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CDE Diabetes

Flashcards: FIT Canada Recommendations for Injection Technique

The Forum for Injection Technique (FIT) Canada emphasizes that the effectiveness of insulin therapy is largely dependent on how it is delivered. Poor technique can lead to erratic absorption, unexplained hypoglycemia, and long-term complications. These flashcards are designed to help pharmacists and healthcare professionals memorize the 4th Edition Recommendations regarding needle length selection, the prevention of lipohypertrophy, and proper site rotation.

Key Topics Covered:

  • Needle Selection: Memorizing the evidence that 4 mm pen needles are recommended for all adults and children, regardless of BMI, to minimize the risk of intramuscular (IM) injection.

  • Lipohypertrophy (LH): Identifying the impact of “lumpy” injection sites on glycemic control—specifically that injecting into LH can reduce insulin absorption by up to 25% and cause significant variability.

  • Site Rotation: Applying structured rotation principles, such as spacing injections at least 1 cm (approx. one finger width) apart and utilizing divided zones to preserve tissue health.

  • Single Use: Reinforcing the strict rule that needles and syringes are single-use devices and must be discarded immediately to prevent tip deformation and infection.

  • Troubleshooting: Recognizing that unexplained hypoglycemia or hyperglycemia is often a sign of injection site complications rather than a need for dose adjustment.

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CDE Diabetes

Practice Exam: FIT Canada Recommendations for Injection Technique

The efficacy of insulin therapy is only as good as the technique used to deliver it. The Forum for Injection Technique (FIT) Canada Recommendations emphasize that correct injection technique is just as critical as the type and dose of insulin prescribed. Poor technique can lead to unexplained hypoglycemia, glycemic variability, and long-term complications.

This practice exam tests your ability to apply the “Golden Rules” of injection, manage injection site complications like lipohypertrophy, and select the appropriate delivery devices for patients of all body types.

Key Concepts Covered in This Exam:

  • Needle Selection: Understanding the evidence supporting the use of 4 mm pen needles as the safest and most effective option for all adults and children, regardless of BMI, to avoid intramuscular (IM) injections.

  • Lipohypertrophy (LH): Mastering the detection and management of “lumpy” injection sites, acknowledging that injecting into LH can reduce insulin absorption by up to 25% and cause erratic glucose levels.

  • Structured Rotation: Applying correct rotation principles—spacing injections at least 1 cm (approx. width of a finger) apart and utilizing divided zones—to preserve tissue health.

  • Single Use: Reinforcing the strict recommendation that needles and syringes are single-use devices and must be discarded immediately to prevent tip deformation, infection, and lipohypertrophy.

  • Psychological Barriers: Addressing patient fears and anxiety regarding injections to improve adherence and comfort.

1. Case: A patient reports unexplained hypoglycemic episodes despite consistent insulin dosing. Upon examination, you discover lipohypertrophic tissue at their usual injection site. What is the most likely explanation?

2. A patient with type 2 diabetes expresses psychological resistance to starting insulin therapy. According to FIT recommendations, what is the most appropriate approach?

3. Lipohypertrophy is best described as:

4. What is the recommended storage temperature for unopened insulin vials and cartridges?

5. Case: A healthcare professional is teaching a parent how to inject insulin into their anxious 7-year-old child. What strategy would be most appropriate to reduce needle anxiety?

6. A patient asks why they should not reuse pen needles. What is the most appropriate response based on FIT recommendations?

7. What percentage of individuals with lipohypertrophy has been observed in international trials?

8. When using cloudy insulin (NPH or premixed), what is the recommended technique for re-suspension?

9. Case: An insulin pump user develops a “pump bump” (localized bump at insertion point) with redness. What is the most likely cause and recommended action?

10. What is the strongest correlating factor in the development of lipohypertrophy according to research?

11. What is the average skin thickness (epidermis and dermis) regardless of age, BMI, gender, or race?

12. A healthcare professional asks about the proper technique for palpating injection sites to detect lipohypertrophy. What is the correct technique?

13. A patient using an 8-mm needle asks about the correct injection technique. What is the appropriate instruction?

14. Why might non-posted (contoured) pen needle designs be preferred over conventional posted-hub designs?

15. Research shows that after avoiding lipohypertrophic sites for 3-6 months, what outcome may be observed?

16. What is the minimum duration a patient should count after depressing the insulin pen injection dose knob before withdrawing the needle?

17. Case: A 4-month-old infant is diagnosed with neonatal diabetes requiring insulin therapy. What is the most appropriate infusion site consideration?

18. What is the recommended distance between injection sites when rotating within an anatomical area?

19. Case: A woman in her third trimester of pregnancy asks where she should inject her insulin. What is the most appropriate recommendation?

20. Case: A patient asks why injection into the buttocks results in slower insulin absorption. What is the scientific explanation?

21. According to FIT Canada, which injection area offers the most consistent absorption of regular and NPH insulin?

22. According to FIT Canada, what is the recommended pen needle length suitable for all people with diabetes, regardless of BMI?

