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Breaking through convention to simplicity in T2DM care – Case study 3

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Breaking through convention to simplicity in T2DM care – Case study 3 Breaking through convention to simplicity in T2DM care – Case study 3

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Question 1 of 15
1. Question
1. Based on this patient’s clinical picture, which of the following would be the best option for treatment intensification?
A. Add a sulphonylurea such as sustained-release gliclazide
B. Up-titrate the dose of insulin glargine, since he is only taking small doses of bolus insulin
C. Convert his basal-bolus insulin regimen to a fixed-ratio combination (FRC) such as iGlarLixi
Question 2 of 15
2. Question
2. Increasing the dose of metformin XR to 1 000mg bd:
A. Would be an option to improve glycaemic control if the patient can tolerate this dose without side effects
B. Would not be an option given his impaired renal function
C. Would not be an option as it cannot be taken together with a FRC
Question 3 of 15
3. Question
3. Given this patient’s profile, his target HbA1c would be:
A. 6.5%
B. 7.0%
C. 7.5%
Question 4 of 15
4. Question
4. With his impaired renal function, the following would apply:
A. He should be recommenced on a low-dose RAAS inhibitor to afford renoprotection
B. He should be restarted on an SGLT-2 inhibitor
C. Vildagliptin has a renoprotective effect and should be continued even if he takes a FRC
D. His metformin should be temporarily stopped during any illness involving significant fluid loss, such as major surgery or diarrhoeal disease
Question 5 of 15
5. Question
5. What specific problems do you anticipate within the first two weeks of the introduction of iGlarLixi and what do you select to deal with them in this patient when introducing this combination?
A. Allergic skin reactions
B. Nausea, diarrhoea, nasopharyngitis, pancreatitis
C. Hypoglycaemia
D. All of the above may be potential complications
Question 6 of 15
6. Question
6. What dose of iGlarLixi do you initiate and why?
A. Initiate all patients at 10 units daily; this follows the same protocol as for basal insulin, given that iGlarLixi contains basal insulin
B. Dosage should be based on the patient’s body weight; this is because it is common practice to initiate insulin at around 0.15-0.2mg/kg body weight
C. For patients uncontrolled on oral agents, a GLP-1 RA or basal insulin at <30 units – initiate at 15 units; for patients uncontrolled on basal insulin ≥30 units – initiate at 30 units. These were the starting guidelines developed from clinical trial experience
D. Patients on oral agents or a GLP-1 RA should be initiated at 10 units daily, or at half the dose of basal insulin currently used; this is to prevent hypoglycaemia
Question 7 of 15
7. Question
7. Do you intensify therapy?
A. The fasting blood glucose target for this patient would be <8.0mmol/l
B. The post-prandial blood glucose target for this patient would be <8.0mmol/l
C. The post-prandial blood glucose target for this patient would be <10.0mmol/l
D. The post-prandial blood glucose target for this patient would be <12.0mmol/l
Question 8 of 15
8. Question
8. Your patient complains of some nausea. What do you suggest?
A. Try to inject after a meal, rather than prior to a meal
B. Take an anti-nausea medication
C. Counsel the patient that the nausea should be transient and will settle with time. If the nausea is severe, reduce the dose temporarily until the nausea settles and then resume up-titration
D. Stop the FRC completely and consider another form of therapy
Question 9 of 15
9. Question
9. When considering the use of a FRC such as iGlarLixi:
A. One would not be able to switch a patient from basal-bolus therapy to FRC therapy
B. One should not consider this therapy until at least two oral hypoglycaemic medications have been tried
C. The delayed gastric emptying associated with GLP-1 RA therapy will not affect the action any other concomitant medication
D. Frequency of blood glucose monitoring should be increased after initiating the FRC
Question 10 of 15
10. Question
10. Which of the following is true?
A. A GLP-1 RA-containing medication such as a FRC would be not be contra-indicated in a patient with a history of diabetic ketoacidosis (DKA)
B. A GLP-1 RA-containing medication such as a FRC should not be prescribed together with a DPP-4 inhibitor
C. A GLP-1 RA-containing medication such as a FRC should not be prescribed together with an SGLT-2 inhibitor
D. Some patients may experience headache or upper respiratory tract infection when taking a GLP-1 RA-containing medication
Question 11 of 15
11. Question
11. After 2-3 months of iGlarLixi treatment, the patient comes back for evaluation. The patient’s HbA1c has improved to 8.3% but his fasting blood glucose levels are still not at target. He has not experienced any hypoglycaemia. What do you do?
A. Leave his dose as is, as he is close to target
B. Add some basal insulin to help reduce his fasting blood glucose
C. Continue gently titrating the FRC, with careful monitoring of blood glucose levels until his fasting blood glucose target is met
D. Add prandial insulin at his main meal to assist with glycaemic control
Question 12 of 15
12. Question
12. The patient returns for follow-up. When you up-titrate, do you?
A. Monitor renal function
B. Reduce the dose of other antidiabetic medication such as sulphonylurea and insulin, as needed, to avoid potential hypoglycaemia
C. Monitor for side effects such as nausea and vomiting, and abdominal pain
D. All of the above
Question 13 of 15
13. Question
13. Your patient presents with nausea and vomiting, and abdominal pain after initiating a FRC. Potential causes include:
A. Common GLP-1 RA-induced nausea, which should settle with time
B. Cholelithiasis
C. Acute pancreatitis
D. Either B or C
Question 14 of 15
14. Question
14. At follow-up after three months, in addition to a review of glycaemic control, the patient’s blood pressure and lipid profile are reviewed:
A. A small increase in blood pressure due to a rise in resting heart rate would be expected
B. A small decrease in systolic blood pressure in the region of 0.6-1.5mmHg would be expected
C. A decrease in triglycerides and LDL-cholesterol would be expected
D. Both B and C
Question 15 of 15
15. Question
15. The patient is reviewed after 12 months. His urine albumin/creatinine ratio and renal function are reviewed. Expected results are:
A. The renal function is expected to decline faster due to the use of the GLP-1 RA
B. The level of proteinuria is expected to increase when using a GLP-1 RA-containing medication
C. The level of proteinuria is expected to decrease with use of a GLP-1 RA, with a slowing of renal decline

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