MTM Diabetes & Cardiovascular Pharmacotherapy 5 — Questions and Answers
Question 1: A patient with T2DM on insulin detemir develops recurrent fasting hyperglycemia despite titration. The pharmacist suspects dawn phenomenon. Which adjustment is most appropriate?
- Add a mealtime rapid-acting insulin at breakfast
- Administer insulin detemir at bedtime instead of morning (Correct answer)
- Switch to premixed insulin 70/30
- Add metformin to suppress hepatic glucose output overnight
Correct answer: Administer insulin detemir at bedtime instead of morning
Administering basal insulin at bedtime targets the overnight rise in glucose from the dawn phenomenon more effectively than morning dosing.
Question 2: Which of the following medications used in heart failure has been shown to improve glycemic control in patients with T2DM by reducing insulin resistance?
- Carvedilol (Correct answer)
- Furosemide
- Spironolactone
- Ivabradine
Correct answer: Carvedilol
Carvedilol, unlike other beta-blockers, has alpha-1 blocking activity that may improve insulin sensitivity and is considered metabolically favorable.
Question 3: A pharmacist performing an MTM review notices a patient with T2DM and dyslipidemia is on niacin. Which concern should be raised regarding niacin use in this population?
- Niacin directly causes insulin resistance and worsens glycemic control
- Niacin has no CV benefit and raises fasting glucose
- Niacin was shown in the AIM-HIGH trial to not reduce CV events despite raising HDL
- All of the above (Correct answer)
Correct answer: All of the above
Niacin worsens insulin resistance, fails to reduce CV outcomes (AIM-HIGH), and raises fasting glucose, making it poorly suited for patients with T2DM.
Question 4: A patient with T2DM and atrial fibrillation is on apixaban for stroke prevention. They ask about taking aspirin for heart protection. What is the best counseling response?
- Aspirin is always safe with direct oral anticoagulants
- Adding aspirin to apixaban significantly increases bleeding risk without additional CV benefit in most patients (Correct answer)
- Aspirin replaces the need for apixaban in atrial fibrillation
- Aspirin should always be added in T2DM patients for primary prevention
Correct answer: Adding aspirin to apixaban significantly increases bleeding risk without additional CV benefit in most patients
Dual antithrombotic therapy (DOAC + aspirin) substantially increases major bleeding risk and is not recommended unless the patient has a specific indication such as recent ACS.
Question 5: Which blood pressure target is recommended for most patients with T2DM and hypertension according to the 2023 ADA Standards of Care?
- Less than 150/90 mmHg
- Less than 140/90 mmHg
- Less than 130/80 mmHg (Correct answer)
- Less than 120/80 mmHg
Correct answer: Less than 130/80 mmHg
ADA recommends a BP target of less than 130/80 mmHg for most patients with diabetes and hypertension to reduce CV and renal risk.
Question 6: A patient with T2DM and a recent myocardial infarction is started on a high-intensity statin. Six weeks later, labs show markedly elevated creatine kinase with muscle pain. What is the most appropriate action?
- Reduce the statin dose and continue therapy
- Discontinue the statin immediately and evaluate for rhabdomyolysis (Correct answer)
- Switch to a water-soluble statin such as pravastatin
- Add CoQ10 supplementation and continue statin
Correct answer: Discontinue the statin immediately and evaluate for rhabdomyolysis
Significantly elevated CK with myalgia raises concern for rhabdomyolysis, requiring immediate statin discontinuation and renal function monitoring.
Question 7: Which of the following best describes the mechanism by which SGLT2 inhibitors reduce hospitalizations for heart failure?
- They increase myocardial contractility by blocking sodium-calcium exchange
- They reduce preload and afterload through osmotic diuresis and natriuresis (Correct answer)
- They lower HbA1c which directly reduces cardiac workload
- They inhibit aldosterone secretion decreasing fluid retention
Correct answer: They reduce preload and afterload through osmotic diuresis and natriuresis
SGLT2 inhibitors reduce cardiac preload and afterload primarily through glucosuria-driven osmotic diuresis and sodium excretion, independent of glycemic effects.
MTM Diabetes & Cardiovascular Pharmacotherapy 5
A patient with T2DM on insulin detemir develops recurrent fasting hyperglycemia despite titration.
The pharmacist suspects dawn phenomenon.
Which adjustment is most appropriate?