23. Case: A patient with diabetes is switching from injecting into a lipohypertrophic site to a healthy site. What counseling should be provided?

24. Case: A patient using an insulin pump develops recurrent unexplained hyperglycemia and increased skin irritation at infusion sites. What is the likely issue and solution?

25. How often should all components of an insulin infusion set (insulin, reservoir, and tubing) be changed?

26. Case: A child aged 5 requires insulin injections. What is the recommended needle length and technique?

27. According to FIT Canada, how should concentrated insulins (U-200, U-300, U-500) be handled regarding syringes?

28. What effect does massaging the injection site immediately before or after injection have on insulin?

29. Case: A lean male patient (BMI 22 kg/m²) reports injecting into his thigh using a 6-mm needle at 90 degrees. He frequently experiences rapid-onset hypoglycemia. What is the most likely cause?

30. Case: A patient taking >50 units of regular or NPH insulin per injection asks about splitting the dose. What is the clinical rationale for this recommendation?

31. Case: A clinical team is debating whether to use alcohol swabs before insulin injections in a community setting. Based on FIT guidelines, what is the correct recommendation?

32. What should be done if pen needles are left attached to the pen between injections?

33. Case: An elderly patient with cognitive impairment requires insulin therapy. What is the preferred delivery device according to FIT recommendations?

34. Why is the arm NOT recommended as a preferred self-injection site?

35. Case: A 55-year-old person with obesity (BMI 38 kg/m²) is initiating insulin therapy. They ask if they need a longer needle due to their body size. What is the most appropriate response?

36. Case: An adolescent with type 1 diabetes has poor glycemic control and admits to sometimes skipping insulin doses due to peer pressure. What is the recommended approach?

37. Case: A patient using a GLP-1 receptor agonist pen asks if they need to prime the pen before each injection. What is the correct guidance?

38. In an institutional setting, what specific safety measure regarding injection devices is emphasized by FIT Canada?

39. Case: A diabetes educator is developing a teaching plan for injection technique. According to the guidelines, what is the most critical educational priority?

40. A patient on insulin pump therapy develops unexplained hyperglycemia with ketones. After correcting with injection, what troubleshooting steps should be taken?


 

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CDE Diabetes

Study Guide: FIT Recommendations for Best Practice in Injection Technique

1. Core Concepts & Goals

  • Objective: To ensure the correct dose of medication is delivered to the correct injection site using proper technique to achieve optimal health outcomes.

  • Golden Rule: Insulin and GLP-1 receptor agonists should be injected into the subcutaneous tissue (fat), avoiding intramuscular (IM) injection.

  • Primary Complication: Lipohypertrophy (rubbery lesions) is the most common complication and leads to glycemic variability and unexplained hypoglycemia.

2. Device Selection & Needle Length

Pen Needles vs. Syringes

  • Needle Length Standard: 4-mm pen needles are suitable for all patients regardless of BMI (Body Mass Index).

    • They reduce the risk of intramuscular (IM) injection compared to longer needles.

    • They provide equivalent glycemic control to 8-mm or 12-mm needles even in patients with obesity.

  • Syringes: The shortest available syringe needle is currently 6-mm.

  • Not Recommended: 12-mm or 12.7-mm needles are generally not recommended due to high IM risk.

Safety & Hygiene

  • Single Use Only: Needles and syringes should be used once and disposed of immediately.

  • Consequences of Reuse: Needle breakage, clogging, inaccurate dosing, and lipohypertrophy.

  • Disposal: Use approved sharps containers; never resheathe (recap) needles.

3. Injection Technique

Preparation

  • Hand Washing: Always wash hands with soap and water; disinfect injection site if required (e.g., hospital setting) but let alcohol dry completely.

  • Cloudy Insulin (NPH/Premix): Gently roll 10 times and tip 10 times until milky white. Do not shake.

  • Priming: Always prime the pen (air shot) to ensure flow. Note: GLP-1 pens may only need priming once per first use (check manufacturer).

Insertion & Angle

  • 4-mm Needles: Inject at a 90-degree angle. A skin lift (pinch-up) is generally not required for adults but may be needed for very lean limbs/abdomens.

  • 6-mm Syringes/Needles:

    • 90-degree into a skin lift.

    • 45-degree may be required for lean individuals if no skin lift is used.

  • 8-mm Needles: Must use a skin lift and inject at 90 degrees. Lean patients should use a 45-degree angle with a skin lift.

The “Skin Lift” (Pinch-up)

  • Method: Lift skin and subcutaneous tissue delicately between thumb and index finger.

  • Avoid: Do not lift muscle. Do not squeeze so hard it causes blanching or pain.

Dwell Time

  • Count to 10: After the dose knob is fully depressed, hold the needle in place for a slow count of 10 seconds to ensure full dose delivery and prevent leakage.

4. Injection Sites & Rotation

Site Selection

  • Preferred Site: The abdomen is preferred for consistent absorption, especially for soluble (Regular) and NPH insulin.

