2019 Q and A | CDE STUDY COURSE

HELLO IT IS NOW 5:00 PM IN CALGARY SO THE 2019 Q AND A SESSION IS NOW CLOSED. THANKS TO EVERYONE FOR THEIR QUESTIONS. IT HAS BEEN MY PLEASURE HELPING YOU PREPARE FOR THE CDE EXAM. BEST OF LUCK TOMORROW! AFTER THE EXAM IF YOU HAVE TEST QUESTIONS YOU WANT TO DISCUSS PLEASE EMAIL ME!

For those people in Calgary, come join me for a drink after the exam at Jamieson’s pub which is down the street from the University of Calgary where you are writing.

Hello this is where the tips, questions and answers from the Q and A on May 24 2019 will be posted. The 2019 Q and A will run on May 24 at 9am to 5pm. (mountain standard time in Calgary). PLEASE DO NOT hit the refresh button multiple times as a hundred users refreshing the 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. You can email me your 2-3 questions at cdestudycourse@gmail.com. Note I may not get to every question. It is first come first serve. My responses are in BOLD

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 1.25 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.

Hi Esmond, I’m getting ready to do the last 2 weeks of cramming as I’m sure everyone is. I will be doing a couple more of your practise exams as well. Can you tell me what I should be looking for in a pass rate , is it the overall % or % on each section I should be aiming for? Also can you please clarify how to do deal with sugar alcohols and calculating how much insulin to take.

Esmond: Hi Sheila, you should aim for a 90% on my exams and all the competencies. The message at the end of the exam should be different if you hit 90% or above.The CDECB keeps the passing mark a secret but you do need to pass every competency to pass the exam. For sugars alcohol they should NOT be counted as carbohydrates when calculating insulin.

Hi Esmond, Sorry to bombard you with questions but I guess you probably expect it the last week! I have seen a few sources say not to combine Linagliptin with insulin but it’s not mentioned in the guidelines. I found a study from 2016 in the Canadian Diabetes Journal that also says it is safe with insulin. I guess I go with that?

Esmond: Linagliptin when combined with insulin had a trend (not statistically significant) towards negative cardiovascular outcomes. Therefore while not contraindicated with insulin it is not indicated with insulin. I wouldnt prescribe linagliptin to patients with insulin as its not an official indication. Please the the Trajenta monograph for details.

I just wanted to let you know that I think your website is great. I purchased practice test #1 and I did really well on it. Then I did the back of the questions in the essentials binder, and I struggled on their education questions The essentials has two chapters – chapter 2 and 11 that focus a lot on education. Do you think this is something that I should focus on the next week?

Thanks for the advice!

Esmond: Hi Lesley, thanks for the question. If you don’t mind I’ll post your question in the Q and A session. The education is definitely something you should focus on as it is one of the competencies for the exam. If you look at Appendix A of the CDECB handbook you will see education has lots of 2-A and 2-B readings, which is less than 1-A and 1-B, but means that there will be several questions that focus on education.

Hi Esmond

Could you clarify the A1c as a screening tool? It’s applicable for type 2 adults not kids but what about pregnancy

Esmond: A1c can be used to diagnose diabetes but there’s a number of reasons it isn’t great as a screening tool (main reason is expense) for large populations. See table 4 on pg S-12. I have a practice question on that. Its applicable to adults, kids and women in pregnancy. Please see pg S-258 for details in pregnancy

Hi Esmond,
I was reading in the reference alcohol causes hypoglycemia primarily by reducing gluconeogenesis in liver rather than affecting glycogenolysis of glycogen. Can you please clarify.

Thanks for the study material , its very helpful.

Esmond: Alcohol likely has an effect on both. Regardless the exam will not have such detailed questions.

1) Which drugs decrease risk of developing T2DM in individuals with PreDM?
Lifestyle/wt loss=60%
Metformin ~30%
TZDs-60-70%
I also read somewhere acarbose? Can you confirm this?

2) OHAs which provide CV protection include Invokana, Jardiance and Victoza. If the multiple choice question include Forxiga, since the results of the DECLARE study are out, do we include that in the answer or stick to the 3 drugs in the 2018 guidelines?

