BC ADM Medication & Therapeutic Interventions 5 — Questions and Answers
Question 1: A patient with T2DM on basal-bolus insulin therapy presents with the 'dawn phenomenon.' The most targeted intervention is:
- Decreasing the dinner bolus dose
- Increasing the morning correction bolus
- Increasing the basal insulin dose or timing adjustment to cover early morning cortisol surge (Correct answer)
- Adding an evening snack to prevent rebound hyperglycemia
Correct answer: Increasing the basal insulin dose or timing adjustment to cover early morning cortisol surge
The dawn phenomenon is caused by early morning counter-regulatory hormone release (GH, cortisol) increasing hepatic glucose output; adjusting basal insulin timing or dose to peak coverage in the early morning hours is the correct approach.
Question 2: Which GLP-1 receptor agonist is approved for once-weekly subcutaneous injection AND has an FDA-approved oral formulation?
- Liraglutide
- Dulaglutide
- Semaglutide (Correct answer)
- Exenatide
Correct answer: Semaglutide
Semaglutide (Ozempic) is available as a once-weekly subcutaneous injection, and oral semaglutide (Rybelsus) is the only FDA-approved oral GLP-1 receptor agonist.
Question 3: A patient develops euglycemic diabetic ketoacidosis (euDKA) while on an SGLT2 inhibitor. Glucose is 178 mg/dL. Which action is most critical?
- Administer IV glucose immediately to raise blood glucose above 250 mg/dL
- Discontinue the SGLT2 inhibitor and initiate insulin and IV fluids with glucose (Correct answer)
- Continue the SGLT2 inhibitor and adjust insulin to clear ketones
- Switch to an oral sulfonylurea and monitor for 24 hours
Correct answer: Discontinue the SGLT2 inhibitor and initiate insulin and IV fluids with glucose
EuDKA requires immediate SGLT2 inhibitor discontinuation followed by insulin and dextrose-containing IV fluids to suppress ketogenesis and restore normal metabolism, even though glucose appears near-normal.
Question 4: When calculating a carbohydrate-to-insulin ratio (CIR) for a patient, the '500 rule' states:
- 500 mg/dL divided by total daily dose equals grams of carb covered per unit (Correct answer)
- Total daily dose divided by 500 equals units needed per gram of carbohydrate
- 500 divided by basal insulin dose equals the correction factor
- 500 calories per meal requires 1 unit of rapid-acting insulin
Correct answer: 500 mg/dL divided by total daily dose equals grams of carb covered per unit
The 500 rule divides 500 by the total daily insulin dose (TDD) to estimate how many grams of carbohydrate are covered by 1 unit of rapid-acting insulin, guiding meal bolus calculations.
Question 5: A patient with T2DM and heart failure with reduced ejection fraction (HFrEF) is best served by adding which glucose-lowering agent beyond metformin?
- Saxagliptin 5 mg daily
- Pioglitazone 15 mg daily
- Dapagliflozin 10 mg daily (Correct answer)
- Exenatide 10 mcg twice daily
Correct answer: Dapagliflozin 10 mg daily
SGLT2 inhibitors like dapagliflozin have demonstrated reduced cardiovascular death and worsening heart failure in HFrEF patients (DAPA-HF trial); TZDs and saxagliptin are contraindicated or associated with increased HF hospitalization.
Question 6: Which characteristic of insulin degludec (Tresiba) makes it particularly advantageous for patients requiring flexible dosing schedules?
- It can be mixed with rapid-acting insulins in the same syringe
- Its half-life exceeds 25 hours, allowing dose timing flexibility of ±8 hours between injections (Correct answer)
- It has no albumin binding, preventing drug interactions
- It does not require dose adjustment in renal impairment
Correct answer: Its half-life exceeds 25 hours, allowing dose timing flexibility of ±8 hours between injections
Insulin degludec has a half-life of >25 hours and forms a stable subcutaneous depot, enabling flexible dosing with intervals of 8–40 hours between doses without significant loss of glycemic control or safety.
Question 7: Alpha-glucosidase inhibitors (acarbose, miglitol) are most effective at reducing which glycemic parameter?
- Fasting plasma glucose
- Postprandial glucose excursions (Correct answer)
- Overnight hepatic glucose production
- Hemoglobin A1C by more than 1.5%
Correct answer: Postprandial glucose excursions
Alpha-glucosidase inhibitors delay intestinal carbohydrate digestion and absorption, specifically blunting postprandial glucose spikes; their effect on fasting glucose and overall A1C reduction is modest (0.5–0.8%).
BC ADM Medication & Therapeutic Interventions 5
A patient with T2DM on basal-bolus insulin therapy presents with the 'dawn phenomenon.' The most targeted intervention is: