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WorksheetsDM Wrap-Up
Total questions: 11
Worksheet time: 6hrs 30mins
Ms. AT is a 77 yo F with a PMHx of T2DM (diagnosed in 1996), CKD, CHF, CAD s/p MI, medullary thyroid cancer (in remission), HLD, and HTN. She is currently on Insulin glargine 48 units qHS, insulin aspart 16 units TID-AC, and Synjardy XR 1000mg/12.5mg one tablet qAM. Her file notes that she is homeless and is not service connected. Which of the following would be appropriate A1c and BG targets?
A1c<6%
FBG<100 mg/dl
PPBG<120mg/dl
A1c<6.5%
FBG<115mg/dl
PPBG<140mg/dl
A1c<7%
FBG<130mg/dl
PPBG<180mg/dl
A1c<8%
FBG<150mg/dl
PPBG<180-200s mg/dl
Which of the following are MICROvascular complications that can occur in diabetic patients? Select all that apply.
Retinopathy
Neuropathy
Nephropathy
Coronary artery disease
A patient with T2DM and CKD (eGFR of 48 ml/min ) has been taking metformin 1000 mg twice daily for the past year. Most recent urine albumin:creatinine ratio of 340 ug/mg cr. His A1c is 7.5% today. Which option would be the most appropriate for this patient in accordance with local VA policy?
Switch Metformin to Synjardy (Metformin/Empagliflozin) 1000mg/12.5mg one tablet BID
Add Lantus (Insulin glargine) 10 units qHS
Switch from Metformin to Glipizide 10mg BID-AC
Add sitagliptin 100 mg once daily
Which of the following agent(s) has been shown to have macrovascular benefit in patients? (select all that apply)
Ozempic (Sustain-6)
Sitagliptin (TECOS)
Metformin (UKPDS)
Empagliflozin (EMPA-REG)
A patient presents to your clinic for his initial appointment for T2DM management while on Metformin 1000mg BID-AC, sitagliptin 100mg qdaily, and pioglitazone 30mg qdaily. His most recent A1c resulted at 6.4% and his most recent BP on file is 110/71 mmHg. He does not have a urine:albumin cr ratio test on file so you order one today. It returns at 28 ug/mg cr. Which of the following options would you recommend for the visit today?
Initiate an ACE inhibitor or ARB based on urine:albumin cr ratio..
No changes necessary, continue current.
Initiate an SGLT2i based on urine:albumin cr ratio.
Increase pioglitazone to max dose of 45mg qdaily
Which of the following medications can be initiated without dose adjustments in renal dysfunction?
Metformin/Metformin SA
Ozempic (semaglutide)
Sitagliptin
Glimepiride
A patient presents to your clinic on glipizide 10 mg BID-AC and insulin glargine 20 units qHS (also known as BIDS therapy). His A1c today returns at 8.7%. His FBG levels average 180-200s mg/dl and his post-prandial levels average in the 210s mg/dl. Which of the following options is most appropriate?
Allergies/ADRs: Metformin/Metformin SA (Severe GI upset/nausea)
Increase insulin glargine by ~10-15% or by 8 units per Treat to Target
Increase glipizide to 20mg BID-AC
Initiate Novolog (insulin aspart) at 7 units TID-AC
Initiate empagliflozin 12.5mg qAM
What patient characteristics should you take into consideration when making individualized A1c goals? i.e A1c<6.5% vs. <7% vs. <8%
Age
Comorbidities
History of hypoglycemia
Patient Preference
Socioecomonic status
A 54 year old Veteran presents to the clinic for DM management on Synjardy XR 1000mg/12.5mg one tablet BID-AC, insulin glargine 60 units qHS, and Novolog 20 units TID-AC. Based on his BG report provided what changes would you recommend today?
Insulin glargine: no change
Insulin aspart to 22 units TID-AC
Insulin glargine: no change
Insulin aspart to 22/20/22 units TID-AC
Insulin glargine to 66 units qHS
Insulin aspart to 22 units TID-AC
Insulin glargine to 66 units qHS
Insulin aspart to 22 units TID-AC
Mrs. RC is 68 yo F who is recently widowed and lives alone. She was diagnosed with T2DM ~5 years ago. Her most recent A1c was 8.3% and eGFR of 28 ml/min. Her PMHx consists of T2DM, HLD, HTN, osteoporosis (previous hip fracture), and obesity. She is currently on empagliflozin 12.5mg qAM. She notes a history of hypoglycemia. Which of the following options is optimal for this patient?
Switch empagliflozin, to start Synjardy XR (Metformin SA/Empagliflozin) 1000mg/12.5mg qAM once daily
Add sitagliptin 100mg qdaily
Add glimepiride 1mg qAM-AC
Add pioglitazone 15mg qdaily
Add semaglutide 0.25mg qweekly x4 weeks and if tolerated increase to 0.5mg qweekly
BONUS TRIVIA QUESTION:
Metformin can cause which vitamin deficiency?
Vitamin D
Vitamin B12
Vitamin C
Vitamin K
