BCPS / Endocrine

Pharmacy Question Bank / BCPS / Endocrine

BCPS

The questions in this section are intended to test your knowledge and skills on pharmacotherapy including biostatistics for practicing pharmacists and pharmacist preparing for BCPS (Board Certified Pharmacotherapy Specialist)
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Question 1
SR’s TSH 0.041mIUn/ml (normal 0.36-3.74mlUn/ml), she has been taking 125mcg of levothyroxine orally for more than a year. What would be the most appropriate drug regimen modification?
A
Increase dose of Levothyroxine to 150mcg oral daily
B
Decrease dose of levothyroxine to 100mcg oral daily
C
Increase dose of Levothyroxine to 150mcg IV daily
D
Decrease dose of levothyroxine to 100mcg IV daily
Question 1 Explanation: 
Decrease the dose to 100mcg orally daily. The TSH level is below therapeutic range (0.358--3.740 uIUn/mL). The TSH level is generally inversely related to the thyroid hormones’ levels. Bioequivalent of oral to intravenous levothyroxine is 2:1 ratio, so changing any dose to IV above 75mcg dose wound be to increase the dose. Reference: Bahn R, et al. hyperthyroidism and other causes of thyrotoxicosis: management guidelines of the american thyroid association and american association of clinical endocrinologists. Endocr Pract. 2011;17(3). Available at: https://www.aace.com/files/hyper-guidelines-2011.pdf. Accessed May 18, 2016.
Question 2
FM is a 49 year old female admitted to the ER with diagnosis of DKA. Pertinent labs are: Na 128 mmol/L, K 7.6 mmol/L, Cl 98 mmol/L, CO2 6 mmol/L, SCr 3.4 mg/dL, BG 1813 mg/dL, pH 6.84, pCO2 27.2 mmHg. She was immediately given 0.1 units/kg IV regular insulin, followed by 0.1 units/kg/hr regular insulin drip and 1 liter NS. What would be FM’s corrected sodium?
A
Unchanged at 128 mmol/L
B
Lower than reported sodium level
C
Higher than reported sodium level
D
Unable to determine with the given labs
Question 2 Explanation: 
Estimated (corrected) plasma sodium = Measured plasma or serum sodium concentration + (2.4 * (Serum glucose - 100) / 100) = 128 mmol/L + (2.4 mmol/L x (1813 mg/dL - 100)/100) = 169 mmol/L. Higher glucose levels in the blood, falsely decreases sodium level. Reference: Hillier T, Abbott R, Barrett E. Hyponatremia: evaluating the correction factor for hyperglycemia. The American Journal of Medicine. 1999;106(4):399-403. doi:10.1016/s0002-9343(99)00055-8.
Question 3
FM is a 49 year old female admitted to the ER with diagnosis of DKA. Pertinent labs are: Na 128 mmol/L, K 7.6 mmol/L, Cl 98 mmol/L, CO2 6 mmol/L, SCr 3.4 mg/dL, BG 1813 mg/dL, pH 6.84, pCO2 27.2 mmHg. She was immediately given 0.1 units/kg IV regular insulin, followed by 0.1 units/kg/hr regular insulin drip and 1 liter NS. What is FM’s Anion gap?
A
65
B
72.6
C
24
D
71
Question 3 Explanation: 
Na - (Cl- + HCO3) = 128 mmol/L - (98 mmol/L + 6 mmol/L) = 128 -104 = 24
Use laboratory sodium to calculate anion gap, not the corrected sodium. Reference: Diabetic ketoacidosis and hyperosmolar hyperglycemic state in adults: Treatment. Uptodate.com. 2016. Available at: http://www.uptodate.com/contents/diabetic-ketoacidosis-and-hyperosmolar-hyperglycemic-state-in-adults. Accessed May 16, 2016.
Question 4
FM is a 49 year old female admitted to the ER with diagnosis of DKA. Pertinent labs are: Na 128 mmol/L, K 7.6 mmol/L, Cl 98 mmol/L, CO2 6 mmol/L, SCr 3.4 mg/dL, BG 1813 mg/dL, pH 6.84, pCO2 27.2 mmHg. She was immediately given 0.1 units/kg IV regular insulin, followed by 0.1 units/kg/hr regular insulin drip and 1 liter NS. What is the appropriate choice of IVF for FM at this time?
A
NS
B
D5NS
C
NS with 150meq of NaHCO3
D
Sterile Water with 150meq of NaHCO3
Question 4 Explanation: 
Her corrected sodium is high, her glucose is high so she should not receive NS or any IVF with D5W. Her pH is <6.9 so she must receive NaHCO3. pH <6.9 is an indication for Bicarbonate in a DKA patient. She should not receive NS with NaHCO3, makes the solution hypertonic. Reference: Diabetic ketoacidosis and hyperosmolar hyperglycemic state in adults: Treatment. Uptodate.com. 2016. Available at: http://www.uptodate.com/contents/diabetic-ketoacidosis-and-hyperosmolar-hyperglycemic-state-in-adults. Accessed May 16, 2016
Question 5
FM is a 49 year old female admitted to the ER with diagnosis of DKA. Pertinent labs are: Na 128 mmol/L, K 7.6 mmol/L, Cl 98 mmol/L, CO2 6 mmol/L, SCr 3.4 mg/dL, BG 1813 mg/dL, pH 6.84, pCO2 27.2 mmHg. She was immediately given 0.1 units/kg IV regular insulin, followed by 0.1 units/kg/hr regular insulin drip and 1 liter NS. What is the appropriate treatment of choice for FM’s hyperkalemia at this time?
A
Sodium polystyrene 60gm PR x1
B
Albuterol 10mg via neb
C
Continue the Insulin drip no other treatment needed
D
Sodium polystyrene 60gm PR x1 OR Albuterol 10mg via neb both appropriate
Question 5 Explanation: 
Current potassium level is 7.6 mmol/L. She received 0.1 units/kg regular insuline and currently receiving Insulin drip,, which is a treatment for hyperkalemia. Because the pH is below 6.9, she should receive Sodium bicarbonate, which pushes potassium intracellularly in response to a rise in systemic pH, this will also bring her potassium down. Reference: Treatment and prevention of hyperkalemia in adults. Uptodate.com. 2016. Available at: http://www.uptodate.com/contents/treatment-and-prevention-of-hyperkalemia-in-adults?source=machineLearning&search=HYPERKALEMIA&selectedTitle=1%7E150§ionRank=1&anchor=H3#H3. Accessed May 16, 2016.
