BC ADM Medication & Therapeutic Interventions 4 — Questions and Answers
Question 1: A patient with T2DM, obesity (BMI 38), and an A1C of 9.1% is seeking the most effective dual therapy for both glycemic control and weight loss. The best combination is:
- Metformin + glimepiride
- Metformin + sitagliptin
- Metformin + semaglutide (Correct answer)
- Metformin + pioglitazone
Correct answer: Metformin + semaglutide
Semaglutide (GLP-1 RA) combined with metformin provides superior A1C reduction and significant weight loss (6–14%) compared to other add-on agents, making it the preferred choice for this patient profile.
Question 2: The 'correction factor' (insulin sensitivity factor) is used in intensive insulin therapy to:
- Calculate the total daily dose of basal insulin needed
- Estimate how much 1 unit of rapid-acting insulin will lower blood glucose (Correct answer)
- Determine the carbohydrate-to-insulin ratio for meal boluses
- Adjust for exercise-induced insulin resistance
Correct answer: Estimate how much 1 unit of rapid-acting insulin will lower blood glucose
The correction factor (e.g., 1 unit lowers glucose by 50 mg/dL) is calculated from the total daily insulin dose and guides supplemental bolus dosing to bring elevated glucose back to target.
Question 3: A patient with long-standing T1DM develops recurrent unexplained hypoglycemia and loss of hypoglycemia awareness. The most appropriate therapeutic adjustment is:
- Increasing the insulin-to-carbohydrate ratio
- Raising glycemic targets temporarily and using CGM with alerts (Correct answer)
- Switching from basal-bolus to twice-daily premixed insulin
- Adding glucagon-like peptide-1 receptor agonist to reduce insulin requirements
Correct answer: Raising glycemic targets temporarily and using CGM with alerts
Hypoglycemia unawareness requires relaxing glycemic targets to allow glucose levels to run higher temporarily, combined with real-time CGM alarms to alert the patient, which can restore awareness over weeks.
Question 4: Which statement about U-500 regular insulin is correct?
- It has the same onset and duration as U-100 regular insulin
- It is 5 times more concentrated and has a longer duration of action than U-100 regular (Correct answer)
- It is only approved for intravenous use in the ICU setting
- It requires no dose conversion when switching from U-100
Correct answer: It is 5 times more concentrated and has a longer duration of action than U-100 regular
U-500 regular insulin is 500 units/mL (5× U-100) and due to depot formation has a duration of action of 17–24 hours, behaving more like an intermediate-acting insulin despite being 'regular' type.
Question 5: When educating a patient about DPP-4 inhibitors, which adverse effect requires specific counseling?
- Weight gain of 2–4 kg over 12 months
- Risk of genitourinary infections
- Possible joint pain (arthralgia) which should prompt reporting (Correct answer)
- Lactic acidosis in renal impairment
Correct answer: Possible joint pain (arthralgia) which should prompt reporting
The FDA has issued a warning about severe, disabling, and potentially persistent arthralgia associated with DPP-4 inhibitors; patients should be counseled to report new or unusual joint pain.
Question 6: A patient on metformin 2000 mg/day with A1C 7.9% requires contrast-enhanced CT imaging. According to current guidelines, metformin should be:
- Discontinued 48 hours before the procedure in all patients
- Held at the time of or before the procedure only if eGFR <30 or acute kidney injury risk (Correct answer)
- Continued without any change because the contrast risk applies only to iodinated oral contrast
- Doubled after the procedure to compensate for stress hyperglycemia
Correct answer: Held at the time of or before the procedure only if eGFR <30 or acute kidney injury risk
Updated guidelines recommend withholding metformin only in patients with eGFR <30 or risk factors for AKI (dehydration, hemodynamic instability) at the time of IV contrast administration, not universally.
Question 7: Tirzepatide's superior glucose-lowering and weight-loss effects compared to semaglutide are primarily due to its:
- Higher binding affinity for GLP-1 receptors than semaglutide
- Dual agonism at both GLP-1 and GIP receptors (Correct answer)
- Additional SGLT2 inhibitory activity within the kidney
- Ability to cross the blood-brain barrier more effectively
Correct answer: Dual agonism at both GLP-1 and GIP receptors
Tirzepatide is a dual GIP and GLP-1 receptor co-agonist; the additive or synergistic incretin effects from both receptor pathways produce greater A1C reduction and weight loss than selective GLP-1 agonism alone.
BC ADM Medication & Therapeutic Interventions 4
A patient with T2DM, obesity (BMI 38), and an A1C of 9.1% is seeking the most effective dual therapy for both glycemic control and weight loss.
The best combination is: