take an extra dose with that meal.
Extreme hypoglycemia
Meglitinide works by stimulating the release of insulin in the presence of glucose
after eating. This lowers your blood glucose level. Some generic names for
meglitinides are repaglinide (re-PAG-lyn-ide) and nateglinide (nah-TAG-lin-ide).
Some brand names for meglitinides are Prandin and Starlix .
A patient is starting therapy with Victoza. What is the appropriate dosing for this
medication?
0.6 mg SC daily for one week, then 1.2 mg SC daily for one week, then increase to
1.8 mg SC weekly if needed.
Victoza (liraglutide)- It can treat type 2 diabetes. It can also promote weight loss in
certain patients. GLP-1 agonist. Victoza does this in 3 ways. It slows food leaving
the stomach, helps prevent your liver from making too much sugar, and helps the
pancreas produce more insulin when your blood sugar levels are high. This is how
the GLP-1 hormone produced by the body works.
Victoza is given as an injection under the skin (subcutaneous). Do not inject it
into a vein or muscle. The best places to give yourself the injection are the front of
your thighs, the front of your waist (abdomen), or your upper arm. You can give
yourself the injection at any time of the day, regardless of meals.
SE- hypoglycemia (w/ insulin or insulin secretogouges such as glyburide), acute
pancreatitis (abd. Pain see doctor), thyroid tumors, renal impairment
Comes in 1.2 or 1.8 mg pens
Trulicity (dulaglutide)
exenatide (Byetta/Bydureon *extended release suspension), approved in 2005/2012.

liraglutide (Victoza, Saxenda), approved 2010.
lixisenatide (Lyxumia), approved in EU 2013.
albiglutide (Tanzeum), approved in 2014 by GSK.
dulaglutide (Trulicity), approved in 2014manufactured by Eli Lilly.
A patient is found unconscious. She is holding a blood glucose meter that reads 48
mg/dL. What is the appropriate treatment?
Glucagon (injectable)
Glucagon is used when a patient is unconscious. Family and friends need to know
how to reconstitute and inject. The kit includes a vial and a syringe that contains the
reconstitution liquid. Inject into the vial and swirl to dissolve the powder. Turn the
patient on their side (when they gain consciousness, they may vomit). Inject into
the buttock, arm or thigh.
CB will begin colesevelam therapy. Her other medications include citalopram,
levothyroxine, metformin and phenytoin. Choose the correct statement:
She will need to take phenytoin and levothyroxine 4 hours before colesevelam.
Colesevelam needs to be dosed 4 hours after phenytoin and levothyroxine. There
are other drugs that require spacing the time of administration from colesevelam.
Bile acid sequesterant.
Other meds to space: insulin or sulfonylureas (glipizide) because the risk of high TG
may be increased, Metformin because the risk of its side effects may be increased
by colesevelam, cyclosporins, hydantoins (e.g. phenytoin), thyroid hormones
(levothyroxine) or warfarin because their effectiveness may be decreased by
colesevelam
Plan: CT scan of the abdomen with iodinated contrast (scheduled for 9/22) to check for
abdominal abscess; hold metformin and start sliding scale insulin to control blood glucose. Start
cefepime 2 grams IV Q24H, levofloxacin 500 mg PO daily and metronidazole 500 mg PO TID.
Patient may eat a regular diet beginning on the afternoon of 9/22 after CT scan has been
completed.
Based on the plan documented, which type of insulin will be added to PQ's
medication profile?
Regular Insulin
Regular (short-acting) or rapid-acting insulins are used for sliding scales and
correction doses. When the blood glucose is elevated, it is best to get it controlled
right away. Long-acting insulins have a slow onset of action.
On the morning of 9/22, the pharmacist recommends an adjustment to PQ's insulin therapy as
she is hyperglycemic despite using 18 units of sliding scale insulin since admission. Which of the
following is an acceptable recommendation?
Insulin glargine 20 units SC daily

Sliding scale insulins alone are no longer recommended to manage hyperglycemia
in hospitalized patients. Per the 2017 ADA guidelines, patient's with poor oral intake
(this patient is not eating a regular diet until later in the day after her CT scan), a
basal insulin regimen with bolus correction doses (aka sliding scale insulin) is
recommended. Short- or rapid-acting insulins and agents that cause hypoglycemia
(such as sulfonylureas) should not be scheduled in a patient that is not eating
regular meals.
Which of the following could worsen hyperglycemia in PQ? (Select ALL that apply.)
FQ- Gatiflox (also assoc. with hypoglycemia). And Levoflox.

Atypical antipsycho- Clozapine and olanzapine (most risky), quetiapine,
paliperidone, risperidone (intermed. Risk), (low risk)-aripiprazole, ziprasidone,
(unknown)- ilopridone, B-blocker- atenolol, metoprolol, propranolol
Infection, Levofloxacin
Infections cause stress on the body and can lead to hyperglycemia. Drugs known to
raise blood glucose include flouroquinolones. Non-selective beta-blockers can cause
hyperglycemia. Metoprolol is a beta-1 selective blocker.
Barbiturates.
Thiazide diuretics.
Corticosteroids.
Birth control pills (oral contraceptives) and progesterone.
Catecholamines.
Decongestants that contain beta-adrenergic agents, such as pseudoephedrine.
The B vitamin niacin. ...
The antipsychotic medicine olanzapine (Zyprexa).
First generation beta blockers such as propranolol (Inderal, InnoPran), nadolol
(Corgard), timolol maleate (Blocadren), penbutolol sulfate (Levatol), sotalol
hydrochloride (Betapace), and pindolol (Visken)
Plan: CT scan of the abdomen with iodinated contrast (scheduled for 9/22) to check
for abdominal abscess; hold metformin and start sliding scale insulin to control
blood glucose. Start cefepime 2 grams IV Q24H, levofloxacin 500 mg PO daily and
metronidazole 500 mg PO TID. Patient may eat a regular diet beginning on the
afternoon of 9/22 after CT scan has been completed.
What is the primary reason that metformin was stopped shortly after admission?
The contrast dye used during the CT scan increase the risk for lactic acidosis.
Metformin must be stopped prior to the use of iodinated contrast dyes, which can
damage the kidneys. It can be restarted 48 hours after the procedure if renal
function is stable. Metformin has a low risk for hypoglycemia. Stop 48 hours before.
7
Feedback Mode
Case
completed.
Question
What is the recommended blood glucose target range while PQ is in the hospital?
140-180 mg/dL
Hospitalized patients should have their BG maintained between 140-180 mg/dL.
Goal plasma blood

Goal plasma blood
glucose ranges
Time of Check glucose ranges
for people without
for people with diabetes
diabetes
Before breakfast (fasting) < 100 70 - 130
Before lunch, supper and snack < 110 70 - 130
Two hours after meals < 140 < 180
Bedtime < 120 90- 150
A1C (also called glycosylated
hemoglobin A1c, HbA1c or < 6% < 7%
glycohemoglobin A1c)
Maintaining a blood glucose level of less than 180 mg per dL (9.99 mmol per L) will
minimize symptoms of hyperglycemia and hypoglycemia without adversely
affecting patient-oriented health outcomes.
History of Present Illness: PQ is a 67 year old female hospitalized on 9/21 with a skin and soft
tissue infection in the abdominal area.
Allergies: Penicillin (rash)
Past Medical History:

Diabetes mellitus type 2
Atrial fibrillation
GERD
Home Medications (all continued on admission):

Metformin 1000 mg PO BID
Metoprolol 50 mg PO BID
Lisinopril 20 mg PO BID
Warfarin 3 mg PO daily
Omeprazole 20 mg PO daily
Vitals:
Height: 5'2" Weight: 120 lbs
BP: 130/86 mmHg HR: 66 BPM RR: 14 BPM
Temp: 101.2F Pain: 1/10
Admission Labs (9/21):

Na (mEq/L) = 141 (135 - 145)
K (mEq/L) = 4.9 (3.5 - 5)
Cl (mEq/L) = 100 (95 - 103)
HCO3 (mEq/L) = 28 (24 - 30)
GLU (mg/dL) = 264 (100 - 125)
BUN (mg/dL) = 22 (7 - 20)
SCr (mg/dL) = 1.1 (0.6 - 1.3)
Mg (mEq/L) = 1.9 (1.3 - 2.1)
PO4 (mg/dL) = 4.4 (2.3 - 4.7)
Ca (mg/dL) = 9.5 (8.5 - 10.5)
WBC (cells/mm3) = 16 (4 - 11 x 103)
Hgb (g/dL) = 12.9 (12 - 16)
Hct (%) = 37 (36 - 46)
Plt (cells/mm3) = 399 (150 - 450 x 103)
INR = 2.2 (0.00 - 1.2)
A1C = 7.2%
completed.
A few days after admission, PQ's infection is resolving and she is eating a regular diet. The team
plans to restart metformin to prepare for discharge. PQ's SCr has not changed since admission.
Which of the following is correct?
Metformin is not contraindicated since her eGFR is >30 mL/min
The new recommendations for metformin treatment are based on eGFR, not SCr
(see p. 554 of the 2017 RxPrep Course Book). If eGFR is not provided, it should be
estimated by calculating the CrCl. PQ's estimated CrCl is 39 mL/min.
Was based on CI of men with SCr >1.5 and women SCr 1.4 but now is based on
eGFR
Patients who have an eGFR between 30 to 45 mL/min/1.73m^2 continue to
receive metformin or metformin-containing meds as long as there is an
appropriate assessment of the risk and benefits of the therapy. Can use CrCl as
an estimate. Do not decrease the dose. Still need worry about lactic acidosis.
The new labeling still indicates that metformin should not be used in patients who
have an eGFR below 30 mL/min/1.73 m2, but it can be continued in those who start
it while their eGFR is above 45 mL/min/1.73 m2. Interestingly enough, the new
labeling doesn't recommend starting metformin in patients with an eGFR between
30 and 45 mL/min/1.73 m2. The label indicates that we should only start metformin
at an eGFR above 45 mL/min/1.73 m2, continue it with assessment of the risks as it
falls below 45 mL/min/1.73 m2, and then stop it altogether if and when the eGFR
falls below 30 mL/min/1.73 m2.
The medical team discusses alternative treatment options to meformin to manage PQ's diabetes.
She does not want to use an injection. Which of the following would be an appropriate choice?
A1C = 7.2%
Pioglitazone- increases insulin sensitivity
Glyburide and dapagliflozin- CrCl to low, liraglutide-Victoza-injectable
Glyburide (Micronase, DiaBeta, Glynase-Renal)- SU- do not use in renal insuff.
patients- , dapagliflozin (Farxiga) a potent and selective inhibitor of the renal
sodium-glucose cotransporter SGLT2 (block glucose reabsorption of glucose by the
kidney, increases glucose excretion) - CrCl is too low to start,
canagliflozin (Invokana) and dapagliflozin (Farxiga).
Do not initiate if below 60, not recommened if stays between 30-60, below 30
contraindicated.
eGFR mL/min/1.73m2 Canagliflozin Dapagliflozin
No dosage adjustment No dosage adjustment
>/= 60
100-300 mg/d 5-10 mg/d
Not recommended
45 60 100 mg daily
eGFR < 60
Not recommended
30-45 N/A
eGFR <45
<30 Contraindicated Contraindicated
liraglutide- injectable, bromocriptine- not a 1 st line option.
SU- glipizide (Glucotrol)- not effected by renal, glimepiride (Amaryl)- not 1 st to be

used with renal impairment but not CI.
Thiazolidinediones- can be used in renal insuffient patients. Pioglitazone (Actos),

