A 53-year-old woman with a history of Graves disease underwent ablative therapy 3

years ago. She experienced significant symptom relief and became euthyroid. Her
thyroid laboratory values today include TSH 0.12 mIU/L (normal 0.5–4.5 mIU/L) and a
free T4 concentration of 3.8 g/dL (normal 0.8–1.9 ng/dL). She states that many of her
previous symptoms have now returned but are mild. Which would be the most
appropriate treatment
option for her condition?
A. Methimazole.
B. Thyroidectomy.
C. PTU.
D. Metoprolol.

Answer: A This patient has relatively mild symptoms, and her ablative therapy worked
initially but now no longer controls her thyroid levels. Methimazole (Answer A) would be
the oral agent of preference given its dosing frequency and lower risk of hepatotoxicity
compared with PTU (Answer C). Thyroidectomy is an option, but it is likely too
aggressive for mild Graves’ disease; thus, Answer B is incorrect. Answer D is not
optimal; β-blockers, which may provide symptomatic relief, will not significantly affect her
thyroid levels.

Answer : C
1800/TDI = 1800/24=75 mg/dl
FD is a 44-year-old, healthy woman. Her father has diabetes mellitus. FD does not
exercise and over the past 5 years has gained 20 pounds. During her last physical exam
a fasting plasma glucose was noted to be 117 mg/dl. On repeat it was 115 mg/dl. Based
on the new American Diabetes Association definition she has “pre-diabetes”. In addition
to diet and exercise which of the following therapies are indicated at this time?
(A) diet and exercise alone
(B) acarbose
(C) metformin
(D) pioglitazone

Answer: A. In the past decade several studies have examined the potential to delay the
development of diabetes in individuals with impaired glucose tolerance (pre-diabetes). In
the Diabetes Prevention Program intense diet and exercise was superior to metformin.
Acarbose and troglitazone have also been shown to delay the development of diabetes.
However, at this time the total economic impact of initiating drug therapy in these patients
is unknown. Presently the ADA guidelines recommend initiating diet and exercise to
delay the development of type 2 diabetes.

TJ is a 52-year-old, obese, African-American woman with newly diagnosed diabetes

mellitus. Diagnosed in 2002 with severe schizophrenia she was placed on olanzapine
with excellent response. Gradually her weight has increased, and for the past 6 months
she has tried diet and exercise with minimal success. Her present A1c is 7.2% increased
from 6.8%. She has no other medical problems.
Which one of the following is the most appropriate action at this point in her therapy?
(A) continue diet and exercise alone for three more months
(B) add glyburide to her diet and exercise
(C) add pioglitazone to her diet and exercise
(D) add metformin to her diet and exercise

Answer: D. Olanzapine can increase appetite and is likely to be increasing this patient’s
weight. After diet and exercise alone have failed to achieve the desired glycemic goals
(A1c less than 7%) several options are available. Glyburide, pioglitazone and metformin
can provide adequate A1c decreases in this patient. However, in the obese patient,
metformin is the preferred initial drug therapy if there are no contraindications to its use
as in this patient. The United Kingdom Perspective Diabetes Study demonstrated no
significant difference in macrovascular outcomes between insulin or sulfonylurea after
diet/exercise fail. However, obese patients given metformin had decreased combined
diabetes-related events compared to conventionally treated patients.

You are asked by the medical staff to refresh their memory of the original findings of the
United Kingdom Prospective Diabetes Study (UKPDS) and Diabetes Control and
Complications Trial (DCCT) trials.
Which one of the following statements best describes the study findings?
A. The DCCT trial confirmed that tight glucose management in type 1 diabetes mellitus
led to better cardiovascular outcomes.
B. According to the DCCT trial, the intensive therapy group had a 50% to 75% reduction
in risk of all microvascular complications.
C. The UKPDS trial confirmed that a hemoglobin A1C (A1C) of greater than 8% led to
worse outcomes compared with an A1C of less than 7%.
D. According to the UKPDS trial, metformin decreased macrovascular complications in
non-obese patients.
Answer B. According to the DCCT trial, the intensive therapy group had a 50% to 75%
reduction in risk of all microvascular complications.
The Diabetes Control and Complications Trial (DCCT) compared intensive with
conventional glycemic control in patients with type 1 diabetes mellitus on the effects of
diabetes complications. The intensive therapy group had a 50% to 70% reduction in the
risk of all microvascular complications.

