MTM Diabetes & Cardiovascular Pharmacotherapy 4 — Questions and Answers
Question 1: A patient with T2DM and stage 4 CKD (eGFR 22 mL/min) needs improved glycemic control. Which agent is safest to initiate?
- Metformin
- Glipizide
- Insulin glargine (Correct answer)
- Sitagliptin standard dose
Correct answer: Insulin glargine
Insulin glargine is safe in advanced CKD as it is not renally cleared; dose adjustments based on glucose monitoring are required.
Question 2: Which cardiovascular outcome trial for a GLP-1 receptor agonist demonstrated the largest relative risk reduction in MACE among T2DM patients with established CVD?
- LEADER (liraglutide)
- SUSTAIN-6 (semaglutide) (Correct answer)
- EXSCEL (exenatide)
- REWIND (dulaglutide)
Correct answer: SUSTAIN-6 (semaglutide)
SUSTAIN-6 demonstrated a 26% relative risk reduction in MACE for semaglutide, one of the largest effects seen in GLP-1 RA cardiovascular outcome trials.
Question 3: A hypertensive patient with T2DM and bilateral renal artery stenosis requires blood pressure control. Which agent should be AVOIDED?
- Amlodipine
- Hydrochlorothiazide
- Lisinopril (Correct answer)
- Metoprolol
Correct answer: Lisinopril
ACE inhibitors are contraindicated in bilateral renal artery stenosis because they can precipitate acute kidney injury by reducing glomerular filtration pressure.
Question 4: Which combination of antidiabetic agents poses the HIGHEST risk of hypoglycemia?
- Metformin + SGLT2 inhibitor
- Sulfonylurea + basal insulin (Correct answer)
- DPP-4 inhibitor + GLP-1 RA
- Metformin + DPP-4 inhibitor
Correct answer: Sulfonylurea + basal insulin
Combining a sulfonylurea with basal insulin significantly increases hypoglycemia risk because both agents independently stimulate insulin-mediated glucose lowering.
Question 5: A patient on amiodarone for atrial fibrillation starts on simvastatin 40 mg. What is the most appropriate recommendation?
- No dose adjustment needed
- Limit simvastatin dose to 20 mg daily (Correct answer)
- Switch to pravastatin to avoid the interaction
- Reduce amiodarone dose instead
Correct answer: Limit simvastatin dose to 20 mg daily
The FDA recommends limiting simvastatin to 20 mg/day when used with amiodarone due to increased myopathy risk from CYP3A4 inhibition.
Question 6: In an MTM consultation, a patient with T2DM reports taking ibuprofen daily for arthritis pain. What is the primary concern related to their cardiovascular medications?
- Ibuprofen decreases effectiveness of insulin
- NSAIDs can raise blood pressure and blunt the effect of antihypertensives (Correct answer)
- Ibuprofen increases the risk of lactic acidosis with metformin
- NSAIDs cause hypoglycemia when combined with sulfonylureas
Correct answer: NSAIDs can raise blood pressure and blunt the effect of antihypertensives
NSAIDs cause sodium retention and vasoconstriction, which can raise blood pressure and reduce the efficacy of antihypertensive medications.
Question 7: Which of the following is an absolute contraindication to the use of GLP-1 receptor agonists?
- History of pancreatitis
- Personal or family history of medullary thyroid carcinoma (Correct answer)
- Mild to moderate renal impairment
- Obesity with BMI > 35 kg/m²
Correct answer: Personal or family history of medullary thyroid carcinoma
GLP-1 receptor agonists carry a black box warning and are contraindicated in patients with personal or family history of medullary thyroid carcinoma or MEN2.
MTM Diabetes & Cardiovascular Pharmacotherapy 4
A patient with T2DM and stage 4 CKD (eGFR 22 mL/min) needs improved glycemic control.
Which agent is safest to initiate?