Question 6
FM was transferred to ICU on Propofol, D5W with 150 meq of NaHCO3 at 150mls/hr, Insulin drip, Potassium, Magnesium and Phosphorus replacement protocol. Few hours later, labs were repeated and pertinent labs are: Na 146 mmol/L, K 2.5 mmol/L, Cl 103 mmol/L, CO2 20 mmol/L, Phosphorus 1.2 mg/dL, triglycerides 741 MG/Dl, Blood Glucose 735 mg/dL. ABG: pH 7.265, pCO2 40.2 mm Hg, pO2 82 mmHg. Serum Creatinine 1.2 mg/dl. What should be FM’s appropriate drug of choice for sedation?
A
Propofol
B
Midazolam
C
Fentanyl
D
Cisatracurium Besylate
Question 6 Explanation: 
Because this patient has high triglycerides, Propofol should be avoided for sedation since it has been shown to increase triglycerides. A better alternative is midazolam. Fentanyl should not be used monotherapy. Cisatracurium Besylate is a paralytic, not appropriate at this time. Reference: Jacobi J, Fraser GL, Coursin DB, et al. Clinical practice guidelines for the use of sedatives and an¬algesics in the critically ill adult. Crit Care Med 2002; 30:119-41.
Question 7
FM was transferred to ICU on Propofol, D5W with 150 meq of NaHCO3 at 150mls/hr, Insulin drip, Potassium, Magnesium and Phosphorus replacement protocol. Few hours later, labs were repeated and pertinent labs are: Na 146 mmol/L, K 2.5 mmol/L, Cl 103 mmol/L, CO2 20 mmol/L, Phosphorus 1.2 mg/dL, triglycerides 741 MG/Dl, Blood Glucose 735 mg/dL. ABG: pH 7.265, pCO2 40.2 mm Hg, pO2 82 mmHg. Serum Creatinine 1.2 mg/dl. What should be FM’s drug of choice for treatment of high triglycerides?
A
Fish oil
B
Fenofibrate
C
Atorvastatin
D
Treatment not needed until triglycerides >1000 mg/dl
Question 7 Explanation: 
For triglyceride levels above 500 mg/dL, it is reasonable to start pharmacological therapy in addition to lifestyle therapy. Fibrates are most effective in decreasing triglyceride levels. Fish oil and Atorvastatin not the best drug for lowering triglycerides. Statins are first line agent to reduce LDL. Reference: Stone NJ, Robinson J, Liechtenstein HA, et al. 2013 ACC/AHA guidelines on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2013. Available at http://circ.ahajournals.org/content/ early/2013/11/11/01.cir.0000437738.63853.7a. Accessed May 4, 2014
Question 8
FM was transferred to ICU on Propofol, D5W with 150 meq of NaHCO3 at 150mls/hr, Insulin drip, Potassium, Magnesium and Phosphorus replacement protocol. Few hours later, labs were repeated and pertinent labs are: Na 146 mmol/L, K 2.5 mmol/L, Cl 103 mmol/L, CO2 20 mmol/L, Phosphorus 1.2 mg/dL, triglycerides 741 MG/Dl, Blood Glucose 735 mg/dL. ABG: pH 7.265, pCO2 40.2 mm Hg, pO2 82 mmHg. Serum Creatinine 1.2 mg/dl. Which of the following is appropriate course of action for FM in regards to her low phosphate level?
A
Give 30mmoles of K Phosphate for phosphate level 1.2mg/dl
B
Give 30mmoles of Na Phosphate for phosphate level 1.2mg/dl
C
It is not recommended to replace phosphate unless concentration falls below 1.0 mg/dl
D
Replacing phosphate can cause hypermagnesemia and hypercalcemia
Question 8 Explanation: 
The current phosphate is 1.2 mg/dL. It is not recommended to replace phosphate unless concentrations fall below 1.0 mg/dL. When phosphate is replaced for level greater than 1.0mg/dl there is actually a risk of adverse effects such as hypomagnesemia or hypocalcemia. Reference: Diabetic ketoacidosis and hyperosmolar hyperglycemic state in adults: Treatment. Uptodatecom. 2016. Available at: http://www.uptodate.com/contents/diabetic-ketoacidosis-and-hyperosmolar-hyperglycemic-state-in-adults-treatment?source=machineLearning&search=dka&selectedTitle=1%7E150§ionRank=1&anchor=H4565770#H4565770. Accessed May 16, 2016
Question 9
FM was transferred to ICU on Propofol, D5W with 150 meq of NaHCO3 at 150mls/hr, Insulin drip, Potassium, Magnesium and Phosphorus replacement protocol. Few hours later, labs were repeated and pertinent labs are: Na 146 mmol/L, K 2.5 mmol/L, Cl 103 mmol/L, CO2 20 mmol/L, Phosphorus 1.2 mg/dL, triglycerides 741 MG/Dl, Blood Glucose 735 mg/dL. ABG: pH 7.265, pCO2 40.2 mm Hg, pO2 82 mmHg. Serum Creatinine 1.2 mg/dl. What should the IVF be changed to?
A
½ NS
B
NS
C
D5NS
D
Keep the NaHCO3
Question 9 Explanation: 
For sodium level above 145 mmol/L, the IVF should be ½ NS. For sodium level below 145 mmol/L the IVF should be NS. The corrected sodium indicates a level that is still above 145 mmol/L. Bicarbonate drip should be discontinued once pH>6.9. Dextrose should not be given for blood glucose >200 mg/dl. Reference: 1) Kitabchi A, Umpierrez G, Miles J, et al. Hypergly¬cemic crises in adult patients with diabetes. Diabe¬tes Care 2009;32:1335-43
2) Diabetic ketoacidosis and hyperosmolar hyperglycemic state in adults: Treatment. Uptodate.com. 2016. Available at: http://www.uptodate.com/contents/diabetic-ketoacidosis-and-hyperosmolar-hyperglycemic-state-in-adults. Accessed May 16, 2016.
