BC ADM Medication & Therapeutic Interventions 3 — Questions and Answers
Question 1: Which rapid-acting insulin analog has the fastest onset of action and is approved for dosing up to 20 minutes after meal start?
- Insulin lispro (Humalog)
- Insulin aspart (NovoLog)
- Faster insulin aspart (Fiasp) (Correct answer)
- Insulin glulisine (Apidra)
Correct answer: Faster insulin aspart (Fiasp)
Faster insulin aspart (Fiasp) contains niacinamide and L-arginine that accelerate initial absorption, giving it an onset of 2.5 minutes and FDA approval for dosing at the start of or up to 20 minutes after meal initiation.
Question 2: A patient on insulin pump therapy presents with persistent hyperglycemia despite multiple bolus corrections. The most likely cause and immediate intervention is:
- Insufficient basal rate; increase basal rate by 20%
- Infusion site occlusion or catheter failure; change the infusion set and site (Correct answer)
- Dawn phenomenon; add NPH at bedtime
- Somogyi effect; reduce nighttime basal rate
Correct answer: Infusion site occlusion or catheter failure; change the infusion set and site
Persistent hyperglycemia unresponsive to bolus corrections in pump therapy most commonly indicates an infusion set or catheter problem, requiring immediate set and site change and often a corrective injection.
Question 3: Colesevelam's glucose-lowering mechanism in T2DM is best described as:
- Inhibiting DPP-4 to raise incretin levels
- Altering bile acid metabolism to improve FXR-mediated glucose homeostasis (Correct answer)
- Blocking intestinal glucose transporters (SGLT1)
- Reducing hepatic glucose output via AMPK activation
Correct answer: Altering bile acid metabolism to improve FXR-mediated glucose homeostasis
Colesevelam binds bile acids in the intestine, altering the enterohepatic bile acid pool and activating farnesoid X receptor (FXR) pathways that improve hepatic and peripheral glucose metabolism.
Question 4: When initiating a GLP-1 receptor agonist, the primary reason for starting at the lowest dose and titrating slowly is to:
- Prevent hypoglycemia during the first week
- Minimize gastrointestinal side effects including nausea and vomiting (Correct answer)
- Allow time for beta-cell regeneration to occur
- Reduce the risk of pancreatitis by gradual enzyme adaptation
Correct answer: Minimize gastrointestinal side effects including nausea and vomiting
GLP-1 receptor agonists commonly cause dose-dependent nausea and vomiting due to delayed gastric emptying; slow titration allows GI accommodation and improves adherence.
Question 5: A 68-year-old patient with T1DM on multiple daily injections frequently experiences nocturnal hypoglycemia. Which intervention is most appropriate?
- Switch basal insulin to NPH given at bedtime
- Reduce mealtime insulin doses by 50%
- Transition to a hybrid closed-loop insulin delivery system (Correct answer)
- Add acarbose with the evening meal
Correct answer: Transition to a hybrid closed-loop insulin delivery system
Hybrid closed-loop systems automatically suspend or reduce basal insulin delivery when glucose is predicted to drop, significantly reducing nocturnal hypoglycemia in T1DM patients.
Question 6: Which drug interaction is most clinically significant for a patient with T2DM starting fluconazole therapy?
- Fluconazole inhibits CYP2C9, increasing sulfonylurea levels and hypoglycemia risk (Correct answer)
- Fluconazole activates CYP3A4, reducing GLP-1 agonist efficacy
- Fluconazole competes with metformin for renal tubular secretion
- Fluconazole blocks SGLT2, causing additive glucosuria
Correct answer: Fluconazole inhibits CYP2C9, increasing sulfonylurea levels and hypoglycemia risk
Fluconazole is a potent CYP2C9 inhibitor; sulfonylureas (especially glipizide, glimepiride) are CYP2C9 substrates, so co-administration can markedly increase sulfonylurea plasma levels and precipitate severe hypoglycemia.
Question 7: Bromocriptine QR (Cycloset) lowers glucose in T2DM primarily by:
- Stimulating pancreatic beta-cell insulin secretion
- Resetting hypothalamic circadian dopaminergic tone to improve hepatic insulin sensitivity (Correct answer)
- Blocking intestinal alpha-glucosidase enzymes
- Enhancing GLUT4 translocation in skeletal muscle via dopamine D2 receptors
Correct answer: Resetting hypothalamic circadian dopaminergic tone to improve hepatic insulin sensitivity
Bromocriptine QR, a dopamine D2 agonist taken at waking, is thought to reset dysregulated hypothalamic dopaminergic activity that drives insulin resistance and hepatic glucose overproduction.
BC ADM Medication & Therapeutic Interventions 3
Which rapid-acting insulin analog has the fastest onset of action and is approved for dosing up to 20 minutes after meal start?