BC ADM Medication & Therapeutic Interventions 2 — Questions and Answers
Question 1: A patient with T2DM and stage 3b CKD (eGFR 35 mL/min) requires glucose-lowering therapy. Which agent is most appropriate?
- Metformin 1000 mg twice daily
- Empagliflozin 10 mg daily
- Dulaglutide 0.75 mg weekly (Correct answer)
- Glipizide 5 mg daily
Correct answer: Dulaglutide 0.75 mg weekly
GLP-1 receptor agonists like dulaglutide are safe in stage 3b CKD; metformin is contraindicated below eGFR 30 and cautioned below 45, SGLT2i lose efficacy and carry risks at this eGFR, and sulfonylureas increase hypoglycemia risk with renal impairment.
Question 2: Which insulin pharmacokinetic property best distinguishes insulin glargine U-300 from insulin glargine U-100?
- Faster onset of action
- Shorter duration of action
- More stable, flatter 24-hour profile with less peak effect (Correct answer)
- Higher glucose-lowering potency per unit
Correct answer: More stable, flatter 24-hour profile with less peak effect
Glargine U-300 forms a smaller subcutaneous depot that dissolves more slowly, producing a flatter, more peakless profile over ≥24 hours and a lower hypoglycemia risk compared to U-100.
Question 3: A patient on basal insulin therapy has consistently elevated fasting glucose but well-controlled postprandial values. The most appropriate next step is:
- Add a GLP-1 receptor agonist
- Titrate the basal insulin dose upward (Correct answer)
- Switch to premixed insulin twice daily
- Add a mealtime rapid-acting insulin
Correct answer: Titrate the basal insulin dose upward
Persistently high fasting glucose with controlled postprandial values indicates the basal insulin dose is insufficient to suppress overnight hepatic glucose production, so upward titration is the first step.
Question 4: Pramlintide is approved as adjunct therapy with mealtime insulin primarily because it:
- Stimulates insulin secretion from beta cells
- Delays gastric emptying and suppresses postprandial glucagon (Correct answer)
- Increases peripheral glucose uptake via AMPK
- Reduces renal glucose reabsorption
Correct answer: Delays gastric emptying and suppresses postprandial glucagon
Pramlintide is a synthetic amylin analog that delays gastric emptying, suppresses postprandial glucagon secretion, and promotes satiety, complementing mealtime insulin's action.
Question 5: Which statement about thiazolidinediones (TZDs) and cardiovascular risk is most accurate?
- Rosiglitazone and pioglitazone both increase risk of heart failure hospitalization equally
- Pioglitazone has demonstrated reduction in MACE in patients with prior stroke or MI (Correct answer)
- TZDs are preferred first-line agents in patients with NYHA Class III heart failure
- TZDs improve insulin sensitivity primarily through hepatic mechanisms
Correct answer: Pioglitazone has demonstrated reduction in MACE in patients with prior stroke or MI
The PROactive trial showed pioglitazone significantly reduced secondary MACE endpoints in patients with established cardiovascular disease, while both TZDs increase heart failure hospitalization risk.
Question 6: A patient taking metformin 2000 mg/day and linagliptin 5 mg/day has an A1C of 8.2%. She has established atherosclerotic cardiovascular disease. Which addition provides the most evidence-based cardiovascular benefit?
- Sitagliptin 100 mg daily
- Canagliflozin 100 mg daily (Correct answer)
- Pioglitazone 30 mg daily
- Glimepiride 2 mg daily
Correct answer: Canagliflozin 100 mg daily
SGLT2 inhibitors like canagliflozin have demonstrated significant reductions in MACE and heart failure hospitalization in patients with established ASCVD, making them the preferred addition per ADA guidelines.
Question 7: The mechanism by which SGLT2 inhibitors reduce the risk of heart failure hospitalization is best attributed to:
- Direct positive inotropic effect on the myocardium
- Natriuresis and plasma volume reduction reducing cardiac preload (Correct answer)
- Reduction in HbA1c below 7% in all patients
- Inhibition of aldosterone secretion in the adrenal cortex
Correct answer: Natriuresis and plasma volume reduction reducing cardiac preload
SGLT2 inhibitors promote natriuresis and osmotic diuresis, reducing plasma volume and cardiac preload, which is a key mechanism behind their heart failure benefits independent of glycemic control.
BC ADM Medication & Therapeutic Interventions 2
A patient with T2DM and stage 3b CKD (eGFR 35 mL/min) requires glucose-lowering therapy.
Which agent is most appropriate?