France and Germany have suspended its sale after a study suggested the drug could raise the risk
of bladder cancer.[4]
Rosiglitazone (Avandia), which was put under selling restrictions in the US and withdrawn
from the market in Europe due to some studies suggesting an increased risk of cardiovascular
events. Upon re-evaluation of new data in 2013, the FDA lifted the restrictions.
Meglitinides- Repaglinide- safely used in renal insuff.- Nateglinide- Severe.advanced
kidney disease can risk for hypoglycemia. Exenatide- primarly renally cleared, no
dose adj. required when CrC> 30. <30 not recommended. Sitagliptin and
saxagliptin- no dose adj are needed for CrCl >20 .
Pramlintide (Symlin, Amylin- no dose adj. for CrCl>20
PQ is switched to pioglitazone. What monitoring parameters should be followed

when using this medication? (Select ALL that apply.)
Monitor patients carefully for symptoms of heart failure
Liver enzymes should be monitored prior to initiation of therapy and periodically
thereafter.
Renal dose adjustment is not necessary for pioglitazone. CBC, K+, and Na+ are not
affected by pioglitazone; therefore, they do not need to be monitored during
therapy.
FK is a 68 y/o female patient who has had type 2 diabetes for about 20 years. She currently takes
metformin 1,000 mg BID, Levemir 30 units at bedtime, and Humalog 6 units TID with meals.
Based on her blood glucose log from the past week, which adjustment to her medications is most
appropriate?
Before breakfast After breakfast After lunch After dinner

Sunday 124 101 158 173
Monday 118 76 139 168
Tuesday 126 108 173 136
Wednesday 109 64 157 159
Thursday 102 94 169 155
Friday 98 89 164 175
Saturday 110 61 177 163
Decrease breakfast Humalog to 4 units

Since FK's after breakfast values are trending low, it is best to cut back on the
amount of insulin taken at breakfast. Her fasting BG levels are well controlled.
A patient is picking up a new prescription for sitagliptin. Which of the following side
effects should be discussed with the patient?
Pacreatitis
Acute pancreatitis is a risk with sitagliptin. It is weight neutral. Other agents in the
class have warnings for heart failure and hepatotoxicity.
The following may be indicative of diabetic ketoacidosis (DKA): (Select ALL that
apply.)
Fruity breath, ketones in urine/blood, coma
MK's mother has been hospitalized and put on insulin therapy. The mother is discharged with a
prescription for insulin glulisine. Her insurance plan does not cover this option. Choose an
acceptable alternative to glulisine:
Apidra (insulin glulisine) It works by lowering levels of glucose (sugar) in the blood.
Insulin glulisine is a faster-acting form of insulin than regular human insulin.
Insulin glulisine is used to treat diabetes in adults and children who are at least 4
years old.
The three rapid-acting insulins currently approved by the US Food and Drug
Administration lispro, aspart (NovoLog), and glulisine (Apidra ) have similar
action curves, with an onset occurring in 515 minutes, a peak in 45 90 minutes,
and an overall duration of about 34 hours.
Insulin aspart
Glulisine is a rapid-acting insulin, choose an alternative rapid-acting insulin such as
aspart or lispro.
What is the estimated average glucose (eAG) of a patient with a hemoglobin A1C
value of 7%?
154 mg/dL
An A1C of 7% equals a mean plasma glucose of 154 mg/dL. Refer to p. 552 of the
2017 RxPrep Course Book.
28.7*A1C-46.7=eAG
6= 126, 6.5=140, 7=154, 7.5=169, 8= 183, 8.5= 197, 9=212
7= 154, +/- 14 points for 0.5
The pharmacist is dispensing a new prescription for pioglitazone. Choose the correct
statement:
This medication has been shown to increase the risk of bladder cancer
Pioglitazone is taken once daily in the morning (15-45 mg daily), with or without
food. The patient should be told to monitor for nausea, abdominal pain, passing
dark-colored urine, the skin and the whites of the eyes turning yellow; these may be
signs of liver damage. It can take a couple of months to have a full effect. More
recently, pioglitazone has been associated with bladder cancer.
JO takes many medications. His daily regimen consists of irbesartan, carvedilol,
furosemide, spironolactone, glimepiride and pioglitazone to treat his NYHA Class III
heart failure and diabetes. His renal clearance is estimated at 39 mL/min. The
potassium taken today is 4.3 mEq/L. Which of the following is a correct statement?
Pioglitazone should be avoided in this patient.
Pioglitazone is contraindicated in NYHA Class III and IV heart failure.
FL is a 54 year-old white male with diabetes and chronic kidney disease. His blood pressure
ranges from 140-152/88-93 mmHg on multiple readings. He has a SCr of 2.8 mg/dL and BUN of
55 mg/dL. Which of the following would be appropriate to treat his hypertension according to
the JNC 8 guidelines?
Losartan
According to JNC 8, initial therapy for any patient with chronic kidney disease (with
or without diabetes) is an ACE inhibitor or ARB.
A pharmacist receives a prescription for Bydureon. Which of the following
statements are correct regarding Bydureon? (Select ALL that apply.)
Exenatide extendend release
Once weekly one time use pen, inject back of upper arm, stomach, thigh.
Pacreatitis, hypoglycemia, kidney (kidney failure rare), stomach problems
TV is a 23 year-old female ( 5'4", 100 lbs) who was just 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 a NPH-regular insulin dosing strategy, calculate the
amount of NPH insulin and the amount of regular insulin the patient should take.
NPH 9 units BID and regular insulin 4 units BID before meals
When using NPH and regular insulin, it is initiated by taking the total daily dose of
insulin and giving 2/3 (67%) of the insulin as the NPH dose and 1/3 (33%) as the
regular insulin dose. NPH is generally given BID and the regular insulin is divided
BID or TID with meals.
A patient brought in a prescription for Glucotrol. Which of the following is an appropriate

generic substitution for Glucotrol?
Glipizide
The generic name of Glucotorl is glipizide.
Metormin- Glucophage, Linagliptin (Trajenta) DPP4 inhibitor, Glyburide (Micronase,
Glynase, Diabeta), Tolbutamide (Orinase)- SU, 1 st gen. K channel blocker.
A patient is experiencing shakiness and anxiety. She tests her blood glucose and finds it is low.
Hypoglycemia is defined as a blood glucose:
Less than 70 mg/dL

Hypoglycemia is defined as a blood glucose < 70 mg/dL.
JD is a patient with type 1 diabetes who takes NPH 10 units BID and regular insulin 5
units BID. She likes to stay well controlled and uses her glucometer often. She is at
a wedding and just tested her blood glucose. Her glucometer shows 220 mg/dL.
JD's target BG is 120 mg/dL and her correction factor is 50. Calculate her correction
dose.
2 units
Correction dose = (220-120)/50 = 2 units
Which among the following statements concerning Glyset is correct?
Miglitol- alpha-glucosidase inhibitor, oral- others acarbose (Precose)
Alpha-glucosidase inhibitors are oral anti-diabetic drugs used for diabetes
mellitus type 2 that work by preventing the digestion of carbohydrates (such as
starch and table sugar). Carbohydrates are normally converted into simple sugars
(monosaccharides), which can be absorbed through the intestine.
Glyset is an alpha glucosidase inhibitor.
Dosed 25-50 mg TID. Weight gain. Not sever hypoglycemia.
A pharmacist receives a prescription for Adlyxin. What is the generic name of Adlyxin?
Alogliptin- (Vipidia, Nesina)
Lixisenatide- (Adlyxin)-GLP-1 receptor agonist
The generic name of Adlyxin is lixisenatide.
GH is starting Humulin 70/30 once daily with breakfast. Choose the correct
statements regarding Humulin 70/30. (Select ALL that apply.)
The typical dose is twice daily, 30 minutes before the morning and evening meal.
GH will need counseling on treatment of hypoglycemia.
Humulin 70/30 is available without a prescription.
70% insulin isophane suspension and 30% regular insulin
Humulin 70/30 is 70% NPH and 30% regular insulin.
A patient gave the pharmacist a prescription for Soliqua 100/33. Which of the following is
the generic for this drug?
Soliqua 100/33 is the combination of Lantus (insulin glargine 100 Units/mL) and
lixisenatide, a GLP-1 receptor agonist, in a once-daily injection
Insulin glargine + lixisenatide
The generic components of Soliqua are insulin glargin and lixisenatide (Adlyxin).
100 units/mL and 33 mcg/mL
A patient is taking Novolog Mix 70/30, 15 units BID. How many units of intermediate acting
insulin does the patient inject in the morning?
10.5
Novolog Mix 70/30 contains 70% insulin aspart protamine suspension and 30%
insulin aspart. The patient is getting an injection of 15 units of this combination
product. 70% of the 15 units = 10.5 units.
WB is an elderly man with diabetes who is being discharged from the hospital. He is
given a new glucose monitor to keep track of his blood glucose values. A few days
later, WB comes into the local pharmacy to report that the meter is not giving the
right numbers. He states that the numbers seem to be running too high and that he
often gets an error message. What are valid reason/s why the meter could be giving
incorrect values or an error message? (Select ALL that apply.)
The meter was not calibrated before first use
The test strips have expired
The test strip may not fully be inserted into the meter.
Test strips are expensive and should be used before the expiration date. The test
strips may be the wrong strip for the device. The patient could have visual problems
and could misread the number. The device may need to be tested with a control
solution. The strips could have been damaged by light or humidity. There are a
number of factors that could make the machine report an error message or an
inaccurate value.
A patient with mildly elevated postprandial blood glucose will begin colesevelam
therapy. Choose the correct statements:
Colesevelam (Welchol) may cause constipation
Colesevelam can be used for both diabetes and dyslipidemia but it can increase
TGs; therefore, it is contraindicated in patients with TGs > 500 mg/dL. The main
side effect is constipation.
What is the correct mechanism of action of exenatide?

A glucagon-like peptide-1 agonist; it increases insulin and decreases glucagon.
Exenatide is an analog of glucagon-like peptide 1 (GLP-1) which increases glucose-
dependent insulin secretion, decreases inappropriate glucagon secretion, and slows
gastric emptying.
A patient is starting Byetta therapy. Which of the following counseling points are
correct and should be discussed with the patient? (Select ALL that apply.)
5mcg BID 60 min before meals morning and evening meals
This SC injection should be palced in the thigh, abdomen, or upper arm.
Before 1st use, this medication must be stored in the refrigerator and protected from
light.
Do not inject the medication after a meal.
Doses should be separated by at least 6 hours or more during the day between
morning and evening meals.
Byetta does not cause dry mouth.
History of Present Illness: UR is a 48 year old male with newly diagnosed type 2 diabetes. He
presents to the clinic on 10/10 for a comprehensive visit to include initiation of diabetes
treatment.
Allergies: NKDA

Gout
Social History:
Married, 2 young children, office job with long periods of sitting, smokes PPD, alcohol
socially on weekends and some evenings during the week. Does not exercise or have any active
hobbies.
Current Medications:
None
Immunizations History: None since childhood