Question 10
FM was transferred to ICU on Propofol, D5W with 150 meq of NaHCO3 at 150mls/hr, Insulin drip, Potassium, Magnesium and Phosphorus replacement protocol. Few hours later, labs were repeated and pertinent labs are: Na 146 mmol/L, K 2.5 mmol/L, Cl 103 mmol/L, CO2 20 mmol/L, Phosphorus 1.2 mg/dL, triglycerides 741 MG/Dl, Blood Glucose 735 mg/dL. ABG: pH 7.265, pCO2 40.2 mm Hg, pO2 82 mmHg. Serum Creatinine 1.2 mg/dl. When should FM’s insulin drip be discontinued and switched to subcutaneous insulin?
A
Once BG <200 mg/dl and Serum Bicarbonate >25 meq/L
B
Once BG <200 mg/dl and Venous pH >7.4
C
Once BG< 150 mg/dl and Serum Bicarbonate>25 meq/L
D
Once BG<200 mg dl and Anion gap <= 12
Question 10 Explanation: 
Insulin drip can be discontinued once BG<200mg/dl AND Anion gap less than or equal to 12 OR BG< 200mg/dl and Venous pH is >7.3 and Serum Bicarb is 15 meq/L or more. Reference: 1) Kitabchi A, Umpierrez G, Miles J, et al. Hypergly¬cemic crises in adult patients with diabetes. Diabe¬tes Care 2009;32:1335-43
2) Diabetic ketoacidosis and hyperosmolar hyperglycemic state in adults: Treatment. Uptodate.com. 2016. Available at: http://www.uptodate.com/contents/diabetic-ketoacidosis-and-hyperosmolar-hyperglycemic-state-in-adults. Accessed May 16, 2016.
Question 11
JM is a 66 YOM comes to your clinic complaining of excessive thirst and urination for the past 1 month. His past medical history includes hypertension and dyspepsia. Home medications includes Amlodipine 5mg by mouth daily and Famotidine 20 mg by mouth twice. He is 5 feet 8 inches and weighs 180 pounds. Point of care plasma glucose test was 224 mg/dl. His 2 average blood pressures is 124/78. Which of the following statement is true about JM’s diagnosis of type 2 diabetes(D2M)?
A
A1C must be above 6.5 % to diagnose him of D2M.
B
2 hours plasma glucose of ≥ 200mg/dl after a 75 gm oral glucose load must be done to diagnose him of D2M.
C
Fasting plasma glucose of ≥ 126 mg/dl must be obtained for a diagnosis of D2M.
D
JM already has a diagnosis of D2M based on his random plasma glucose of ≥ 200mg/dl and the presence of diabetes mellitus symptoms.
Question 11 Explanation: 
Answer D. This patient’s symptoms of excessive thirst and urination over the past month plus random plasma glucose ≥ 200mg/dl gives him diagnosis for diabetes. Answer choices A, B, and C are also correct options for criteria to meet diagnosis for any patient, however they do not fit this patient specifically. Only one of these 4 criteria has to be met to meet diagnosis. The AACE/ACE 2015 guidelines defines possible symptoms of diabetes mellitus as frequent thirst (polydipsia), frequent urination (polyuria), polyphagia (extreme hunger), blurred vision, weakness, and unexplained weight loss. Reference: 1. American Diabetes Association. In Standards of Medical Care in Diabetes 2016. Diabetes Care 2016;39(Suppl. 1)
2. Garber AJ, et al. Consensus Statement by the American Association of Clinical Endocrinologists and American College of Endocrinology on the Comprehensive Type 2 Diabetes Management Algorithm – 2016 Executive Summary. Endocr Pract. 2016; 22(1):84-113
Question 12
JM is a 66 YOM comes to your clinic complaining of excessive thirst and urination for the past 1 month. His past medical history includes hypertension and dyspepsia. Home medications includes Amlodipine 5mg by mouth daily and Famotidine 20 mg by mouth twice. He is 5 feet 8 inches and weighs 180 pounds. Point of care plasma glucose test was 224 mg/dl. His 2 average blood pressures is 124/78. JM’s CMP and Lipid panel are back, pertinent labs includes K 3.8, Na 139, Creatinine 1.1, BUN 15, total cholesterol 165, LDL 105, HDL 35, Triglycerides 244. Which of the following drug regimen modification is appropriate for JM?
A
Change famotidine to pantoprazole
B
Increase the dose of Amlodipine to 10 mg daily
C
Change Amlodipine to Lisinopril 10mg orally daily
D
Add Losartan 80mg orally daily
Question 12 Explanation: 
Answer C. Diabetic patients are recommended to be on either an ACEI or ARB first line for hypertension therapy per both ADA and AACE/ACE guidelines. The goal BP per ADA guidelines is <140/90 mmHg and <130/80 mmHg per AACE/ACE. The patient’s current BP of 124/78 meets the goal. Answer C is correct because monotherapy of ACEI is a correct option and lisinopril 10 mg once daily is a correct starting dosage. Answer D is incorrect because adding would further drop the BP. Pt is already at goal. Answer B is incorrect because amlodipine alone is not first line recommended for HTN in diabetes. Answer A is irrelevant. Reference: 1. American Diabetes Association. In Standards of Medical Care in Diabetes 2016. Diabetes Care 2016;39(Suppl. 1)
2. Garber AJ, et al. Consensus Statement by the American Association of Clinical Endocrinologists and American College of Endocrinology on the Comprehensive Type 2 Diabetes Management Algorithm – 2016 Executive Summary. Endocr Pract. 2016; 22(1):84-113
Question 13
JM is a 66 YOM comes to your clinic complaining of excessive thirst and urination for the past 1 month. His past medical history includes hypertension and dyspepsia. Home medications includes Amlodipine 5mg by mouth daily and Famotidine 20 mg by mouth twice. He is 5 feet 8 inches and weighs 180 pounds. Point of care plasma glucose test was 224 mg/dl. His 2 average blood pressures is 124/78. What’s the goal A1C for JM?
