2020 Q and A

Hello this is where the tips, questions and answers from the Q and A on Oct 23 2020 will be posted. The 2020 Q and A will run on Oct 23 at 9am to 5pm.  (mountain 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 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

The password to the Zoom meetings is CDE2020

For the 1-2 pm (mountain time) session the link is: https://us02web.zoom.us/j/81152305940?pwd=dEVBVEluMDhmRm0rdDlqNS9GSUtLZz09

For the 4-5:30 pm (mountain time) session the link is:  https://us02web.zoom.us/j/82590911187?pwd=YXZYYnRKUHdtSjlkbEYvWXpPM21OUT09

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.

Hi Esmond,

Please see the attached Travel Guidelines handout from Alberta Diabetes Link (www.albertadiabeteslink.ca) C-endo’s Diabetes Education website with information for patients and professionals.

Please feel free to let your participants know about the website and that they can use any of the handouts in their own practice!

Steph Tilley BSc, RD, CDE
C-Endo Clinic (Dr Sue Pedersen’s clinic)

 

Hi Esmond. I am still confused about premix insulin composition ,peak and duration of action. Also I was wondering if there is benefit to using dpp 4 inhibitors with glp1 agonists given the cost.

Thank you.
Carrie Ali
Hello Carrie, a lot of people find pre-mixed insulins confusing. Pre-mixed insulin comes in two types. Pre mixed short acting and Pre mixed rapid acting. You can think of pre mixed insulin as two different type of insulin in the same bottle with two different peaks and duration. So for example Humulin Mix 30/70 is a pre-mixed short acting insulin. If you gave a patient 100 units of it in one injection you would be basically giving him 30 units of Humulin R (with its own peak and duration) and 70 units of NPH (with its own peak and duration). If you gave 100 units in one injection of Novomix 30 then again its 30 units of Novorapid and 70 units of NPH. 
No typically medications with the same mode of action dont provide additional benefit. The DPP-4 is doing little and not worth the cost.
Esmond

 

Dear Esmond,
First I want to thank you for all your help and amazing webpage you provided us.
I have 2 main questions:
1- During live session with Dr Pederson, a question regarding Insulin dose adjustment in time zone change came up and she mentioned that she’ll send some case study. I’m not sure if I cannot find it or it’s not there. I need some more explanation regarding dose adjustment.
2- Difference between Dawn phenomenon and Symogi effect and how to diagnose and differentiate and treatment for Dawn phenomenon.Regards,
Sepi
Hello Sepi
1- I copied Steph’s  email at the top of the page with resources for time zone change adjustments. Look under Living with Diabetes -> Travel
2- Another person has asked this exact question and  I answered them in the Exam Forum. Please look under Exam Forum-> Pathophysiology -> Dawn Phenomenon

 

I have a patient case which I’m unsure about. I have a patient with September bloodwork showing FBG- 6.9. A repeat October bloodwork showed FBG- 5.5 and A1C -6.9% How would you classify this patient?
My understanding is the first FBG classifies the patient as pre-diabetes. The second FBG indicates normal but the A1C indicates diabetes. I’m not sure how to classify this patient.
On a side note, do you only need 1 test to classify the patient as pre-diabetic or do you need 2 confirmatory tests for pre-diabetes?
Thank you so much for your help!
Sara
Hi Sara
Interesting. He doesn’t fit into any category. I would repeat the labwork again. Under the figure it does say if discordant use the right most category. He likely has pre-diabetes. His readings are too high to be normal. The guidelines don’t say for pre-diabetes but I would want to make sure with another test before I break the news to the him/her. 

 

Hello Esmond,

Your website is so helpful. Thank you so much for taking the time to create all the VERY helpful materials!

Hi Esmond I have difficulty understanding how to calculate the insulin sensitivity factor. Thank you for the tip for 100 divided by total daily dose.

60 Q quizz: Question 20 of 60

You mention that the formula for calculating insulin sensitivity factor (ISF) or Corrector factor (CF) is 100/Total daily dose if using rapid insulin, and 83/TDD if using short acting insulin.

If patient is on 60+60+40+20+20=200. Therefore, 100/200 =0.5.