  • Other Sites: Thighs (upper third anterior lateral) and Buttocks (posterior lateral upper).

  • The Arm: The arm is not a preferred site for self-injection due to difficulty ensuring a 90-degree angle and high risk of IM injection into the deltoid.

  • Avoid: Umbilicus (stay 2-3 cm away), moles, scars, and lipohypertrophy.

Rotation Strategy

  • Systematic Rotation: Essential to prevent lipohypertrophy.

  • Spacing: Injections should be spaced at least 1 to 2 cm (one finger width) apart.

  • Plan: Rotate sites within the same anatomical area (e.g., abdomen) at the same time of day to reduce glycemic variability.

5. Complications: Lipohypertrophy

  • Definition: “Rubbery” or thickened lesions in the fat tissue caused by insulin’s anabolic effect and needle reuse/lack of rotation.

  • Consequences:

    • erratic/blunted absorption (insulin pooling).

    • Unexplained hypoglycemia or hyperglycemia.

    • Increased insulin requirements (higher doses needed).

  • Detection: Visual inspection and palpation (sweeping motion with fingertips).

  • Management: Stop injecting into the area immediately. Use a new needle every time. Rotate sites.

    • Clinical Pearl: When switching from a lipo (rubbery) site to healthy tissue, reduce the insulin dose (often by ~20%) to prevent hypoglycemia, as absorption will suddenly improve.

6. Special Populations

Pregnancy

  • Preferred Site: Abdomen.

  • Third Trimester: Use the lateral sides of the abdomen (flanks) as the central skin becomes taut.

  • Needle: Use 4-mm needles to avoid fetal harm or IM injection.

Pediatrics

  • Needles: 4-mm is the safest length.

  • Technique:

    • Children >6 years: 4-mm at 90 degrees (no pinch usually needed).

    • Children 2-6 years: 4-mm with a skin lift.

  • Sites: Buttocks may be better for preschool children due to more fat tissue.

Older Adults

  • Considerations: Thinner skin, reduced dexterity, cognitive changes.

  • Device: Pens are preferred over syringes for safety and ease of use.

  • Cognitive Assessment: Use the Clock Drawing Test to assess ability to manage injection therapy.

7. Insulin Infusion (Pumps)

  • Change Frequency: Infusion sets should be changed every 2 to 3 days to prevent infection and lipohypertrophy.

  • Cannula Selection:

    • Teflon: Flexible, comfortable. Change every 2-3 days.

    • Steel: For those with Teflon allergies or kinking issues (e.g., pregnancy, high muscle mass). Change every 2 days.

  • Troubleshooting: “Unexplained hyperglycemia” = Check for occlusion/kinking. If ketones present, give insulin via pen/syringe immediately.

8. Storage & Handling

  • In-Use Insulin: Store at room temperature (max 25-30°C) to reduce injection pain and air bubbles.

    • Usually good for ~28 days (check manufacturer).

  • Unopened Insulin: Refrigerator (2 to 8°C). Do not freeze.

  • Extreme Temps: Avoid direct sunlight or temperatures >30°C.

Reference:

Berard L, Desrochers F, Husband A, MacNeil G, Roscoe R. FIT Canada Recommendations for Best Practice in Injection Technique – 4th Edition. Accessed June 8, 2025. http://www.fit4diabetes.com/canada-english/
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CDE Diabetes

Flashcards: Clinical Practice Guidelines Tools & Resources

The 2018 Clinical Practice Guidelines provide a suite of practical tools designed to translate evidence into daily patient care. These flashcards are designed to help pharmacists and healthcare professionals memorize the critical acronyms, screening protocols, and safety checklists—from the “SADMANS” sick-day rules to the specific criteria for driving safety—ensuring you are ready for any clinical scenario.

Key Topics Covered:

  • Sick Day Management: Memorizing the “SADMANS” mnemonic to identify medications (Sulfonylureas, ACE inhibitors, Diuretics, Metformin, ARBs, NSAIDs, SGLT2 inhibitors) that must be paused during acute illness to prevent kidney injury.

  • Vascular Protection: Recalling the “ABCDES” checklist (A1C, BP, Cholesterol, Drugs, Exercise/Eating, Smoking/Stress) used in the Patient Care Flow Sheet to ensure comprehensive risk reduction.

  • Insulin Pharmacokinetics: Mastering the onset, peak, and duration profiles for various insulin types (rapid, short, intermediate, and long-acting) to optimize dosing and prevent hypoglycemia.

  • Neuropathy Screening: Reviewing the correct technique for using the 10g Semmes-Weinstein monofilament and 128 Hz tuning fork to detect loss of protective sensation.

  • Driving Safety: Understanding the specific assessment criteria for private vs. commercial drivers, including the requirements for glucose monitoring and hypoglycemia awareness.

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CDE Diabetes

Practice Exam: Clinical Practice Guidelines Tools & Resources

Translating clinical guidelines into daily practice requires practical, accessible tools. The 2018 Guidelines provide a suite of resources—from vascular protection checklists to sick-day protocols—that function as the “how-to” manual for patient safety and comprehensive care.