Vitals:
BP: 154/96 mmHg HR: 83 BPM RR: 20 BPM Temp: 98.6F Pain: 1/10
Labs (fasting):
AST (units/L) = 24 (10 - 40)
ALT (units/L) = 21 (10 - 40)
TC (mg/dL) = 206 (125 - 200)
TG (mg/dL) = 165 (< 150)
HDL (mg/dL) = 34 (> 40)
LDL (mg/dL) = 163 (<100)
GLU (mg/dL) = 264 (100 - 125)
Na (mEq/L) = 141 (135 - 145)
K (mEq/L) = 4.2 (3.5 - 5)
Cl (mEq/L) = 100 (95 - 103)
HCO3 (mEq/L) = 28 (24 - 30)
BUN (mg/dL) = 22 (7 - 20)
SCr (mg/dL) = 1.2 (0.6 - 1.3)
Mg (mEq/L) = 1.9 (1.3 - 2.1)
PO4 (mg/dL) = 4.4 (2.3 - 4.7)
Ca (mg/dL) = 9.5 (8.5 - 10.5)
TSH (mIU/L) = 1.9 (0.3 - 3.0)
Hgb A1C = 10.6 %
Urinary albumin excretion (mg/24 hours) = 20 (< 30)
Which of the following should be recommended for UR at this time? (Select ALL that apply.)
Influenza vaccine (inactivated, shot), Pneumococcal polysaccharide vaccine,
hepatitis b vaccine
The patient is not a candidate for the live influenza vaccine. This is not used in
patients with chronic disease. He should receive the influenza shot (inactivated), the
pneumococcal polysaccharide vaccine (Pneumovax 23), and the hepatitis B vaccine.
treatment.
Allergies: NKDA

Gout
Social History:
hobbies.
None
Vitals:
Labs (fasting):
AST (units/L) = 24 (10 - 40)
ALT (units/L) = 21 (10 - 40)
TC (mg/dL) = 206 (125 - 200)
TG (mg/dL) = 165 (< 150)
HDL (mg/dL) = 34 (> 40)
LDL (mg/dL) = 163 (<100)
GLU (mg/dL) = 264 (100 - 125)
Na (mEq/L) = 141 (135 - 145)
K (mEq/L) = 4.2 (3.5 - 5)
Cl (mEq/L) = 100 (95 - 103)
HCO3 (mEq/L) = 28 (24 - 30)
BUN (mg/dL) = 22 (7 - 20)
SCr (mg/dL) = 1.2 (0.6 - 1.3)
Mg (mEq/L) = 1.9 (1.3 - 2.1)
PO4 (mg/dL) = 4.4 (2.3 - 4.7)
Ca (mg/dL) = 9.5 (8.5 - 10.5)
TSH (mIU/L) = 1.9 (0.3 - 3.0)
Hgb A1C = 10.6 %
According to the ADA guidelines, what is the best therapy to start in UR?
Basal insulin + mealtime insulin
Combination injectable therapy should be considered in patients with severe
hyperglycemia, defined as a BG 300 mg/dL or A1C 10%.
treatment.
Allergies: NKDA

Gout
Social History:
hobbies.
None
Vitals:
Labs (fasting):
AST (units/L) = 24 (10 - 40)
ALT (units/L) = 21 (10 - 40)
TC (mg/dL) = 206 (125 - 200)
TG (mg/dL) = 165 (< 150)
HDL (mg/dL) = 34 (> 40)
LDL (mg/dL) = 163 (<100)
GLU (mg/dL) = 264 (100 - 125)
Na (mEq/L) = 141 (135 - 145)
K (mEq/L) = 4.2 (3.5 - 5)
Cl (mEq/L) = 100 (95 - 103)
HCO3 (mEq/L) = 28 (24 - 30)
BUN (mg/dL) = 22 (7 - 20)
SCr (mg/dL) = 1.2 (0.6 - 1.3)
Mg (mEq/L) = 1.9 (1.3 - 2.1)
PO4 (mg/dL) = 4.4 (2.3 - 4.7)
Ca (mg/dL) = 9.5 (8.5 - 10.5)
TSH (mIU/L) = 1.9 (0.3 - 3.0)
Hgb A1C = 10.6 %
UR is going to be started on Levemir at 0.3 units/kg/day. How many mLs does he

need to draw up into the syringe to administer this dose?
0.25 mL
Levemir comes as 100 units/mL. UR requires 25 units (182 lbs/2.2 = 82.7 kg x 0.3
units/kg = 24.8 units). This is 0.25 mLs.
treatment.
Allergies: NKDA

Gout
Social History:
hobbies.
None
Vitals:
Labs (fasting):
AST (units/L) = 24 (10 - 40)
ALT (units/L) = 21 (10 - 40)
TC (mg/dL) = 206 (125 - 200)
TG (mg/dL) = 165 (< 150)
HDL (mg/dL) = 34 (> 40)
LDL (mg/dL) = 163 (<100)
GLU (mg/dL) = 264 (100 - 125)
Na (mEq/L) = 141 (135 - 145)
K (mEq/L) = 4.2 (3.5 - 5)
Cl (mEq/L) = 100 (95 - 103)
HCO3 (mEq/L) = 28 (24 - 30)
BUN (mg/dL) = 22 (7 - 20)
SCr (mg/dL) = 1.2 (0.6 - 1.3)
Mg (mEq/L) = 1.9 (1.3 - 2.1)
PO4 (mg/dL) = 4.4 (2.3 - 4.7)
Ca (mg/dL) = 9.5 (8.5 - 10.5)
TSH (mIU/L) = 1.9 (0.3 - 3.0)
Hgb A1C = 10.6 %
UR's total daily insulin dose will be 0.6 units/kg/day. The physician wants to use a basal-bolus
strategy with Levemir and NovoLog. What would be the recommended starting doses for
theNovoLog?
8 units before breakfast, lunch, and dinner
50% of the total daily dose will be basal and 50% will be bolus (0.3 units/kg/day X
82.7 kg = 24.8 units/3 meals = 8 units before each meal.
Proper advice on insulin injection technique for UR should include: (Select ALL that
apply.)
The abdomen is the preferred sit for injection because it has the fastest and most
predictable absorption.
Unused insulin vials or cartridges should be refrigerated; vials in use can be kept at
room temperature.
NPH, regular insulins and some pre-mixed insulins do not require a prescription.
Always wipe injection site with an alcohol swab before administration.
treatment.
Allergies: NKDA

