Pharmacologic Management Flashcards: 2024 Diabetes Update

You have reviewed the study guide for the Diabetes Canada 2024 Pharmacologic Update, and now it is time to test your knowledge.

This is arguably the most critical section of the CDE exam. The 2024 Guidelines have cemented a paradigm shift in diabetes care: we are no longer treating “sugar” in isolation; we are treating risk. The exam will require you to look beyond the A1C number and identify patients who need Cardiorenal Protection regardless of their glycemic control.

What to expect in this quiz: This practice exam focuses on the complex decision trees introduced in the latest update. You will be tested on:

The “Cardiorenal Path”: Identifying patients with ASCVD, Heart Failure, or CKD who require an SGLT2 inhibitor or GLP-1 RA, even if their A1C is already at target.
The “1.5% Rule”: Knowing when to bypass monotherapy and initiate Metformin + a second agent immediately at diagnosis.
Symptomatic Decompensation: Recognizing the clinical signs (weight loss, severe hyperglycemia) that mandate the immediate start of Insulin.
Heart Failure Nuances: Specifically recalling that SGLT2 inhibitors are the only class proven to reduce hospitalizations for heart failure.

1. Case: A patient with type 2 diabetes and heart failure with preserved ejection fraction (HFpEF) needs therapy intensification. Which medications have demonstrated benefit?

Only GLP1-RAs
TZDs
Sulfonylureas
Dapagliflozin and empagliflozin

2. According to the guidelines, which long-acting basal insulin analogues may be considered to reduce the risk of nocturnal hypoglycemia?

NPH insulin
Insulin detemir
Insulin glargine U-100
Insulin degludec or insulin glargine U-300

3. Case: A patient asks whether using both a GLP1-RA and SGLT2 inhibitor together will provide additional cardiorenal benefit. What does the evidence show?

The combination is not recommended
Yes, trials have confirmed additional cardiorenal benefit
No clinical trials have assessed the combination for cardiorenal protection, so additional benefit is unknown
The combination provides no glycemic benefit

4. Case: A patient using a GLP1-RA is scheduled for elective surgery. According to the User’s Guide, what is the concern?

Increased DKA risk
GLP1-RA may delay gastric emptying increasing the risk of pulmonary aspiration
Increased hypoglycemia risk
No special precautions are needed

5. According to the guidelines, what is the level of evidence supporting the use of basal-bolus injection therapy or CSII for cardiorenal protection in type 2 diabetes?

All insulins have demonstrated cardiorenal protection
Insulin does not have specific cardiorenal benefits but is used for glycemic control
Insulin has demonstrated cardiorenal protection in clinical trials
Insulin has CV benefit but not renal benefit

6. According to the 2024 guidelines, what is the recommended first-line antihyperglycemic medication for most people with type 2 diabetes who require pharmacotherapy?

Metformin
Sulfonylurea
GLP1-RA
SGLT2 inhibitor

7. According to the User’s Guide, what is the concern with using oral semaglutide compared to subcutaneous semaglutide?

Oral semaglutide has smaller weight/A1C-lowering effects
Oral semaglutide cannot be used with metformin
Oral semaglutide has more GI side effects
Oral has more CV benefit

8. According to the evidence, what is the A1C threshold above target where combination therapy is recommended as initial pharmacologic therapy?

More than 2.0% above target
More than 0.5% above target
More than 1.5% above target
More than 1.0% above target

9. Which GLP1-RAs have demonstrated reduction in major adverse cardiovascular events (MACE) in people at high CV risk?

Lixisenatide, exenatide, and oral semaglutide
All GLP1-RAs have demonstrated CV benefit
Dulaglutide, liraglutide, and subcutaneous semaglutide
Only injectable semaglutide

10. According to the guidelines, which SGLT2 inhibitors have demonstrated reduction in MACE outcomes in people at high CV risk?

Canagliflozin and empagliflozin
Dapagliflozin and ertugliflozin
All SGLT2 inhibitors
Only empagliflozin

11. Case: A diabetes educator is evaluating a patient with type 2 diabetes who is not meeting glycemic targets. Before intensifying pharmacologic therapy, what should be assessed according to the guidelines?

Only the patient’s weight
Only medication adherence
Potential precipitants of increasing A1C and medication adherence including barriers to adherence
Only the need for insulin

12. What is the recommended starting dose of metformin to minimize gastrointestinal side effects?

500 mg once daily
250 mg or 500 mg twice daily
2,000 mg once daily
1,000 mg once daily

13. What is the recommended target dose of metformin when initiating therapy?

500 mg daily
1,500 mg daily
2,000 mg daily
1,000 mg daily

14. Which drug class is associated with negligible risk for hypoglycemia and leads to weight loss?

Thiazolidinediones
GLP1-RAs and SGLT2 inhibitors
Sulfonylureas
DPP4 inhibitors

15. According to the guidelines, what is the recommended approach for initiating bolus insulin in type 2 diabetes?

Start with full basal-bolus regimen immediately
Start with 1 injection at the largest meal
Start with bolus insulin at all meals
Start bolus insulin before basal insulin

16. According to the evidence, what is the effect on A1C when combining metformin with another agent at the outset compared to metformin alone?

0.1% to 0.2% lower
1.5% to 2% lower
No difference
0.4% to 1% lower

17. According to the guidelines, what is the timeframe goal for reaching target A1C after dose adjustments or additions of medications?