A
≤6.5%
B
≤6.0%
C
≤7.5%
D
≤8.5%
Question 13 Explanation: 
Answer C. ≤7.5% is the goal A1C per ADA guidelines for an elderly adult (>65 years) with few coexisting chronic illness and intact cognitive/functional status. ≤6 is non-existent. ≤ 6.5 is only for healthy, non-elderly adults without risk of hypoglycemia per AACE/ACE guidelines. ≤8.5 is for elderly adults with complex/poor health with end-stage chronic disease. Reference: 1. American Diabetes Association. In Standards of Medical Care in Diabetes 2016. Diabetes Care 2016;39(Suppl. 1)
2. Garber AJ, et al. Consensus Statement by the American Association of Clinical Endocrinologists and American College of Endocrinology on the Comprehensive Type 2 Diabetes Management Algorithm – 2016 Executive Summary. Endocr Pract. 2016; 22(1):84-113
Question 14
JM is a 66 YOM comes to your clinic complaining of excessive thirst and urination for the past 1 month. His past medical history includes hypertension and dyspepsia. Home medications includes Amlodipine 5mg by mouth daily and Famotidine 20 mg by mouth twice. He is 5 feet 8 inches and weighs 180 pounds. Point of care plasma glucose test was 224 mg/dl. His 2 average blood pressures is 124/78. If his Estimated 10-y ASCVD risk ≥7.5%. Based on the results of the lipid panel what would be the most appropriate management of dyslipidemia?
A
Add Atorvastatin 40mg daily
B
Add Fenofibrate 45mg daily
C
Add Lovastatin 40mg daily
D
Recheck lipid panel in 3 month and treat if LDL ≥ 180mg/dl
Question 14 Explanation: 
Answer A. Answer A is correct. Since patient’s estimated 10-y ASCVD risk ≥7.5% and is diabetic classifies him for high intensity statin therapy per 2013 ACC/AHA Cholesterol Guidelines. Option B is not correct since the patient’s TG are 244. Only when >500 does the AACE/ACE recommend adding a fibrate. Option C is incorrect since lovastatin 40 is a moderate intensity statin and this patient needs high intensity. Option D is incorrect since the patient’s ASCVD risk and the fact that patient is diabetic puts him for needing statin. Reference: 1. Stone NJ, Robinson JG, Lichtenstein AH, et al. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014;63:2889-2934.
Question 15
Which of the following class of antidiabetic medications can increase triglycerides?
A
Bile acid sequestrant
B
GLP-1 agonist
C
Thiazolidinediones
D
SGLT2 Inhibitor
E
Alpha-glucosidase inhibitors
Question 15 Explanation: 
Answer A. The only bile acid sequestrant, colesevelam (Welchol), has been shown to increase triglycerides through mechanism of: activation of phosphatidic acid phosphatase with promotes triglyceride synthesis. GLP-1 agonists work on GLP 1 receptors to increase insulin secretion, decrease glucagon secretion, and increase satiety. Thiazolidinediones activate nuclear transcription factor PPAR gamma to increase insulin sensitivity. SGLT2 inhibitors inhibit glucose reabsorption in the kidney. Alpha-glucosidase inhibitors slow down digestion and absorptions of carbs in the gut. Reference: 1. Welchol (colesevelam) tablets and powder for oral suspension package insert. Parsipanny, NJ: Daiiki Sankyo 2014.
2. Sheperd J. Mechanism of action of bile acid sequestrants and other lipid-lowering drugs. Cardiology. 1989; 76 Suppl 1:65-71; discussion 71-74.
Question 16
When is it recommend to stop metformin?
A
when the estimated glomerular filtration (eGFR) is <30 mL/min/1.73 m2
B
when estimated glomerular filtration (eGFR) is <50 mL/min/1.73 m2
C
when creatinine clearance <30 ml/min
D
when creatinine clearance <50 ml/min
Question 16 Explanation: 
Metformin should be stopped when eGFR falls below 30. This is the only cutoff that is recommended for absolute discontinuing. If the eGFR falls between 30-44 while on therapy, benefits and risks of discontinuing should be evaluated. New initiation is only recommended when eGFR >45. Reference: 1. US Food and Drug Administration (FDA) MedWatch for Metformin-containing Drugs: Revised Warnings for Certain Patients With Reduced Kidney Function. Retrieved April 8, 2016. Available at: http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm494829.htm?source=govdelivery&utm_medium=email&utm_source=govdelivery
2. Eknoyan G, Lameire N, et al. KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. Journal of International Society of Nephrology. Jan 2013;3(1): 91-111
Question 17
Which of the following antidiabetic medication works by inhibiting carbohydrate breakdown?
A
Acarbose
B
Metformin
C
Dapagliflozin
D
Pioglitazone
Question 17 Explanation: 
Acarbose is an alpha glucosidase inhibitor that inhibits carbohydrate breakdown. Metformin is a biguanide that decreases hepatic glucose production. Dapagliflozin is a SGLT2 inhibitor to decrease glucose reabsorption in the kidney. Pioglitazone is a TZD that increases insulin sensitivity. Sitagliptin is a DPP-4 inhibitor that works on incretins/increase insulin secretion/decrease glucagon secretion. Reference: 1. American Diabetes Association. In Standards of Medical Care in Diabetes 2016. Diabetes Care 2016;39(Suppl. 1)
Question 18
Which of the following antidiabetic medication works by increasing insulin sensitivity?
A
Miglitol
B
Saxagliptin
C
Canagliflozin
D
Pioglitazone
Question 18 Explanation: 
Answer D. Pioglitazone is a TZD that increases insulin sensitivity. Miglitol is an alpha glucosidase inhibitor that inhibits carb breakdown. Saxagliptin is a DPP-4 inhibitor that works on incretins/increase insulin secretion/decrease glucagon secretion. Canagliflozin is a SGLT2 inhibitor to decrease glucose reabsorption in the kidney. Glimepiride is a sulfonylurea which increases insulin secretion. Reference: 1. American Diabetes Association. In Standards of Medical Care in Diabetes 2016. Diabetes Care 2016;39(Suppl. 1)
Question 19
Which of the following antidiabetic medication works by decreasing glucose reabsorption?