3) Prevalence of DM worldwide = 6.8%, is the prevalence in Canada of T2 ~8.3%? I keep seeing that number…

Thanks!

Esmond:

The STOP-NIDDM trial showed a 25% reduction in progression with Arcarbose. There was a test question last year asking students to what was the reduction in progression with TZD, metformin and lifestyle changes. A) 60-60-60, B) 60-30-60, C) 30-30-30, etc. So it may show up on your exam. See pharmacotherapy on pg S-22
Declare showed that Forxiga did not reach statistical significance for some CV outcomes so it is not recommended for CV protection. Please see my videos on studies for more information
Prevalence on pg S-2 of the guidelines is 9.3% in 2015

For weight management component I have come across some differences/ confusion interms of the amount of weight loss in both sources.
Refer below…..

Question 1

Diabetes Canada Guidelines: Ch.7 Weight Management says this….
The slide on “Healthy Behaviour Interventions” mentions:
-Reasonable weight loss goals of 2-4 kg/month

whereas in the textbook “The Essentials: Building Competency in diabetes education” 4th edition.
In Ch.5: Treatment Modalities it mentions:
-Optimal rate of weight loss is 1-2kg per month

Question 2 Weight Management programs

Diabetes Canada Guidelines: Ch.7 Weight Management says this….
Table 4: Checklist for Weight management programs mentions:
-Reasonable weight loss goals are set at 1-2 kg/month

whereas in the textbook The Essentials…
In the Weight management program checklist it mentions
Weight loss goals are set at 1-2 lbs/week

thanks again for your help
Ummad

Esmond: For the exam ALWAYS go with the 2018 guidelines answer. Chapter 7 in the guidelines is Self Management education and I dont see any of the text that you mentioned in that chapter. Can you email me the page number? I would use 1-2kg as I can find that number on pg S-125 in the guidelines.

Hi Esmond, I have some other questions for you-

to treat or not to treat pseudo-hypoglycemia?

Generally you treat psuedo-hypoglycemia as its uncomfortable for the patient.

Diagnostic test for type 1 DM in children- A1C is not supposed to be the only test for diagnosis but what else is used routinely ( besides C-peptide and auto-antibody levels)?

That is up to the endocrinologist to decide and is a specialist question

How often is A1C measured in pregnancy?

It says in the guidelines that the optimal frequency is unknown on pg S-258. A1c may be measured more frequently than 3 months.

Can you explain a bit more about the Stepwise study when adding bolus insulin- I thought it was when adding on to already established basal routine. Now I am seeing examples of just starting with bolus as the initial insulin start. I am confused.

The Stepwise study https://journals.aace.com/doi/abs/10.4158/EP10323.OR showed that adding one or two bolus injections to basal insulin is an effective alternative to adding three injections all at once. Starting bolus insulin vs basal insulin first is a totally different story. There are some cases where it is better to start just with bolus insulin (for example only high post prandials, afraid of overnight hypoglycemia, commercial drivers, etc). I’ve heard that this is more common in Europe.

Q 1 HI Esmond I have a question , if you have ISF 1:3 THAT MEAN 1 UNIT OF INSULIN NEED TO REDUCE BG BY 3 MMOL , AND IF ISF 1:1 THAT MEAN 1 UNIT OF INSULIN NEED TO REDUCE BG BY 1 MMOL ?? IS THAT CORRECT ? SO HOW IS YOUR QUESTIONS # 5 FOR INSULIN RESISTANT YOU CHOOSE THE ANSWER C ?

You are thinking backwards for this question. Lets say you punch two people with 1 unit of force. One is a huge bodybuilder who bruises for 1 day. The other is a skinny frail elderly person who bruises for 3 days. Who is more resistant to your punch? The bodybuilder because he only bruised for a day. Who is more sensitive? The skinny frail elderly person because she bruised for 3 days which is greater than 1 day. The same with insulin, a patient who needs more insulin is more resistant. Lets say you inject two people with 1 unit of insulin. One is a huge bodybuilder whose sugars drop 1 mmol/L. The other is a skinny frail elderly person whose sugars drop 3 mmol/L. The skinny frail elderly person is more sensitive to insulin.

