Hello this is where the tips, questions and answers from the Q and A on May 25 2018 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 15-30 minutes to answer questions so please only hit refresh every 45-60 minutes.

IT IS NOW 5PM IN CALGARY (MOUNTAIN TIME) AND ESMOND IS OFF-LINE AND WILL NOT BE ANSWERING ANY MORE QUESTIONS. BEST OF LUCK TO YOU ALL ON THE EXAM TOMORROW! 

Tips
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 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.

In reviewing the study exam questions,  one formula you recommend to know is converting A1C to mmol/l.  I went to the ADA Diabetes Pro site/reference you suggested however I was not able to use the guide as it asked for a “source”? It only gave me the information in mg/dl.
If you know the formula or can suggest another source for the formula please advise.
Thank you for your help,

Esmond: The link is https://professional.diabetes.org/diapro/glucose_calc  The source is strangely worded but basically it giving you an option of either converting A1c to average blood glucose or average blood glucose to A1c. Another formula I learned last week  is  ((A1c-6) x 2 ) +6. So for example an A1c of 6 = (6-6) x 2 +6= average blood glucose 6 mmol/L. While an A1c of 9= (9-6) x2 +6= 12mmol/L average blood glucose. Its a rough guide but its easy to remember and should be sufficient for the test. There is another formula in the essentials which is (28.7 X A1c)- 46.7/ 18 but I would not be able to do that on the test without a calculator.

Esmond: I think increasing the novorapid would be a good choice. I would try to get more readings first. Note that the AM fasting is lower than the Bedtime reading so it seems that the evening Lantus is at the right dose. It seems like that patient’s fasting sugar is high all the time. Another option would to add a correction factor if the patient is willing and able. You could add a correction factor of 1:2 with a target of 7 mmol/L.

Hi Esmond I am confused about the alcohol question. It says 10 grams of alcohol but is this equal to 17.2 ml?

Esmond:  There is a weird discrepancy in the guidelines that I will email Diabetes Canada about. So here is the reference on pg S51
The same precautions regarding alcohol consumption in the
general population apply to people with diabetes (159). Alcohol
consumption should be limited to 2 standard drinks per day and
<10 drinks per week for women and 3 standard drinks per day or
<15 drinks per week for men (1 standard drink: 10 g alcohol,
341 mL 5% alcohol beer, 43 mL 40% alcohol spirits, 142 mL 12%
alcohol wine).
It says that 1 standard drink = 10g of alcohol which is equal to 12.7 ml BUT
if you take the examples they all = ~ 17.2 mls (eg 341 x 5% beer=
17.05 ml). For the exam I would go with the 17.2 ml
because that is what they used in the example. The same discrepancy is
in the 2018 guidelines. I hope Diabetes Canada will email me back with
a definitive answer. Thanks

and it doesn’t mention anything about an education program either but does state:

b) All drivers with diabetes should undergo a comprehensive
medical examination at the time of application for
a commercial license and at least every 2 years thereafter
by a physician or nurse practitioner competent in managing
patients with diabetes. This should include an
assessment of glycemic control; frequencies and severities
of hypoglycemia; symptomatic awareness of hypoglycemia
and the presence of retinopathy, neuropathy,
nephropathy, amputation and/or vascular disease. A decision
should be made on whether any of these factors
could increase the risk of a motor vehicle accident. The
assessment should include the completion of a questionnaire
that assesses the risk of hypoglycemia, including
the nature of the work, type of motor vehicle,
flexibility of scheduling, recognition of symptoms of hypoglycemia
and ability to treat hypoglycemia, and document
the frequency of mild or severe hypoglycemia in
the last 12 months

Hi Esmond,
Could you provide the onset, peak, duration  times of sglt2 inhibitors ?

Esmond: They are all slightly different (and wont be tested on the exam) but roughly:
Peak plasma concentrations (median Tmax) occurring 1 to 2 hours post-dose
The apparent terminal half-life (t1/2) (expressed as mean ± standard deviation) was 10-13 hours
Duration would be roughly 3 x T 1/2 so ~30-39 hours

For insulin peak times…the rapid, short and basal is clearly listed. When we get into the premixes, do I assume they peak twice?
Humulin 30/70, Novolin 30/70, etc are short and intermediate so they would peak at 2-3 hours and 5-8 hours?
Novomix 30, Humalog Mix 25 and 50 are rapid and intermediate so they would peak at 1-2 hours and 5-8 hours?

