Free BCACP Ambulatory Diabetes Management Questions and Answers — Questions and Answers
Question 1: A 62-year-old male with a 10-year history of type 2 diabetes, established atherosclerotic cardiovascular disease (ASCVD), and hypertension is currently treated with metformin 1000 mg BID, lisinopril 20 mg daily, and atorvastatin 40 mg daily. His A1c is 7.8% and his blood pressure is 135/85 mmHg. According to the most recent ADA Standards of Care, which of the following is the most appropriate addition to his regimen?
- A. Sitagliptin
- B. Glipizide
- C. Liraglutide (Correct answer)
- D. Pioglitazone
Correct answer: C. Liraglutide
The ADA Standards of Care recommend adding an agent with proven cardiovascular benefit in patients with type 2 diabetes and established ASCVD, independent of A1c. GLP-1 receptor agonists (like liraglutide) and SGLT2 inhibitors have demonstrated cardiovascular benefits. Liraglutide, specifically, has been shown to reduce the risk of major adverse cardiovascular events. Sitagliptin is a DPP-4 inhibitor and is considered weight-neutral with no proven cardiovascular benefit. Glipizide, a sulfonylurea, is associated with a risk of hypoglycemia and weight gain, and lacks cardiovascular benefit. Pioglitazone, a TZD, is associated with a risk of heart failure and weight gain.
Question 2: A patient with type 1 diabetes uses a continuous glucose monitor (CGM). Their recent 14-day report shows the following data: Time in Range (70-180 mg/dL) is 65%, Time Below Range (<70 mg/dL) is 6%, and Time Above Range (>180 mg/dL) is 29%. According to the international consensus on CGM targets, which metric should be the primary focus for improvement?
- A. Increasing Time in Range to >70% (Correct answer)
- B. Decreasing Time Below Range to <1%
- C. Decreasing Time Above Range to <20%
- D. Increasing Mean Glucose
Correct answer: A. Increasing Time in Range to >70%
The international consensus recommends a target Time in Range (TIR) of >70% for most adults with type 1 or type 2 diabetes. While reducing time below range is critical for safety (target <4% for level 1 and <1% for level 2 hypoglycemia), the patient is only slightly above the general target. The primary goal is to increase the overall time spent in the target glycemic range, which will inherently address the time spent above range. Increasing mean glucose would be counterproductive.
Question 3: Which of the following vaccinations is recommended by the CDC for all unvaccinated adults aged 19-59 with diabetes mellitus, to be administered as soon as feasible after diagnosis?
- A. Zoster vaccine (RZV)
- B. Human papillomavirus (HPV) vaccine
- C. Measles, mumps, and rubella (MMR) vaccine
- D. Hepatitis B virus (HBV) vaccine (Correct answer)
Correct answer: D. Hepatitis B virus (HBV) vaccine
The CDC specifically recommends the Hepatitis B vaccine for all unvaccinated adults aged 19 through 59 years with diabetes. This recommendation is due to the increased risk of Hepatitis B transmission through shared blood glucose monitoring equipment. For adults 60 years or older with diabetes who have not previously received the vaccine, it may be administered at the discretion of the healthcare provider. While other vaccines like Zoster, HPV, and MMR are important, the HBV vaccine has a specific recommendation for this age group of adults with diabetes.
Question 4: A 58-year-old female with type 2 diabetes, heart failure with reduced ejection fraction (HFrEF), and chronic kidney disease (eGFR 40 mL/min/1.73m²) has an A1c of 8.1% on metformin and glimepiride. Which medication would be the most appropriate agent to add for both glycemic control and reduction of heart failure hospitalizations?
- A. Alogliptin
- B. Nateglinide
- C. Dapagliflozin (Correct answer)
- D. Lixisenatide
Correct answer: C. Dapagliflozin
SGLT2 inhibitors, such as dapagliflozin, have been shown to have robust benefits in reducing hospitalizations for heart failure and progression of renal disease, regardless of the presence of atherosclerotic cardiovascular disease. These benefits are independent of their glucose-lowering effects. Given the patient's comorbidities of HFrEF and CKD, an SGLT2 inhibitor is the preferred add-on agent according to current guidelines. Alogliptin, nateglinide, and lixisenatide do not offer the same demonstrated benefits for heart failure hospitalization.
Question 5: A patient calls the ambulatory care clinic reporting symptoms of shakiness, sweating, and confusion. They checked their blood glucose and it was 62 mg/dL. The pharmacist should advise the patient to take which of the following immediate actions, according to the ADA's 'Rule of 15'?
- A. Eat a full meal immediately.
- B. Inject their prescribed glucagon kit.
- C. Consume 15 grams of simple carbohydrates and recheck blood glucose in 15 minutes. (Correct answer)
- D. Drink a large glass of diet soda and rest.
Correct answer: C. Consume 15 grams of simple carbohydrates and recheck blood glucose in 15 minutes.
This patient is experiencing Level 1 hypoglycemia (glucose <70 mg/dL but ≥54 mg/dL). For a conscious patient able to swallow, the standard treatment is the 'Rule of 15': consume 15 grams of a fast-acting carbohydrate (like 4 ounces of juice or 3-4 glucose tablets), wait 15 minutes, and then recheck blood glucose. If still low, the process is repeated. A full meal is not the immediate treatment. Glucagon is reserved for severe hypoglycemia when the patient is unable to take carbohydrates orally. Diet soda contains no sugar and would not correct the hypoglycemia.
Question 6: An ambulatory care pharmacist is initiating basal insulin for a 68-year-old patient with type 2 diabetes and an A1c of 9.5%. The patient weighs 100 kg. Which of the following is a common and appropriate starting dose for once-daily insulin glargine?
- A. 30 units
- B. 50 units
- C. 5 units
- D. 10 units (Correct answer)
Correct answer: D. 10 units
When initiating basal insulin in a patient with type 2 diabetes, a common starting dose is 10 units once daily or a weight-based dose of 0.1-0.2 units/kg/day. For this 100 kg patient, 0.1-0.2 units/kg would be 10-20 units. A starting dose of 10 units is a safe and standard approach, which is then titrated based on fasting blood glucose levels. Starting at 30 or 50 units would be too aggressive and increase the risk of hypoglycemia. Starting at 5 units may be too conservative for an A1c of 9.5% but is sometimes used in very cautious scenarios.
Free BCACP Ambulatory Diabetes Management Questions and Answers
A 62-year-old male with a 10-year history of type 2 diabetes, established atherosclerotic cardiovascular disease (ASCVD), and hypertension is currently treated with metformin 1000 mg BID, lisinopril 20 mg daily, and atorvastatin 40 mg daily.
His A1c is 7.8% and his blood pressure is 135/85 mmHg.
According to the most recent ADA Standards of Care, which of the following is the most appropriate addition to his regimen?