Q2 DO WE NEED TO MEMORIZE CHO SERVING FOR ALL FOODS?? CAN YOU HELP ADVISING WHICH COMES MORE OFTEN ?

It is impossible to memorize all the CHO servings for foods. As I have said it my exams try to memorize common items like a slice of bread, a glass of juice, an apple, etc. Popsicles and gingersnap cookies have all shown up and are in the lists here:

http://cdestudycourse.com/wp-content/uploads/2019/06/Beyond-the-Basics.pdf (most up to date)

http://family-medicine.ca/images/DM-Carb-list-beyond-the-basics.pdf

Q3 I HEARED ABOUT QUESTION HONEY MOON PERIOD BUT I DIDNT SEE ANY AT YOUR EXAM ?

Just because it wasn’t on my exam doesn’t mean it wont show up on tomorrow’s exam. My exams are a best guess on what will be on the tomorrow’s exam.

Q4 EDUCATION PART I CANT MEMORIZE ALL MODULES CAN YOU HELP WITH HINTS ?

That is a difficult part of the exam. Try to review my education questions carefully.

THANKS

Can you please review what we should know about the impact of cannabis on diabetes?

Increases energy uptake by decreasing satiety signals, increases insulin resistance, may lead to increases in body weight and dyslipidemia

Questions for the Q and A:
1. When screening for T2 in adults they say if they are very high risk on the risk calculator OR if they have additional risk factors. Would “additional risk factors” be the risk factors for T2 diabetes such as: Atypical antipsychotics, associated illnesses, member of a high risk group etc.? If so, does that mean any adult with those risk factors is screened every 6 to 12 months or how many additional risk factors would be needed?

That section is vaguely worded because there is no perfect formula. When something is vaguely worded it means it wont show up on the exam because people can interpret the wording differently and argue that their answer is right. I would interpret having two factors as needed for the more frequent screening of 6 to 12 months. You should be familiar with Table 1 on pg S-17 for the exam.

May send more questions.

All the best,

Megan

Hi Esmond,

Can you briefly explain DKA and HHS? I’m not quite understanding the concepts behind both. HHS is an extreme form of DKA but why is the pH in HHS higher? Someone who has DKA may not progress to HHS- why?

Thanks

Adrienne

DKA and HHS are two separate conditions with some overlapping features. HHS is not an extreme form of DKA. The distinguishing factor between them is that DKA has ketones and ketoacidosis and HHS generally does not. Ketones are acidic which is why the pH is lower than in HHS.

Question #2: Dyslipidemia and statin therapy. When do you intensify statin therapy for someone who is on a statin but does not have an elevated LDL-C? Would they still require a 50% reduction from baseline? If someone does have an elevated LDL-C and they have reduced by 50% but are still not below 2.0 mmol/L do you keep the dose the same or intensify to meet target less than 2.0?

Cheers,

If they meet the requirements for statin therapy as per the Vascular Reduction chapter guidelines then I would start them on statin therapy regardless of their current LDL. Statins seems to help prevent CV disease even if LDL is well controlled. The question of intensifying their statin if they are on target is controversial and likely wont be on the exam. One study showed that the lower the LDL the lower the CV outcomes even if LDL was below 2. However this has to be balanced against side effects. In real life, for my practice I try to get LDL down as low as possible even increasing the dose if their LDL is below 2. However sometimes its a challenge just to get patients to take their statin because of all the things they read on the internet. If they have side effects than I back off on the dose.

Post-prandial sugars are the best predictors of outcomes for elderly pts with diabetes. Can you summarize if there are any other generalizations to closely monitoring the parameters: pre-prandial, post-prandial, and A1C, for other population groups?

Please see table 4 on pg S-12 for some parameters. I dont think they are other specific population groups.