Gout
Social History:
hobbies.
None
Vitals:
Labs (fasting):
AST (units/L) = 24 (10 - 40)
ALT (units/L) = 21 (10 - 40)
TC (mg/dL) = 206 (125 - 200)
TG (mg/dL) = 165 (< 150)
HDL (mg/dL) = 34 (> 40)
LDL (mg/dL) = 163 (<100)
GLU (mg/dL) = 264 (100 - 125)
Na (mEq/L) = 141 (135 - 145)
K (mEq/L) = 4.2 (3.5 - 5)
Cl (mEq/L) = 100 (95 - 103)
HCO3 (mEq/L) = 28 (24 - 30)
BUN (mg/dL) = 22 (7 - 20)
SCr (mg/dL) = 1.2 (0.6 - 1.3)
Mg (mEq/L) = 1.9 (1.3 - 2.1)
PO4 (mg/dL) = 4.4 (2.3 - 4.7)
Ca (mg/dL) = 9.5 (8.5 - 10.5)
TSH (mIU/L) = 1.9 (0.3 - 3.0)
Hgb A1C = 10.6 %
According to the current American Diabetes Association (ADA) guidelines, UR should
be counseled on the following goals of therapy:
Prepradial blood glucose 80-130 mg/dL and peak postprandial blood glucose <180
mg/dL
The ADA treatment goals for patients with type 2 diabetes are preprandial blood
glucose 80-130 mg/dL and peak postprandial blood glucose < 180 mg/dL.
According to the current American Diabetes Association (ADA) guidelines, which of the
following are treatment options to treat UR's blood pressure? (Select ALL that apply.)
HCTZ, Amlopipine, Lisinopril, Valsartan
According to the 2017 ADA guidelines, patient's with diabetes and no albuminuria
may be treated with an agent from any of the preferred drug classes (thiazides,
calcium channel blockers, ACE inhibitors or ARBs). There is no longer a preference
for ACE inhibitors or ARBs in patients with diabetes and hypertension only.
The new guidelines emphasize control of systolic blood pressure (SBP) and diastolic blood
pressure (DBP) with age- and comorbidity-specific treatment cutoffs. The new guidelines also
introduce new recommendations designed to promote safer use of angiotensin converting
enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs).
Important changes from the JNC 7 guidelines2 include the following:
In patients 60 years or older who do not have diabetes or chronic kidney disease, the goal blood
pressure level is now <150/90 mm Hg.
In patients 18 to 59 years of age without major comorbidities, and in patients 60 years or older
who have diabetes, chronic kidney disease (CKD), or both conditions, the new goal blood
pressure level is <140/90 mm Hg.
First-line and later-line treatments should now be limited to 4 classes of medications: thiazide-
type diuretics, calcium channel blockers (CCBs), ACE inhibitors, and ARBs. - See more at:
http://www.ajmc.com/journals/evidence-based-diabetes-management/2014/january-2014/the-jnc-
8-hypertension-guidelines-an-in-depth-guide#sthash.RL9CDP6o.dpuf
When initiating therapy, patients of African descent without CKD should use CCBs and
thiazides instead of ACE inhibitors.
Use of ACE inhibitors and ARBs is recommended in all patients with CKD regardless of ethnic
background, either as first-line therapy or in addition to first-line therapy.
ACE inhibitors and ARBs should not be used in the same patient simultaneously.
CCBs and thiazide-type diuretics should be used instead of ACE inhibitors and ARBs in
patients over the age of 75 years with impaired kidney function due to the risk of hyperkalemia,
increased creatinine, and further renal impairment. - See more at:
http://www.ajmc.com/journals/evidence-based-diabetes-management/2014/january-2014/the-jnc-
8-hypertension-guidelines-an-in-depth-guide#sthash.RL9CDP6o.dpuf
To provide more choices for people with diabetes who also have hypertension (high blood
pressure), medication recommendations have been expanded in the Standards to now include
four options as first-line treatment. According to the guidelines, any of the four classes of blood
pressure medications that have shown beneficial cardiovascular outcomes in people with
diabetesACE inhibitors, angiotensin receptor blockers, thiazide-like diuretics or
dihydropyridine calcium channel blockersmay be used as initial therapy for hypertension. -
See more at: http://www.diabetes.org/newsroom/press-releases/2016/american-diabetes-2017-
standards-of-care.html#sthash.b48h7Yit.dpuf
A patient is using insulin glargine. Insulin glargine has a duration of action of at
least:
24 hours
Insulin glargine is a long-acting "basal" insulin and can last 24 hours.
A patient gave the pharmacist a prescription for Amaryl 1 mg PO daily #30. Which
of the following is an appropriate generic substitution for Amaryl?
Glimepiride
The generic name of Amaryl is glimepiride.
A patient gave the pharmacist a prescription for Januvia 100 mg daily #30. Which of
the following is an appropriate generic substitution for Januvia?
Sitagliptin, Saxagliptin (Onglyza)
The generic name of Januvia is sitagliptin.
A patient is taking Humalog Mix 75/25, 10 units BID. How many units of insulin
lispro does the patient inject in the morning?
2.5 units
Humalog Mix 75/25 contains 75% insulin lispro protamine suspension and 25%
insulin lispro. The patient is getting an injection of 10 units of this combination
product. 25% of the 10 units = 2.5 units.
Which sulfonylurea has a partially active metabolite that is renally cleared, and can
result in more hypoglycemia, especially in patients with impaired renal clearance?
Glyburide
Glyburide can cause significant hypoglycemia, particularly among elderly patients
who have reduced renal clearance.
Which of the following lifestyle modifications should be encouraged for UR? (Select ALL that
apply.)
Smoking cessation
Do not sit for prolonged periods of time
Perform moderate-intensity physical activity at least 150 minutes/week.
Goal waist circumference of < 40 inches.
Medical nutrition therapy (MNT) should be provided to all patients diagnosed with
diabetes. Lifestyle management is critical. The 2017 ADA Guideline Update states
that patients should not sit for longer than 30 minutes at a time. This has been
updated on the 2017 Errata and Updates page on the RxPrep website under the
Student Resources page.
A pharmacist receives a prescription for Bydureon. Which of the following
statements are correct regarding Bydureon? (Select ALL that apply.)
Bydureon is given once per week
Patients may experience weight loss
Bydureon has a boxed warning for thyroid cancer, which was seen in rats.
Bydureon is given weekly and carries a boxed warning for thyroid cancer. Pens
should never be shared.
Self-monitoring of blood glucose (SMBG) is an important part of diabetes care.
Which of the following statements are true about SMBG? (Select ALL that apply.)
SMBG allows patients to see the effects of their diet, physical activity, and
medications.
SMBG can aid patients in recognizing hyperglycemia.
SMBG is recommended for anyone on insulin and sometimes in patients on oral
medications. The challenge lies in insurance coverage as many patients cannot
afford the cost (for the test strips mainly) if paid out of pocket.
A patient is taking insulin NPH at bedtime. She injects regular insulin before lunch,
at about 12:30 PM. The patient is often hypoglycemic at around 3:00 PM. Choose
the correct response:
The regular insulin should be decreased.
Based on the onset and peak effects of regular insulin, the hypoglycemia
experienced at 3:00 PM is most likely due to the regular insulin injected at 12:30
PM. It would be best to decrease the dose of the regular insulin to see if this fixes
the hypoglycemia.
A patient has received a new glucometer. She has not used one previously.
Counseling points should include:
Let the hand hang down below the heart for 30 seconds to allow blood to pool in the
fingertips.
The hands should be dry, as water will dilute the blood sample. The finger pads
should not be used as a testing site. A new test strip should be used for each test.
Alternate testing sites are not recommended when blood glucose is changing or
when hypoglycemia is suspected because alternate sites can give a test result that
is 20 - 30 minutes old.
BP is picking up a new prescription for repaglinide. What is a possible side effect
from this medication?
Hypoglycemia.
Not peripheral edema, pancreatitis, flatulence, significant weight loss
Repaglinide (Prandin) can cause hypoglycemia and weight gain.
KS is picking up a new prescription for glipizide. What are possible side effects from
this medication? (Select ALL that apply.)
Hypoglycemia and weight gain
A patient is using propranolol for migraines. She has just begun therapy with
glipizide. The patient may not be able to recognize the following symptoms of
hypoglycemia: (Select ALL that apply.)
Shakiness, anxiety, palpitations.
Beta blockers can block shakiness, anxiety and palpitations brought on by
hypoglycemia. Sweating and hunger may still be present.
A patient is about to begin therapy with pramlintide. Which of the following
statements are correct regarding pramlintide? (Select ALL that apply.)
This medication must be titrated as it can cause significant nausea.
This medication is a synthetic analog of amylin which prevent glucagon secretion
following a meal
This medication is contraindicated in patients with hypoglycemia unawareness.
Pramlintide (Symlin) is injected before meals and can cause weight loss
What is the mechanism of action of glimepiride?
Stimulates insulin secretion from the pancreas
Glimepiride works by stimulating insulin secretion from the pancreatic beta cells.
Which of the following formulations contain metformin? (Select ALL that apply.)
Xigduo XR (dapagliflozin (farxiga)/metformin), Glucophage, Janumet XR
(sitagliptin/metformin)-Januvia
Oseni contains alogliptin and pioglitazone; Avandaryl contains glimepiride and
rosiglitazone.
The antihyperglycemic action of miglitol results from a reversible inhibition of
membrane-bound intestinal -glucoside hydrolase enzymes.
Miglitol (Glyset)
Repaglinide (Prandin) can cause hypoglycemia and weight gain- meglitinides. SU-
Glipizide- hypoglycemia and weight gain.
Trulicity (dulaglutide), Victoza (liraglutide)- Victoza does this in 3 ways. It slows
food leaving the stomach, helps prevent your liver from making too much sugar,
and helps the pancreas produce more insulin when your blood sugar levels are high.
This is how the GLP-1 hormone produced by the body works.
Empagliflozin (Jardiance)
Levemir 0.3 units/kg/day
Total insulin dose 0.6 units/kg/day
Diabetes II-
Which of the following statements are true regarding amylin? (Select ALL that
apply.)
Amylin slows gastric emptying, suppresses glucagon secrection, increases satiety,
and is secreted from pancreatic beta cells.
Controls post-prandial plasma glucose by affecting post-prandial glucagon.
Amylin helps to control post-prandial glucose.
All of the following are considered rapid-acting insulins except:
Detemir
Detemir is a long-acting insulin. Levemir (inuslin detemir)
Which of the following syringes has the thickest needle?
18 G
The smaller the number, the larger the needle.
A pharmacist wishes to review the new guidelines for the treatment of diabetes. Guidelines for
this condition are written by: (Select ALL that apply.)
The American Association of Clinical Endocrinologists
The American Diabetes Association
The AACE and ADA write guidelines for the management of diabetes.
When hyperosmolar hyperglycemic syndrome (HHS) occurs:
Patients are severely dehydrated
Hyperosmolar hyperglycemic state (HHS) is a complication of diabetes mellitus
(predominantly type 2) in which high blood sugars cause severe dehydration,
increases in osmolarity (relative concentration of solute) and a high risk of
complications, coma and death. It is diagnosed with blood tests.
HHS is predominantly a complication of type 2 diabetes (rarely type 1) in which high
BG can cause severe dehydration and increases in osmolarity. The condition is a
medical emergency.
Which of the following statements are correct in regards to U-500 insulin?
U-500 insulin is preferred when a patient requires > 200 units of insulin per day.
U-500 insulin is regular insulin that is 5 times as concentrated compared to U-100
insulin; therefore, dosing errors and the potential for patient harm is great. It should
not be mixed with other insulins.
A patient begins acarbose therapy but cannot tolerate it due to the side effects. She has primarily
high postprandial blood glucose. She is also using insulin glargine and says she eats two meals
each day and does not mind injecting insulin. She wants her blood glucose tightly controlled.
Which of the following insulins would be best to help control her postprandial blood glucose
levels?
Novolog
A rapid-acting insulin would be best for controlling postprandial blood glucose
levels.
Acarbose (Precarbose)
Acarbose is a glucosidase inhibitor. It works by slowing down the enzyme that turns
carbohydrates into glucose. This results in a smaller rise in blood sugar levels
following a meal. Alpha-glucosidase
Ben comes to the pharmacy with a prescription for Invokana. Which of the following
statements regarding Invokana are correct?
Canagliflozin (Invokana)- SGLT2 subtype 2 sodium-glucose transport inhibitor,
dose 100 mg daily,
Can cause vaginal yeast infections
urinary tract infections,

increased urination,
yeast infections,
vaginal itching,
thirst,
constipation,
nausea,
fatigue,
Linagliptin (Tradjenta)DD4, Dapaliflozin (Farxiga), Empagliflozin (Jardiance),

Which of the following statements regarding insulin glargine therapy is correct?
(Select ALL that apply.)
Lanus 100 u/mL, Toujeo 300 u/mL
Insulin detemir (levemir) are all clear.
It comes in 300 units/mL
It is a long-acting, basal insulin
It should not be mixed with other insulins
It is a available in a Solostar pen
Alpha cells of the pancreas secrete which of the following:
Glucagon
Alpha cells secrete glucagon.
A female patient in the diabetes clinic has heard that Byetta can cause weight loss in some
patients. She wishes to try it. The pharmacist is going to counsel her on using Byetta. Which of
the following instructions are correct?
Which of the following is a correct statement regarding alpha-glucosidase inhibitor
therapy?
These medications are used to lower post-prandial hyperglycemia.
Since these agents prevent the digestion of complex carbohydrates, starchy foods
will not effectively reverse a hypoglycemic episode. Glucose tablets or gel should be
used to reverse hypoglycemia. Table sugar is sucrose and should not be used.
Patients using exenatide should be counseled regarding the rare, but possible risk of:
Severe abdominal pain due to the risk of acute pancreatitis

Pancreatitis is a rare complication of exenatide use. The majority of cases occurred
in patients with at least one other factor for pancreatitis, such as heavy alcohol use
or high triglycerides.
A 43 year-old female patient with type 2 diabetes and normal renal function started
taking Januvia 100 mg daily in the morning. Which of the following statements is
correct regarding Januvia?
Dulaglutide-Trulicity-GLP-1 agonist
Januvia-Sitagliptin
Onglyza-Saxagliptin
Linagliptin-Tradjenta
Januvia works by blocking dipeptidyl peptidase 4.
Januvia is weight neutral and does not cause significant hypoglycemia by itself. It is
best at reducing postprandial glucose. You may take this with or without food.
Swab the top of both vial with an alcohol swab
Inject 12 units of air into the NPH insulin vial
Inject 3 units of air into the Rgular insulin vial
Withdraw 3 units of Regular insulin into the syringe by pulling down on the plunger
Withdraw 12 units of NPH insulin into the syringe by pulling down on the plunger
Air must be injected into both vials before insulin can be withdrawn.
Maria is a 74 year old female with diabetes who presents with a non-healing ulcer on her left toe.
Her physician states that it will be difficult to heal the ulcer unless her blood glucose (BG) values
are tightly controlled. He writes the following order and discontinues her long-acting insulin:
BG < 60 mg/dL, hold insulin and contact MD

BG 150-200 mg/dL, give 2 units insulin
BG 201-250 mg/dL, give 4 units insulin
BG > 250 mg/dL, call MD.
What is this name for this type of order?
Sliding Scale
Sliding scales are used in the hospital and at home to correct hyperglycemia (they
are correction doses).
A patient is currently using U-500 insulin and will be transitioned to U-100 regular human
insulin. He currently uses 4 units of the U-500 insulin with breakfast, 5 units with lunch, and 8
units with dinner. How many mL of U-100 regular human insulin is needed to cover his lunch
dose? (Answer must be numeric; no units or commas; include leading zero when the answer is
less than 1.)
0.05
Setting it up as a ratio: 100 units/mL = 5 units/X mL; where x = 0.05 mL
Everything is in units not mLs. Have to pay attention to the question.
What is the primary mechanism of action of metformin?
Decreasing the amount of glucose released by the liver
Metformin lowers the rate of hepatic glucose output by decreasing gluconeogenesis.
AW is a 35 y/o, 5'5", 65 kg female with a history of type 1 diabetes. Her current insulin regimen
is:
8 units NPH and 2 units lispro before breakfast (7 am)

2 units lispro before lunch (12 pm)
2 units lispro before dinner (6 pm)
4 units NPH at bedtime (10 pm).
Her blood glucose value ranges are as follows:
Before breakfast: 100-120 mg/dL

After lunch: 200-220 mg/dL
After dinner: 110-130 mg/dL
At bedtime: 130-150 mg/dL
Using the above case, which of the following would be the most appropriate insulin
recommendation?
Increase before lunch lispro dose

