CDE Medication Management 2 — Questions and Answers
Question 1: A patient with type 2 diabetes and stage 3 CKD (eGFR 35 mL/min) is currently on metformin 1000 mg twice daily. What is the most appropriate action?
- Continue metformin at the current dose
- Reduce metformin dose and monitor eGFR closely
- Discontinue metformin immediately (Correct answer)
- Switch to metformin extended-release only
Correct answer: Discontinue metformin immediately
Metformin is contraindicated when eGFR falls below 30 mL/min and should be discontinued at eGFR <30; at eGFR 30-45 it requires dose reduction and close monitoring, but at eGFR 35 most guidelines recommend stopping.
Question 2: Which GLP-1 receptor agonist is administered once weekly and has demonstrated significant cardiovascular risk reduction in the SUSTAIN-6 trial?
- Exenatide (Byetta)
- Liraglutide (Victoza)
- Semaglutide (Ozempic) (Correct answer)
- Dulaglutide (Trulicity)
Correct answer: Semaglutide (Ozempic)
Semaglutide (Ozempic) is a once-weekly GLP-1 RA that showed significant reduction in major adverse cardiovascular events in the SUSTAIN-6 cardiovascular outcomes trial.
Question 3: A patient taking glipizide reports episodes of dizziness, sweating, and shakiness before lunch. Which intervention is most appropriate?
- Add a bedtime snack
- Reduce the glipizide dose or switch to a shorter-acting sulfonylurea (Correct answer)
- Increase carbohydrate intake at all meals
- Add metformin to reduce hypoglycemia risk
Correct answer: Reduce the glipizide dose or switch to a shorter-acting sulfonylurea
Sulfonylurea-induced hypoglycemia before meals indicates the dose may be too high or the medication duration is mismatched with meal timing; dose reduction is the primary intervention.
Question 4: What is the primary mechanism by which SGLT2 inhibitors lower blood glucose?
- Stimulate insulin secretion from beta cells
- Decrease hepatic glucose production
- Inhibit renal glucose reabsorption, increasing urinary glucose excretion (Correct answer)
- Enhance peripheral insulin sensitivity
Correct answer: Inhibit renal glucose reabsorption, increasing urinary glucose excretion
SGLT2 inhibitors block sodium-glucose cotransporter 2 in the proximal renal tubule, preventing reabsorption of filtered glucose and causing glucosuria.
Question 5: A patient with type 1 diabetes uses an insulin-to-carbohydrate ratio of 1:15 and a correction factor of 1:50. If pre-meal glucose is 220 mg/dL, target is 120 mg/dL, and the meal has 60g carbs, how many total units should be given?
- 4 units
- 6 units (Correct answer)
- 8 units
- 10 units
Correct answer: 6 units
Meal dose = 60÷15 = 4 units; correction dose = (220-120)÷50 = 2 units; total = 6 units.
Question 6: Which class of diabetes medication is associated with the highest risk of causing lactic acidosis?
- DPP-4 inhibitors
- Biguanides (metformin) (Correct answer)
- Thiazolidinediones
- Alpha-glucosidase inhibitors
Correct answer: Biguanides (metformin)
Metformin, a biguanide, carries a risk of lactic acidosis, particularly in patients with renal impairment, liver disease, or conditions causing tissue hypoxia.
Question 7: Pioglitazone (Actos) is contraindicated in patients with which condition?
- Hypertension
- New York Heart Association Class III or IV heart failure (Correct answer)
- Stage 2 CKD
- Hypothyroidism
Correct answer: New York Heart Association Class III or IV heart failure
Thiazolidinediones like pioglitazone cause fluid retention and are contraindicated in NYHA Class III-IV heart failure due to risk of worsening cardiac function.
CDE Medication Management 2
A patient with type 2 diabetes and stage 3 CKD (eGFR 35 mL/min) is currently on metformin 1000 mg twice daily.
What is the most appropriate action?