CDE Medication Management 5 — Questions and Answers
Question 1: A patient reports taking his metformin 500 mg twice daily but has persistent GI side effects (nausea, diarrhea) after 6 weeks. What is the best recommendation?
- Discontinue metformin and switch to a DPP-4 inhibitor
- Switch to metformin extended-release (XR) formulation (Correct answer)
- Add a proton pump inhibitor to reduce GI symptoms
- Reduce the dose to 250 mg twice daily permanently
Correct answer: Switch to metformin extended-release (XR) formulation
Metformin extended-release formulation is associated with significantly fewer GI side effects than immediate-release metformin and is often better tolerated.
Question 2: Which GLP-1 receptor agonist is available as an oral tablet (not injectable)?
- Liraglutide (Victoza)
- Oral semaglutide (Rybelsus) (Correct answer)
- Dulaglutide (Trulicity)
- Albiglutide (Tanzeum)
Correct answer: Oral semaglutide (Rybelsus)
Oral semaglutide (Rybelsus) is the only GLP-1 receptor agonist currently available in tablet form, taken once daily on an empty stomach with a small amount of water.
Question 3: A patient taking canagliflozin (Invokana) is scheduled for surgery. What is the recommended perioperative management?
- Continue the medication up to the day of surgery
- Hold canagliflozin at least 3-4 days before surgery due to euglycemic DKA risk (Correct answer)
- Double the dose the day before surgery to maintain glucose control
- Switch to insulin only on the day of surgery
Correct answer: Hold canagliflozin at least 3-4 days before surgery due to euglycemic DKA risk
SGLT2 inhibitors should be held 3-4 days before surgery due to risk of euglycemic diabetic ketoacidosis (eDKA), which can occur perioperatively even with normal glucose levels.
Question 4: Which insulin formulation is considered 'ultra-rapid acting' and has the fastest onset of action?
- Regular insulin (Humulin R)
- Insulin lispro (Humalog)
- 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 absorption, giving it an onset within 2-4 minutes, making it the fastest commercially available mealtime insulin.
Question 5: A patient with type 2 diabetes, BMI 38, and HbA1c 8.8% wants to lose weight while improving glycemic control. Which medication would best address both goals?
- Glimepiride (Amaryl)
- Pioglitazone (Actos)
- Semaglutide (Ozempic) (Correct answer)
- Sitagliptin (Januvia)
Correct answer: Semaglutide (Ozempic)
GLP-1 receptor agonists like semaglutide provide significant weight loss (5-15% body weight) alongside meaningful HbA1c reduction, making them the preferred choice for obese patients needing dual benefit.
Question 6: What is the appropriate treatment for mild-to-moderate hypoglycemia (glucose 54-70 mg/dL) in a conscious patient?
- Administer glucagon injection immediately
- Consume 15-20 grams of fast-acting carbohydrates and recheck glucose in 15 minutes (Correct answer)
- Drink a full glass of orange juice and eat a large meal
- Call emergency services and wait for IV dextrose
Correct answer: Consume 15-20 grams of fast-acting carbohydrates and recheck glucose in 15 minutes
The '15-15 rule' recommends 15g of fast-acting carbohydrates (e.g., glucose tablets, juice), recheck in 15 minutes, and repeat if still below 70 mg/dL.
Question 7: A patient asks why their provider prescribed both basal insulin glargine and a GLP-1 receptor agonist. What is the best explanation?
- The two drugs work identically but have synergistic effects
- Basal insulin addresses fasting glucose while GLP-1 agonist targets postprandial glucose, weight, and CV risk (Correct answer)
- The combination is used only when the patient cannot afford SGLT2 inhibitors
- GLP-1 agonists prevent hypoglycemia caused by glargine
Correct answer: Basal insulin addresses fasting glucose while GLP-1 agonist targets postprandial glucose, weight, and CV risk
The basal insulin/GLP-1 RA combination (e.g., Xultophy, Soliqua) is complementary: basal insulin targets fasting hyperglycemia while GLP-1 RA addresses postprandial glucose, promotes weight loss, and provides cardiovascular benefits.
CDE Medication Management 5
A patient reports taking his metformin 500 mg twice daily but has persistent GI side effects (nausea, diarrhea) after 6 weeks.
What is the best recommendation?