Since the BG is high after lunch, it would be preferable to increase the dose of the
rapid-acting insulin prior to lunch.
ST is hospitalized for diabetic ketoacidosis (DKA). Treatment of DKA generally
includes which of the following therapies: (Select ALL that apply.)
NS or NS, Insulin, Potassium
At what degree of renal impairment is metformin contraindicated?
eGFR <30 ml/min/1.73 m2 for all patients
New package labeling for metformin lists a contraindication to use with eGFR < 30
mL/min/1.72 m2
Factors that the prescriber should take into consideration when selecting an oral
agent for initial therapy to treat type 2 diabetes include which of the following?
(Select ALL that apply.)
Efficacy
Weight gain/loss
Blood glucose levels at the time of diagnosis
Hemoglobin A1C value
Patient preference
All are factors in selecting initial therapy for type 2 diabetes management.
Which of the following is the correct brand name for metformin combined with
empagliflozin?
Empagliflozin ( Jardiance)
Synjardy (empagliflozin + metformin)
Metformin + empaglifozin is Synjardy.
A patient is given insulin glargine and experiences hypoglycemia. Which of the following
statements is correct?
The hypoglycemia is likely to reappear; blood glucose should be frequently
monitored.
Although insulin glargine is a long-acting insulin that has no peak, all insulins can
cause hypoglycemia. Some are more likely to cause hypoglycemia due to onset of
action and peak effects.
A patient uses an insulin pen injection to administer an insulin dose and reports a
"wet spot" on his skin after administration. What is the most likely cause of this "wet
spot"?
Incomplete insulin injection
This would be a sign of incomplete injection of the insulin. Patient should be
instructed to keep the needle under the skin for 5-10 seconds so all the medication
stays subcutaneous.
Which of the following are correct regarding insulin? (Select ALL that apply.)
Insulin stimulates glucose uptake from the blood
Insulin is a hormone
Insulin stimulates formation of glycogen
Insulin promotes storage of glucose in the liver and muscle cells in order to form
glycogen. Once insulin levels fall, the glycogen stores are converted to glucose and
secreted into the blood. Insulin inhibits glucagon secretion.
AM is 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
Humalog AM should take.
Lantus 24 units at bedtime and Humalog 8 units before meals
When using basal and meal-time insulin (called bolus) 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).
A patient injects himself with regular human insulin. He currently injects 5 units with breakfast,
7 units with lunch, and 11 units with dinner. He is going to be switched to insulin lispro. How
much lispro will he inject with his dinner? (Answer must be numeric; no units or commas;
round the final answer to the nearest WHOLE number.)
11
Regular to rapid-acting insulin is 1:1 conversion.
A 42 year old female patient has been newly diagnosed with type 2 diabetes. She has been started
on sitagliptin therapy. At initial diagnosis, her hemoglobin A1C was 9.5%. Over the next two
years, her hemoglobin A1C has risen to 11.2%. The doctor decides to initiate insulin therapy.
Which of the following insulin options would be the best choice?
Lantus at bedtime
A basal insulin such as Lantus should be initiated. Pumps are used for highly
motivated patients who have been controlled on injections. Rapid-acting insulins are
appropriate for meal-time control, often in combination with a basal agent.
Humulin 70/30 is dosed 30 minutes before breakfast and 30 minutes before dinner.
Which of the following medications when used alone rarely cause hypoglycemia?
(Select ALL that apply.
Metformin, pioglitazone, NOT glimepiride (Amaryl), pramlintide (symlin), repaglinide
(Prandin)
Drugs that make the pancreas secrete more insulin are the highest risk of causing
hypoglycemia.
Once opened, how many days is Afrezza stable at room temperature?
3 days
Once opened, Afrezza is stable for 3 days at room temperature.
Sealed or unopened foil packages of Afrezza may be stored in a refrigerator at 36 F
to 46 F (2 C to 8 C) until the expiration date. If a sealed foil package is not
refrigerated, it must be used within 10 days. Once a foil package has been opened
at room temperature, sealed blister cards and strips must be used within 10 days,
and opened strips must be used within 3 days. Before use, the cartridges should be
at room temperature for 10 minutes.12
Gweneth is a 34 y/o female (ht 5'7", wt 134 lbs) who is admitted to the hospital for DKA. She
stopped taking her insulin regimen of Levemir 32 units at bedtime and insulin glulisine 6 units at
meals a few days ago. Below are her labs:
Lab test Normal range Admission

Sodium 135-145 mEq/L 142
Potassium 3.5-5 mEq/L 4.4
Chloride 97-107 mEq/L 99
HCO3 22-28 mEq/L 18
SCr 0.6-1.1 mg/dL 1.2
BUN 7-20 mg/dL 40
Glucose 70-110 mg/dL 555
Calcium 8.5-10.5 mg/dL 9.8
Gweneth is to be started on an insulin drip. What is the recommended initial infusion rate, in
units per hour?
6
1.1units/kg/day is given to a patient as a continuous insulin drip for a DKA patient
after 0.15 kg/IV dose
The initial dosing of IV insulin is recommended at 0.1 units/kg/h for patients
presenting with DKA [11] and 0.025 units/kg/h in patients who are not in DKA but
have hyperglycemic crisis, or for those who have renal insufficiency
To switch from continuous insulin drip to subQ, calculate the TDD of insulin given
once the patient is stable. 80% of that is the total daily dose for SubQ.
Transition f
rom IV to SQ I
nsulin:
Explanation of the Suggested Doses
Determine the average hourly rate of intravenous insulin (over the

past 8 hours) and multiply by
24 hours to determine the daily IV insulin requirement
Convert 2/3rds (about 70%) of the daily IV insulin requirement to

subcutaneous insulin
Give 50% as basal insulin, ordered daily.
Give 50% as scheduled short/rapid acting insulin in divided doses
If the patient is on enteral nutrition, divide into 4 doses of regular

insulin and give every
6 hours. If enteral feeds are stopped abruptly, start an IV infusion of
10% Dextrose
(D10) at the same rate as the feedings and hold scheduled regular
insulin
If thepatientiseating,divide into 3 doses of a rapid acting ana

log and give before meals.
Hold if patient is NPO
Short/rapid acting insulin can be adjusted to allow for changes in

diet/steroids/etc. It
may be adjusted or held based upon patient conditions
Order correction insulin which is given regardl

ess of nutrition status to cover hyperglycemia
Very Low Dose Scale: recommended for patients on 0-32 units of

basal insulin
Low Dose Scale: recommended for patients on 33-56 units of basal

insulin
Moderate Dose Scale: recommended for patients on >56 units of

basal insulin
High Dose Scale: not recommended as an initial scale
Discontinue intravenous insulin infusion 60 minutes after the first dose

of subcutaneous insulin is
VANDERBILT UNIVERSITY MEDICAL CENTER

MULTIDISCIPLINARY SURGICAL CRITICAL CARE
SURGICAL INTENSIVE CARE UNIT
INSULIN TRANSITION
PROTOCOL
Purpose:
To improve glycemic control when transitioning
from a continuous insulin infusion (CII)
to
subcutaneous
insulin
and provide guidance on
appropriate insulin dosing regimens.
Patient Categories:
-
Category
1
:
Patients with a history of DM
OR
those
requiring
insulin infusion of
3 units/h
-
Category
2
:
P
atients without a history of diabetes requiring
CII < 3
unit
s
/h
infusion
transition to SSI
Transition From IV to SQ Insulin
For
Category 1
patients:
1.
Determine average hou
rly rate of CII and multiply by 24 to obtain the average insulin
requirement for the past 24 hours.
Clinical judgment may supersede exact c

alculation of 24 hour insulin requirements if
patients clin
ical status has rapidly changed or if the patients BG/CII rate has not
been
stable
2.
Calculate 70% of the 24h insulin requirement. This will be the total daily
dose (TDD) of
subcutaneous insulin div
ided into long and short acting insulin.
a.
Give 50%
of
TDD
as basal insulin
(insulin glargine)
i.
Basal insulin should be administered 2 hours prior to discontinuation of
CII
ii.
Give regardless of oral intake
b.
Give 50% of TDD as scheduled short acting insulin in
divided doses
i.
For patients on continuous tube feeds
or those not with stable diet (
preferred)
:
1.
Divide
TDD
into 4 doses of
regular
insulin
given
every 6 hours.
2.
If tube feeds are stopped,
hold scheduled regular insulin
a.
C
onsider starting a 10% dextrose infus
ion to maintain euglycemia
ii.
For patients
stable
on a regular diet
(three meals per day):
1.
D
ivide
TDD
into 3 doses of rapid acting
insulin and give before meals
2.
H
old if patient is NPO
3.
Order SQ insulin sliding scale per the SICU protocol
to be given with sche
duled short acting
insulin (same type of insulin and
same frequency
The proper sequence of drawing up regular and NPH insulin into a single syringe is:
Draw up regular then NPH
Draw up the regular (clear) first before NPH (cloudy).
If a person consumes 60 grams of carbohydrate per meal and takes 6 units of
insulin at meal time to keep the blood glucose level within target, what is the
carbohydrate to insulin ratio?
10:1
60/6 = 10 which is a 10:1 ratio.
What are the three natural hormones that our bodies make to regulate glucose that
are replaced or replicated as medications?
Amylin, GLP-1, insulin
Amylin, GLP-1 and insulin are all hormones that have been replicated into drug
therapy.
Which among the following statements is/are correct regarding blood glucose
meters? (Select ALL that apply.)
Some machines require calibration before the first use.
Any amount of blood is not sufficient for a glucometer
Extreme temperatures will damage the glucometer
Alternate site testing results may not be accurate when blood glucose is changing
rapidly.
Some meters allow for blood glucose testing at alternate sites.
The inadequacies of alternate site testing are due to physiologic differences in
circulation between the fingertips and other test sites; there can be a lag in glucose
values in these sites during periods of rapid glucose changes. Keep glucometers out
of the hot sun (such as in a car during a hot summer) or in freezing temperatures. A
large enough drop of blood is required by glucometers to accurately measure blood
sugar.
Which of the following is true about using an ACE inhibitor or ARB in patients with
diabetes according to the ADA guidelines? (Select ALL that apply.)
Patients with diabetes should be screened for albuminuria at least yearly.
ACE inhibitors or ARBs are recommended for primary prevention of diabetic kidney
disease in patients with diabetes who have normal blood pressure and albuminuria.
ACE inhibitors or ARBs (not combined) are recommended for primary prevention of
diabetic kidney disease in patients with diabetes who have normal or high blood
pressure and albuminuria. They are not recommended when the patient does not
have albuminuria and is normotensive and the ADA no longer gives preference to
ACE inhibitors or ARBs in patients with diabetes and high blood pressure if there is
no evidence of albuminuria (this is now consistent with JNC 8 guidelines).
Drug-induced diabetes may be caused by the following medications: (Select ALL
that apply.)
Prednisone, Protease Inhibitors, Clozapine
Systemic steroids, protease inhibitors and atypical antipsychotics are examples of
medications that can raise blood sugar and cause drug-induced diabetes.
Which of the following statements are true regarding metformin? (Select ALL that
apply.)
Metformin is a biguanide.
Metformin lower A1C by 1-2%
Metformin can cause vitamin B12 deficiency when used long-term
Metformin is a biguanide and it is only used to treat type 2 diabetes.
Decreasing the amount of glucose released by the liver
Metformin lowers the rate of hepatic glucose output by decreasing gluconeogenesis.
Which of the following statements related to the use of glucagon are correct? (Select ALL that
apply.)
Glucagon is hormone sec
A female patient in the diabetes clinic has heard that Byetta can cause weight loss in some
patients. She wishes to try it. The pharmacist is going to counsel her on using Byetta. Which of
the following instructions are correct?
Take two daily within an hour before your morning and evening meals (or before
the two main meals of the day, at least 6 or more hours apart.
Due to nausea, patients should be started at a low dose which should be taken
within an hour before meals.
A patient with diabetes has been taking Novolog 70/30, 42 units twice daily. How many units of
insulin aspart protamine does this patient inject each morning? (Answer must be numeric; no
units or commas; round the final answer to the nearest WHOLE number.)
29
Novolog 70/30 is 70% insulin aspart protamine and 30% insulin aspart. The patient injects 42
units in the morning. 42 units x .70 = 29.4, or 29 units of insulin aspart protamine each morning.
History of Present Illness: JL, a 62 year old Hispanic male, is being seen on 1/10 for a routine
follow up and to initiate anti-diabetic treatment. He has had a foot and eye exam within the last 6
months and both were normal. His father and brother have dyslipidemia and his mother has
diabetes. He does not smoke, but enjoys an alcoholic drink twice a month. JL typically has two
pieces of toast with coffee for breakfast, Jack in the Box or McDonalds for lunch (near his
workplace; he does not have time to pack a lunch), and chicken quesadillas and/or beef burritos
with brown rice and beans for dinner.
Allergies: Sulfa

