Complete this CE activity online at ProCE.com/InsulinPart2

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1 Complete this CE activity online at ProCE.com/InsulinPart2

2 Case 1: A 67 year old male with T2DM History and Presentation John is a 67 year old retiree who has been visiting your pharmacy/clinic for over 2 years. He was diagnosed with T2DM 6 years ago. He has tried both metformin and sulfonylureas but has since discontinued them because of intolerable GI side effects and efficacy concerns, respectively. Three months ago, he had an A1C of 8.4%, with no changes to his diabetes therapy at that time. He presents today for a follow up visit. Medical History T2DM x 6 years HTN x 5 years Dyslipidemia for 2 years Social History Retired bank manager Active health insurance Nonsmoking with no illicit drug use Infrequent caffeine use (<1 times per week) Occasional alcohol use (~1 drink per week) Self reported largest meal of the day is dinner with evening snacks Family History Diabetes Mellitus Type 2 (mother) Myocardial Infarction (father) Current Medications Insulin glargine (pen) 80 units twice per day Insulin aspart (pen) units per meal + Correction Lisinopril 10 mg daily Atorvastatin 10mg daily Physical Examination Height 5 feet 6 inches Weight 280 lbs Body Mass Index (BMI) 45 kg/m 2 Blood Pressure 124/76 mm Hg Heart rate 74 bpm Slightly decreased sensation in both feet bilaterally; no evidence of retinopathy Laboratory Results (Sample obtained this morning) A1C 8.7% Serum Creatinine (SCr) 1.2 mg/dl Urinary albumin:creatine ratio (ACR) <10 mg/g creatinine Estimated glomerular filtration ratio (egfr) >100 ml/min/1.73 m 2 Low density lipoprotein cholesterol (LDL C) 105 mg/dl High density lipoprotein cholesterol (HDL C) 50 mg/dl Triglycerides 140 mg/dl

3 Question 1 What would you do first? A. Ask John how he injects his insulin B. Ask John how many times a day he tests his blood sugar C. Have John show you how he injects his insulin D. Have John tell you what he eats in a typical day Question 2 Once you are confident that John s injection technique is appropriate, what medication change would you make? A. Increase insulin glargine U 100 to 60 units TID B. Increase insulin aspart to 65 units TID C. Switch to regular insulin U 500 D. Switch to insulin glargine U 300 E. No change is needed at this time Question 3 John s prescriber agrees that concentrated insulin would be appropriate and would like to switch him to U 500. For a total daily dose of 300 units to be given twice daily, how would you instruct John to draw up 150 units of U 500 insulin? A. Using a U 100 syringe, draw to the 60 units marking B. Using a U 100 syringe, draw to the 30 units marking C. Using a tuberculin syringe, draw 0.2 ml D. Using a tuberculin syringe, draw 0.4 ml

4 Case 2: A 60 year old female with T2DM History and Presentation Elaine is 60 years old, and is a new patient at your pharmacy/clinic. She was diagnosed with T2DM 5 years ago. She lives with her family, her husband and their son (age 24) and daughter (age 20). You have no previous laboratory information for Elaine but when you asked about her A1C, she stated that it was high the last time. Medical History HTN x 6 years Dyslipidemia for 6 years T2DM x 5 years Social History Works as a crossing guard for the local elementary school Active health insurance Nonsmoking with no illicit drug use No caffeine use Occasional alcohol use (~4 drinks per week) Self reported large breakfast and dinner; smaller meal, or no meal, around lunchtime Family History Diabetes Mellitus Type 2 (mother) Current Medications Insulin glargine (vial) 80 units once daily at bedtime Insulin Lispro (vial) 25 units per meal + correction with snacks Lisinopril 20 mg once daily Simvastatin 40 mg once daily Aspirin 81 mg once daily Physical Examination Height 5 feet 0 inches Weight 160 lbs Body Mass Index (BMI) 31 kg/ m 2 Blood Pressure 118/78 mm Hg Heart rate 90 bpm No evidence of retinopathy or neuropathy Laboratory Results (Sample obtained this morning) A1C 9% Serum Creatinine (SCr) 0.6 mg/dl Urinary albumin:creatine ratio (ACR) <10 mg/g creatinine Estimated glomerular filtration ratio (egfr) >100 ml/min/1.73 m 2 Low density lipoprotein cholesterol (LDL C) 95 mg/dl High density lipoprotein cholesterol (HDL C) 35 mg/dl Triglycerides 185 mg/dl