This practice exam tests your proficiency in utilizing these essential algorithms and checklists to manage cardiovascular risk, prevent acute complications, and ensure safe medication practices.

Key Concepts Covered in This Exam:

  • Vascular Protection: Mastering the “ABCDES” of diabetes care (A1C, BP, Cholesterol, Drugs, Exercise/Eating, Smoking/Stress) to implement global vascular protection.

  • Sick Day Management: Applying the “SADMANS” protocol to identify which medications (Sulfonylureas, ACE inhibitors, Diuretics, Metformin, ARBs, NSAIDs, SGLT2 inhibitors) must be paused during acute illness to prevent kidney injury.

  • Hypoglycemia Protocols: Reviewing the steps for recognizing and treating mild-to-moderate hypoglycemia (15g carbohydrate rule) versus the management of severe hypoglycemia requiring glucagon.

  • Driving Safety: Understanding the assessment criteria for drivers with diabetes, including the requirements for blood glucose monitoring and the implications of hypoglycemia unawareness.

  • Foot Care & Screening: utilizing the specific checklists for daily foot care and understanding the “Dos and Don’ts” to prevent ulceration and amputation.

Please go to Practice Exam: Clinical Practice Guidelines Tools & Resources to view this quiz

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Study Guide: Diabetes Canada Clinical Practice Tools

1. Screening & Diagnosis: Postpartum GDM

Review the “Postpartum Screening” tool.

  • The “Why”: GDM increases the risk of T2D significantly. A fasting glucose alone can miss up to 40% of dysglycemia in postpartum women.
  • Screening Protocol:
    • Method: 75g Oral Glucose Tolerance Test (OGTT).
    • Timing: Between 6 weeks and 6 months postpartum.
    • Ongoing Surveillance:
      • If negative: Rescreen every 3 years (or sooner if risk factors present) and before a future pregnancy.
      • If positive (Prediabetes/T2D): Refer to diabetes education/management.
  • Prevention: Lifestyle modification (diet/exercise) can reduce T2D risk by up to 60%.
     

2. Pharmacotherapy: T2D Management

Review the “Cardiorenal Protection” and “Stepwise Approach” tools.

A. Cardiorenal Protection (The “ABCDE” of Prevention)
Prioritize agents with proven benefit for ASCVD, HF, or CKD regardless of A1C target.
  • High CV Risk: Start GLP-1 RA and/or SGLT2i.
  • Heart Failure (HF): Start SGLT2i (Dapagliflozin, Empagliflozin, Canagliflozin).
  • CKD: Start SGLT2i, GLP-1 RA, and/or nsMRA (Finerenone).
  • Statin Therapy: Recommended if:
    • Age 40.
    • Age 30 with diabetes >15 years.
    • Any microvascular complications or CV risk factors.

B. Renal Function & Medication Safety

Memorize the eGFR cut-offs for holding/stopping meds.

  • Metformin:
    • eGFR < 15 or dialysis: Avoid/Stop.
    • eGFR 15-29: Max dose 500 mg/day.
    • eGFR 30–44: Max dose 1000 mg/day.
  • SGLT2 Inhibitors:
    • Dapagliflozin: Do not initiate if eGFR < 25 (can continue until dialysis).
    • Empagliflozin: Do not initiate if eGFR < 20 (can continue until dialysis).
    • Canagliflozin: Do not initiate if eGFR < 30 (can continue until dialysis).
  • Sulfonylureas:
    • Glyburide: Avoid if eGFR < 60 (Use Gliclazide instead).

3. Insulin Management

A. Initiation in Type 2 Diabetes

  1. Basal Start:
    • Start at 10 units at bedtime or 0.1–0.2 units/kg (for lean individuals <50kg).
    • Titration: Increase by 1 unit every day until fasting BG is 4–7 mmol/L.
    • Tresiba (Degludec): Increase by 2–4 units every 3–7 days.
  2. Basal-Plus: If targets not met, add 1 injection of bolus insulin at the largest meal (start ~4 units or 10% of basal dose).
  3. Basal-Bolus: Start TDD at 0.3–0.5 units/kg. Split 40-50% Basal / 50-60% Bolus.

B. Insulin Pharmacokinetics (Key for Exam scenarios)

  • Rapid-Acting (Aspart, Lispro, Glulisine): Onset 9–20 min, Peak 1–1.5 h, Duration 3–5 h.
  • Fiasp (Faster Aspart): Onset 4 min, Peak 0.5–1.5 h.
  • Basal:
    • Glargine U-100 (Lantus): Duration up to 24h, no peak.
    • Glargine U-300 (Toujeo): Duration >30h.
    • Degludec (Tresiba): Duration 42h.
    • Icodec (Awiqli): Once weekly, duration >7 days.

C. Automated Insulin Delivery (AID) Safety

If an AID pump fails, how do you transition to injections?