1 to 2 months
9 to 12 months
3 to 6 months
12 to 18 months

18. What is the typical A1C reduction with non-insulin antihyperglycemic agent monotherapy?

0.1% to 0.3%
0.5% to 1.5%
2.0% to 3.0%
3.0% to 4.0%

19. Case: A patient with type 2 diabetes experiences declining kidney function. According to the guidelines, at what eGFR level is metformin contraindicated?

<45 mL/min/1.73 m²
<15 mL/min/1.73 m²
<60 mL/min/1.73 m²
<30 mL/min/1.73 m²

20. Case: A patient is concerned about the risk of DKA with SGLT2 inhibitors. According to the User’s Guide, when should SGLT2 inhibitors be held?

SGLT2 inhibitors never need to be held
Only during hospitalization
If fasting, consuming a low-carbohydrate diet, at risk for volume depletion, or prior to major surgery
Only if blood glucose exceeds 15 mmol/L

21. Case: A patient with type 2 diabetes has GI intolerance to immediate-release metformin. According to the User’s Guide, what strategies can be used?

Increase the dose to overcome side effects
Stop metformin permanently
Add a proton pump inhibitor
Switch to extended-release metformin

22. Case: A diabetes educator is counselling a patient about sulfonylureas. What are the key concerns with this drug class?

Weight neutral with low hypoglycemia risk
Weight gain and hypoglycemia
Weight loss and hypoglycemia
GI side effects and weight gain

23. According to the evidence comparing metformin with other agents as monotherapy, what are the relative advantages of metformin?

Metformin has the fewest GI side effects
Metformin causes the most weight loss
Metformin has comparable A1C lowering to sulfonylureas but better glycemic durability, negligible hypoglycemia risk, no weight gain, and lower CV risk
Metformin has the greatest A1C lowering

24. According to the guidelines, when should insulin be initiated immediately with or without metformin?

When A1C is above 7%
Only when other oral agents have failed after 12 months
When the patient is over 80 years old
In individuals with metabolic decompensation and/or severe symptomatic hyperglycemia

25. Case: A patient asks about tirzepatide compared to GLP1-RAs. According to the User’s Guide, what does the evidence show?

Tirzepatide has the same efficacy as semaglutide
Tirzepatide has lower A1C and weight reduction than semaglutide
Tirzepatide has superior CV outcome benefits than semaglutide
Tirzepatide shows greater A1C and weight reduction than semaglutide

26. According to the UKPDS, what was demonstrated with metformin monotherapy in newly-diagnosed participants who had overweight?

Weight gain
No cardiovascular benefit
Increased risk of hypoglycemia
Cardiovascular and all-cause mortality benefits

27. Case: A 58-year-old patient with newly diagnosed type 2 diabetes has an A1C of 9.5% (target 7.0%). According to the guidelines, what is the recommended initial pharmacotherapy approach?

Start metformin in combination with another antihyperglycemic agent
Start with lifestyle modifications for 6 months before initiating pharmacotherapy
Start insulin only
Start metformin alone and reassess in 6 months

28. Case: A patient with type 2 diabetes and chronic kidney disease (CKD) needs intensification of therapy. According to the guidelines, which SGLT2 inhibitors have demonstrated evidence of benefit for CKD?

Only canagliflozin and empagliflozin
Canagliflozin, dapagliflozin, and empagliflozin
Only canagliflozin and dapagliflozin
Only empagliflozin

29. Case: A patient with type 2 diabetes develops heart failure with reduced ejection fraction (HFrEF). According to the guidelines, which medication class should be prioritized?

DPP4 inhibitors
SGLT2 inhibitors
GLP1-RAs
Sulfonylureas

30. Case: A healthcare team is considering using a TZD for a patient. According to the User’s Guide, what potential benefits and risks should be considered?

A1C lowering with minimal hypoglycemia but increased risk of HF, weight gain, fluid retention, and bone fractures
No significant risks
Only GI side effects
Weight loss and hypoglycemia risk

31. Case: A diabetes educator is discussing NPH insulin with a patient. According to the User’s Guide, what is a major challenge with NPH insulin?

Substantial day-to-day variability in its glucose-lowering effect
It cannot be mixed with other insulins
It must be given three times daily
It causes more weight gain than long-acting analogues

32. According to the guidelines, what are the benefits of adding insulin to non-insulin antihyperglycemic agents compared to using insulin alone?

Lower cost
Faster onset of action
No difference in outcomes
Better glycemic levels with a lower dose of insulin, less weight gain and less hypoglycemia

33. According to the User’s Guide, what is the dose-response relationship for SGLT2 inhibitors regarding glucose lowering and cardiorenal benefits?

Only the highest doses provide cardiorenal benefits
Higher doses provide substantially more glucose lowering and greater cardiorenal benefits
Dose-response varies by specific SGLT2 inhibitor
The dose-response curve is rather flat; low doses seem to be as effective as high doses for cardiorenal benefits

34. According to the guidelines, what should be done when bolus insulin is introduced into a treatment regimen?

Discontinue SGLT2 inhibitors
Continue all oral agents including sulfonylureas
Discontinue metformin
Discontinue insulin secretagogues

35. According to the guidelines and User’s Guide, why should GLP1-RAs NOT be used together with DPP4 inhibitors?

Increased CV risk
Increased DKA risk
Increased hypoglycemia risk
No clinically significant glycemic benefit from the combination

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