Hi Esmond,
Thank you for making this site so great.
I see conflicting information for statins and ace I/arb usage in vascular protection.1. This has **> and =** for 55, 40 and 30 years old.2. This reference has > for all of these ages and no = too.3. A. Guidelines have for statins > or = 40 and
>30B. For ace I/arb it has > or =55.Q: I am hoping I should go with:
> or = with 55 and 40
And > 30 for the ages ?? How it is in the actual guidelines?

Esmond: For the exam ALWAYS go with the 2018 guidelines answer.

My students have pointed out a number of discrepancies in the 2008, 2013 and 2018 guidelines. I have emailed the guidelines committee several times over the years and I have NEVER heard a response back. I wish they had a committee member in charge of ensuing everything is the same and there are no discrepancies.

Please see the recommendations from pg S-166-167 for more details

Statin therapy should be used to reduce CV risk in adults with type 1 or
type 2 diabetes with any of the following features:
a. Clinical CVD [Grade A, Level 1 (79)]
b. Age ≥40 years [Grade A, Level 1 (79,80), for type 2 diabetes; Grade
D, Consensus for type 1 diabetes]
c. Age <40 years and 1 of the following:
i. Diabetes duration >15 years and age >30 years [Grade D,
Consensus]
ii. Microvascular complications [Grade D, Consensus]
iii. Warrants therapy based on the presence of other CV risk factors
according to the 2016 Canadian Cardiovascular Society Guide
lines for the Diagnosis

ACE inhibitor or ARB, at doses that have demonstrated vascular protec
tion, should be used to reduce CV risk in adults with type 1 or type 2 dia
betes with any of the following:
a. Clinical CVD [Grade A, Level 1 (70,73)]
b. Age ≥55 years with an additional CV risk factor or end organ damage
(albuminuria, retinopathy, left ventricular hypertrophy) [Grade A,
Level 1 (70,73)]
c. Microvascular complications [Grade D, Consensus].

Also
Q: ECG is > 40 or > 30 with DM > 15 years
(Similar to statins, but statins above is >or= to 40)??

ECG is similar but > instead of ≥

Q: The vascular protection tool for HCP shows this: patient >30 years old (31), but diabetes only for 15 years and recommends a statin. Guidelines has >15 years. Is it assuming that if 15 years already must be over that, but not quite 16 so is counted??

Can you email a link to that case. I cant find that exact case study.

HI Esmond,

I have one more qs:

Do we get questions based on statistics like how much percentage of people can experience blindness due to retinopathy etc. ? Do we have to remember percentages for microvascular / macrovascular disorders.

Thanks a lot. Gaurav

Yes there will be questions on statistics I have created a Statistics Quiz in the Free Quizzes section to help you with that.

Hello Esmond

In the 2nd exam, for question 28, the Insulin Pen start checklist that was included as a reference states Commercial drivers should have a BG of 6 before driving. Guidelines states BG to be 5 before driving?

The Beyond Basics brochure I have from 2015 has different quantities for carbs than the reference you provided

Thanks,

Jennifer

Hi Esmond,

Esmond: For the exam ALWAYS go with the 2018 guidelines answer.

I’m a little confused about the proper way to conduct a foot assessment with the 10g monofilament. What is the difference between Appendix 11a (Rapid Screening for Diabetic Neuropathy Using the 10 g Semmes- Weinstein Monofilament) and Appendix 12 (Monofilament testing in the diabetic foot)? I guess one is for diagnosis/presence of neuropathy and the other for predicting risk of future foot complications? Think I’ve answered my own question now that I type this but will still send :)

Guess I’m wondering when/why you use one vs the other and are they done at the same time.

Generally I use a monofilament as they are easy to carry around and I get them free from the drup reps vs a tuning fork that I have to pay for. The difference in 11a and 12 is that in 11a you are touching the same spot on their toe vs 12 where you are touching different places.

Also I’ve conducted tests similar to Appendix 11a and think I understand the concept, but in Appendix 12 it says to press the filament to foot and have patient respond yes/no and which foot, then repeat twice with at least one mock application for a total of 3. Does this mean you actually ask 4 times, so 3 real checks with monofilament and then your mock application. Scoring says 2/3 then there is protective sensation and less than 2/3 then protective sensation is absent and increased risk of ulcer.