  • Basal Replacement: Total daily basal = Pump TDD 2.
    • Transition: Give rapid-acting insulin every hour until long-acting takes effect if pump off >1 hour.
  • Bolus: Use the pump’s Insulin-to-Carb Ratio (ICR).
  • Correction: Use the pump’s Insulin Sensitivity Factor (ISF).

4. Safety: Hypoglycemia & Sick Days

Review “Keeping People Safe” tools.

A. Sick Day Management: “SADMANS”

Hold the following medications during dehydrating illness (vomiting/diarrhea) to prevent kidney injury:

  • S – Sulfonylureas

  • A – ACE Inhibitors

  • D – Diuretics

  • M – Metformin

  • A – ARBs

  • N – NSAIDs

  • S – SGLT2 Inhibitors

B. Hypoglycemia Management

  • Level 1 (<3.9 mmol/L) & Level 2 (<3.0 mmol/L): Treat with 15g fast-acting carb. Retest in 15 min.
  • Level 3 (Severe/Unconscious): Glucagon (3mg intranasal or 1mg SC/IM).
  • Driving Guidelines (“5 to Drive”):
    • Check BG before driving and every 4 hours.
    • If BG < 4.0, stop and treat. Wait until BG 5.0 mmol/L to drive.
    • Wait 45-60 mins for brain function to restore.

5. Special Populations: Ramadan Fasting

Review “Ramadan Fasting Position Statement”.

A. Risk Stratification
  • Very High Risk (MUST NOT FAST): T1D with A1C >9%, hypoglycemia unawareness, recent DKA/severe hypo, pregnancy (on insulin).
  • High Risk (SHOULD NOT FAST): T2D with poor control, pregnancy (diet controlled), intense labor.

B. Medication Adjustments During Fasting

  • Metformin/SGLT2i/GLP-1: No dose change usually needed (SGLT2i take at Iftar). Note: Hold SGLT2i if elderly/diuretic use.
  • Sulfonylureas: Switch to Gliclazide/Repaglinide (lower hypo risk).
    • Gliclazide: Take at Iftar (sunset); reduce dose if needed.
  • Insulin:
    • Basal: Reduce dose by 15–30%.
    • Premix: Take normal morning dose at Iftar; reduce Suhur (predawn) dose by 25–50%.

6. Complications Screening: Foot Care

Review “Inlow’s 60-second Diabetic Foot Screen”.

A. The 60-Second Screen
  • Look: Skin (ulcer, callus), Nails (thick, ingrown), Deformity (Charcot, bunions).
  • Feel: Temperature (hot=infection/Charcot, cool=ischemia).
  • Ask: “Do your feet ever feel numb, tingle, or burn?”.

B. Risk Categories & Management

Risk CategoryDefinitionScreen
Frequency
Very Low (0)No LOPS (Loss of Protective Sensation), No PAD

Yearly

 

 

Low (1)LOPS or PAD

6–12 Months

 

 

Moderate (2)LOPS + PAD or Deformity

3–6 Months

 

 

High (3)History of ulcer/amputation

1–3 Months

 

 

UrgentActive ulcer, infection, Charcot

 

Immediate

 

 

 

7. Psychosocial & Immunizations

Review “Diabetes Distress Scale” and “Immunizations”.

A. Diabetes Distress Scale (DDS)
  • Interpretation: A mean item score 2.0 indicates moderate distress worthy of clinical attention.
  • Domains: Emotional Burden, Physician Distress, Regimen Distress, Interpersonal Distress.
  • Action: If score 3.0, administer full scale and discuss specific sources.

B. Recommended Immunizations

Adults with diabetes should receive:

  • Annual: Influenza, COVID-19.
  • One-time/Series:
    • Pneumococcal: Pneu-C-20 or Pneu-C-21 (one dose).
    • Hepatitis B: If not vaccinated in childhood.
    • Shingles (Herpes Zoster): Recombinant Zoster Vaccine (RZV) (2 doses) for age 50.
    • RSV: Adults 50 (individualized).

References:

Many tools can be downloaded at: For Health-Care Providers Tools & Resources 

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CDE Diabetes

Flashcards: Clinical Tools & Resources (Appendices)

The Appendices of the Clinical Practice Guidelines are the practical “engine room” of diabetes care, containing the specific tools needed to translate theory into action. These flashcards are designed to help pharmacists and healthcare professionals quickly recall critical lists—from the “SADMANS” sick-day protocol to insulin pharmacokinetics—ensuring you have these references at your fingertips when patient safety is on the line.

Key Topics Covered:

  • Sick Day Management: Memorizing the “SADMANS” mnemonic to identify medications (Sulfonylureas, ACE inhibitors, Diuretics, Metformin, ARBs, NSAIDs, SGLT2 inhibitors) that must be held during acute illness to prevent kidney injury.

  • Insulin Pharmacokinetics: Recalling the specific onset, peak, and duration profiles for rapid-acting, short-acting, intermediate, and long-acting insulins to optimize timing and avoid hypoglycemia.

