CMEducation Resources: ACP Diabetes

A. Clinical Questions

1. Which of the following statements about the micro- and macrovascular risks associated with type 2 diabetes is TRUE?

a) While the risk for development of microvascular complications becomes significant at diabetic glycemic levels, the relationship between atherosclerosis and CVD begins long before the diagnosis of type 2 DM

b) Hyperglycemia plays a major role in the development of microvascular complications and reduces the risk of CV risk by 25%

c) The glycemic threshold considered for diagnosis of diabetes is based on the risk for developing CVD

d) Glucose levels alone are a valid predictor for cardiovascular risk

2. All of the following are appropriate goals for diabetes management EXCEPT:

a) A1c <6% for patients with advanced macrovascular complications

b) A1c < 7% for most patients

c) Cessation of cigarette smoking

d) Goal LDL < 100 mg/dL for most patients

3. Less stringent A1c goals may be appropriate for which of the following patients?

a) Patients with advanced microvascular complications

b) Patients with advanced macrovascular complications

c) Patients with extensive comorbid conditions

d) All of the above patients may qualify for less stringent A1c goals

e) None of the above patients qualify for less stringent A1c goals

4. Which of the following statements regarding therapeutic goals for glycemic indicators outlined by national treatment guidelines is FALSE?

a) AACE/ACE and IDF guidelines recommend A1C goals of <6.5%

b) ADA/EASD guidelines recommend FPG goals of 70-130 mg/dL

c) IDF guidelines recommend FPG goals of < 100 mg/dL

d) AACE/ACE guidelines recommend PPG goals of < 180 mg/dL

5. Which of the following statements regarding key considerations in the management of type 2 diabetes is FALSE?

a) The mechanisms driving hyperglycemia change with duration of the disease

b) The loss of beta cell function drives the full expression of the disease

c) Clinical inertia often results in prolonged exposure to hyperglycemia, thereby leading to increased risk of complications

d) Maximizing doses of first- and second-line agents before introducing additional therapies will always improve adherence and clinical outcomes

6. Progression of type 2 diabetes is characterized by which of the following features?

a) Escalating need for treatments that increase risk of hypoglycemia

b) Declining beta-cell function

c) Worsening risk of MI, stroke, and microvascular events

d) All of the above

e) None of the above

7. Which of the following is an appropriate potential new strategy for managing disease progression in patients with type 2 diabetes?

a) Strive for lower A1c goals (<6%) in all patients

b) Use synergistic drug combinations with complementary actions to slow disease progression and maximize effect

c) Avoid overburdening patients with multiple treatments unless disease progresses

d) Continue increasing the doses of first-line and second-line therapy, beyond current recommended doses, unless the patient gets side effects

8. AJ is a 58-year old man with a recent history of type 2 diabetes. After being well controlled on metformin (2000 mg per day) treatment alone for 1 year, his latest A1c is 8.2%. Which of the following treatment options would be LEAST appropriate for AJ?

a) Increase his dose of metformin

b) Add a sulfonylurea to his treatment regimen

c) Add basal insulin to his treatment regimen

d) Add a GLP-1 agonist to his treatment regimen

9. Which of the following statements about recent clinical trial findings related to the use of insulin in patients with type 2 diabetes is FALSE?

a) In a substudy of the UKPDS, patients with newly diagnosed type 2 diabetes demonstrated that early addition of insulin to oral agent monotherapy maintained glucose levels below target for 6 years

b) In the Treat-to-Target trial, glargine and NPH insulin demonstrated equivalent efficacy when added to 1 or 2 oral agents in type 2 diabetes

c) In the Treat-to-Target trial, rates of hypoglycemia were significantly lower with glargine than with NPH

d) In a recent study that examined the strategy of adding basal insulin versus a third oral agent to oral combination therapy with metformin and sulfonylurea, it was demonstrated that overall A1c reductions were significantly better with a maximal dose of rosiglitazone than with a low dose of insulin glargine

10. BP is a 42-year old man who was diagnosed with diabetes and started on metformin therapy 4 months ago. His current HbA1c is 8.2%. According to the ADA/EASD consensus algorithm, which of the following would be the LEAST appropriate next step in therapy for BP?

a) Add a sulphonylurea

b) Add basal insulin glargine

c) Add a glitazone

d) Add postprandial insulin

11. Which of the following statements regarding the ADA/EASD guidelines and treatment algorithm is TRUE?

a) Recommended glycemic target is HbA1c < 6.0%

b) Early addition of basal insulin therapy should be used in patients not meeting target goals

c) Initial therapy should include lifestyle interventions and insulin

d) Reevaluation of glycemic status and addition of medications should be conducted slowly to allow for maximal glycemic lowering

12. Which of the following statements about the pharmacokinetic characteristics of insulin glargine is FALSE?

a) Peak action occurs at approximately 5-7 hours from administration

b) Duration of action is approximately 24 hours

c) Glargine produces a flat action profile similar to that if continuous subcutaneous insulin infusion

d) Onset of action is approximately 2 hours

13. Which of the following statements regarding insulin glargine in type 2 diabetes is TRUE?

a) Clinical trials have demonstrated significant intra-patient variability

b) Studies demonstrate that once-daily insulin glargine was less effective than NPH insulin given once or twice daily in reducing A1c levels

c) Clinical trials have demonstrated that nocturnal hypoglycemia was less frequent when using insulin glargine than with NPH insulin

d) Studies show that when compared to NPH insulin, insulin glargine use resulted in more weight gain