Meaning 1 unit of insulin is expected to bring him down 0.5 mmol/L? I do not understand this. May you please explain what it means..?

Hi Madonna
That is correct this patient needs 1 unit to bring him down 0.5 mmol/L. If his target was 7 and he was at 9 he would need 4 units. If another person has a ISF of 1:2 then that patient would only need 1 units to bring him down from 9 to 7. 

I also do not understand well question 50: most resistant to insulin?

Thank you so much!

Madonna

For this question you need to calculate who has the most resistant ratio as that person is the most resistant to insulin. In the example in the previous question the person with the ISF of 1:0.5 mmol/l or 1:2 mmol/L. Who is most sensitive? The patient with the ISF of 2 mmol b/c he needs less insulin to bring him down. 

Try thinking of this way. You punch a sumo wrestler with 1 unit of force and he moves 0.5 meters. You then punch an anorexic girl with 1 unit of force and she moves 2 meters and falls down. Who is more sensitive to your punch? The anorexic girl

Now switch the scenario for diabetes. You inject a sumo wrestler with 1 unit of insulin and his sugars drop 0.5 mmol/L. You inject a anorexic girl with 1 unit of insulin and her sugars drop 2.0 mmol/L and she has a low and faints. Who is more sensitive?

Hi Esmond,

Would you be able to help clarify regarding the following questions:
1) Screening for depression & eating disorders in Children with T2DM: on p S252, Recommendation #17 says to screen biannually. However, on p S250 in Table 1, it says to screen yearly. Do you know which screening time frame we should follow?
Hello Monica
That is an error in the guidelines. I will email them and try to find an answer. However they have not responded to my emails in previous years about errors. 
2) p S205 (under Blockade of renin angiotensin aldosterone system, the first few sentences): says ACE/ARB can reduce risk of CKD independent of their effect on BP. But then it goes on to say this protective effect is only in people with diabetes AND hypertension. Protective effect is NOT demonstrated in normotensive people with diabetes. However, according to the guidelines, ACE/ARB is recommended regardless of baseline BP. Can you clarify this?
This recommendation is based on the BENEDICT study that studied kidney disease in hypertensive patients given an ACE vs non-ACE BP med vs ACE+ non-ACE BP med (combo) vs placebo. BP went down in ACE, non-ACE med and combo but kidney disease only went down with ACE and combo. Kidney disease in non-ACE med and placebo was about the same. They interpreted this as ACE reduce risk of CKD regardless of BP lowering effect. For details please see the BENEDICT study.  https://www.nejm.org/doi/full/10.1056/NEJMoa042167
The EUCLID study showed another ACE med had no effect in people who had normotensive. For details please see: https://pubmed.ncbi.nlm.nih.gov/9269212/
ACE/ARB are not recommended regardless of BP. Review this checklist:
You are in the CKD chapter so for patients with diabetes and CKD an ACE/ARB is recommended but not every patient with diabetes has CKD.
3) p S66 (Table 1)- Can you clarify why a low carb diet can increase renal load?
I’m not sure. That would have been a good question to ask Dr Pedersen’s dietitian. 
Thank you very much for your help!
-Monica

Hi esmond ,
I am reviewing the questions on Essentials. The question 29, regarding benefits of exercise confused me. Does exercise improve glycemic control for type1?  The feedback answer is D, all of the above. But I remember exercise doesn’t help glycemic control in type i patients. Please clarify. Thanks!
Xiao

Hi Xiao, some studies have shown exercise helps with glycemic control with type 1 and type 2 diabetes. Please see pg S54, S55, and S57 of the guidelines. If you can find the page number where you read that “exercise doesn’t help” (like Monica does above) that would be helpful. 