  • Neuropathy Screening: Reviewing the correct application of the 10g Semmes-Weinstein monofilament and 128 Hz tuning fork to detect loss of protective sensation.

  • Etiologic Classification: Distinguishing between different types of diabetes, including those induced by drugs (e.g., atypical antipsychotics, glucocorticoids) or genetic defects (e.g., MODY).

  • Titration Protocols: Mastering the standard initiation and titration rules for basal insulin (e.g., starting at 10 units and increasing by 1 unit daily until fasting targets are met).

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CDE Diabetes

Practice Exam: Clinical Tools & Resources (Appendices)

The Appendices of the 2018 Guidelines are not merely supplementary material; they are the “engine room” of clinical practice. They provide the practical tools, algorithms, and reference charts necessary to translate evidence into daily patient care—from safe insulin titration and sick day management to comprehensive foot exams and driving safety assessments.

This practice exam tests your proficiency in utilizing these essential tools to ensure patient safety, accurate classification, and effective self-management support.

Key Concepts Covered in This Exam:

  • Sick Day Management: Mastering the “SADMANS” protocol—knowing which medications (like sulfonylureas, ACE inhibitors, diuretics, metformin, and SGLT2 inhibitors) to pause during acute illness to prevent kidney injury and adverse effects.
  • Insulin Pharmacokinetics: Memorizing the onset, peak, and duration of various insulin types (e.g., rapid-acting analogues vs. NPH vs. long-acting basal insulins) to optimize timing and prevent hypoglycemia.
  • Titration Protocols: Applying the specific algorithms for starting and adjusting basal insulin, such as the rule to increase basal insulin by 1 unit daily until the fasting glucose target is reached.
  • Neuropathy Screening: Understanding the correct technique for using the 10g Semmes-Weinstein monofilament and the 128 Hz tuning fork to detect loss of protective sensation and assess ulcer risk.
  • Etiologic Classification: Differentiating between Type 1, Type 2, and “Other specific types” of diabetes, including those induced by drugs (e.g., glucocorticoids, atypical antipsychotics) or genetic defects (e.g., MODY).

Please go to Practice Exam: Clinical Tools & Resources (Appendices) to view this quiz

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CDE Exam Study Guide: Clinical Practice Guidelines Appendices (2018)

1. Diabetes Charter (Appendix 1)

Key Takeaway: The Charter defines the rights and responsibilities of people living with diabetes, healthcare providers, governments, and organizations. The central theme is dignity, respect, and equity.

  • The Vision: A country where people with diabetes live to their full potential.
  • Guiding Principles:
    • Treat people with dignity and respect.
    • Advocate for equitable access to care.
    • Enhance quality of life for patients and caregivers.

A. Rights of Canadians with Diabetes

  • Respect & Dignity: To be free from stigma and discrimination.
  • Access: Affordable/timely access to meds, devices, supplies, and healthy food regardless of income or location.
  • Care Team: Timely diagnosis and education from an interprofessional team (nurse, dietitian, pharmacist, etc.).
  • Decision Making: To be an active partner in decisions regarding their own care.
  • Accommodation:
    • Schools/Daycares: Full participation with reasonable accommodation and assistance.
    • Workplaces: Supportive environments that do not discriminate and provide reasonable accommodation.

B. Responsibilities of Canadians with Diabetes

  • Self-Management: Manage diet, exercise, and medication to the best of their ability and personal circumstances.
  • Transparency: Be honest and open with health providers to allow for suitable care plans.
  • Education: Actively seek information and support.

C. Responsibilities of Health-Care Providers

  • Partnership: Treat people with diabetes as full partners in their care.
  • Evidence-Based Care: Apply up-to-date clinical practice guidelines (CPG).
  • Early Diagnosis: Diagnose diabetes as early as possible.
  • System Navigation: Help patients navigate the healthcare system.

D. Institutional Responsibilities

  • Schools/Daycares: Must ensure staff have accurate information, provide a safe environment for self-management, and protect children from discrimination.
  • Workplaces: Must eliminate discrimination and provide accommodation.
  • Governments: Guarantee fair access to care regardless of income/location and address disparities in vulnerable populations.

2. Etiology & Classification (Appendix 2)

Key Takeaway: While Type 1 and Type 2 are most common, you must recognize “Other Specific Types” often triggered by medications or genetics.

  • Drug-Induced Diabetes: Be able to identify drugs that induce hyperglycemia:
    • Glucocorticoids (e.g., prednisone)
    • Atypical Antipsychotics (e.g., clozapine, olanzapine)
    • Statins (HMG CoA reductase inhibitors)
    • Thiazides (diuretics)
    • Calcineurin inhibitors (transplant drugs)
  • Genetic Syndromes: Commonly associated with diabetes include Down syndrome, Turner syndrome, and Klinefelter syndrome.

3. Physical Activity Prescription (Appendix 4)

Key Takeaway: “Smarter Step Count” prescription.

