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Breaking through convention to simplicity in type 2 diabetes care – Case study 2

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Breaking through convention to simplicity in type 2 diabetes care – Case study 2 Breaking through convention to simplicity in type 2 diabetes care – Case study 2

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Question 1 of 16
1. Question
1. At this juncture, the patient is very reluctant to increase his insulin doses as he is concerned about more weight gain and risk of hypoglycaemia. He accepts he would have to change his lifestyle, lose weight and see a dietitian. What would be the most beneficial next step in his T2DM management?
A. Add a sulphonylurea
B. Start patient on basal bolus insulin; there is no choice as his results are dire
C. Change to iGlarLixi and focus on diet, exercise and weight loss. His postprandial readings are especially elevated and the iGlarLixi might have a weight benefit
Question 2 of 16
2. Question
2. The fixed-dose insulin/GLP-1 agonist must be taken with each meal.
A. True
B. False
Question 3 of 16
3. Question
3. The GLP-1 agonist acts by:
A. Working on the satiety centre so that the patient feels fuller for longer
B. Reducing glucagon release
C. Slowing gastric emptying
D. All of the above
Question 4 of 16
4. Question
4. What are the possible issues associated with swopping the patient from premixed insulin to iGlarLixi?
A. Gastrointestinal side effects, including nausea and bloating
B. Fluctuating glucose levels while titrating to the correct dose
C. Both A and B
Question 5 of 16
5. Question
5. At what dosage do you initiate the FDC and why?
A. Start at 30U daily
B. Start at 20U pre-breakfast and 10U pre-supper
C. Start at 17U pre-supper
D. Halve the dose and start at 15U
Question 6 of 16
6. Question
6. At follow-up, the patient was feeling much more positive and felt that his glycaemic control had improved. Looking at the below SMBG graph, would you?
A. Change to basal bolus insulin, as he is not at target
B. Increase the iGlarLixi by 2U and continue lifestyle changes. Reassess HbA1c in three months
C. Leave iGlarLixi dose exactly as is
Question 7 of 16
7. Question
7. The patient complains of some nausea and other discomfort. What do you suggest?
A. Continue the iGlarLixi and counsel the patient that this is a known side effect. Prescribe anti-nausea medication, change diet further, advise smaller meals and reassess. If this continues, the patient is to inform you as medication might then need to be optimised
B. Stop iGlarLixi and go back to premixed insulin
C. Don’t do anything, this will disappear
D. Stop iGlarLixi and change to basal bolus insulin
Question 8 of 16
8. Question
8. What is the next step, considering his glucose levels are generally at target?
A. Stop all current medication and start basal bolus insulin
B. He is at too high a risk for insulin as he might have hypoglycaemic episodes; rather put him on oral medication only
C. Continue his medication for another six months as he has already been through a lot
D. Add a SGLT-2 inhibitor and adjust his iGlarLixi dose as per his glucose levels
Question 9 of 16
9. Question
9. HbA1c in all patients should be <7%.
A. True
B. False
Question 10 of 16
10. Question
10. GLP-1 agonists have been associated with:
A. Risk of pancreatitis
B. All forms of cancer
C. Dementia
D. Colon cancer
Question 11 of 16
11. Question
11. What are the targets in this patient?
A. Fasting glucose <7mmol/l; HbA1c <6.5%
B. Fasting glucose <7mmol/l; best possible HbA1c without hypoglycaemia
C. There are no strict targets as he is a cardiac patient
Question 12 of 16
12. Question
12. Which of the following statements is true regarding GLP-1 agonists?
A. The SUSTAIN-6 and LEADER trials have shown cardiovascular benefit
B. Use together with DPP-4 inhibitors for maximum benefit
C. Oral GLP-1 agonists are available in South Africa
D. GLP-1 agonists should not be used if there is any renal dysfunction
Question 13 of 16
13. Question
13. What should the patient be educated about regarding injecting technique for iGlarLixi (which he ideally should have been taught when he initially started with the premixed insulin)?
A. Use a new needle daily
B. Rotate the injection sites to prevent lipohypertrophy
C. Do an airshot to ensure that there are no air bubbles
D. All of the above
Question 14 of 16
14. Question
14. What other disorders occurring secondary to the patient’s raised BMI would you look for or expect?
A. Hyperuricaemia
B. Obstructive sleep apnoea (OSA)
C. Osteoarthritis
D. All of the above
Question 15 of 16
15. Question
15. At follow-up, his LDL-c was noted to be 2.2mmol/l. Will you:
A. Increase his statin dose until a target of 1.4mmol/l is achieved
B. Continue current dose as his LDL-c is marginally lower
C. Ask him to decrease cholesterol in his diet
D. Ask him to exercise more
Question 16 of 16
16. Question
16. His BP at follow-up was 150/90mmHg. What is your next step?
A. Suggest he discusses this with his cardiologist in three months when he is reviewed
B. Aim to bring his BP down as low as possible. There is no lower limit as the lower the BP is, the better for the heart
C. Increase his ARB dose to achieve a target of <130/80mmHg
D. Add an alpha-blocker, e.g. doxazocin, to his hypertensive medication

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