 

Hi Esmond,

First of all I can not appreciate and thank you enough for all your hard work and effort that you put in for this website! It’s an excellent resource.
I just wanted a clarification for exam perspective: do we need to memorize the table to calculate ICR based on BMI? I did memorize it but I have to write it first,and it seems a little difficult with the online exam this time. Please guide or give me some tips to count it.
Thanks
shital
Hi Shital, I dont think it necessary to memorize the ICR based on BMI method. Its rarely used in real life and I have never seen a question on it on the exam. The concept is that the higher the BMI the higher insulin resistance the patient has. 
Thanks
Esmond

 

Hi Esmond ,

Regarding the Nutrition chapter, should we follow the recommendation12 or follow the table 1 for health benefits, like the effects for CV, BP, BW? Thanks!
Xiao
I would be familiar with recommendation 12 but Table 1 in the Nutrition chapter is too complex to memorize for the exam. 
Thanks
Esmond

 

Hi Esmond,
I would think that the answer could be any of the first three? Not sure how I can only pick two…

Shairoz

Hi Sharioz the answer is A. Unexpected lows could be due to infusion site malfunction but it could also be extra sugar the patient did not account for, pt is ill, pt took corticosteroids etc. There are lots of reasons for unexpected lows even though the first thing to suspect is infusion site malfunction. iii is wrong because if the infusion site is properly working you just used a syringe for no reason. iv is wrong because you wouldnt change the ratio based on one reading it should be a patter of highs after using the ratio. 

Thanks
Esmond

 

 

Could you please help with this question ? Bisi

Hello Bisi, I was able to use Paint to improve the resolution of the picture. Its still blurry but I think the answer is C. How you solve the answer is add all the insulin together to find the TDD (total daily dose) which is 35. Then take 60% as bolus and 40% as basal. 60% of 35 is 21 then divide by 3 meals is 7 units with each meal. 40% of 35 is 17. So that is answer C. Thanks

Esmond

Hello Esmond

I see you are getting a lot of questions already. I am sorry to add to your work load!

Can you please help me understand all the different ways of calculating out insulin and it what scenario to use it:

Essential 5th Edition offers several methods:

  • Pg 6-93 for premixed insulin therapy “initiate at 5-10 units once or twice daily or a dose of 0.5 Units/kg/day” does this imply a client can be started on 20 U NPH? No, pre-mixed insulin is not the same as NPH so there is no implication
  • Pg 6-88  Basal “initiate at dose of 10 units once daily or 0.1 to 0.2 Units/kg” this is the same as the guidelines. However I would imagine if the client is obese the best option would be to calculate. Yes, if you have a client that’s very obese he may need 100+ units of insulin to be well controlled. Starting at 10 and increasing by 1 would take months to get to target and would be discouraging for the patient 

the dose based on the weight rather than starting at 10 units. Perhaps the same idea for an underweight person.

  • Pg 6-91 “calculate the total daily dose: 0.3 to 0.5 Units/Kg or the sum of the individual’s current insulin doses. When would the first part of this sentence be used? The first part would be for a person not on insulin. The second part would be for a person who is one some other regimen like mixed insulin 
  • Pg 6-69 Type 2 Diabetes: the average total daily dose TDD requirement is  1.0 to 1.5 units/kg/day however can be up to 2.0 units/kg/day. What is insulin dosing method would you use for a T1DM client? Neither I find those averages to be too general and adjust the dosage based on the patients response. I completely ignore the average dose requirements. 
  • I have been told NPH is a good choice for managing elevated blood glucose from prednisone use. Have you found this effective in your experience?  I have found NPH effective for treating hyperglycemia with prednisone. NPH follows the prednisone induced peak in sugars nicely
  • Pg 6-87 have you come across any studies that state smoking reduces the rate of rapid and short acting insulin absorption? I have not
  • When switching a client from Insulin Aspart to FIASP would you caution the client to lower the dose? No FIASP just works 5 min faster so there is no need to decrease the dose. 

Thanks again,

Mary

 

