CDE Medication Management 4 — Questions and Answers
Question 1: A patient using an insulin pump (CSII) develops hyperglycemia with ketones. What is the most common mechanical cause?
- Pump battery failure
- Infusion set occlusion or site failure (Correct answer)
- Incorrect carbohydrate ratio programmed
- Insulin degradation due to heat
Correct answer: Infusion set occlusion or site failure
Infusion set occlusion or catheter site failure is the most frequent mechanical cause of hyperglycemia with ketone production in pump users because subcutaneous rapid-acting insulin delivery is interrupted.
Question 2: Which statement best describes the Somogyi effect in insulin-treated patients?
- Morning hyperglycemia caused by insufficient basal insulin overnight
- Morning hyperglycemia caused by rebound from nocturnal hypoglycemia triggering counter-regulatory hormones (Correct answer)
- Afternoon hyperglycemia following a carbohydrate-rich lunch
- Elevated fasting glucose due to growth hormone surge at dawn
Correct answer: Morning hyperglycemia caused by rebound from nocturnal hypoglycemia triggering counter-regulatory hormones
The Somogyi effect (rebound hyperglycemia) occurs when nocturnal hypoglycemia triggers counter-regulatory hormones (glucagon, epinephrine, cortisol) that overshoot and cause morning hyperglycemia.
Question 3: A type 2 diabetes patient with an HbA1c of 9.5% and established atherosclerotic cardiovascular disease is starting medication. According to ADA guidelines, which drug class should be prioritized after metformin?
- Sulfonylurea
- DPP-4 inhibitor
- GLP-1 receptor agonist with proven CV benefit (Correct answer)
- Alpha-glucosidase inhibitor
Correct answer: GLP-1 receptor agonist with proven CV benefit
ADA guidelines recommend GLP-1 receptor agonists or SGLT2 inhibitors with proven cardiovascular benefit as preferred second-line agents in patients with established ASCVD.
Question 4: What is the recommended storage instruction for an insulin pen that is currently in use?
- Store in the refrigerator between uses
- Store at room temperature (below 77°F/25°C) for up to 28-30 days (Correct answer)
- Store in the freezer to extend shelf life
- Keep away from light only; temperature does not matter
Correct answer: Store at room temperature (below 77°F/25°C) for up to 28-30 days
An insulin pen in use should be stored at room temperature (below 77°F/25°C) for up to 28-30 days depending on the insulin type; refrigerating in-use pens can cause discomfort and is unnecessary.
Question 5: A patient asks about combining exenatide (Byetta) with insulin. Which statement is accurate?
- Exenatide can be mixed directly in the same syringe as insulin
- Exenatide should not be used with mealtime insulin due to additive hypoglycemia risk without clear benefit evidence (Correct answer)
- Exenatide can only be used with basal insulin, never bolus
- GLP-1 agonists are always contraindicated with any insulin
Correct answer: Exenatide should not be used with mealtime insulin due to additive hypoglycemia risk without clear benefit evidence
Exenatide should not be combined with prandial insulin as this increases hypoglycemia risk; basal insulin combinations with GLP-1 RAs (e.g., Xultophy, Soliqua) are approved but not mixing in the same syringe.
Question 6: Which monitoring parameter is most important to assess regularly in patients taking thiazolidinediones (TZDs)?
- Serum creatinine and eGFR
- Liver function tests and signs of fluid retention/edema (Correct answer)
- Complete blood count for anemia
- Serum potassium levels
Correct answer: Liver function tests and signs of fluid retention/edema
TZDs require monitoring of liver function (hepatotoxicity risk) and signs of fluid retention such as edema or weight gain, which can precipitate or worsen heart failure.
Question 7: A patient with type 1 diabetes using multiple daily injections (MDI) wants to know the correct injection technique. Which guidance is most appropriate?
- Rotate injection sites within the same body region for consistent absorption (Correct answer)
- Use the same injection spot each time to improve absorption predictability
- Always inject into the abdomen for fastest absorption regardless of timing
- Inject intramuscularly for faster action
Correct answer: Rotate injection sites within the same body region for consistent absorption
Rotating injection sites within the same anatomical region (e.g., rotating within the abdomen) provides consistent absorption rates while preventing lipohypertrophy.
CDE Medication Management 4
A patient using an insulin pump (CSII) develops hyperglycemia with ketones.
What is the most common mechanical cause?