Esmond: that is correct but the insulin activity peak for the intermediate would be not be as high as the peak for the short or rapid acting insulin. Pretend as if the person was taking two separate injections. For a great resource on combo insulin peaks and duration try : http://www.globalrph.com/combination-insulins.htm this is the same website that I use to calculate eGFR for my patients

Please explain how insulin affects fat cells? Why do people on insulin gain weight?
Please explain insulin 70/30 mechanism of action. So if someone is on 20 units of 30/70 insulin how much NPH are they on?

Esmond: Insulin stimulates fat cells to take in glucose from the blood and then covert it into lipids for storage. The more lipids that are stored in fat cells the more weight a person gains. Insulin 70/30 is the same as two separate injections of a regular and intermediate acting insulin such as Humulin R and Humulin N. So 70% x 20 units= 14 units

Which medications would always be discontinued when insulin is started?

Esmond: Always is a difficult word because in clinical practice because medications are regularly used off label or when contraindicated. But for the exam I would say stop thiazolidinedione (Actos, Avandia) because it may cause heart failure, sulfonylureas (Diamicron, Glyburide, etc.) because its a duplication of therapy and Trajenta because in trials, when used in combination of insulin there was a slight but non-significant increase in negative cardiovascular outcomes.

1) if a patient is on oral agents, lantus and is not achieving targets…how frequent should smbg occur? At least 1x/day (bolus requirements) or 2x/day(orals and not too target)?

2) clarification…
A)start bolus: 10 units or 0.1-0.2 units/kg

B)Add bolus(at least 1x/day): 2-4 units with breakfast or largest meal or 10% of basal dose

C) MDI: TDD(0.3-0.5units/kg) then divided 40% basal and 60% TID bolus

3) clarification…
Glucagon:
– protein to amino acid
-trigs to FFA
-glycogen to glucose and glycerol

Insulin:
-amino acid to protein
-FFA to trigs
-glucose to glycogen
Is this the right idea?

Esmond: 1) It doesnt say so in the guidelines but I would say the most frequent SMBG counts. So I would say 2x/day minimum.
2) A) Correct for both, you can use either. This is from the insulin start tool at http://guidelines.diabetes.ca/cdacpg_resources/insulin_prescription_may_5_2014.pdf Start at a low dose of 10 units at bedtime (may start at lower dose [0.1 -0.2 units/kg] for lean patients [<50 kg]).
B) Correct for both, you can use either
C) Correct
3) Correct- Remember that anabolic hormones build simple molecules to more complex molecules while catabolic hormones like glucagon do the opposite.

When a pt is on rapid insulin – what is an acceptable PPG response? (Example pre supper rbs is 5.7 and they take 8 units of novorapid and 2-hr post supper rbs is 7.7.). When would you increase or decrease rapid insulin.

Esmond: Generally you do not want sugars increasing by more than 3 mmol/L after meals. If more than 3 mmol/L then increase. If going low after then decrease.

Here are some questions:
1) which stat should we memorize for prevalence of diabetes in Canada? In your patho course, you said 7.6% in 2010. In the Essentials, there is a multiple question for 2011 stat (choices are 2.5%, 5.6%, 6.8% and 8.3%). I assume it is 8.3% given it is projected to rise to 10.8% by 2020??

2) in the Essentials, they say patients experiencing pseudo-hypoglycemia should still treat with 15g of glucose if they feel symptomatic. Is that true? In practice I have been advising a snack (carb + protein) or their expected meal to prevent spike in BG and to let body restore appropriate hypo recognition as BG normalizes.

3) what should a person on pump do when tests he/she tests and sees an unexplained high blood glucose?
i) assess infusion site and tubing
ii) give correction dose using pump and re-test in 1-2hrs
iii) change the infusion set and give correction dose using syringe
iv) change the carb to insulin ratio to prevent high BG

Choices:
a) i and ii
b) i and iv
c) ii and iii
d) ii and iv

Esmond:
1) I would use that stat in the 2013 guidelines which is 6.8%
2) Yes, I cant remember where I was taught that but, because the
patient is experiencing a low we treat it as a low. Its not in the
guidelines though.
3) I would say A) assuming that the infusion set is ok.

I am still having difficulty on how to adjust insulin and I know this is a big portion of the exam.
If all you have are highs throughout the day, I thought you would want to address the first morning high but in several examples they seem to fix the post supper high….any tips on how to tackle insulin adjustment questions.