Thank You,

I interpret it as 4 times so I dont get how it suggests to get to 2/3. I’ve always used to 10 point system.

Can we bring our purse and jacket into the room and have our cell phone turned off in purse?
Says in booklet to have turned off.On the exam registration it says cell phones are not permitted. In room? Only not on desk? Can we keep in purse turned off?
Melanie

For the Calgary exam, there is a table at the front (behind the invigilators) that everybody puts their cell phones, jacket, purse, backpacks, etc. If you don’t have it turned off it rings and bothers everyone else writing.

Hi Esmond,

Question #3: The guidelines state to add SGLT2i with renal protection should be added if person with T2 not at Target and they have CVD if eGFR over 30 however the appendix states to discontinue Empa and Canagiflozin for eGFR under 45. Can you clarify when you add an SGLT2i for renal protection? Is it ok to start Cana or Empa if eGFR under 45? Also, what are the most important meds to memorize from that appendix?

Thanks,

This is a bit tricky because of all the new studies that are coming out on SGLT-2 inhibitors and kidney function (the latest being CREDENCE which was presented in a few weeks ago). There is evidence that SGLT-2 inhibitors significantly benefit kidney function, even when used in people with low kidney function. However SGLT-2i are not very effective for lowering sugars when kidney function is low (as you need to push fluid through the kidneys in order to filter out sugar to urinate out). So the drug monograph states to not use under a certain threshold but it may have kidney protective effects. The drug monographs will change soon to reflect the new studies. You would have to decide case by case if the benefits to CV and renal outweigh the risks for SGLTi if their kidney fucntion is between 30-45 ml/min.

All drugs are important to be familiar with for the exam

Hi Esmond,

I have a question that I found in Essentials.

Can you please tell us what you think is the right answer? and the reason as well.

Essentials say option D is the right answer.

I am attaching an image with this email.

Thanks and sorry for emailing late.

Bhavin

I dont know the answer but this is how I would approach it

A) Incorrect as the lunch post prandials are ok

B) Incorrect- it would help the bedtime sugars but the before dinner sugars are already high so correcting for that later wont help

C) Incorrect- NPH is typically spaced 12 hours apart so it would be unusual to start at lunch

D) This may not be what I do in real life but one of these answers has to be correct so by process of elimination I think the answer is D. What the question writer is testing you on is to see if you understand that NPH has a duration of 18 hours. The NPH is running out of steam before dinner and at bedtime. By changing it to a long acting the question writer thinks it will last the full 24 hours and eliminate the highs before supper and at bedtime.

Hi Esmond,

Question:

On pg S-48 and pg S-155 of the 2018 CPG, there is conflict in effects of Vitamin C and E on A1C levels, one says decrease, the other one says failed to decrease (Natural Health Products chapter),

Please clarify,

Thanks,

Mahsa

Hello Mahsa, you are mixing up falsely increased with actually increased. The table on pg S-48 lists things that can falsely increase/decrease A1c. For example a patient who has poor control of his diabetes could bleed out and get an transfusion of blood from a person without diabetes. If that patient goes for an A1c test the next day it will show he has excellent control because they are testing the A1c of the transfused blood. This would falsely decrease his A1c. The table on S-155 shows that vitamin C failed to decrease A1c as a treatment to diabetes.

Hi Esmond,

thank you so much for putting in all the time to help us study-your website is an amazing resource.

Just 1 question:

When calculating ISF for regular insulin, you mention the formula 83/TDD. I did not see this anywhere in the guidelines. Will we be expected to use this formula on the exam or the usual 100/TDD?

thanks

Hanna

Hi Hanna, the 83/TDD is for short acting insulin (Humulin R and Toronto) while the 100/TDD is for rapid acting insulin (Novorapid, Humalog, Apidra, FIASP). Generally everyone uses the 100/TDD formula now

Hi again,

As per sick day management,

if you become sick and are unable to drink enough fluid to keep hydrated, you should STOP following medication: …, Nonsteroidal Anti-inflammatory Drugs (NSAIDs).

