Q and A Session 2017

Hello this is where the tips, questions and answers from the Q and A on May 26 from 1pm to 7pm (Mountain Standard Time in Calgary) will be posted. PLEASE DO NOT hit the refresh button multiple times as a hundred users refreshing same page will CRASH THE SERVER for the entire night!!! It will take me 15-45 minutes to answer questions so please only hit refresh every 45-60 minutes.

1) Remain calm and go with the answer that you first selected. The people I know that have failed the test panicked and kept changing their answers. Everyone is nervous and that is normal, especially if this is the first time you are writing. Even I was nervous last year even though I have taught dozens of other people, have written the exam before and have created tests. Take a few deep breathes and remain calm.
2) Do not waste too much time on any one question. You have 165 questions in 3.5 hours so 1.3 minutes per question. Remember there are twenty five “pilot” questions that are simply being tested and do not count. So if you spend 10 minutes on a tricky question that is worth nothing then you have wasted a lot of time.
3) Read the question slowly and carefully. Some questions will ask “which of the following is correct” and some questions will ask “which of the following is incorrect“. I caught myself choosing the wrong answer because I did not read the question carefully at first.

NOTE: It is now 7pm in Calgary and Esmond is offline. Good luck to everyone on the test tomorrow!!
Is it important to know the brand name and generic name of the medications, or do they always use both?
Esmond: In my exam 6 years ago you had to know both but the exam I wrote last year had both names of the medication so I assume they will use both this year as well.

Does intensive glycemic control reduce macrovascular complications in type 1 or 2?
Esmond: Unclear, researchers are still debating. The evidence for macrovascular complications is not as clear as the microvascular complication. Both the DCCT and UKPDS did show reductions in macrovascular complications but it took 20-30 years so researchers and endocrinologists still debate the significance of the macrovascular findings

If you have nocturnal hypoglycemia, will this always be followed by rebound hyperglycemia?
Esmond: No, some peoples sugars will stay on the low side throughout the night and wake up still low. One endocrinologist I listened to says most her patients did not have rebound hyperglycemia.

UKPDS and other research studies:
What do you suggest we know/memories regarding these studies? (UKPDS, DCCT, ACCORD, ADVANCE, DAWN, HAPO)
Esmond: I would suggest that you know the general information from the UKPDS and the DCCT ie what type of diabetes was studied, the results, duration of study and general info of the follow up studies. For ACCORD now that there was an increase in mortality in the intensive group. The other studies have not shown up in any of my tests.

I am struggling with the education principles- Should i be using Building Compentency to study this? And for example—someone told me there was a question on the “grief cycle” on their test—I haven’t seen anything about this. Have you?
Esmond: that is probably the more tricky subject. One year I got a question on acculturation which I still cannot find a good definition for. Everyone was confused and talking about it after the test. I didnt get a question on the grief cycle. I would suggest the Building Competency book for the education principles section as well as CDA chapter on self management education on pg S26 of the guidelines.

What is the target from pregnancy and diabetes (I have two conflicting sources. one says Esmond: Whenever you have conflicting sources the Diabetes Canada (CDA) guidelines ALWAYS win out. So as per guidelines the target for pregnancy is ≤7.0%  for both type 1 and type 2 diabetes

My second question. My essentials book states that you can never mix rapid with Long-acting, but then I found a source in my advanced manual, stating that sometimes Lantus can be mixed with a rapid insulin in the same syringe. Just wondering if they ask this on the exam, what you would recommend answering?
Esmond: I dont think they would ask this on the exam. Mixing insulins together can change their time action profile. For example in the Lantus monograph it states that Lantus must never be mixed with other insulins. An experiment done on dogs with mixed lantus and regular insulin showed a delayed onset of action and altered bioavailability.

Can you help me with insuin analogues. How do you differentiate between them and “ordinary insulins” —am I correct in saying regular and NPH insulins are more “ordinary”-and rapids and long acting are analogues b/c of the amino acid sequence changes?
Esmond: I think this is covered in my pathophysiology lecture #1. Yes you are correct, regular and NPH insulin have the same amino acid sequence as the insulin that our pancreases are secreting right now (assuming you are not diabetic). Regular insulin is ordinary human insulin and NPH is regular insulin with protamine crystals to slow the action. Rapid and long acting insulins like novorapid or lantus have altered amino acid sequences which makes them analogues.

Could you please clarify the calculations of insulin dosing? I see in some manuals calculating basal at 0.1-0.2U/kg/d, vs the Essentials binder stating a standard 0.5u/kg/d TDD; vs some premixed starting doses at 0.5-0.1u/kg/d. I’ve been trying to stick with the TDD = 0.5u/kg/d, with basal being about 50% of this, and meal time about 50%/3 meals. (unless patient is a large eater, than increasing to bolus to 60%/3 meals).
Esmond: all of these calculations are correct. There is no one way to start insulin. For the test however I would stick the what the Diabetes Canada guidelines suggest on appendix 3 which suggests similar calculations to ones you have listed above

Also, I am a little confused between the difference of a CHO:ins ratio, vs correction factors, verses VIDS and when to use each. Could you clarify?
Esmond: So a carbohydrate to insulin ratio is how much insulin a patient takes per gram of carb so for example 1 unit per 15 grams
A correction factor is how much insulin a patient takes to reduce their blood sugar by x mmol/L so for example 1 unit to reduce 2 mmol/L
A VIDS (variable insulin dosing schedule) is just a correction factor with how much insulin already calculate out so for example:
BG Insulin dose
≤4  0 units
4-7 5 units
7-9 6 units
9-11 7 units
11-13 8 units etc

How do you explain to patients the mechanism behind ACE inhibitors worsening SCr (eGFR), but improving ACR/slowing progression of nephropathy?
Esmond: this one is really really hard to explain via email and I dont understand it completely myself. Think of the area of nephrons before and after the glomerulus. Think of the glomerulus as a coffee filter. If there is hypertension its like a high pressure fire hose blasting the coffee filter and damaging it. ACE inhibitors reduce the pressure of the fire house (but mostly post glomerulus pressure) so by reducing the filtration it also increases the serum creatinine in the blood leading to worsening SCr temporily but now that you have decreased the pressure the glomerulus/coffee filter will last longer overall.