Esmond: For insulin adjustment remember to treat hypoglycemia first before hyperglycemia. Then look at what insulin they are using. If fasting sugars are high then increase basal. If post prandial sugars are high then increase bolus at the appropriate meal. Remember the equations for Insulin to Carb ratio (which is 500/Total daily dose) and Insulin sensitivity/Correction ratio formula (100/Total daily dose if on rapid and 83/TDD if on regular). If the bedtime sugars and fasting morning sugars are about equal then the evening bolus is doing its job of keep the sugars stable. If the sugar is spiking after supper and the supper bolus is not correcting it then its the supper bolus that needs adjustment. The supper bolus should stop the 2 hr PC BG from climbing more than 3 mmol/L above the before supper reading.

What is the vitamin D recommendations for people who have diabetes?
Esmond: From pg S51 of the 2013 guidelines: Routine vitamin and mineral supplementation is generally not recommended. Supplementation with 10 mg (400 IU) vitamin D is recommended for people >50 years of age

Please briefly explain the difference between dawn effect and somogyi effect and what kind of a question could we get related to these.
Also, what do we need to know about the continuous glucose monitoring?
Thanks
Esmond: Dawn effect is the rise in sugars that happens in the early morning. It is due to the natural cycle of counter regulatory hormones such as  cortisol, epinephrine and growth hormone that prepare the body for waking up. Somogyi effect happens when the sugars dip too low in the morning and the liver responds by dumping out excess sugar causing the morning sugars to be high. Typical questions involve the need to check sugars overnight before increasing basal insulin at bedtime. For continuous glucose monitoring I haven’t seen any questions.

I  have question re: aerobic exercise VS resistance exercise. I know resistance exercise increase insulin sensitivity, how about Aerobic exercise – does it have the same effect? The CDA guideline does not mention anything.  What should I remember the major differences between these two exercises for tomorrow’s exam?

I also slightly confused about the age factor for elderly. Age is not a consideration factor for A1C target, right? Should I only consider about the frailty and risk of hypoglycemia when answering any questions related to elderly?  For example, an healthy elderly without any comorbidities, should aim for A1C of < or equal to 7.0 %, but not suppose to aim for 6.5%, right?

Esmond:
Aerobic exercise tends to burn more sugar right at that time and, in general, may cause more hypoglycemia. Intensive exercise may cause a slight increase in sugars initially as the body tries to release glucose to the muscles

Correct, but you have to use your clinical judgement. Most of the benefit of controlling blood sugars is to prevent negative outcomes 10-20 years down the road. If I had a healthy patient but was 120 years old, I would probably use a more relaxed target.

pt with dm for 20 years A1c 7.2%
Rapid: 12 breakfast, 10 lunch and 16 supper
Lantus 48 HS
FBS : 5.4, 8.3, 4.3, 9.1
AC lunch: 7.2, 3.6, 5.6, 3.9
AC supper: 8.0, 13.1, 11.3, 8.2
HS: 6.0, 6.7, 7.9, 8.0
3am: 3.7, 4.0, 3.9
– options to choose
>> A) increase lunch 10%
>> B) decrease lunch 20%
>> c) decrease before lunch and HS by 10%
>> D) decrease HS by 10%

Esmond: I would chose D) as you treat hypoglycemia first. In real life I would probably decrease the rapid breakfast to 10 units to stop the before lunch lows as well. The AC supper sugars are quite high so reducing the before lunch bolus is wrong.

1)Rapid: 8 units breakfast, 7 units lunch, 10 units supper
Nph: 30 units HS
Breakfast at 8am, lunch noon, and nothing until supper at 730/8pm

FBS: 6.3, 7.2, 6.0, 7.9
AC lunch: 7.3, 5.2, 8.2, 6.8
2hr lunch: 9.0, 7.5
AC supper: 10.3, 11.9, 13.2, 12.5
HS: 11.5, 9.3, 10.2, 9.8

A) increase lunch rapid by 2
B) increase supper rapid by 2
C) start Nph 4 units lunch
D) start nph 4 units breakfast

Esmond: The way the question is written I think the test writer wants the answer to be D). B) is wrong because the AC supper sugar is already high and the HS is about the same which means the 10 units at supper is doing its job. C) is wrong because you dont start NPH at lunch. A) would be a reasonable choice but the 2 hr lunch is ok so I dont think thats what the exam writer wants. So that leaves D) as the NPH peaks in 5-8 hours , which is after the 2 hr PC lunch but before the AC supper.