A
Empagliflozin
B
Exenatide
C
Pioglitazone
D
Linagliptin
Question 19 Explanation: 
Answer A. Empagliflozin is a SGLT2 inhibitor to decrease glucose reabsorption in the kidney. Linagliptin is a DPP-4 inhibitor that works on incretins/increase insulin secretion/decrease glucagon secretion. Pioglitazone is a TZD that increases insulin sensitivity. Exenatide is a GLP-1 agonist which increase insulin secretion/decrease glucagon secretion/increase satiety. Reference: 1. American Diabetes Association. In Standards of Medical Care in Diabetes 2016. Diabetes Care 2016;39(Suppl. 1)
Question 20
Which of the following sites of action is targeted by antidiabetic drug class, Incretins?
A
Kidney
B
Muscle
C
Stomach
D
Pancreas
E
C and D.
Question 20 Explanation: 
Answer E. Incretins work by stimulating synthesis of insulin from the pancreatic beta cells, decrease Glucagon secretion. It works on stomach by slowing gastric emptying and brain by controlling appetite. Reference: 1. American Diabetes Association. In Standards of Medical Care in Diabetes 2016. Diabetes Care 2016;39(Suppl. 1)
2. Prins JB. Incretin mimetics and enhancers: mechanism of action. Aust Prescr: 2008:31:102-4.
Question 21
Which of the following sites of action is targeted by antidiabetic drug class, SGLT2 inhibitors?
A
Kidney
B
Muscle
C
Stomach
D
Liver
E
Pancreas
Question 21 Explanation: 
Answer A. SGLT2 inhibitors work in the kidney because the SGLT2 receptors are in the nephrons to block glucose reabsorption in the body. Reference: 1. Chao, Edward. SGLT-2 Inhibitors: A New Mechanism for Glycemic Control. Clin Diabetes. 2014 Jan;32(1): 4-11.
Question 22
SR is a 69 YOM, weight 236 pounds, height 5’8”. Past medical history includes hypertension, diabetes mellitus, CHF with reduced ejection fraction. His BP 137/86, A1c 9.7, Serum creatinine 1.0 mg/dL. His current medications include Metformin 1000mg by mouth BID, Insulin glargine 20 units SQ at bedtime, Glipizide 10mg by mouth twice daily. Atorvastatin 40mg by mouth daily, Lisinopril 20mg by mouth daily, Carvedilol 12.5mg BID, Furosemide 20mg by mouth daily and Spironolactone 12.5mg by mouth daily. SR also complains of several hypoglycemic episodes on days he skips meal or eats late. IBW = 68.4 kg ; actual BW = 107.3 kg. >120% overweight; adjBW = = 84 kg CrCL = 82.8 mL/min Which of the following would be the most appropriate option for management of his type 2 diabetes Mellitus?
A
D/C Glipizide and add Pioglitazone 30mg by mouth daily
B
D/C Glipizide and add Dapagliflozin 10mg by mouth daily
C
D/C Glipizide and add Dulaglutide 0.75mg SQ once weekly
D
Increase Insulin glargine 40 units and add Insulin Lispro sliding scale
Question 22 Explanation: 
Answer C. Glipizide should be discontinued because it works by increasing insulin secretion and one of its main side effects is hypoglycemia. Since the patient does not eat stable meals, this is what is contributing to his episodes of hypoglycemia and this drug should not be used for him. Dapagliflozin would not get to goal A1c. Its A1c reduction capabilities is from 0.5% - 1%. Pioglitazone is not a good option for this patient since there is a black box warning for exacerbating heart failure. Dapagliflozin is not a good option since it works by reducing reabsorption in the kidney which can cause volume depletion in this patient who is already on furosemide. Adding Dulaglutide 0.75mg once weekly would simplify regimen and drop A1c to goal. GLP-1 agonist can drop A1c by average 1%-1.5%. Option D is not ideal either because increasing a long acting insulin glargine in addition to sliding scale will just contribute to hypoglycemia. Sliding scale insulin are potentially inappropriate medication per the beer’s criteria. Reference: 1. American Diabetes Association. In Standards of Medical Care in Diabetes 2016. Diabetes Care 2016;39(Suppl. 1)
2. American Geriatrics Society 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. Journal of the American Geriatrics Society. 2015;63(11):2227-2246. doi:10.1111/jgs.13702.
3. Actos (pioglitazone) package insert. Deerfield, IL: Takeda Pharmaceuticals America, Inc.; 2013 Nov.
4. Farxiga (dapagliflozin) package insert. Princeton, NJ: Bristol-Myers Squibb Company; 2016 Aug.
5. Trulicity (dulaglutide) package insert. Indianapolis, IN: Eli Lilly and Company; 2014 Sept.
Question 23
SR is a 69 YOM, weight 236 pounds, height 5’8”. Past medical history includes hypertension, diabetes mellitus, CHF with reduced ejection fraction. His BP 137/86, A1c 9.7, Serum creatinine 1.0 mg/dL. His current medications include Metformin 1000mg by mouth BID, Insulin glargine 20 units SQ at bedtime, Glipizide 10mg by mouth twice daily. Atorvastatin 40mg by mouth daily, Lisinopril 20mg by mouth daily, Carvedilol 12.5mg BID, Furosemide 20mg by mouth daily and Spironolactone 12.5mg by mouth daily. SR also complains of several hypoglycemic episodes on days he skips meal or eats late. IBW = 68.4 kg ; actual BW = 107.3 kg. >120% overweight; adjBW = = 84 kg CrCL = 82.8 mL/min What should be SR’s goal A1c?