Hi Esmond,

Thank you for making yourself available to answer our questions in preparation for the exam.
I have a question for you after reviewing the Diabetes and Driving chapter of the CPF. On pg. S152, Recommendations 4 and 5, it is stated:
4. Private and commercial drivers with diabetes and hypoglycemia unawareness or history of severe hypoglycemia in the past 12 months must measure their BG level immediately before and at least every 2 hours while driving or wear a real-time CGM device [Grade D, Consensus]
5. If any of the following occur, health-care professionals should inform people with diabetes treated with insulin secretagogues and/or insulin to no longer drive, and should report their concerns about the person’s fitness to drive to the appropriate driving licensing body:
1. Any episode of severe hypoglycemia while driving in the past 12 months [Grade D, Consensus].
2. More than 1 episode of severe hypoglycemia while awake but not driving in the past 6 months for private drivers, and in the past 12 months for commercial drivers [Grade D, Consensus].
My question is: if private and commercial drivers with DM and a history of hypo unawareness or severe hypoglycemia in the past 12 months should be told not to drive and be reported to the provincial licensing body (Recommendation 5), how is it that the same private and commercial drivers with DM and hypo unawareness or severe hypo in the last 12 months measure their BG level before and every 2 hours while driving? Shouldn’t they refrain from driving in the 1st place? If this question came up in the exam I would be unsure about indicating whether they should not be driving, or checking their BG before and every 2 hours while driving.
I must be misinterpreting something after all the reading that I have been doing in the past weeks.
Thanks a lot for your help!
Maira
Hi Maira, hmm I agree with your interpretation but then that doesn’t make sense. I assume that once they have met with their health care professional to minimize further lows then they can drive again? 
Esmond
Dear Esmond,
I have a couple of questions for you:
1.  Using the example that you gave in Exam #2, are we expected to know all the alternative natural products and how much they decrease A1C?? That is unrealistic since I would easily look that up if asked in my references.  If so, could you give examples of the most common ones?
There seems to always be one question on natural health products in every exam. I have never been able to memorize all of them so I would just know some and hope that one that you know shows up on the exam. 
2. Can I assume that any cookie would have 5g CHO like the  gingersnap cookies in your questions?  That was a good question, but I thought about the sandwich first since I was not sure about the cookies CHO count.
Its difficult to say what you can and can’t assume on the exam. I would read the question carefully.
3. If starting insulin, how soon should the patient discountinue secretogogues like glyburide or gliclazide? I know they generally should not be used together but exams don’t usually let you do d/c one and start another as a choice.
Usually I d/c the SU after the pt gets to target with insulin. For the exam if there is a choice to d/c later I would choose that if not I will choose the d/c right away choice assuming that is answer the question is asking for. Thanks Esmond
Thank you for your guidance as I prepare for the CDE exam on Saturday.
Best Regards,
Penny

Why would the answer not be all except the second one?
According to essentials answer sheet their answer is BThank you :)Shairoz

 

Hi Shairoz

The official answer to this question is B but I would have gone with A. i is correct and ii is wrong. However I would say iv is wrong as well. If the patient’s sugars are high I would still want them to enjoy sweets on special occasions as we work towards their target. I think iii is correct so would have gone with A. 

Thanks
Esmond

Hi Esmond, I’m still hung up on when to initiate an SGLT2i…. Guidelines say …”for clinical CVD and eGFR>30, SGLT2i to reduce MACE, HHF and progression of nephropathy”
Would you initiate an SGLT2i for no CVD/low CVD risk if GFR under 60?
I’m also trying to ignore the new (Oct 2020) recommendations, but it is hard when practice is different from what we have to know for the exam.
Thanks
Virginia
Hi Virginia, I think I can see where the confusion is. Fig 2 on S94 is different then Recommendation #7 on S99. Its further complicated by the new guidelines and new product monographs which have allowed SGLT-2 inhibitors to be used when eGFR >30. I think they made an error on Fig 2. If you look at the bottom it says * May be considered… but then there are no * in Fig 2. I think they meant to put the * by Jardiance and Invokana.  
Thanks
Esmond
Hi Esmond,
Thank you for answering my previous questions. I have another question I needed clarification on:
In the 2018 Quick Reference Guide, “Screening & Diagnosis of T2DM in adults”, it shows for those with no risk factors, we can screen “Age >40 or high risk” every 3 years. I find this confusing, as how can one be considered “high risk” if they don’t have any risk factors?
Also, if someone has even just one risk factor in Table 1 (p S17), would that mean they need to be screened every 6-12 months? For example, if someone had gestational diabetes (which is in Table 1), do they need to be screened q6-12months? Another reference on the Diabetes Canada website says history of GDM should be screened every 3 years.
Thank you for your time!
-Monica
Hello Monica, thanks for the question. 
Its high risk using the CANRISK diabetes calculator so there is are risk factors. The CANRISK calculator asks various questions and then estimates a diabetes risk. It can be found here: https://www.healthycanadians.gc.ca/en/canrisk
That would be more a judgement call. Having one risk factors would mean to screen more often but that doesnt mean they have to be screened 6-12 months. I would probably only screen 6-12 months if they had a number of risk factors. 
Thanks Monica

