To answer this question you need to be familiar with the terminology of diabetes and know which terms mean the same thing.
-Insulin sensitivity factor (ISF) and correction factor (CF) are the same thing and the terms used interchangeably. Both of those terms are used to describe how much one unit of insulin decreases blood sugars for a given patient. For example an ISF or CF of 1:2 means that 1 unit of insulin will bring down a particular patient’s sugar by 2 mmol/L
-The second terminology is carbohydrate exchanges and grams of carbohydrate. An exchange is just an amount of carbohydrate (usually but not always 15 grams). So a 15 gram exchange is just 15 grams of carbohydrate. A 10 gram exchange is just 10 grams of carbohydrate. Two 15 gram exchanges is 30 grams of carbohydrate. An insulin to carbohydrate ratio (ICR) or exchange ratio is the amount of insulin needed to negate the rise in sugars from an amount of carbohydrate. For example a insulin to carb ratio of 1:15 or a insulin to exchange (with 15 grams for each exchange) ratio of 1:1 means that if a patient takes 1 unit per 15 grams of carbohydrate they consume then that patients sugars should only minimally rise post prandially.
-The next key to understanding this question is insulin resistance. The more insulin a person needs to bring down their sugars, the more resistant they are to insulin. Think about it this way. Who is more resistant to insulin? A 6 month baby child where 1 unit of insulin brings down his/her sugars 10 mmol/L or a person who is obese who needs 10 units to bring down their sugars 1 mmol/l? Which one would you be more comfortable giving a large dose of insulin to? That is the person who is more resistant to insulin. So looking at all the answers
A) An ISF of 1:3 is the most sensitive of all the patients because 1 unit brings the most mmol/L. So is the wrong answer. An ISF of 1:3 means that the patient needs 3.3 units of insulin to bring down their sugars 10 mmol/L. A ICR of 1:20 is the second most sensitive most sensitive
B) An ISF of 1:2 is not the most sensitive. An ICR of 1:15 is not the most sensitive
C) As ISF of 1:1 is the most resistant meaning that this patients needs 10 units to bring down their sugars 10 mmol/L vs 3.3 for the patient in answer A). An ICR of 1:5 is the most resistant and means that for a 50 carb meal this patient needs 10 units to negate the rise in sugars
D) An ISF of 1:2 is not the most resistant. An 0.5 per exchange (15 grams) is the most sensitive. A 0.5 per 15 grams means the patient needs 1 unit per 30 grams of carbohydrate. This means that this patient needs 1.6 units to cover a 50 carb meal. Compare that to the patient in answer C) which requires 10 units.

A) Incorrect- This is too large of a starting dose and may lead to hypoglycemia
B) Incorrect- This is a default starting dose (10 units) for basal insulin but there is another answer that is also correct.
C) Incorrect- This is a acceptable lower starting dose for people who weigh under 50 kg (0.1-0.2 units per kg) but there is another answer that is also correct
D) Incorrect- This dose is too low
E) Correct- Both B and C are both correct

Please see Example A on Appendix 9 on pg S317 of 2018 Diabetes clinical practice guidelines and pg 2 of the Diabetes Canada insulin prescription tool at https://www.diabetes.ca/DiabetesCanadaWebsite/media/Managing-My-Diabetes/Tools%20and%20Resources/insulin-prescription-fillable-EN.pdf?ext=.pdf (will open in new window) for more details

A) Correct- the usual starting dose for bolus insulin is 2-4 units. Studies have shown it has little effect on A1c whether you start with the biggest meal of the day or the largest post prandial rise in blood sugar of the day. So 2-4 units with either breakfast or dinner would be correct
B) Incorrect- this is too high of a starting dose given the information you are given
C) Incorrect- you could start bolus insulin at every meal but generally you start with one meal. Also the patient specifically asks for minimal injections. Studies show that you get the largest benefit in A1c reduction when adding bolus insulin to the first meal. You still get A1c reduction benefit when adding bolus insulin to the second and third meal but the reduction is less than the first one. So overall not the best answer therefore not the correct answer.
D) Incorrect- this is too high of a starting dose given the information you are given
E) Incorrect- only A) is correct

Please see Example B of Appendix 9 on pg S317 of the 2018 Diabetes Canada guidelines for more details for more details

Generally when adjusting insulin you look for patterns of lows first then patterns of highs. If no pattern of lows or highs then the patient is in euglycemia so don’t change anything
1) Look for patterns of lows, if happening at fasting times then reduce basal, if happening after meals reduce bolus
2) Look for patterns of highs, if happening at fasting times then increase basal, if happening after meals increase bolus

A) Incorrect- when adjusting insulin you must look at when it takes effect not when it is administered. We want to stop the hypoglycemia before breakfast, however stopping the morning NPH wont help. The NPH will peak in 5-8 hours and last for ~18 hours. He is taking the NPH at 8am so it will peak around 1pm-4pm and last till 2am at most. He is having lows around 7-8am so reducing the morning NPH will not help
B) Incorrect- when adjusting insulin you must look at when it takes effect not when it is administered. We want to stop the hypoglycemia before breakfast, however stopping the morning Humalog (lispro) wont help. The Humalog will peak in 1-2 hours and last for 4-5 hours. He is taking the breakfast Humalog at 8am so it will peak around 9am and stop working around 12 pm. This is nowhere close to the lows he is having at 7-8am
C) Incorrect- generally you treat hypoglycemia before you treat lows. Also the 10.1 is only 0.1 above target and there is no pattern.
D) Correct- to fix the morning hypoglycemia you reduce the evening NPH which is taking effect throughout the night and causing the lows

Please see Appendix 5 and 6 on pg S312 of the 2018 Diabetes Canada clinical practice guidelines for more details

