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1. Which is the odd one out?
a) adult-onset diabetes
b) impaired glucose tolerance
c) impaired fasting glucose
d) metabolic syndrome
e) syndrome X
2. According to the latest Canadian Diabetes Association guidelines (2008), what HbA1c level should normally prompt either the addition of insulin to treatment, or combination therapy with more than one oral antihyperglycemic drug?
a) > 6.5%
b) > 7.0%
c) > 8.0%
d) > 9.0%
e) > 10.0%
f) > 12.0%
3. Again, according to CDA 2008 guidelines, which is likely to bring the bigger reduction in HbA1c?
a) one oral antihyperglycemic drug at maximal dose
b) two oral antihyperglycemic drugs at submaximal dose
4. End-stage renal disease can cause HbA1c scores to be elevated in a patient who does not actually have insulin resistance.
5. Iron, vitamin B12, and folate deficiency anemias can also cause HbA1c scores to be elevated in a non-diabetic patient.
6. Patients may exhibit a high HbA1c score if they test after eating a sugary breakfast.
7. When starting a patient on insulin, you should discontinue other antihyperglycemic medications.
8. Adding metformin to insulin can reduce insulin requirements and weight gain.
9. Patients who take metformin should not concurrently take a statin.
10. Inhaled insulin has been linked to increased cough and reduced pulmonary function scores.
11. The landmark ACCORD trial cast doubt on the benefits of very strict glycemic control because the most tightly-controlled patients suffered excess deaths from hypoglycemic events.
12. Which of these is the fastest-acting?
a) insulin NPH
13. Metformin is contraindicated if eGFR is < 60 mL/min.
14. Which drug class is most associated with risk of hypoglycemic events?
a) DPP-4 inhibitors (“gliptins”)
b) thiazolidinediones (TZDs, “glitazones”)
e) GLP-1 analogues (incretin mimetics, i.e. liraglutide [Victoza])
15. Which insulin regimen has the lowest risk of hypoglycemic events and the least weight gain, at the cost of somewhat looser glycemic control?
a) prandial dosing
b) biphasic dosing
c) basal bedtime dosing
1. a) Adult-onset diabetes is a synonym for type 2 diabetes. The other answers are various terms for pre-diabetes (syndrome X is nowadays considered an obsolete term).
2. d) HbA1c of > 9.0% should trigger either combined therapy or insulin administration, according to CDA guidelines.
3. b) Two low-dose drugs tend to work better than one high-dose.
4. a) True, due to low red cell turnover.
5. a) True, for the same reason.
6. b) False, HbA1c measures glucose bound to red cells, thus the average amount of glucose in the blood over the average life of the patient’s red cells (typically about the last 3-4 months). Failure to fast before the test would make no noticeable difference, but patients are often asked to fast because of other glucose tests that are performed concurrently.
7. b) False, you should normally continue other antihyperglycemic medication when starting insulin, but be aware of increased risk of congestive heart failure and fluid retention when TZDs are combined with insulin, and of a lack of evidence on safety for combinations of insulin and incretin drugs (liraglutide, exenatide, saxagliptin, sitagliptin).
8. a) True, the combination of metformin and insulin is well-tested and considered to bring synergistic benefit.
9. b) False, cardiovascular risk factors should generally be treated aggressively in diabetic patients, and there is no reason to avoid
statins when taking antihyperglycemic drugs.
10. a) True, inhaled insulin has been linked to cough and decreased respiratory function. Accurate dosing has also proved difficult.
11. b) False, the excess deaths among tightly-controlled patients in ACCORD were due to cardiovascular events.
12. d) Aspart is a rapid-acting insulin analogue, while detemir and glargine are long-acting basal insulin analogues, and insulin NPH is intermediate-acting.
13. b) False. Metformin is contraindicated at eGFR <30 mL/min. Caution and monitoring is advised when eGFR in the 30-60 mL/min range.
14. c) Sulfonylureas are the antihyperglycemic drugs most associated with hypoglycemic events.
15. c) Basal bedtime dosing is the regimen with the least weight gain and lowest risk of “hypos,” and is usually recommended for patients new to insulin therapy, unless they need very tight prandial/postprandial control. Long-acting analogues can further reduce hypo risk.
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