Hello Esmond,

I hope this is not too late. Here are some questions for you:
– Similar to a question asked already, but to diagnose DM, you need 2 values in the diabetes range (if asymptomatic to hyperglycemia). So, if only one value is in the range, let’s say the A1C, it would be preferable to retest the A1C right? Preferably you want a different test. And vice versa, if FPG is in the diabetes range, but A1C is normal, you retest the FPG? (Except for random plasma glucose, which is recommended to use an another kind of test)? Look at figure 1 on p S18. There is a fine print that says if discordant use the right most side of the algorithm. I would probably retest using a different test. 
– Could you explain the mechanism behind some factors affecting A1C such as erythrocyte pH, vitamin C/E, aspirin, alcoholism…? Some of the mechanisms affect the rate of glycosylation of the hemoglobin. Think of it as different coatings to prevent rust or accelerate rust. This doesn’t affect the actual blood sugar but affects how fast the glycosylation is occurring which is what an A1c test measures. 

– When on a certain regimen of MDI and you want to switch to another regimen  MDI, there is no dose reduction? When looking on your insulin calculation cheat sheet and the question you answered above, there was no reduction? There are no special adjustments for this. 
I assume if you go from twice daily to once daily long acting OR from Toujeo to Lantus, for example, you would need to consider the dose reduction then right? For twice daily to once daily yes for sure. For Toujeo or Lantus not necessarily though it would be an ok idea just to be cautious. Thanks Esmond

I also have been reading the Q&A. I saw a question asked regarding the renal load and low carbohydrate diet. As a dietitian, this would be explained by higher protein intake if carbohydrate intake is reduced. Meaning, kidneys have more protein to filter.

Thank you so much for your time and devotion to help us. :)

Josée

Hi Esmond,

Question #81 of the Essentials
Which would be the best answer to this question ? Would it be C ?
Thanks,
Lorraine
Hi Lorraine, the official answer is D. C is not correct as you don’t dose intermediate or long acting insulin in the middle of the day. They are always dosed daily or twice daily. A is incorrect as the 2 hours after lunch sugar is already on target. B is the closest to right answer but note that it would not fix the before dinner sugars. Also note that the bedtime to before breakfast sugars drop by 3-4. Even if you brought the bedtime sugars to 7 then they would drop 3-4 to 3-4 mmol/L by morning which is too low. Therefore the only completely correct answer is D. 

Hi Esmond,

I see that sometimes % is used when adjusting insulin (e.g. reduce basal by 10%). I always went with the 1-2 units per day rule. When do we use % and how would we determine how much percentage?

Thanks,

Lorraine

Hello Lorraine, it depends on the patient. If the patient is a moderate dose of insulin or higher around 30+ units of insulin then I start increasing by 10%. I have one patient who is on 300 units of Toujeo so going up by 1 unit daily would take a forever to get to target. 

Hi Esmond, I forgot to ask about travel questions. how detailed are the question son insulin and travel and  can you give some tips to easily remember timezones an insulin changes. I will join again at 4 pm

Hi Marleis, you don’t have to memorize the timezones for the exam. Just know if you are losing time you need to decrease the insulin and if you are increasing time then you dont increase the basal you would just do another extra bolus. In real life you could just switch to Tresiba and not have to deal with these time zone differences. Hopefully they will have that as an option on the exam! 

Thanks so much
Marleis

Hi Esmond, me again. one more question regarding autonomic complications.  Can you speak this.  Why is reduced sensation in the feet not an autonomic complication?

Hi Marleis, I can see your referring to Question #17 of the Essentials. Im not sure why the answer is C. I guess that all the other options such as anyhyrosis, orthostatic hypotension, and gastropareis dont involve thiking or sensing?

Hey Lorraine just answered this question. Its because loss of sensation is considred to be a sensorimotor neuropathy not autonomic. Thanks Esmond

Thank you
Marhleis