Dyslipidemia
Bipolar disorder
Pravachol 40 mg daily
Lamictal 25 mg daily
Tylenol 325 mg Q4-6H PRN
Omega-3 fatty acids 1,000 mg daily
MVI daily
Vitals:
1/10 Labs (fasting):

AST (units/L) = 24 (10 - 40)
ALT (units/L) = 21 (10 - 40)
TC (mg/dL) = 235 (125 - 200)
TG (mg/dL) = 192 (< 150)
HDL (mg/dL) = 34 (> 40)
LDL (mg/dL) = 163 (<100)
GLU (mg/dL) = 180 (100 - 125)
Na (mEq/L) = 141 (135 - 145)
K (mEq/L) = 4.2 (3.5 - 5)
Cl (mEq/L) = 100 (95 - 103)
HCO3 (mEq/L) = 28 (24 - 30)
BUN (mg/dL) = 22 (7 - 20)
SCr (mg/dL) = 1.6 (0.6 - 1.3)
eGFR (mL/min/1.73 min2) = 54 (> 60)
Mg (mEq/L) = 1.9 (1.3 - 2.1)
PO4 (mg/dL) = 4.4 (2.3 - 4.7)
Ca (mg/dL) = 9.5 (8.5 - 10.5)
TSH (mIU/L) = 1.9 (0.3 - 3.0)
Hgb A1C = 8.7 %
Urinalysis = albumin (+) and ketones (-)
A1C > 6.5

Diagnostic criteria includes AIC 6%, a fasting plasma glucose (FPG) 126 mg/dL,
a 2-hour plasma glucose of 200 mg/dL during a 75 g oral glucose tolerance test
(OGTT) or hyperglycemic crisis and a random plasma glucose 200 mg/dL.
Allergies: Sulfa

Dyslipidemia
Bipolar disorder
MVI daily
Vitals:

AST (units/L) = 24 (10 - 40)
ALT (units/L) = 21 (10 - 40)
TC (mg/dL) = 235 (125 - 200)
TG (mg/dL) = 192 (< 150)
HDL (mg/dL) = 34 (> 40)
LDL (mg/dL) = 163 (<100)
GLU (mg/dL) = 180 (100 - 125)
Na (mEq/L) = 141 (135 - 145)
K (mEq/L) = 4.2 (3.5 - 5)
Cl (mEq/L) = 100 (95 - 103)
HCO3 (mEq/L) = 28 (24 - 30)
BUN (mg/dL) = 22 (7 - 20)
SCr (mg/dL) = 1.6 (0.6 - 1.3)
eGFR (mL/min/1.73 min2) = 54 (> 60)
Mg (mEq/L) = 1.9 (1.3 - 2.1)
PO4 (mg/dL) = 4.4 (2.3 - 4.7)
Ca (mg/dL) = 9.5 (8.5 - 10.5)
TSH (mIU/L) = 1.9 (0.3 - 3.0)
Hgb A1C = 8.7 %
Which risk factors for type 2 diabetes does JL have? (Select ALL that apply.)
BMI > 25 kg/m2

First-degree relative with diabetes
Hypertension and HDL < 35 mg/dL and/or TG > 250 mg/dL are risk factors for type
2 diabetes.
Allergies: Sulfa

Dyslipidemia
Bipolar disorder
MVI daily
Vitals:

AST (units/L) = 24 (10 - 40)
ALT (units/L) = 21 (10 - 40)
TC (mg/dL) = 235 (125 - 200)
TG (mg/dL) = 192 (< 150)
HDL (mg/dL) = 34 (> 40)
LDL (mg/dL) = 163 (<100)
GLU (mg/dL) = 180 (100 - 125)
Na (mEq/L) = 141 (135 - 145)
K (mEq/L) = 4.2 (3.5 - 5)
Cl (mEq/L) = 100 (95 - 103)
HCO3 (mEq/L) = 28 (24 - 30)
BUN (mg/dL) = 22 (7 - 20)
SCr (mg/dL) = 1.6 (0.6 - 1.3)
eGFR (mL/min/1.73 min2) = 54 (> 60)
Mg (mEq/L) = 1.9 (1.3 - 2.1)
PO4 (mg/dL) = 4.4 (2.3 - 4.7)
Ca (mg/dL) = 9.5 (8.5 - 10.5)
TSH (mIU/L) = 1.9 (0.3 - 3.0)
Hgb A1C = 8.7 %
Which of the following is an appropriate recommendation to treat JL's diabetes?

Metformin
Metformin is the first-line agent to treat diabetes if there are no contraindications to
use. Since JL has an eGFR > 45 mL/min, metformin is considered safe to use
according to the updated package labeling requirements.
JL is started on Glucophage XR 500 mg once daily. Which of the following
statements is correct?
The maximum effective dose is 2-2.5 grams daily.
Glucophage XR can be titrated to 2-2.5 grams daily unless the blood glucose is well-
controlled on a lower dose.
JL is started on Glucophage XR 500 mg once daily. Which of the following counseling points are
correct? (Select ALL that apply.)
Do not break, crush, or chew this medication, mild diarrhea is a common side effect,
bloating, an empty shell of the medication may be seen in the stool
Mild diarrhea and abdominal discomfort may occur with metformin therapy
initiation. Some branded products, including Glucophage XR can leave an empty
shell in the stool. Lactic acidosis is a rare side effect.
According to the American Diabetes Association (ADA), JL should keep his fasting
blood glucose within this range:
80-130 mg/dL
Fasting blood glucose values for patients with diabetes should be 80-130 mg/dL (per
ADA), less than 110 mg/dL (per AACE).
According to the American Diabetes Association, the treatment hemoglobin A1C

goal for JL should be:
<7%
Although < 7% is the A1C treatment goal, target goals should be individualized for
patients. A more stringent A1C goal may be more appropriate for younger adult
patients not experiencing hypoglycemia. A less stringent A1C goal may be
appropriate for patients with severe hypoglycemia, extensive co-morbid conditions,
those with limited life expectancy, etc.
What is the correct blood pressure goal for JL according to the ADA guidelines?
<140/90
All patients with diabetes (regardless of age) should be treated to a goal blood
pressure less than 140/90 mmHg according to the 2017 ADA guidelines and the JNC
8 blood pressure guidelines.
Which of the following is correct when evaluating JL's need for primary prevention of
cardiovascular events using aspirin?
JL is a candidate for aspirin therapy as he is >50 years of age and has ASCVD risks
factors besides diabetes
Primary prevention is for patients who patients have not yet had an event. It is
recommended to use ASA for primary prevention in patients with diabetes who are
>/= age 50 years and have at least 1 additional major ASCVD risk factor (e.g., LDL
> 100 mg/dL, hypertension). Primary prevention is for patients who patients have
not yet had an event. It is recommended to use ASA for primary prevention in
patients with diabetes who are >/= age 50 years and have at least 1 additional
major ASCVD risk factor (e.g., LDL > 100 mg/dL, hypertension).
Which of the following adjustments should be made to JL's dyslipidemia therapy?
Change to atorvastatin 40 mg daily
JL should receive high-intensity statin therapy based on CVD risk and age. The only high-
intensity regimen provided as an option is atorvastatin 40 mg daily.
Which of the following options would be most appropriate to add to treat JL's blood pressure?
Altace
The patient has albuminuria and should be started on an ACE inhibitor or ARB for renal
protection.
Which one of the following agents does not have a significant impact on postprandial glucose
lowering in patients with type 2 diabetes?
Insulin glargine
Insulin glargine controls fasting plasma glucose.
Which of the following are true statements regarding the Novolog Flexpen?
The Novolog Flexpen is stable at room temperature for 28 days.
The Novolog Flexpen is stable for 28 days at room temperature, is a clear insulin, and can
provide a more accurate dose due to ease of changing the dial to the correct number of units
needed. Needles should never be reused.
Which of the following brand/generic pairs is correct?
Glyburide-Diabeta
What is the boxed warning associated with Symlin
Hypoglycemia
Symlin can cause significant hypoglycemia.
Diabetes III
Afrezza is what type of insulin?
Rapid-acting insulin
Afrezza is a rapid-acting insulin.
A patient is using the carbohydrate-counting meal planning approach to adjust her
mealtime insulin. How many grams of carbohydrates are typically considered one
serving per the ADA?
15 grams
15 grams of carbohydrates is considered 1 serving.
What is the mechanism of action of the thiazolidinediones?

Pioglitazone (Actos), Rosiglitazone (Avandia)- PPAR gamma agoints- that improve
insulin sensitivity in the muscle cells.
Thiazolidinediones are PPAR gamma agonists that improve peripheral insulin
sensitivity (increase uptake and utilization of glucose).
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 leading zero when the
answer is less than 1; round the final answer to the nearest TENTH.)
0.2
Patient was taking 100 units/mL or 1 mL dose. 1 mL x 1/5 = 0.2 mL. Or set up as a
ratio, 500 units/mL = 100 units/X mL; where x = 0.2 mL.
Which type of insulin is used in an IV solution?