14. Which of the following options is the LEAST appropriate way to initiate basal insulin in a patient with type 2 diabetes?

a) Start with 10 units of bedtime insulin glargine

b) Start with 10 units of morning NPH insulin

c) Start with 10 units of morning insulin glargine

d) Start with 10 units of bedtime insulin detemir

15. Which of the following statements regarding the early initiation, addition, or intensification of insulin therapy in type 2 diabetes is FALSE?

a) Early insulin therapy has been shown to have beneficial effects on short-term glycemic control but little effect on long-term control

b) Short-term positive effects of early insulin initiation is explained by rapid reduction of glucotoxicity

c) Early initiation of insulin therapy may lead to immediate improvement in beta-cell function

d) Initiation of insulin therapy, after failure of lifestyle modification and an oral agent, is one option recommended in the ADA guidelines

16. All of the following are potential barriers associated with insulin initiation in diabetes, EXCEPT:

a) Potential for hypoglycemia

b) Weight gain

c) Potential for unpredictable action of long-acting formulations

d) Improved cognitive function with oral agents

17. When initiating insulin therapy in patients with type 2 diabetes, patients should be advised to maintain regular eating habits and exercise schedules, centered around their insulin treatment regimen.

a) True

b) False

18. All of the following should be a primary consideration when designing/adjusting insulin regimens in patients with type 2 diabetes EXCEPT:

a) Basal insulin dose should be adjusted to provide adequate coverage of fasting glucose

b) When used in a basal-bolus regimen, basal insulin dose should comprise approximately 20% of the total daily insulin dose

c) Timing and dosage of prandial insulin should be adjusted according to the carbohydrate intake of each meal

d) All patients starting insulin regimens should be referred to a diabetes educator

19. TK is a 64-year old woman with a 3-year history of type 2 diabetes. Despite losing 10 pounds in the past year, her most recent A1c is 7.9%. Her current medication regimen includes metformin and a sulfonylurea. You decide to add insulin treatment to her regimen. Which of the following is the MOST appropriate next step in therapy for TK?

a) Start with bedtime intermediate-acting insulin; check fasting glucose weekly and increase dose until fasting levels are in target range; check A1c in 6 months

b) Start with morning basal insulin; check fasting glucose daily and increase dose until fasting levels are in target range; check A1c in 6 months

c) Start with bedtime basal insulin; check fasting glucose daily and increase dose slowly until fasting levels are in target range; check A1c in 3 months

d) Start with morning intermediate-acting insulin; check fasting glucose daily until fasting levels are in target range; check A1c in 3 months

20. Rapid-acting insulin analogues control post-prandial glucose levels better than regular insulin, but cause more hypoglycemia.

a) True

b) False

21. Which of the following is LEAST likely to contribute to the general delay in initiating insulin therapy in patients with type 2 diabetes?

a) Patient feelings of failure/guilt

b) Provider reluctance due to concerns over compliance

c) Relative expense of insulin analogs

d) Perceived complexity of insulin administration

22. In which of the following patients with type 2 diabetes would it be MOST appropriate to initiate insulin therapy?

a) A newly diagnosed 80-year old patient who is treatment naïve

b) A patient who has been on metformin monotherapy for 6 months with an A1c of 7%, who is prone to hypoglycemic episodes

c) A newly diagnosed 58-year old patient with severe hyperglycemia at diagnosis

d) All of the above would be good candidates for insulin therapy

e) None of the above would be good candidates for insulin therapy

23. GG is a 68-year old woman with a 3-year history of type 2 diabetes. Her A1c is 8.1% and she is currently on metformin, a sulfonylurea, and bedtime basal insulin. Her fasting plasma glucose levels are consistently around 110 mg/dL and her postprandial levels are around 180 mg/dL. Which of the following is the MOST appropriate next step in therapy for GG?

a) Increase her dose of basal insulin by 4 units and continue to monitor her fasting glucose daily

b) Discontinue her basal insulin and initiate treatment with a GLP-1 receptor agonist

c) Increase her dose of basal insulin by 2 units and add a pre-meal rapid-acting insulin

d) Add a rapid acting insulin before the largest meal with or without discontinuing her sulfonylurea

B. Subjective Practice Assessment/Attitudes/Perceptions/Demographic

1. Approximately how many patients with type 2 diabetes do you see EACH WEEK?

a) None

b) 1-5

c) 6-10

d) 11-15

e) More than 15

2. When managing your patients with type 2 diabetes, to which of the following national guidelines/recommendations are you most likely to refer?

a) American Association of Clinical Endocrinologists (AACE)/American College of Endocrinology (ACE)

b) American Diabetes Association (ADA)/European Association for the Study of Diabetes (EASD)

c) International Diabetes Federation (IDF)

d) Other

3. How confident are you in your ability to appropriately manage your patients with type 2 diabetes who are not achieving glycemic targets?

a) Not confident at all

b) Somewhat confident

c) Moderately confident

d) Very confident

4. How confident are you in your ability to set appropriate treatment targets in your patients with type 2 diabetes based on their individualized needs?

a) Not confident at all

b) Somewhat confident

c) Moderately confident

d) Very confident

5. How confident are you in your ability to appropriately identify patients with type 2 diabetes who may benefit from insulin therapy?

a) Not confident at all

b) Somewhat confident

c) Moderately confident

d) Very confident

6. Currently, how often do you initiate insulin therapy as second or third-line treatments in your patients with type 2 diabetes who are not achieving adequate glycemic control on oral therapies?

a) Almost never

b) Sometimes

c) Often

d) Almost always

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