A
<6.5
B
<7.0
C
<7.5
D
<8.5
Question 23 Explanation: 
Answer C. This patient is elderly >65 years old which qualifies him for A1C goal <7.5%. While they do have certain co-morbidities/chronic illnesses of CHF, stage 2 CKD (CrCl 82.8 mL/min), and HTN, this patient does not meet at least 3 chronic illnesses that meet the criteria per the guidelines to have a less stringent A1C goal of <8. This list consists of “arthritis, cancer, congestive heart failure, depression, emphysema, falls, hypertension, incontinence, stage 3 or worse chronic kidney disease, myocardial infarction, and stroke”. This patient only meets 2 of these. In order to meet goal for <8.5 goal A1C, the patient must qualify with presence of one of the following: “single end-stage chronic illness, such as stage 3–4 congestive heart failure or oxygen-dependent lung disease, chronic kidney disease requiring dialysis, or uncontrolled metastatic cancer”. The goal <6.5 is only for healthy, non elderly adults per AACE/ACE. Reference: 1. American Diabetes Association. In Standards of Medical Care in Diabetes 2016. Diabetes Care 2016;39(Suppl. 1)
Question 24
LP is a 67 YOW, weight 210 pounds height 5’ 2”. Past medical history of hypertension, dyspepsia, Dyslipidemia, Ulcerative colitis, Asthma. Her BP is 130/ 82, A1c 8.5. Serum creatinine 0.8 mg/dL. Her current Metformin 500mg by mouth BID, Insulin glargine 40 units SQ at bedtime, Atorvastatin 80mg by mouth daily, Lisinopril 20mg by mouth daily, Amlodipine 10mg daily, pantoprazole 40mg daily, Mesalamine 1000mg four times daily. Which of the following would be the most appropriate option for management of his type 2 diabetes Mellitus?
A
Add Pioglitazone 30mg by mouth daily
B
Add Empagliflozin 10mg by mouth daily
C
Add Exenatide 2mg SQ once weekly
D
Add Acarbose 100mg by mouth three times a day
Question 24 Explanation: 
Answer B. Add Empagliflozin 10mg by mouth daily is the most appropriate answer. Acarbose is not a good option due to possible irritation of patient’s ulcerative colitis. Exenatide is not a good choice since GLP-1 agonists also have high risk of GI side effects. Pioglitazone is not a good option since it can cause weight gain and the patient is already >90% overweight. Add Empagliflozin 10mg by mouth daily is the most appropriate answer since there is no contraindication. Reference: 1. American Diabetes Association. In Standards of Medical Care in Diabetes 2016. Diabetes Care 2016;39(Suppl. 1)
2. Garber AJ, et al. Consensus Statement by the American Association of Clinical Endocrinologists and American College of Endocrinology on the Comprehensive Type 2 Diabetes Management Algorithm – 2016 Executive Summary. Endocr Pract. 2016; 22(1):84-113
Question 25
LP is a 67 YOW, weight 210 pounds height 5’ 2”. Past medical history of hypertension, dyspepsia, Dyslipidemia, Ulcerative colitis, Asthma. Her BP is 130/ 82, A1c 8.5. Serum creatinine 0.8 mg/dL. Her current Metformin 500mg by mouth BID, Insulin glargine 40 units SQ at bedtime, Atorvastatin 80mg by mouth daily, Lisinopril 20mg by mouth daily, Amlodipine 10mg daily, pantoprazole 40mg daily, Mesalamine 1000mg four times daily. What should be LP’s goal A1c?
A
<8.5
B
<6.5
C
<8.0
D
<7.5
Question 25 Explanation: 
Answer D. The patient has intact cognitive and functional status. He only has a few co-existing chronic illnesses of stage 2 CKD and HTN. The patient qualifies for the <7.5% goal due to age >65 years. The <7% goal is for non, elderly, healthy adults per ADA. The goal <6.5 is only for healthy, non elderly adults per AACE/ACE. Reference: 1. American Diabetes Association. In Standards of Medical Care in Diabetes 2016. Diabetes Care 2016;39(Suppl. 1)
2. Garber AJ, et al. Consensus Statement by the American Association of Clinical Endocrinologists and American College of Endocrinology on the Comprehensive Type 2 Diabetes Management Algorithm – 2016 Executive Summary. Endocr Pract. 2016; 22(1):84-113
Question 26
PG is a 86 YOW, weight 182 pounds, height 5’10”. Past medical history of hypertension, GI bleed, osteoarthritis, renal failure stage 4 (GFR = 15-30 mL/min), CHF with preserved ejection fraction. Her BP is 142/ 92, A1c 9.3. Her current Metformin 500mg by mouth BID, Insulin glargine 20 units SQ at bedtime, Atorvastatin 20mg by mouth daily, Lisinopril 5mg by mouth daily, Diltiazem 360mg daily, pantoprazole 40mg BID, Acetaminophen 650mg q6hr. Which of the following would be the most appropriate option for management of his type 2 diabetes Mellitus?
A
Discontinue Metformin and Pioglitazone 30mg by mouth daily
B
Discontinue Metformin add Empagliflozin 10mg by mouth daily
C
Discontinue Metformin add Exenatide 2mg SQ once weekly
D
Discontinue Metformin and Increase Insulin glargine 30 units and add 5 units Lispro subcutaneously TID
Question 26 Explanation: 
Answer D. Pioglitazone is not a good option since it can exacerbate his CHF and caries a black box warning. Empagliflozin is not a good option since it is contraindicated in patients with eGFR <30. Exenatide use is not recommended in patients with CrCL<30 mls/hr. Exenatide is not a good option because the patient’s hx of GI bleed is a precaution for use since the drug can slow gastric emptying. Increasing patient’s long acting insulin and adding low dose short acting is an appropriate choice. Reference: 1. American Diabetes Association. In Standards of Medical Care in Diabetes 2016. Diabetes Care 2016;39(Suppl. 1)
2. Garber AJ, et al. Consensus Statement by the American Association of Clinical Endocrinologists and American College of Endocrinology on the Comprehensive Type 2 Diabetes Management Algorithm – 2016 Executive Summary. Endocr Pract. 2016; 22(1):84-113
Question 27
PG is a 86 YOW, weight 182 pounds, height 5’10”. Past medical history of hypertension, GI bleed, osteoarthritis, renal failure stage 4 (GFR = 15-30 mL/min), CHF with preserved ejection fraction. Her BP is 142/ 92, A1c 9.3. Her current Metformin 500mg by mouth BID, Insulin glargine 20 units SQ at bedtime, Atorvastatin 20mg by mouth daily, Lisinopril 5mg by mouth daily, Diltiazem 360mg daily, pantoprazole 40mg BID, Acetaminophen 650mg q6hr. What should be the goal A1c?