Short acting
Regular insulin is used for IV solutions.
Which of the following drugs stimulates insulin secretion from functioning beta
cells?
Glimperimide (Amaryl)
Amaryl is an insulin secretagogue.
Which of the following medications are glucagon-like peptide-1 agonists? (Select
ALL that apply.)
GLP-1
Exenatide (byetta/bydureon)
Liraglutide (Victoza, Saxenda)
Albiglutide (Tanzeum)
Dualglutide (Trulicity)
Trulicity, Tanzeum and Victoza are GLP-1 agonists.
Farxiga (dapagliflozin SGLT2) Onglyza (saxagliptin)-DPP4 sitagliptin (Januvia)
A patient with diabetes has been taking Novolog 70/30, 34 units twice daily. How
many units of insulin aspart does this patient inject each evening? (Answer must be
numeric; no units or commas; round the final answer to the nearest WHOLE
number.)
10
Novolog 70/30 is 70% insulin aspart protamine and 30% insulin aspart. The patient
injects 34 units each evening. 34 units x .30 = 10.2, or 10 units.
A patient with diabetes has been on Humalog and Levemir. He currently uses a total of 66 units
per day. Using a typical basal-bolus regimen, how much Levemir would he inject at bedtime?
(Answer must be numeric; no units or commas; round the final answer to the nearest WHOLE
number.)
33
Which of the following are glucagon-like peptide-1 agonists that are available as a
once weekly injection? (Select ALL that apply.)
Dualaglutide (Trulicity), albiglutide (Tanzeum)
Exenatide (Bydureon)
Dulaglutide and albiglutide are given once weekly; the other once weekly agent is
exenatide extended release (Bydureon).
A 38 year-old female (80 kg) is on insulin for her type 1 diabetes. She takes 19 units
of NPH BID and 5 units of rapid-acting insulin at breakfast and dinner. Calculate her
insulin-to-carbohydrate ratio using the rule of 500
500/TDD
1:10
A patient is picking up a new prescription for Afrezza. When should the pharmacist
counsel the patient to take this medication?
Immediate before meals
Afrezza should be taken immediately prior to meals.
Which of the following diabetes medications have a significant risk of hypoglycemia? (Select
ALL that apply.)
Diabeta (Glyburide), natelglinide (Starlix)
FP is a 54 year-old white male with diabetes. His blood pressure ranges from 130-138/80-88
mmHg on multiple readings. What would be an appropriate medication to treat his hypertension?
No therapy is needed at this time
Frank does not need any medication at this time as he is meeting his goal BP of <
140/90 mmHg according to JNC 8 and the ADA.
HJ needs better control of his type 2 diabetes. His last A1C was 8.2% and he is
compliant with his metformin 1,000 mg BID. He states he does not want to gain
weight and refuses to take any kind of injectable medication. Which medication
option would be most appropriate for HJ, based on his personal preferences?
Sitagliptin (Januvia)-DDP4
Sitagliptin does not cause weight gain and comes as an oral formulation.
A patient has a new prescription for repaglinide 1 mg TID #30. How should the
pharmacist counsel the patient to take the medication? (Select ALL that apply.)
If you plan to skip a meal skip the dose for that meal
Take your dose 15-30 minutes prior to a meal
Repaglinide (Prandin) should be taken within 15-30 minutes prior to meals. If meal is
consumed and the dose is missed, then skip the dose and take at the next
scheduled time (i.e. the next meal).
Meglitinides- lowers blood sugar by stimulating insulin from Beta cells
A patient with diabetes is using Humulin N twice daily and Humulin R three times daily. He
currently uses a total of 90 units of insulin per day. Using a standard NPH-regular insulin
regimen, how much NPH does he inject in the morning? (Answer must be numeric; no units or
commas; round the final answer to the nearest WHOLE number.)
30
45-2/3=30
A patient has a new prescription for Actos 15 mg daily #30. Which of the following is an
appropriate generic substitution for Actos?
Pioglitazone
A patient with type 1 diabetes injects herself with 70 units of insulin each day. Using the rule of
500, determine how many grams of carbohydrates are covered with this regimen per 1 unit of
insulin. (Answer must be numeric; no units or commas; round the final answer to the nearest
WHOLE number.)
7-500/70=7
n
A hospitalized patient has been using Novolin 70/30, 46 units in the morning and 24 units at
night. He is going to be switched to a regimen of lispro and glargine. How much glargine will he
need to take daily? (Answer must be numeric; no units or commas; round the final answer to the
nearest WHOLE number.)
39
46 * 0.7= 40.25
46 * 0.3 = 13.8
24= 78.05/2=39
How many days is the Levemir Flexpen stable at room temperature?
42 days
The Levemir Flexpen is stable for 42 days at room temperature.
A patient uses insulin glargine twice daily. She injects 40 units in the morning and
60 units in the evening. What size syringe should be provided to the patient?
A 1 mL syringe
Syringes come in 0.3, 0.5 and 1 mL sizes. Most patients will receive the 1 mL
syringes (100 per box). If a patient injects under 30 or 50 units, a smaller syringe
should be used and will provide a more accurate dose. However, if they inject more
at a different time, the patient would not get two different size syringes.
A patient currently uses 30 units of Lantus daily and 10 units of lispro with
breakfast, lunch, and dinner. She is going to be started on pramlintide and needs to
be counseled on how to adjust her dose of insulin. Select the correct adjustments.
Do not adjust Lantus and reduce lispro to 5 units with meals
Mealtime insulins need to be reduced by 50% when starting pramlintide.
CD is taking pioglitazone for his diabetes management. Which of the following are possible risks
when taking this medication? (Select ALL that apply.)
Weight gain, edema, hepatic failure, bladder cancer
Pioglitazone has multiple warnings and side effects including hepatic failure, bladder
cancer, peripheral edema and weight gain, and fractures.
Which of the following is a DPP-4 inhibitor?
Linagliptin
Linagliptin is a DPP-4 inhibitor.
Which of the following vaccination recommendations is appropriate for a 67-year-old
patient with type 2 diabetes who received a dose of PPSV23 at age 55?
One dose of PCV13 followed by one done of PPSV23 12 months later
One dose of PCV13 followed by one dose of PPSV23 12 months later should be
recommended for this patient.
Wendy is picking up a new prescription for Byetta. What important storage and
handling tips should be discussed with the patient? (Select ALL that apply.)
Store unopened pens in the refrigerator
Once opened, the pen can kept at room temperature.
Don store the pen with the needle attached as it may leak and form air bubbles.
Do not freeze the medication. Never use if the pen has been frozen.
Discard after 30 days after the first use, even if some drug remains in the pen.
Also, patients should be instructed to use a punture-resistant container to discard
the needles. The pen should be protected from light.
What is the correct mechanism of action of canagliflozin?
D
It increases urinary glucose excretion by blocking the sodium glucose co-transporter-2
Canagliflozin works by blocking the sodium glucose co-transporter-2, thereby
increasing urinary glucose excretion.
Afrezza is contraindicated in which type of patient?
An individual with asthma.
Afrezza is contraindicated in patients with chronic lung disease such as asthma or
COPD.
Which of the following insulins are classified as basal insulin? (Select ALL that
apply.)
Tresiba (insulin degludec), Lantus (insulin glargine) 300 Units/mL
Levemir, Tresiba and Toujeo are all basal insulins.
DK is a 52 y/o male patient who has had type 2 diabetes for about 15 years. He currently takes
metformin 1,000 mg BID and Levemir 22 units at bedtime. His most recent A1C, drawn 2 weeks
ago, was 8.6%. Which of the following adjustments to his medications is most appropriate, based
on his glucose readings from the last week?
Before breakfast After breakfast Before lunch After lunch Before

dinner After dinner
Sunday 158 177 166 202 200
246
Monday 169 189 159 189 192
231
Tuesday 165 182 182 264 245
267
Wednesday 172 189 180 190 193
202
Thursday 167 174 167 207 187
234
Friday 174 182 155 212 199
210
Saturday 162 184 169 197 204
236
Icrease Levemir to 26 units at bedtime
It is important to control fasting blood glucose first, then prandial levels.
Which of the following are side effects seen with dapagliflozin that should be discussed with the
patient? (Select ALL that apply.)
Genital mycotic infections, urinary tract infections, diabetic ketoacidosis
Dapagliflozin is not associated with weight gain or pancreatitis.
A patient is prescribed Afrezza. After how many days does the inhaler need to be
replaced?
15 days
The Afrezza inhaler device needs to be replaced every 15 days.
PT is a 47 y/o female who has had type 2 diabetes for about 5 years. She has previously been
well controlled on metformin 1,000 mg BID. Her most recent A1C, drawn last week, was 7.6%.
She was asked to check glucose readings four times daily and keep a glucose log for a week, in
order to determine what changes need to be made to her therapy. Which of the following glucose
readings are not currently at goal?
Before breakfast After breakfast After lunch After dinner

Sunday 126 168 188 208
Monday 118 174 190 198
Tuesday 122 172 182 196
Wednesday 112 159 188 207
Thursday 118 155 199 210
Friday 128 163 199 212
Saturday 106 164 182 188
After lunch and after dinner

Paulina's after lunch and after dinner readings exceed ADA goals.
Preprandial capillary PG 80-130
Peak postprandial capillary PG <180
A1c=<7
More stringent (<6.5) Less stringent <8.0
Which of the following recommendations should be given to patients with diabetes on how to
care for their feet? (Select ALL that apply
B
Apply moisturizer sparingly to the tops and bottoms of clean, dry feet.
C
Trim toenails straight across and file to the contour of the toe.
D
E
Avoid walking barefoot.
Clean and check feet daily. Do not apply moisturizer between the toes. Avoid extreme
temperatures.
LJ uses the following insulin regimen: Levemir FlexTouch 20 units subcutaneously QHS
and Humalog 4 units subcutaneously TIDAC. How long will her insulin pen and vial last?
3ml=300u/20=15
100u/ml =10 ml=1000u/4*3=83
Most insulin pens, including the Levemir FlexTouch, comes as 100 units/mL (3 mL). Most
insulin vials, including Humalog, come as 100 units/mL (10 mL). There is total of 300 units of
insulin detemir in the pen (300 units/20 units per day = 15 days). There is a total of 1,000 units of
insulin lispro in the vial (1,000/12 units per day = 83 days).
JC is a 54 year old female (BMI 24) with type 2 diabetes. Her medical history is otherwise
unremarkable except for mild asthma since childhood. JC does not smoke, drink or use illicit
drugs. Her family history for cardiac disease is negative. Today, her blood pressure is 125/76
mmHg and heart rate is 74 BPM. Her fasting laboratory values are: TC 130 mg/dL, LDL 60
mg/dL, HDL 50 mg/dL, TG 100 mg/dL, and SCr 1.3 mg/dL. She has NKDA and is currently
taking metformin for her diabetes and some inhalers for her asthma. She follows her lifestyle
modifications strictly so she doesn't have to take additional medications for diabetes.
What antiplatelet medication should JC be taking for prevention of CVD?
JC does not meet the criteria for starting antiplatelet therapy at this time. Refer to p.
549 of the 2017 RxPrep Course Book.
Antiplatelet therapy
Aspirin (75-162mg) should be considered for primary prevention in patients with
type 1 and type2 who have increase CVD risk (10year risk. This includes men >50
of age or women > 60 of age who at least one addition major risk factor (family hx.
Of CVD, dyslipidemia, albuminuria, smoking or hypertension). Aspirin 75-162
mg.day should be used for secondary prevention unless the patient has an allergy
or contraindication to use. If the patient has an aspirin allergy clopidogrel 75 mg is
recommended.
Which of the following are acceptable treatment options for patients experiencing
hypoglycemia? (Select ALL that apply.)
4 oz of orange juice, 1 serving of glucose gel
15-20 grams of carbohydrates are recommended for treating hypoglycemia which
includes 8 oz of milk, 3-4 glucose tabs, non-diet soda (4 oz), 2 tablespoons of raisins
and other items. Be sure to retest in 15 minutes and have the patient eat a small
amount of food to prevent recurrence.
A hospitalized patient has been using Humulin 70/30, 70 units in the morning and
20 units at night. He is going to be switched to a regimen of lispro and detemir. How
much detemir will the patient need to take? (Answer must be numeric; no units or
commas; round the final answer to the nearest WHOLE number.)
90*.7=63 umits
Humulin 70/30 is 70% NPH and 30% regular. The patient is receiving 63 units of NPH
(70% of 90 units). NPH to detemir is a 1:1 conversion.
Which of the following medications requires the patient to gently rock the pen side
to side 5 times to mix, then have the pen sit 15-30 minutes depending on the dose,
and rock again 5 times to mix prior to injecting?
Tanzeum (Albiglutide)
Tanzeum requires this patient counseling for gently mixing the medication prior to
injection.
A patient is picking up a new prescription for acarbose. Choose the correct statements: (Select
ALL that apply.)
Many patients have difficulty with flatulence and diarrhea from this medication
Acarbose is dosed with the first bit of each main meal
Gi effects (FLATULENCE,diarrhea, abdominal pain), weight neutral, no hypoglycemia,
increase in LFTs (acarbose), decrease A1C 0.5-0.8, decrease postpranial BG.
Acarbose is weight neutral. GI side effects are the most common issue (abdominal
pain, diarrhea, flatulence). Glucose tablets or gel are required to treat hypoglycemia
with these agents.
3-4 glucose tablets
A patient is scheduled to receive iodinated contrast dye and has been told to hold
her metformin prior to the procedure. When should her metformin be reinitiated?
48 hours after the procedure and when renal function has been confirmed as normal
Metformin should be restarted after 48 hours has elapsed from receiving the
contrast dye and the patient's eGFR has been confirmed to be stable.
Which of the following combinations is correct?
Glyburide-Metformin (Glucovance)
Ezetimibe-Simvastain (Vytorin) (Zetia-Zocor)
Sitagliptin-Metformin (Janumet)
Glipizide-Metformin (Metaglip) (Glucotrol)
Pioglitazone-Metformin (Actoplus Met) (Actos)
Glucovance is glyburide + metformin.
How many days is Lantus stable at room temperature?
Lantus is stable for 28 days at room temperature.
Levemir is stable for 42 days at room temperature.
UV is a 58 year old female with diabetes, history of myocardial infarction, hypertension,
dyslipidemia and osteoporosis. She is currently taking metformin XR 2000 mg PO daily,
glipizide XL 20 mg daily, lisinopril 20 mg PO daily, metoprolol XL 100 mg PO daily, aspirin 81
mg PO daily, atorvastatin 80 mg PO daily and alendronate 35 mg PO weekly. Her A1C is 8.2%,
BP 138/88 mmHg, and LDL = 100 mg/dL.
Which of the following medications could decrease the risk of death in UV if added to her
regimen?
Empagliflozin (Jardiance) and Liraglutide (Victoza)
Empaglifozin and liraglutide should be considered in patients with long-standing
diabetes (that is not well controlled) and established atherosclerotic cardiovascular
disease.
History of Present Illness: KT is a 23 year-old female being seen in clinic on 2/10 for diabetes
management. Of note, KT was hospitalized 2 months ago because she stopped taking her
medications for a few days. Since then, she has attended a diabetes education class and met with
her dietitian. She feels some tingling in her feet for which she takes gabapentin. She does not
smoke and drinks alcohol only on special occasions.
Allergies: NKDA
Current Medications (2/10):