Generally when adjusting insulin you look for patterns of lows first then patterns of highs. If no pattern of lows or highs then the patient is in euglycemia so don’t change anything
1) Look for patterns of lows, if happening at fasting times then reduce basal, if happening after meals reduce bolus
2) Look for patterns of highs, if happening at fasting times then increase basal, if happening after meals increase bolus

A) Incorrect- there was only one high post prandial reading after breakfast. Increasing insulin based on one reading is not ideal. Generally you treat hypoglycemia before you treat hyperglycemia
B) Incorrect- Generally you treat hypoglycemia before you treat hyperglycemia. Increasing the Toujeo (concentrated glargine) would likely lead to more lows after lunch
C) Correct- lowering the FIASP (aspart) would reduce the hypoglycemia after lunch
D) Incorrect- while lowering the Toujeo (concentrated glargine) would reduce hypoglycemia it would result in more fasting hyperglycemia. Reducing the lunch FIASP (aspart) is a much better answer

Please see Appendix 5 and 6 on pg S312 of the Diabetes Canada clinical practice guidelines for more details

Generally when adjusting insulin you look for patterns of lows first then patterns of highs. If no pattern of lows or highs then the patient is in euglycemia so don’t change anything
1) Look for patterns of lows, if happening at fasting times then reduce basal, if happening after meals reduce bolus
2) Look for patterns of highs, if happening at fasting times then increase basal, if happening after meals increase bolus

Like in real life you should expect that patients to miss taking readings. On the exam you will have to take your best guess even with incomplete information. You can complain about the “unfair” question after the exam to the CDECB but it wont help you pass the exam.

A) Correct- this is the best answer out of all the given answer, even though in real life you would only increase the lunch bolus.  You can complain about the “unfair” answer but the worst thing to do is get frustrated or angry during the exam. This will result in you losing your peace of mind and guaranteeing that you will fail the exam.
B) Incorrect-  Generally you do correct hypoglycemia before hyperglycemia but there is no hypoglycemia before breakfast. Even if there was, reducing the Apidra wont help as the Apidra doesnt peak for another 2 hours. If there was fasting hypoglycemia you would reduce the basal insulin, in this case Tresiba.
C) Incorrect- there is only one reading above 7 and its only 0.1 above target. The patient forgot to take his after supper reading so maybe he had a big birthday dinner and his post prandials were very high. You cant assume numbers.
D) Incorrect- there is no after lunch hypoglycemia. Decreasing the Tresiba would cause all the readings to increase causing hyperglycemia at other times.

Please see appendix 5 and 6 on pg S313 of the 2018 Diabetes Canada clinical practice guidelines for more details

The formula for calculating ISF or Correction Factor (CF) is 100 divided by Total Daily Dose (TDD) if using rapid acting insulin or 83 divided by TDD if using short acting insulin. This patient is on 60+60+40+20+20= 200 for TDD. 100/200= 0.5. Meaning 1 unit of insulin is expected to bring him down 0.5 mmol/L.

A) Correct- this is the correct ISF or CF
B) Incorrect- A 1:1 ratio means 1 unit brings down the patients sugars by 1 mmol/L which is incorrect
C) Incorrect- A 1:2 ratio means 1 unit brings down the patients sugars by 2 mmol/L which is incorrect
D) Incorrect- A 1:2.5 ratio means 1 unit brings down the patients sugars by 2.5 mmol/L which is incorrect

To calculate ICR you take 500/Total daily dose (TDD). So for this patient 15+15+5+10+5=50. 500/50= 1:10 ICR which means for every 10 grams of carbohydrate this patient consumes taking 1 unit of insulin should minimize her blood glucose rise.

A) Incorrect- An ICR of 1:1 means that the patient needs 1 unit of insulin for every 1 gram of carbohydrate they consume to minimize blood glucose rise
B) Incorrect- An ICR of 1:5 means that the patient needs 1 unit of insulin for every 5 gram of carbohydrate they consume to minimize blood glucose rise
A) Correct- this is the correct ICR
A) Incorrect- An ICR of 1:15 means that the patient needs 1 unit of insulin for every 15 gram of carbohydrate they consume to minimize blood glucose rise

The key to this question is to calculate the ICR the patient used for each meal. Remember to subtract fibre from the total carbohydrate (since fibre does not break down into glucose) the divide the available carbohydrate by the numbers of bolus units used.

A) Incorrect- the time he used a 1:2 ratio his post prandial sugars dropped from 5.6 to 3.4 causing hypoglycemia. This ratio is too aggressive
B) Correct- the times he used this ratio (6 to 6.5 and 6 to 6.8) his post prandial sugars did not increase by more than 3 mmol/L and kept him at target. This ratio should be used for the rest of his meals.
C) Incorrect- the time he used a 1:10 ratio his post prandial sugars spiked significantly from 6.4 to 10.9 causing hypoglycemia. This ratio is too aggressive
D) Incorrect- the time he used a 1:2 ratio his post prandial sugars dropped from 5.6 to 3.4 causing hypoglycemia. This ratio is too aggressive

A) Incorrect- As a general rule when you switch from twice daily insulin to once daily insulin you reduce to dose by 20% to avoid hypoglycemia. Tresiba (degludec) is equally effective in the morning and the evening
B) Incorrect- As a general rule when you switch from twice daily insulin to once daily insulin you reduce to dose by 20% to avoid hypoglycemia. Tresiba (degludec) is equally effective in the morning and the evening
C) Correct- a 20% reduction in dose is the general rule. The timing of morning or evening is irrelevant
D) Incorrect- there should be a 20% reduction not a 20% increase

Note that the exam often uses older insulins so my Practice Exams often have many questions on older insulins even though I don’t typically use them in my real life practice.