  • Goal: Increase baseline step count by 3,000 steps per day within 1 year.
  • Increments:
    • If baseline <5,000 steps: Add 500 steps at first visit.
    • If baseline 5,000-7,499: Add 750 steps at first visit.
    • If baseline 7,500: Add 1,000 steps at first visit.

5. Self-Monitoring of Blood Glucose (SMBG) (Appendix 5)

Key Takeaway: Frequency of testing depends on the treatment regimen and glycemic stability.

  • Basal-Bolus (MDI) or Pump: Test 4 times daily (before meals and bedtime).
  • Oral Agents / Lifestyle only: If meeting targets, frequent testing is not usually required.
  • Newly Diagnosed (<6 mos): Test 1 time/day at different times to learn how lifestyle affects BG.
  • Safety Occupations: As required by employer/driving guidelines.

6. Insulin Pharmacokinetics (Appendix 6)

Key Takeaway: You must know the Onset, Peak, and Duration to troubleshoot hypoglycemia or hyperglycemia patterns.

Insulin TypeExamplesOnsetPeakDuration

Rapid-
Acting

Aspart, Lispro,
Glulisine		10–15 min1–2 h

3–5 h

 

 

Short-
Acting		Regular
(Toronto)		30 min2–3 h

6.5 h

 

 

IntermediateNPH (Cloudy)1–3 h5–8 h

Up to 18 h

 

 

Long-
Acting		Glargine U-100, Detemir90 minNone

Up to 24 h

 

 

Ultra-LongDegludec,
Glargine U-300		90 minNone

>30 h

 

 

7. Sick Day Management: "SADMANS" (Appendix 8)

Key Takeaway: When a patient is ill, dehydrated, or has acute renal decline, certain medications must be PAUSED to prevent acute kidney injury (AKI) or adverse effects.

Instructions: Stop the following meds if unable to maintain hydration; restart when well.

  • S – Sulfonylureas (risk of hypoglycemia)
  • A – ACE Inhibitors (risk of renal decline)
  • D – Diuretics / Direct Renin Inhibitors (risk of volume depletion)
  • M – Metformin (risk of lactic acidosis/reduced clearance)
  • A – Angiotensin Receptor Blockers (ARBs) (risk of renal decline)
  • N – Non-steroidal Anti-inflammatory Drugs (NSAIDs) (risk of renal decline)
  • S – SGLT2 Inhibitors (risk of DKA/volume depletion)

Exam Tip: Remember that insulin should not inherently be stopped during sick days; often doses need adjustment (usually increasing) due to stress hyperglycemia, but the “SADMANS” list refers specifically to non-insulin meds that pose safety risks during dehydration.

8. Insulin Initiation & Titration in T2D (Appendix 9)

Key Takeaway: The standard approach for starting insulin in Type 2 Diabetes involves safety first (avoiding hypo) and gradual titration.

  • Starting Basal Insulin:
    • Start: 10 units at bedtime.
    • Titrate: Increase by 1 unit per day until fasting glucose target (4.0–7.0 mmol/L) is reached.
    • Exception: Degludec is titrated every 3–4 days (2 units) or once weekly (4 units) due to longer half-life.
  • Safety Rule: Do not increase dose if the patient has >2 hypo episodes (<4.0 mmol/L) in a week or any nocturnal hypoglycemia.
  • Adding Bolus (Basal Plus): Start 2–4 units at one meal (usually largest). Titrate by 1 unit daily to target 2hr post-meal 8.0 mmol/L .

9. Driving Guidelines (Appendix 10)

Key Takeaway: Assessment for fitness to drive focuses on hypoglycemia awareness and severity.

  • Commercial Drivers: Disqualified if they have any episodes of severe hypoglycemia during waking hours in the past 12 months .
  • Private Drivers: Assessment focuses on severe hypoglycemia in the past 6 months .
  • Monitoring Rule: Drivers on insulin/secretagogues must monitor at least every 4 hours while driving.
  • Supplies: Must have monitoring equipment and rapid carbs within reach in the vehicle.

10. Foot Care & Neuropathy Screening (Appendices 11, 12, 13)

Key Takeaway: Screening must be done annually using a 10g Monofilament or 128 Hz Tuning fork to assess risk of ulceration.

A. 10g Semmes-Weinstein Monofilament Test

  • Technique: Apply perpendicular to skin until it buckles for ~1 second.
  • Sites: Dorsum of great toe (screening) or plantar sites (comprehensive).
  • Scoring (Screening):
    • Test 8 stimuli (4 per foot).
    • Score < 3/8 correct = Likely Neuropathy.
    • Protective sensation is absent if 2 out of 3 applications at a single site are incorrect.

B. 128 Hz Tuning Fork (On-Off Method)

  • Apply to the bony prominence of the great toe.

  • Patient must identify when vibration is felt and when it stops.

C. Foot Care Checklist

  • DO: Check feet daily, use mirror, trim nails straight across, buy shoes in late afternoon (feet swell).
  • DO NOT: Soak feet, use hot water bottles, walk barefoot, use over-the-counter corn/wart removers.