Levemir 21 units QHS
Insulin lispro 7 units TID before meals
Gabapentin 300 mg TID
Paxil 40 mg daily

Type 1 diabetes
Depression
Peripheral neuropathy
Vitals (2/10):
Temp: 98.6F Pain: 1/10
12/11 to 2/10 Blood Glucose Value Ranges (self-monitored):

Before breakfast: 95 - 120 mg/dL
After lunch: 110 - 125 mg/dL
After dinner: 200 - 225 mg/dL
At bedtime: 130 - 150 mg/dL

AST (units/L) = 23 (10 - 40)
ALT (units/L) = 25 (10 - 40)
GLU (mg/dL) = 107 (100 - 125)
Na (mEq/L) = 141 (135 - 145)
K (mEq/L) = 4.2 (3.5 - 5)
Cl (mEq/L) = 100 (95 - 103)
HCO3 (mEq/L) = 28 (24 - 30)
BUN (mg/dL) = 18 (7 - 20)
SCr (mg/dL) = 0.9 (0.7 - 1.3)
Mg (mEq/L) = 1.9 (1.3 - 2.1)
PO4 (mg/dL) = 4.4 (2.3 - 4.7)
Ca (mg/dL) = 9.5 (8.5 - 10.5)
TSH (mIU/L) = 1.9 (0.3 - 3.0)
Hgb A1C = 7.8%
Urinalysis = albumin (-) and ketones (-)
2/10 Tests: Eye exam with normal findings
12/9 Labs (hospital admission):

GLU (mg/dL) = 390 (100 - 125)
Hgb A1C = 8.5%
Urinalysis = albumin (-) and ketones (+)
pH = 7.24 (7.35-7.45)
pCO2 (mmHg) = 25 (35 - 45)
pO2 (mmHg) = 92 (80 - 100)
6/14 Labs (clinic visit 8 months prior):

GLU (mg/dL) = 113 (100 - 125)
Hgb A1C = 7.9%
Question
What is the primary cause KT's diabetes?
Autoimmune destruction of pancreatic beta cells
In type 1 diabetes, the immune system attacks the insulin-producing beta cells in
the pancreas, which are located in the islets of Langerhans.
Allergies: NKDA

Paxil 40 mg daily

Type 1 diabetes
Depression
Vitals (2/10):


AST (units/L) = 23 (10 - 40)
ALT (units/L) = 25 (10 - 40)
GLU (mg/dL) = 107 (100 - 125)
Na (mEq/L) = 141 (135 - 145)
K (mEq/L) = 4.2 (3.5 - 5)
Cl (mEq/L) = 100 (95 - 103)
HCO3 (mEq/L) = 28 (24 - 30)
BUN (mg/dL) = 18 (7 - 20)
SCr (mg/dL) = 0.9 (0.7 - 1.3)
Mg (mEq/L) = 1.9 (1.3 - 2.1)
PO4 (mg/dL) = 4.4 (2.3 - 4.7)
Ca (mg/dL) = 9.5 (8.5 - 10.5)
TSH (mIU/L) = 1.9 (0.3 - 3.0)
Hgb A1C = 7.8%

GLU (mg/dL) = 390 (100 - 125)
Hgb A1C = 8.5%
pH = 7.24 (7.35-7.45)
pCO2 (mmHg) = 25 (35 - 45)
pO2 (mmHg) = 92 (80 - 100)

GLU (mg/dL) = 113 (100 - 125)
Hgb A1C = 7.9%
Calculate KT's insulin-to-carbohydrate ratio, using the rule of 500.
21+21=42
500/42=12 carbs to 1 unit of insulin
KT's ICR is 12:1, where 12 grams of carbohydrates are covered by 1 unit of rapid-
acting insulin.
Allergies: NKDA

Paxil 40 mg daily

Type 1 diabetes
Depression
Vitals (2/10):


AST (units/L) = 23 (10 - 40)
ALT (units/L) = 25 (10 - 40)
GLU (mg/dL) = 107 (100 - 125)
Na (mEq/L) = 141 (135 - 145)
K (mEq/L) = 4.2 (3.5 - 5)
Cl (mEq/L) = 100 (95 - 103)
HCO3 (mEq/L) = 28 (24 - 30)
BUN (mg/dL) = 18 (7 - 20)
SCr (mg/dL) = 0.9 (0.7 - 1.3)
Mg (mEq/L) = 1.9 (1.3 - 2.1)
PO4 (mg/dL) = 4.4 (2.3 - 4.7)
Ca (mg/dL) = 9.5 (8.5 - 10.5)
TSH (mIU/L) = 1.9 (0.3 - 3.0)
Hgb A1C = 7.8%

GLU (mg/dL) = 390 (100 - 125)
Hgb A1C = 8.5%
pH = 7.24 (7.35-7.45)
pCO2 (mmHg) = 25 (35 - 45)
pO2 (mmHg) = 92 (80 - 100)

GLU (mg/dL) = 113 (100 - 125)
Hgb A1C = 7.9%
Which of the following is a likely cause of KT's hospitalization on 12/9?

Stopped taking her insulin
Stopping insulin (such as running out) or serious infections/stress can precipitate a
hyperglycemic crisis (such as DKA) in patients with type 1 diabetes.
Based on labs from 12/9, what treatment should KT have received at that time?
Normal saline, insulin, and potassium replacement as needed
KT was experiencing diabetic ketoacidosis and needed to be treated with normal
saline initially (followed by normal saline), potassium replacement as needed,
and insulin. Sodium bicarbonate may be given when the pH < 7.0.
When KT was in the hospital on 12/9 she was started on an insulin drip. What would the initial
rate (units/hr) of her infusion have been?
7 units/hr
The initial insulin IV infusion rate is 0.1 units/kg/hr (155 lbs/2.2 lbs/kg X 0.1 units/kg)
= 7 units/hr.
According to the ADA guidelines, which insulin dose may need to be adjusted during
today's clinic visit (2/10)?
Lispro, before dinner
KT's blood glucose after dinner is over 180 mg/dL, therefore, her
insulin before dinner should be adjusted to manage the hyperglycemia.
KT attended the grand opening of a restaurant this past weekend and sampled 8 different dishes.
She tested her blood glucose when she got home, which showed 246 mg/dL. KT's target blood
glucose is 120 mg/dL. Calculate her correction dose using the rule of 1800.
1800/42=42.86
246-120=126/42.86=3units
KT's correction dose is (246 -120)/43 = 3 units.
Which microvascular complication(s) of diabetes are present in KT? (Select ALL that apply.)
Retinopathy, nephropathy, peripheral neuropathy and autonomic neuropathy
(including impotence and gastroparesis) are all microvascular complications of
diabetes. KT is recieving treatment for peripheral neuropathy. Her eye exam and
urinalysis are negative for microvascular disease. She should be tested for
autonomic neuropathy.
Which of the following insulins are available in a concentration of 200 units/mL?
Insulin lispro quickpen 200units/ml
Insulin lispro and degludec are available as a 200 unit/mL pen.
Insulin degludec (Tresiba) 100 units, 200 units/mL pen Flex-Touch

Meglitinide Works by Stimulating The Release of Insulin in The Presence of Glucose

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Diabetes

exenatide (Byetta/Bydureon *extended release suspension), approved in 2005/2012.

Insulin glargine 20 units SC daily

FQ- Gatiflox (also assoc. with hypoglycemia). And Levoflox.

Goal plasma blood

Allergies: Penicillin (rash)

Past Medical History:

Home Medications (all continued on admission):

Admission Labs (9/21):

liraglutide- injectable, bromocriptine- not a 1 st line option.

SU- glipizide (Glucotrol)- not effected by renal, glimepiride (Amaryl)- not 1 st to be

Thiazolidinediones- can be used in renal insuffient patients. Pioglitazone (Actos),

PQ is switched to pioglitazone. What monitoring parameters should be followed

Before breakfast After breakfast After lunch After dinner

Decrease breakfast Humalog to 4 units

A patient brought in a prescription for Glucotrol. Which of the following is an appropriate

Less than 70 mg/dL

What is the correct mechanism of action of exenatide?

Past Medical History:

Immunizations History: None since childhood

Past Medical History:

Immunizations History: None since childhood

Past Medical History:

Immunizations History: None since childhood

UR is going to be started on Levemir at 0.3 units/kg/day. How many mLs does he

Past Medical History:

Immunizations History: None since childhood

Past Medical History:

Immunizations History: None since childhood

Important changes from the JNC 7 guidelines2 include the following:

urinary tract infections,

Linagliptin (Tradjenta)DD4, Dapaliflozin (Farxiga), Empagliflozin (Jardiance),

Severe abdominal pain due to the risk of acute pancreatitis

BG < 60 mg/dL, hold insulin and contact MD

What is this name for this type of order?

Decreasing the amount of glucose released by the liver

Metformin lowers the rate of hepatic glucose output by decreasing gluconeogenesis.

8 units NPH and 2 units lispro before breakfast (7 am)

Her blood glucose value ranges are as follows:

Before breakfast: 100-120 mg/dL

Increase before lunch lispro dose

Lab test Normal range Admission

Determine the average hourly rate of intravenous insulin (over the

Convert 2/3rds (about 70%) of the daily IV insulin requirement to

Give 50% as basal insulin, ordered daily.

Give 50% as scheduled short/rapid acting insulin in divided doses

If the patient is on enteral nutrition, divide into 4 doses of regular

If thepatientiseating,divide into 3 doses of a rapid acting ana

Short/rapid acting insulin can be adjusted to allow for changes in

Order correction insulin which is given regardl

Very Low Dose Scale: recommended for patients on 0-32 units of

Low Dose Scale: recommended for patients on 33-56 units of basal

Moderate Dose Scale: recommended for patients on >56 units of

High Dose Scale: not recommended as an initial scale

Discontinue intravenous insulin infusion 60 minutes after the first dose

VANDERBILT UNIVERSITY MEDICAL CENTER

Clinical judgment may supersede exact c

Metformin lowers the rate of hepatic glucose output by decreasing gluconeogenesis.

Past Medical History:

1/10 Labs (fasting):

A1C > 6.5

Past Medical History:

1/10 Labs (fasting):