5 Question 1 After a comprehensive review, you are confident with Elaine s injection technique and adherence to her current medications. How would you optimize her diabetes management? A. Increase insulin lispro 40 units TID B. Switch to insulin regular U 500 BID C. Switch to insulin regular U 500 TID D. Switch insulin glargine to insulin detemir 40 units BID E. Switch to insulin glargine U 300 only Question 2 Based on the information provided, which of the following is the best rationale that makes Elaine a good candidate for U 500? A. She has a good support system and no physical impairments B. She has a stable meal plan/schedule C. She is already on a bolus insulin regimen D. She is on a high dose of basal insulin regimen Question 3 The endocrinologist would like to try switching Elaine to concentrated insulin, specifically U 500. What is the total daily dose, and how would you instruct her to draw up the U 500 insulin? A. 155 units total daily dose; using a U 100 syringe, draw to the 50 units marking B. 105 units total daily dose; using a U 100 syringe, draw to the 30 units marking C. 105 units total daily dose; using a tuberculin syringe, draw 0.2 ml D. 155 units total daily dose; using a tuberculin syringe, draw 0.1 ml

6 Case 3: 60 year old female with T2DM History and Presentation Margaret is a 60 year old new patient at your clinic. She was diagnosed with T2DM 5 years ago. She is a widow who lives alone with no children. You have no previous laboratory information for Margaret but when you asked about her A1C, she stated that it was high the last time. Additionally, she says that she experiences muscle cramping in her legs, usually around lunchtime and dinnertime. Medical History HTN x 6 years Dyslipidemia x 6 years T2DM x 5 years Arthritis x 1 year Glaucoma x 6 months Social History Works as a crossing guard for the local elementary school Active health insurance Caffeine use = 2 cups coffee daily Occasional alcohol use (~4 drinks per week) Self reported large breakfast and dinner; smaller meal, or no meal, around lunchtime Family History Diabetes Mellitus Type 2 (mother) Current Medications Insulin glargine (pen) 80 units once daily at bedtime Insulin Lispro (pen) 25 units per meal + correction with snacks Lisinopril 20 mg once daily Simvastatin 40 mg once daily Aspirin 81 mg once daily Naproxen (OTC) 275mg twice daily (with food) Latanoprost 0.005% 1 drop in each eye daily Physical Examination Height 5 feet 0 inches Weight 160 lbs Body Mass Index (BMI) 31 kg/m 2 Blood Pressure 120/76 mm Hg Heart rate 70 bpm Increased intraocular pressure and mild retinopathy Laboratory Results (Sample obtained this morning) A1C 9% Serum Creatinine (SCr) 0.6 mg/dl Urinary albumin:creatine ratio (ACR) <10 mg/g creatinine Estimated glomerular filtration ratio (egfr) >100 ml/min/1.73 m 2 Low density lipoprotein cholesterol (LDL C) 95 mg/dl High density lipoprotein cholesterol (HDL C) 35 mg/dl Triglycerides 185 mg/dl

7 Question 1 After a comprehensive review, you are confident with Margaret s injection technique and adherence to her current medications. How would you optimize her diabetes management? A. Increase insulin lispro to 27 units TID B. Start liraglutide once daily C. Switch to regular insulin U 500 D. Switch insulin glargine to insulin detemir 40 units BID E. Switch to insulin glargine U 300 only Question 2 Why isn t Margaret a good candidate for U 500 therapy? (Select all that apply) A. Glaucoma B. Arthritis C. Hypertension D. Dyslipidemia E. Lives alone

