2023 Q and A

The time in Calgary is in Mountain Standard Time

 

The 2023 Question and Answer sessions are scheduled for:

May 8- Deadline for sending in questions for Dr Akshay Jain to cdestudycourse@gmail.com

May 15- Dr Akshay Jain Q and A session at 5:30-6:30 pm (Mountain Standard Time)

Note that Dr Akshay Jain does NOT allow recording so this session will not be uploaded to YouTube afterwards.

Join Zoom Meeting
Finished

May 24- Esmond Q and A session at 5:30-6:30 pm (Mountain Standard Time)

 

Note that I have taken May 25 and 26 as vacation so I will be available to answer questions on the exam forum throughout the day.

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.
Some questions will give you answers that are like a long list. For example
Which of the following are all fruits?
A) Cakes, watermelons, apples, oranges and blueberries
B) Cantaloupes, watermelons, mangoes, pears and doughnuts
C) Apples, oranges, bananas, cherries and raspberries
The key to answering these questions is to look for the ones that are wrong first. Once you see cakes and doughnuts you know the answer is C. This helps you narrow down the possible answers.

Esmond Q and A Questions so far

Hi Esmond,

Thanks for the email and informative Q and A session. This question is likely outside of the realm of the CDE exam but I was hoping to get a simplified explanation on:
1.) How does potassium and insulin impact each other? Especially in the context of DKA
I don’t work in emergency but insulin drives potassium out of the blood and into cells. I’ve heard of using insulin to treat hyperkalemia. In terms of DKA, you are administrating a lot of insulin because 1) sugars are high 2) you need extra insulin to overcome the insulin resistance called by the ketones. However too much insulin drives too much potassium out of the blood leading to hypokalemia. Likely the patient has lost fluids due to vomiting and diarrhea and this also results in loss of potassium. Therefore IV potassium is required to treat hypokalemia if present.
2.) Can you explain insulin metabolism in the body. I know the kidney is responsible for 25-40%. I’ve read something on “first pass metabolism” with the liver on exogenous vs endogenous insulin. Trying to wrap my head around what the differences of metabolism for endogenous vs exogenous insulin!
Good question, so when we eat or when we take a drug its digested and the blood goes to the portal vein to the liver. The liver is a major site of drug deactivation/clearance (the other being the kidney). This is first pass metabolism reduces the effectiveness of some oral drugs, so if you are using the IV version you need to use a lower dose. For insulin, the metabolism of endogenous and exogenous insulin is similar however differences in the absorption slow down exogenous insulin significantly. Being deposited into the bloodstream and bound into hexamers slows the absorption.
3.) Why is Lantus able to be split BID dosing but not Basaglar?
Basalglar can be split. Basalglar is just generic Lantus (glargine)
Brianne

 

Hi Edmond,
Do you know if the exam will give the names of oral meds in the combination meds? I can’t remember from the last time I wrote.
Thanks,
Christy
In my previous exams, both names were provided

 

Hello Esmond,
How are you? I hope you are enjoying the long weekend
I have a few questions for the Q&A sessions:
Could you explain why AIC will decrease if patients take aspirin, vitamin C and E, as well as in reticulocytosis?

Good question Amy, in general any condition that shortens erythrocyte survival or decreases mean erythrocyte age (e.g., recovery from acute blood loss, hemolytic anemia) falsely lowers Hb A1c test results, regardless of the assay method (147). Vitamins C and E are reported to falsely lower test results, possibly by inhibiting Hb glycation (230, 231). Iron deficiency anemia increases test results (232). Food intake has no significant effect on test results. Hypertriglyceridemia, hyperbilirubinemia, uremia, chronic alcoholism, chronic ingestion of salicylates, and opiate addiction reportedly interfere with some assay methods, falsely increasing results (204, 233).

The above is copied and pasted for the article listed at the end of that chapter can can be found at https://academic.oup.com/clinchem/article/57/6/e1/5620987

An increase in circulating RETICULOCYTES, which is among the simplest and most reliable signs of accelerated ERYTHROCYTE production. Reticulocytosis occurs during active BLOOD regeneration (stimulation of red bone marrow) and in certain types of ANEMIA, particularly CONGENITAL HEMOLYTIC ANEMIA. So more red blood cells mean less time for sugars to accumulate.

Why does alcoholism increase AIC? see above

In one of the practice exams, you mentioned that you would never prescribe Humulin 30/70. What is the reason?

Humulin 30/70 uses short acting insulin like Toronto or Humulin R (which I never use) with intermediate acting insulin like NPH or Humulin N (which I also never use). So I would never use a combo of them when there are better insulins.

What are the ACE inhibitors and ARB (brand and generic names) commonly used to treat hypertension in people with diabetes? in people with heart failure?

ACE-inhibitors (ACE-I) ends with pril, i.e. (Altace) rami-pril, (Coversyl) perindo-pril
Angiotensin Receptor Blockers (ARB) ends sartan, i.e, (Micardis) telmi-sartan, (Atacand) cande-sartan, (Diovan) val-sartan.
The same are used in diabetes and heart failure
Beta blockers ends with olol, i.e. bisopr-olol, metopr-olol
Thiazide diuretics end with ide, i.e. hydrochlorothiaz-ide, indapam-ide
Newer calcium channel blockers end with dipine, i.e. amlo-dipine, felo-dipine

 

Thank you
Kind regards
Amy

Hi Esmond,
Thanks for the reminder for the upcoming Q&A session. I was wondering if you could please clarify, I always thought basal insulins were started before rapid- is this not true?
Can you please go over this! Thank you

Rida Chaudhry
Registered Dietitian, CDE

Lets use a case as an example. Your patient Dr Stephen Strange is a busy brain surgeon with type 2 diabetes that is poorly controlled. He works 7am to 7pm doing surgery and has one meal per day due to his busy schedule. He is not willing to change anything. He is maxed out on all other medications. His sugars are

6 am- Before breakfast- 11-12
12pm- Middle of work day- 4-5
6pm- Still working- 4-4.5
9pm- After supper 17-18

What are the risks in putting him on basal insulin?
His wife is a medical lawyer and demands to know which page number in the guidelines where it states basal insulin must be started first. Which page number do you point her to?
What would be the benefits of putting him on bolus insulin at supper? What other professions would benefit from starting bolus first?

 

The twin popsicle is on that handout as well listed as 15g

 

Hi Will remission of Type 2 be on the exam?

 

The “Stay Safe when you have diabetes and sick” has 1 twin popsicle as 15 grams

 

There is no screening for t1dm since it can’t be detected anyway from what I understand

 

Other than the DCCT, UKPDS and their follow up studies will we be asked to know the names of other studies and their outcomes?

 

Can you please confirm if its 30% or 10% of people with DM have major depressive disorder? Thank you

 

Worsening retinopathy with intense glycemic shifts – T1DM + T2DM? Or just T1DM…

 

Do you happen to have the answer key for the essentials edition 4 exam?

Esmond sorry again for the same question, page 181 table 3 also said Do not use gemfibrozil in combination with a statin due to increased risk of myopathy and rhabdo.

 

do we need to know all just the basics cups = 15 g serving for each fruit as an example

why do they call it a 7 point profile when it’s 8 tests

 

HTN assessment schedule for DM1 and DM2 in kids?

 

Can you kindly confirm Drug of Choice for Lean Elderly with DM2 is DPP-4 inhibitor, for Obese Elderly pt with DM2 is Metformin ?

 

At what weight should Basal insulin be started at less than 10 units ?