References:

Appendix 1: Diabetes Canada Diabetes Charter. Canadian Journal of Diabetes. 2018;42:S307. doi:10.1016/j.jcjd.2017.11.001
Appendix 2: Etiologic Classification of Diabetes Mellitus. Canadian Journal of Diabetes. 2018;42:S308. doi:10.1016/j.jcjd.2017.10.041
Appendix 3: Examples of Insulin Initiation and Titration Regimens in People with Type 2 Diabetes. Canadian Journal of Diabetes. 2013;37, Supplement 1:S200-S201. doi:10.1016/j.jcjd.2013.02.041
Appendix 4: Smarter Step Count Prescription. Canadian Journal of Diabetes. 2018;42:S311. doi:10.1016/j.jcjd.2017.12.005
Appendix 5: Self-Monitoring of Blood Glucose (SMBG) Recommendation Tool for Health-Care Providers. Canadian Journal of Diabetes. 2018;42:S312-S313. doi:10.1016/j.jcjd.2017.10.043
Appendix 6: Therapeutic Considerations for Renal Impairment. Canadian Journal of Diabetes. 2013;37, Supplement 1:S207-S208. doi:10.1016/j.jcjd.2013.02.044
Diabetes Canada. Appendix 6: Types of Insulin. Canadian Journal of Diabetes. 2018;42:S314. doi:10.1016/j.jcjd.2017.12.006
Appendix 8: Sick-Day Medication List. Canadian Journal of Diabetes. 2018;42:S316. doi:10.1016/j.jcjd.2017.10.045
Diabetes Canada. Appendix 9: Examples of Insulin Initiation and Titration Regimens in People With Type 2 Diabetes. Accessed April 11, 2025. https://guidelines.diabetes.ca/appendices/appendix9
Appendix 10: Sample Diabetes and Driving Assessment Form. Canadian Journal of Diabetes. 2018;42:S319. doi:10.1016/j.jcjd.2017.10.050
Appendix 11A: Rapid Screening for Diabetic Neuropathy Using the 10 g Semmes-Weinstein Monofilament. Canadian Journal of Diabetes. 2018;42:S320. doi:10.1016/j.jcjd.2017.10.046
Appendix 11B: Rapid Screening for Diabetic Neuropathy Using the 128 Hz Vibration Tuning Fork (the “On-Off” Method). Canadian Journal of Diabetes. 2018;42:S321. doi:10.1016/j.jcjd.2017.10.054
Appendix 12: Monofilament Testing in the Diabetic Foot. Canadian Journal of Diabetes. 2018;42:S322. doi:10.1016/j.jcjd.2017.10.047
Appendix 13: Diabetes and Foot Care: A Checklist. Canadian Journal of Diabetes. 2018;42:S323. doi:10.1016/j.jcjd.2017.10.048
Appendix 14: Diabetic Foot Ulcers—Essentials of Management. Canadian Journal of Diabetes. 2018;42:S324. doi:10.1016/j.jcjd.2017.10.049
Appendix 15: Glycated Hemoglobin Conversion Chart. Canadian Journal of Diabetes. 2018;42:S325. doi:10.1016/j.jcjd.2017.10.051
Categories
CDE Diabetes

Flashcards: Diabetes and MASLD (Chapter 42)

Metabolic Dysfunction-associated Steatotic Liver Disease (MASLD)—formerly NAFLD—is a highly prevalent comorbidity in Type 2 diabetes that significantly increases the risk of cirrhosis, hepatocellular carcinoma, and cardiovascular death. These flashcards are designed to help pharmacists and healthcare professionals quickly recall the 2024 Clinical Practice Guidelines Update regarding the new nomenclature, the two-step screening algorithm for fibrosis, and the emerging pharmacotherapeutic options.

Key Topics Covered:

  • New Terminology: Understanding the transition from NAFLD to MASLD (Metabolic Dysfunction-associated Steatotic Liver Disease) and MASH (Metabolic Dysfunction-associated Steatohepatitis) [cite: Ch42-Diabetes-and-Metabolic-Dysfunction-associated-Steatotic-Liver-Disease-in-Adults.pdf].

  • Screening Protocol: Memorizing the two-step algorithm: starting with the FIB-4 index (age, AST, ALT, platelets) every 3 years to rule out advanced fibrosis in patients with Type 2 diabetes [cite: Ch42-Diabetes-and-Metabolic-Dysfunction-associated-Steatotic-Liver-Disease-in-Adults.pdf].

  • Risk Stratification: Identifying the thresholds for referral: knowing that a low FIB-4 score (<1.3) allows for continued primary care management, while higher scores require second-line testing (e.g., FibroScan).

  • Pharmacotherapy: Recalling that GLP-1 receptor agonists and SGLT2 inhibitors are the preferred antihyperglycemic agents for patients with MASLD, and that pioglitazone has specific benefits for MASH.

  • Statin Use: Reinforcing that statins are safe and essential for cardiovascular protection in this population, despite potential mild elevations in liver enzymes.