8 Case 4: A 56 year old female with T2DM History and Presentation Rachel is 56 years old and has been visiting your pharmacy/clinic for just over 4 years. She was diagnosed with T2DM 4 years ago. The only problem she reports is occasional episodes of nocturnal hypoglycemia (about 3 to 5 per month). She was just discharged from the hospital today due to a severe hypoglycemic event that occurred at 3 AM 2 days ago. When she was monitored 3 months ago, Rachel had an A1C of 9.6%. She presents today with a new prescription for insulin lispro (pen) 10 units TID before meals. However, she says that she does not want to start bolus insulin because she has erratic meal and work schedules. Rachel tells you to throw away the prescription for lispro, as she will never use it. Medical History T2DM x 4 years Dyslipidemia x1 year Social History High school principal Active health insurance Nonsmoking with no illicit drug use Frequent caffeine use (3 4 cups daily) Infrequent alcohol use (~1 drink per 2 weeks) Meal schedule and size is erratic because of her work Family History Cardiovascular disease (mother) Diabetes mellitus type 2 (father) Current Medications NPH (pen) 63 units twice per day; morning (7 AM) and 2 hours before bed (9 PM) Metformin 1000 mg daily Sitagliptin 100 mg daily Simvastatin 20 mg daily Physical Examination Height 5 feet 8 inches Weight 210 lbs Body Mass Index (BMI) 32 kg/m 2 Blood Pressure 136/84 mm Hg Heart rate 72 bpm No evidence of retinopathy or neuropathy Laboratory Results (Sample obtained this morning at the hospital) A1C 8.6% Serum Creatinine (SCr) 1.1 mg/dl Urinary albumin:creatine ratio (ACR) <10 mg/g creatinine Estimated glomerular filtration ratio (egfr) >100 ml/min/1.73 m 2 Low density lipoprotein cholesterol (LDL C) 110 mg/dl High density lipoprotein cholesterol (HDL C) 38 mg/dl Triglycerides 190 mg/dl

9 Question 1 After a comprehensive review, you are confident with Rachel s injection technique and adherence to her current medications. What medication change would you make? A. Start insulin lispro at 10 units TID B. Switch to regular insulin U 500 C. Switch to insulin glargine U 100 D. Switch to insulin glargine U 300 E. No change is needed at this time Question 2 Rachel s prescriber agrees to switch to U 300 insulin glargine. What would be your recommendation for switching from 63 units twice daily (126 units/day) NPH to insulin glargine U 300? A. Using a U 100 syringe, draw to 21 units marking (63 units) and inject twice daily B. Using a U 100 syringe, draw to 49 units marking (126 units) and inject once daily C. Using the U 300 pen, dial to 126 units and inject once daily D. Using the U 300 pen, dial to 51 units and inject twice daily Question 3 Rachel s prescriber asks you how insulin glargine can be titrated? You respond: A. Rachel should return to the prescriber's office in 2 days and the prescriber can advise how to titrate. B. Rachel should return to the pharmacy/clinic in 2 days and the pharmacist can advise how to titrate. C. Rachel can titrate the dose herself every 4 days, based on a protocol provided by her prescriber. D. Rachel should wait 3 months for the next A1c level and then have the prescriber titrate the dose.

10 Case 5: A 59 year old male with T2DM History and Presentation Ray is 59 years old and has been visiting your pharmacy/clinic for just over 1 year. He was diagnosed with T2DM 4 years ago. The only problem he reports is frequent drowsiness. He does not want to start bolus insulin because he "already takes 1 shot per day and that's enough." Three months ago, he had an A1C of 8.6%, and presents today for a follow up visit. Medical History T2DM x 4 years Dyslipidemia x 1 year Social History Office Depot store manager Active health insurance Nonsmoking with no illicit drug use Frequent caffeine use (3 4 cups daily) Alcohol use (~1 drink per day, maybe 2 on Sunday) Meal schedule and size is erratic because of his work Family History Cardiovascular disease (mother) Diabetes mellitus type 2 (father) Current Medications Insulin glargine U 100 (pen) 52 units 1 hour before bed (11:30 PM) Increased from 46 units 6 months ago Increased from 40 units 9 months ago Increased from 34 units 12 months ago Metformin 1000 mg daily Sitagliptin 100 mg daily Simvastatin 20 mg daily Physical Examination Height 5 feet 8 inches Weight 210 lbs Body Mass Index (BMI) 32 kg/m 2 Blood Pressure 136/84 mm Hg Heart rate 72 bpm No evidence of retinopathy or neuropathy Laboratory Results (Sample obtained this morning) A1C 9.1% Serum Creatinine (SCr) 1.1 mg/dl Urinary albumin:creatine ratio (ACR) < 10 mg/g creatinine Estimated glomerular filtration ratio (egfr) > 100 ml/min/1.73 m 2 Low density lipoprotein cholesterol (LDL C) 110 mg/dl High density lipoprotein cholesterol (HDL C) 38 mg/dl Triglycerides 190 mg/dl