A
<6.5
B
<7.5
C
<8.0
D
<8.5
Question 27 Explanation: 
Answer C. The patients A1C goal should be <8 because they have multiple chronic illnesses of HTN, CKD stage 4, osteoarthritis, and heart failure and they are elderly. The patient does not have end stage chronic illness that meets the <8.5 criteria. The <7.5% goal is solely due to age >65 years. The <7% goal is for non, elderly, healthy adults per ADA. The goal <6.5 is only for healthy, non elderly adults per AACE/ACE. Reference: 1. American Diabetes Association. In Standards of Medical Care in Diabetes 2016. Diabetes Care 2016;39(Suppl. 1)
2. Garber AJ, et al. Consensus Statement by the American Association of Clinical Endocrinologists and American College of Endocrinology on the Comprehensive Type 2 Diabetes Management Algorithm – 2016 Executive Summary. Endocr Pract. 2016; 22(1):84-113
Question 28
Which of the following medication is more likely to cause weight gain?
A
Miglitol
B
Linagliptin
C
Exenatide
D
Pioglitazone
E
Empagliflozin
Question 28 Explanation: 
Answer D. TZDs, such as pioglitazone, along with sulfonylureas and insulins are the only anti-diabetic drugs that can cause weight gain. Miglitol, an alpha glucosidase inhibitor, is weight neutral. Linagliptin is a DPP-4 inhibitor and weight neutral. Exenatide is a GLP-1 agonist which can cause weight loss. Empagliflozin is a SGLT2 inhibitor which can cause weight loss. Reference: 1. American Diabetes Association. In Standards of Medical Care in Diabetes 2016. Diabetes Care 2016;39(Suppl. 1)
2. Garber AJ, et al. Consensus Statement by the American Association of Clinical Endocrinologists and American College of Endocrinology on the Comprehensive Type 2 Diabetes Management Algorithm – 2016 Executive Summary. Endocr Pract. 2016; 22(1):84-113
Question 29
Which of the following medication is more likely to cause hypoglycemia?
A
Miglitol
B
Saxagliptin
C
Canagliflozin
D
Pioglitazone
E
Glimepiride
Question 29 Explanation: 
Answer E. All antidiabetic meds are neutral for causing hypoglycemia except insulins and sulfonylureas. Glimepiride is a sulfonylurea. Miglitol is an alpha glucosidase inhibitor. Saxagliptin is a DPP-4 inhibitors. Canagliflozin is an SGLT2 inhibitor. Pioglitazone is a TZD. Reference: 1. American Diabetes Association. In Standards of Medical Care in Diabetes 2016. Diabetes Care 2016;39(Suppl. 1)
2. Garber AJ, et al. Consensus Statement by the American Association of Clinical Endocrinologists and American College of Endocrinology on the Comprehensive Type 2 Diabetes Management Algorithm – 2016 Executive Summary. Endocr Pract. 2016; 22(1):84-113
Question 30
Which of the following drug class has a black boxes warning in patients with personal or family history of medullary thyroid carcinoma?
A
Bile acid sequestrant
B
GLP-1 agonist
C
Thiazolidinediones
D
SGLT2 Inhibitor
E
Alpha-glucosidase inhibitors
Question 30 Explanation: 
Answer B. Only GLP-1 agonists have a black box warning for medullary thyroid tumors so use is contraindicated in patients with personal or family history of it. No other anti-diabetic drugs have this warning. Reference: 1. Nauck, MA, Friedrich N. Do GLP-1 –Based Therapies Increase Cancer Risk? Diabetes Care Aug 2013; Supp 2: S245-52
Question 31
SGLT2 inhibitors are recommended to be given in the morning for what reason?
A
To prevent hypoglycemia
B
To decrease likelihood of getting nausea and vomiting
C
To prevent nocturnal polyuria
D
To prevent insomnia
Question 31 Explanation: 
Answer: C- Because SGLT2 inhibitors work by preventing reabsorption of glucose in the kidneys, this increases frequency of urination. If you take the drug in the morning, it will prevent nocturnal polyuria. SGLT2 inhibitors do not cause hypoglycemia, do not have high risk of nausea/vomiting, and no adverse reactions of insomnia. Reference: 1. Garber AJ, et al. Consensus Statement by the American Association of Clinical Endocrinologists and American College of Endocrinology on the Comprehensive Type 2 Diabetes Management Algorithm – 2016 Executive Summary. Endocr Pract. 2016; 22(1):84-113
2. American Diabetes Association. In Standards of Medical Care in Diabetes 2016. Diabetes Care 2016;39(Suppl. 1)
Question 32
Which of the following should be monitored when a patient is on SGLT2 inhibitor?
A
Hydration status
B
Blood pressure
C
Blood glucose
D
Renal function
E
All of the above
Question 32 Explanation: 
Answer E. Because SGLT2 inhibitors work by preventing reabsorption of glucose in the kidneys, this increases frequency of urination. All of the options are monitoring requirements since the hydration status, blood pressure, blood glucose, and renal function may all be changed from increased urination (from the mechanism of the drug). Reference: 1. Garber AJ, et al. Consensus Statement by the American Association of Clinical Endocrinologists and American College of Endocrinology on the Comprehensive Type 2 Diabetes Management Algorithm – 2016 Executive Summary. Endocr Pract. 2016; 22(1):84-113
Question 33
Which of the following is/are common side effects of GLP1 inhibitor?
A
Nausea/Vomiting/Diarrhea
B
Polyuria
C
Bradycardia
D
Dry mouth
Question 33 Explanation: 
Answer A. Nausea, vomiting, diarrhea are some of the most common side effects of GLP1 inhibitors. GLP1 inhibitor actually can cause dehydration. Bradycardia is not, they can actually cause increases in heart rate. Dry mouth and polyuria are not side effects of GLP1 Inhibitor. Reference: 1. Bydureon (exenatide extended-release) package insert. San Diego, CA: Amylin Pharmaceuticals, Inc.; 2015 Sep.