Do we need to know the dosages of the medications?
Esmond: Ive never been tested on the doses of medications so I would assume no

This is from the essentials:
Which statements are not true:
1. the abdomen is the preferred site for insulin administration
2. Daily absorption can vary up to 10% using the same site at the same time
3. patients should inject within the same anatomical area and systematically rotate their injection within that site.
4. Injection of insulin into a lipohypertrophy site increases the rate of insulin absorption
a. 1 and 4
b. 2 and 4
c. 2 and 3
d. 2 and 4
The suggested answer was C – but I am not convinced.
Esmond: 1) is correct the abdomen is the suggested site 2) I dont know the exact stats but 10% seems reasonable 3) is correct 4) is wrong as a lipohypertrophic site often decreases the rate of insulin absorption. I would choose 1 and 3 but that doesnt seem to be an answer. 4 is wrong so anything involving 4 is wrong so you are left with c.
Update: on pg 6-68 it says absorption can vary 30% so im not sure which answer is correct since 2) and 4) are wrong
Update #2: I did not take my own advice and read the question carefully. Its asking for whats NOT TRUE so B should be the correct answer

question 33 of practice exam refers to a patient using 30/70 insulin who requires insulin adjustment secondary to acL and HS hypos. The correct answer is ‘switch to a premixed analogue’. Did I miss something VERY big? Is 30/70 not a premixed analogue? Any explanation is greatly appreciated.
Esmond: 30/70 mixes like humulin 30/70 and novolin 30/70 are mixes of regular insulin and regular insulin with protamine. They are not analouges because their amino acid sequences have not changed. Premixed analouges like Humalog mix 25 of Novo mix 25 are mixes with insulin that has had their amino acid sequence changed. Please see one of the previous questions on the difference between ordinary insulin and an analouge.

What test differentiate type 1 and type2 ? Specially when onset is odd ie type 1 in old age or type 2 in child ? Test for Lada vs mody?Is there set of test series to differentiate ?
Esmond: There are tests to specifically diagnose type 1 diabetes (such as serum c-peptide or anti insulin, anti GAD and anti islet antibodies but that is for an endocrinologist and should not be on the test) but there is no special type 1 vs type 2 test that is generally used in clinical practice. LADA is just a late stage onset of type 1 so you could test the labs I mentioned above. MODY is diagnosed through genetic screening and clinical symptoms. There is not specific blood test for MODY

Do we need to memories daily intake value of sweetener like Sachirrin-5mg/kg/day?
Esmond: I was asked what was the maximum intake of cyclamate on a test so yes this may show up on the test.

Thanks for a great practice exam! I would like to ask a question on alcohol. On p. S51 of the Guideline, one standard drink is 10g but the CDA patient information states 13.6g.
I don’t understand the conflicting information. Please claify.
Esmond: 1 gram of water= 1ml of water but 1 gram of alcohol= 1.3ml of alcohol. Alcohol is less dense than water so you need more mls to equal a gram of it. Pg S51 states 10 ml of alcohol not grams.

My question has to do with pumps, and basal rates. The essentials book states “the most common reason to adjust the basal rate is the need to increase the early morning basal as a result of an in target 3am BG, followed by a high fasting BG, or a 2 hr postprandial BG within target followed by a high preprandial BG. The majority of the time fewer than 3 basal rates will keep BG in target. To calculate the basal rate you take 50% of the TDD and divide that by 24 hrs. I haven’t seemed to come across anything about 2 or 3 basal rates. Can you clear this up for me?
Esmond: You can adjust insulin pumps so that they give you different rates of basal insulin throughout the day. Say your patient has a rate of 2 units per hour. He goes to they gym every day between 6-7pm. You can decrease the rate to 0.75 units per hour between 6-7pm. Say you notice due to dawn syndrome his sugars rise from 3 am to 6am. You can increase his rate from 2 units to 3.75 units per hour from 3-6am. During the initial conversion from multiple daily insulin to an insulin pump is when you do all those calculations. Say he was 96 units TDD when he was on MDI, you would take 50% of that which is 48 and then divide it by 24 for 2 units per hour (normally in real life you would decrease 25-33%).

The question about the smoker who is in the action phase because he is attending group sessions. Why so?? Thought should be in contemplation as he didnt quit smoking yet?

Esmond: He is in the action stage because he quit at the stop smoking cessation group and has started taking steps to change. Contemplative is action with 6 months and no changes yet. Please follow this link for more information

The Transtheoretical Model

Just to clarify would we aim for a lower A1C (6.5) in a newly diagnosed diabetic patient or still say 7 or less…
Esmond: in general for a newly diagnosed patient we would aim for an A1c of 7 or less. The decision to drop to 6.5% is for some patients who would benefit from reduced nephropathy and retinopathy at the cost of more risk of hypoglycemia is made later on.