11 Question 1 What would you do first? A. Ask Ray how he injects his insulin. B. Ask Ray how many times a day he tests his blood sugar. C. Have Ray show you how he injects his insulin. D. Have Ray tell you what he eats in a typical day. Question 2 After observing Ray s injection method, you notice inaccurate technique. Which of the following is NOT part of appropriate injection technique? A. Patient attaches the needle and removes both the outer (large) cap and the inner (smaller) protective cap. B. Patient dials a 2 unit dose, holds the pen upright, depresses the button, and releases a 2 unit air shot as a priming method. C. Patient dials his dose of 52 units, injects the needle into his skin at a 90 degree angle, then dials the knob back down to "zero" on the window. D. Patient injects the needle into the skin and holds in place for 8 seconds before removing the needle from his abdomen. Question 3 After carefully reviewing the appropriate injection technique with Ray and watching him demonstrate it back correctly, how soon should you schedule him for follow up? A. 3 to 7 days B. 2 to 3 weeks C. 1 month D. 3 months

12 Case 6: A 49 year old male with T2DM History and Presentation Steve is 49 years old and has been visiting your pharmacy/clinic for over 2 years. He was diagnosed with T2DM 6 years ago. Three months ago, he had an A1C of 9.2%, with no changes to his diabetes therapy at that time. He presents today for a follow up visit. Medical History T2DM x 6 years Dyslipidemia x 2 years Social History Community church custodian Active health insurance Nonsmoking with no illicit drug use Caffeine use (1 2 cups daily) Occasional alcohol use (~1 3 drinks per week) Self reported largest meals of the day are breakfast and dinner. He does not eat lunch or snacks. Family History Diabetes Mellitus Type 2 (mother) Current Medications Metformin 1000 mg twice daily Linagliptin 5 mg daily Atorvastatin 10 mg daily Physical Examination Height 5 feet 6 inches Weight 280 lbs Body Mass Index (BMI) 45 kg/m 2 Blood Pressure 124/76 mm Hg Heart rate 74 bpm Mild retinopathy reported; no neuropathy Laboratory Results (Sample obtained this morning) A1C 9.7% Serum Creatinine (SCr) 1.0 mg/dl Urinary albumin:creatine ratio (ACR) <10 mg/g creatinine Estimated glomerular filtration ratio (egfr) >100 ml/min/1.73 m 2 Low density lipoprotein cholesterol (LDL C) 105 mg/dl High density lipoprotein cholesterol (HDL C) 50 mg/dl Triglycerides 140 mg/dl

13 Question 1 Steve s physician wants to start him on insulin. Steve is agreeable, but does not want to inject himself more than once daily. He is also worried about hypoglycemia, as he lives alone and has minimal family in the area to call on for help. What insulin regimen would you recommend? A. Insulin determir U 100 at bedtime B. Insulin glargine U 100 at bedtime C. Insulin glargine U 300 at bedtime D. NPH insulin at bedtime E. NPH insulin before breakfast Question 2 Steve s physician agrees with your recommendation of insulin glargine U 300, and Steve is agreeable to this therapy. What dose would you start him on? A. 10 units daily B. 25 units daily C. 50 units daily D. 56 units daily Complete this CE activity online at ProCE.com/InsulinPart2