2. Garber AJ, et al. Consensus Statement by the American Association of Clinical Endocrinologists and American College of Endocrinology on the Comprehensive Type 2 Diabetes Management Algorithm – 2016 Executive Summary. Endocr Pract. 2016; 22(1):84-113
Question 34
Which of the following class of antidiabetic medication may cause urinary tract infections?
A
Bile acid sequestrant
B
GLP-1 agonist
C
Sulfonylurea
D
SGLT2 Inhibitor
E
Alpha-glucosidase inhibitor
Question 34 Explanation: 
Answer D. SGLT2 inhibitors are the only anti-diabetic drug that works in the kidney to decrease glucose reabsorption in the nephron. Because of the area that these drugs work in, they cause increased risk of UTIs. None of the other anti-diabetic drugs work in the kidney. Reference: 1. Invokana (canagliflozin) package insert. Titusville, NJ: Janssen Pharmaceuticals, Inc; 2016 Aug.
2. American Diabetes Association. In Standards of Medical Care in Diabetes 2016. Diabetes Care 2016;39(Suppl. 1)
Question 35
Which of the following class of antidiabetic medication may cause fluid retention?
A
Bile acid sequestrant
B
GLP-1 agonist
C
Thiazolidinediones
D
SGLT2 Inhibitor
E
Alpha-glucosidase inhibitor
Question 35 Explanation: 
Answer C. Thiazolidinediones may cause fluid retention through proposed mechanism of increasing reabsorption in the collecting duct of the kidney and increasing vascular permeability in adipose tissue. Bile acid sequestrants work in the intestine to bind bile acids which doesn’t affect fluid retention. GLP-1 receptor agonists work to activate these receptors to secrete insulin from beta pancreatic cells/decrease glucagon secretion/ increase satiety and doesn’t affect fluid retention. SGLT2 inhibitors actually cause increase of fluid elimination through the kidneys. Alpha-glucosidase inhibitors work in the gut to decrease carb absorption/digestion and have no affect on fluid retention. Reference: 1. Yang T, Soodvilai S. Renal and Vascular Mechanisms of Thiazolidinediones- Induced Fluid Retention. PPAR Research. 2008. Article ID 943614.
2. American Diabetes Association. In Standards of Medical Care in Diabetes 2016. Diabetes Care 2016;39(Suppl. 1)
Question 36
Which of the following class of antidiabetic medication may cause upper respiratory infection?
A
Sulfonylurea
B
GLP-1 agonist
C
Thiazolidinediones
D
SGLT2 Inhibitor
E
Alpha-glucosidase inhibitor
Question 36 Explanation: 
Answer C. Upper respiratory tract infection (8.4—14.9%) with TZDs. The likely mechanism is due to fluid retention. The other answer choices do not have any incidence of them. SGLT2 inhibitors have increased risk of UTI. Reference: Avandia (rosiglitazone) package insert. Research Triangle Park, NC: GlaxoSmithKline; 2016 Sept.
Actos (pioglitazone) package insert. Deerfield, IL: Takeda Pharmaceuticals America, Inc.; 2013 Nov.
Question 37
Which of the following antidiabetic medication may cause cyanocobalamin deficiency?
A
Saxagliptin
B
Canagliflozin
C
Pioglitazone
D
Glimepiride
E
Metformin
Question 37 Explanation: 
Answer E. Metformin is associated with vitamin B12 deficiency because it affects the calcium dependent membrane uptake of it. All other drug classes are not associated with this. Reference: Liu KW, Lok KD, Jean W. Metformin-related vitamin B12 deficiency. Age Aging. 2006. 35(2): 200-201.
Question 38
Which of the following class of antidiabetic medication has the highest risk of hypoglycemia?
A
Sulfonylurea
B
GLP-1 agonist
C
Thiazolidinediones
D
SGLT2 Inhibitor
E
Alpha-glucosidase inhibitor
Question 38 Explanation: 
All antidiabetic meds are neutral for causing hypoglycemia except insulins and sulfonylureas. Insulins and sulfonylureas are the highest risk.
Question 39
SJ is a 71 YOM, weight 253 pounds, height 5’ 11”. Past medical history gout, hypertension, dyslipidemia, COPD and pancreatitis while on Sitagliptin. His BP is 138/88, A1c is 9.4. Serum creatinine 1.0mg/dL. His current medications includes, Metformin 1000mg BID, Insulin glargine 30 units SQ at bedtime, Acarbose 100mg tid, Atorvastatin 80mg by mouth daily, Ramipril 10mg by mouth daily, Tiotropium 18mcg inhaled daily. Which of the following would be the most appropriate option for management of his type 2 diabetes Mellitus?
A
Add Empagliflozin 10mg by mouth daily
B
Add Exenatide 2mg SQ once weekly
C
Add Linagliptin 5mg by mouth daily
D
Increase Insulin glargine 60 units and add Insulin Lispro sliding scale
Question 39 Explanation: 
Answer: A- Empagliflozin is the best option for this patient. Linagliptin is not an option since patient has already tried Sitagliptin (in the same drug class), and patient had pancreatitis. GLP1- agonists also are associated with pancreatitis so use of Exenatide would not be recommended. Pioglitazone should not be used because the patient is ~52% overweight and it can cause weight gain. Increasing the long acting insulin dose and adding short acting sliding scale is an not an appropriate option since sliding scale in elderly adults in on the BEERs list due to potential increased risk of errors/hypoglycemia. Reference: 1. Food and Drug Administration (US FDA) Drug Medwatch-FDA investigating reports of possible increased risk of pancreatitis and pre-cancerous findings of the pancreas from incretin mimetic drugs for type 2 diabetes. Retrieved Mar. 14, 2013. Available on the World Wide Web at http://www.fda.gov/Drugs/DrugSafety/ucm343187.htm.
2. American Geriatrics Society 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc. 63:2227-2246, 2015.
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