Categories
CDE Diabetes

Practice Exam: Glycemic Management in Type 1 Diabetes (Chapter 41)

This new “Special Article” and Clinical Practice Guideline (Chapter 41) represents a significant consolidation in the Diabetes Canada guidelines. It replaces the previous separate chapters for Adults (2018, Ch. 12) and Children/Adolescents (2018, Ch. 34).

For the CDE candidate, this chapter is high-yield. It moves away from age-stratified silos and towards a lifespan approach that prioritizes technology, mental burden reduction, and aggressive complication prevention.

Before you jump into the practice questions, here are the 5 Key Practice Changes you need to know:

  1. AID is the New Gold Standard The guidelines no longer present insulin pumps as a second-line option for specific candidates. Automated Insulin Delivery (AID) systems are now the preferred treatment method for all individuals (adults and children) to optimize glycemia and improve person-reported outcomes. If AID is not possible, CGM should be used with pump therapy or basal-bolus injections.
  2. Pediatric Targets Have Tightened Historically, A1C targets for children were higher to avoid hypoglycemia. However, new evidence links chronic hyperglycemia in young children to white matter structural changes in the brain. Consequently, the recommended A1C target for the pediatric population is now <7.0% across all age groups.
  3. “Ultra” Insulins are Preferred To minimize hypoglycemia and improve outcomes, ultra-rapid and ultra-long-acting insulin analogues should be considered in place of standard rapid- or long-acting analogues for both adults and children.
  4. Adjunctive Therapies (Non-Insulin) The guidelines now open the door for adjunctive therapies in adults, such as Metformin, GLP-1 RAs, or SGLT2 inhibitors, to help meet goals. However, this comes with strict safety warnings, particularly regarding the risk of euglycemic DKA with SGLT2i use.
  5. Managing Emergencies There are updated protocols for hypoglycemia and DKA:
    • Hypoglycemia: Intranasal glucagon is recommended for adults and children.
    • DKA: Subcutaneous insulin can be safely used to manage non-severe DKA , and fluid resuscitation in children can be more aggressive than previously feared.

1. According to the STOP DKA protocol, what blood ketone level should prompt adjustment to diet or insulin in well patients on SGLT2 inhibitors?

2. When should mealtime rapid- or ultrarapid-acting insulin boluses be delivered for optimal glycemic control?

3. Which biosimilar insulin is available in Canada as an alternative to glargine 100 U/mL?

4. What is the subcutaneous insulin dosing protocol studied for mild to moderate DKA in children?

5. What is a potential complication of ultrarapid-acting insulin in IPT or AID that is more common than with rapid-acting analogues?

6. Which weekly basal insulin was recently approved in Canada for type 1 diabetes, but is NOT recommended due to safety concerns?

7. A 3-year-old child with type 1 diabetes is brought to the emergency department unresponsive with severe hypoglycemia. Injectable glucagon is not available. What is the MOST appropriate action?

8. What is the currently available ultrarapid-acting insulin analogue in Canada?

9. According to the guideline, which therapy is classified under ‘Conventional Therapy’ using updated terminology

10. A 28-year-old woman with type 1 diabetes is started on dapagliflozin for glycemic improvement. She presents 3 weeks later with nausea, vomiting, and mild abdominal pain. Her blood glucose is 9.2 mmol/L. What is the MOST critical next step?

11. What is a key difference in hypoglycemia treatment for children using AID systems compared to BBI or IPT?

12. What is the updated terminology for ‘Multiple Daily Injections (MDI)’ according to the 2025 guidelines?

13. Regarding teplizumab for type 1 diabetes prevention, which statement is CORRECT according to the 2025 guidelines?

14. In the DCCT trial, what was the median A1C achieved among participants randomized to intensive insulin therapy?

15. A 6-year-old child on AID experiences a glucose reading of 3.5 mmol/L while playing. She is conscious and able to swallow. How much fast-acting carbohydrate should she consume?

16. For which population does Diabetes Canada recommend AID systems as the preferred insulin delivery method?

17. Which of the following correctly describes ‘IPT + PLGS’?

18. In which severity of pediatric DKA can subcutaneous insulin be safely used as an alternative to intravenous insulin?

19. Which of the following outcomes does AID NOT significantly improve according to meta-analyses?

20. According to international consensus, what improvement in Time in Range (TIR) is considered clinically significant?

21. For a child aged 7 years on basal-bolus injection therapy experiencing level 1 hypoglycemia, how much oral carbohydrate should be used for treatment?

22. Which adjunctive therapy in type 1 diabetes has the highest relative risk of ketoacidosis?

23. A 14-year-old adolescent with type 1 diabetes for 2 years has an A1C of 9.5%. The family is resistant to insulin pump therapy due to concerns about wearing a device. What is the BEST recommendation based on current evidence?

24. A 42-year-old man with type 1 diabetes and BMI of 32 kg/m² is interested in adjunctive therapy for weight loss. He has a history of recurrent urinary tract infections. Which therapy is MOST appropriate?

25. What is the primary reason weekly insulin (icodec) is NOT recommended for most adults with type 1 diabetes?

26. What unique type of ketoacidosis is associated with SGLT2 inhibitor use in type 1 diabetes?

27. According to the 2025 Diabetes Canada guidelines, what is the recommended A1C target for children with type 1 diabetes?

28. What insulin dose reduction was recommended in liraglutide trials when initiating therapy in type 1 diabetes?

29. What is the target sensor glucose range recommended by Diabetes Canada for Time in Range calculations?

30. For an unconscious child aged 5 years with severe hypoglycemia, what is the recommended glucagon route of administration?

31. What is the approximate relative risk of ketoacidosis with SGLT2 inhibitors in type 1 diabetes compared to placebo?

32. What does the acronym ‘AID’ stand for in the context of type 1 diabetes management?

33. A parent asks about the differences between available AID systems for their 10-year-old child. According to guidelines, what should clinicians inform families about system selection?

34. A 35-year-old woman with type 1 diabetes for 15 years has an A1C of 8.2% on BBI therapy with long-acting analogue and rapid-acting analogue. She experiences frequent nocturnal hypoglycemia. Which intervention would BEST address both concerns?