I looked at different resource, such as Diabetes Canada and Diabetes Quebec patient’s resource (attached) for sick day management, and do not see ASA as part of medications to be stopped. Kindly clarify,

ASA is a NSAID so that should be stopped

Hi Esmond,

Thanks for the great practice exams and all the info on your site! I love some of your analogies.

I have come across a few items that I am wondering about.

1) With regards to the time zone insulin adjustments, it is enough to know east to west is a longer day and vice versa and no change north to south. Will we have to calculate adjustments to the basal insulins or is it enough to know to recommend an increase or decrease?

Hi Alicia I think that should be enough but I don’t know what will be on the test. Also note that +/- 2 hours you dont need to adjust. Generally you dont increase insulin if gaining hours

2)For sick day management and SADMANS, do we only recommend to hold these meds if we know they are dehydrated? For example, if someone if feeling under the weather but they are drinking adequate amounts do we still recommend to hold?

Only if they are dehydrated, losing fluid (vomiting, diarrhea) or cant hold down fluid. If they are drinking fine and just feel a bit under the weather then continue meds.

3) For exam purposes is there a difference in Lantus and basaglar?

No, little difference in real life as well

4) If BG is less than 2.8mmol/L and you treat with 20grams of carbs and they don’t come up over 2.8mmol/L in 15 minutes, would you treat with 20 again or 15, assuming the pt is still conscious of course!

That is an interesting theoretical question. For patient safety I would personally chose 20 grams.

Thanks for your help!

Alicia

Does cannabis mask Hypoglycemia and/or DKA.

Im not sure and I dont think its mentioned in the guidelines. Maybe hypoglycemia because you are high but I dont see how it would mask DKA

Hi Esmond

Sorry for the late qs. which of the following antihyperglycemic agents are safe to use with an eGFR > 60 ml/min without the need for caution or a reduction in dose?

Alpha glucosidase inhibitor, Biguanide, Sufonylurea, TZDs, Incretin mimetics?

Hi Jennifer, if their eGFR is greater than 60ml/min then their renal function for all medications at all doses is fine. Please look at figure 2 on pg S94 of the guidelines for details.

How should carbs be distributed throughout the day?

6 small meals per day

50% at breakfast, 25% at lunch 25% dinner

3 small meals and snacks

25% breakfast 40% lunch 35% dinner

The guidelines do not recommend any specific distribution only that they be spread out. But you may need to know the macronutritent distribution.

In adults with diabetes, the macronutrient distribution as a percentage
of total energy can range from 45% to 60% carbohydrate, 15% to 20% protein
and 20% to 35% fat to allow for individualization of nutrition therapy based
on preferences and treatment goals [Grade D, Consensus].

THANKS

JENNIFER

Hi Esmond, another question for you:

Can someone just use glucose readings from a CGM to know if they are meeting targets ? I saw a question related to interpreting numbers from a CGM and didn’t know if we are supposed to just use those or to have finger tests to confirm. I actually have a patient who is finding his numbers are always 2 mmol apart from his Flash Libre and finger stick on a separate meter. What is the ideal way to see a patient’s numbers to make adjustments to meds or lifestyle?

Flash glucose monitoring like the Freestyle libre measures interstitial fluid which lags behind blood glucose by 5-15 minutes. You can use libre measurements to assess overall blood sugar control but I wouldn’t use them to adjust insulin or correct for lows as they lag several minutes behind actual blood glucose. That’s why the libre can also take strips to measure blood glucose. Also note that the libre is a bit inaccurate for the first 24 hours.

Thanks for all the help!
I hope I have this right
For NPH bid titration
1. For the NPH given at breakfast, test before supper. If it is not within 4-7 adjust the breakfast NPH accordingly
2. For the NPH at supper, test before breakfast. Again if not in 4-7 range adjust the supper dose accordingly

Correct, assuming no other insulins or medications on board. Please review S-313 for details.