One of the physicians you work with in a family medicine clinic talks to you about the
Diabetes Prevention Program (DPP) study. He has a patient with prediabetes and is
deciding whether to initiate intensive lifestyle changes or metformin and lifestyle changes.
He cannot recall the details of the study and asks you for your help in applying the results
to his patient. According to the DPP study.
what is the best advice to provide to the physician to help manage his patient?
A. Lifestyle interventions reduced the risk of developing diabetes by 80%.
B. Metformin reduced the risk of developing diabetes more than intensive lifestyle
interventions.
C. Behavior modification in conjunction with intensive diet and exercise reduced the risk
of developing diabetes.
D. Intensive diet and exercise with an aim of 20% loss and maintenance of body weight
was recommended.
Answer C. Behavior modification in conjunction with intensive diet and exercise reduced
the risk of developing diabetes. The Diabetes Prevention Program study evaluated
several study arms, primarily intensive lifestyle interventions compared with metformin
and lifestyle interventions in the prevention of developing diabetes. The intensive lifestyle
intervention study arm of the trial lowered the risk of diabetes by 58% and more than the
metformin arm of the study. The intensive lifestyle group of the study followed a low-fat
and low-calorie diet and exercised 150 minutes/week, with an aim of losing and
maintaining 7% of body weight, and underwent behavioral modification.
A 56-year-old man is admitted to the hospital for the treatment of ongoing lower extremity
cellulitis and pain. Vital signs are within normal limits. Laboratory results are as follows:
sodium 140 mEq/L, potassium 4.4 mEq/L, chloride 105 mEq/L, CO2 26 mEq/L, blood
urea nitrogen 15 mg/dL, serum creatinine 1.6 mg/dL, blood glucose 270 mg/dL, white
blood cell count 14.2 x 103 cell/mm3, hemoglobin 9.2 g/dL, hematocrit 28%, and platelet
count 262,000/mm3. A hemoglobin A1C is ordered and returns elevated at 9.2%. He
reports taking no medications prior to admission.
Which is the most appropriate initial treatment option for this patient’s hyperglycemia?
A. Metformin 500 mg orally twice daily in addition to correctional insulin with a goal to
decrease A1C to less than 7
B. Insulin glargine 10 units subcutaneously at bedtime in addition to correctional insulin
with a goal blood glucose of less than 180 mg/dL
C. Insulin infusion of 2 units/hour titrated to a goal blood glucose of less than 200 mg/dL
D. Correctional insulin initiated alone and changed to an oral sulfonylurea at discharge
Answer B . This hospitalized patient has an acute infection, as well as hyperglycemia and
a new diagnosis of diabetes. American Diabetes Association guidelines recommend that
treatment with subcutaneous insulin with basal, correctional, and mealtime administration
is preferred, with a goal random blood glucose of less than 180 mg/dL. The use of
metformin in this patient will likely have no immediate effect and should not be used in
patients with renal insufficiency or the need for radiocontrast dye for imaging. Use of
sliding-scale insulin alone is not recommended because of its poorer efficacy and the
higher risk of hypoglycemia in hospitalized patients.

Which medication is the most appropriate choice for a patient with a diagnosis of
Cushing’s syndrome who did not experience adequate symptom relief after surgical
resection for a pituitary adenoma?
A. Ketoconazole.
B. Spironolactone.
C. Hydrocortisone.
D. Bromocriptine

Answer: A
Ketoconazole is used in patients with Cushing’s syndrome because it reduces cortisol
synthesis. Answer B, spironolactone, is used in patients with hyperaldosteronism. Answer C is
inappropriate because Cushing’s syndrome results in cortisol concentrations that are too high,
and adding a corticosteroid to treat its symptoms could make theproblem worse.
Bromocriptine, Answer D, is used to treat acromegaly, not Cushing’s syndrome.
Answer: C. This patient with type 1 diabetes is demonstrating consistent elevated pre-
prandial blood glucose before lunch. An increase in morning Humulin R would help to
lower these readings and is the correct answer (Answer C). Increasing morning Humulin
R might help cover the lunch

A woman with type 2 DM has an A1c of 8.6%. She is receiving insulin glargine (60 units
once daily at bedtime) and insulin aspart (8 units before breakfast,
7 units before lunch, and 12 units before dinner).
She is very consistent in her carbohydrate intake at each meal. Her morning fasting
plasma glucose (FPG) and premeal blood glucose (BG) readings have consistently
averaged 112 mg/dL. Her bedtime readings are averaging between 185 and 200 mg/dL.
Which is the best insulin adjustment
to improve her overall glycemic control?
A. Increase her prebreakfast aspart to 10 units.
B. Increase her predinner aspart to 14 units.
C. Increase her bedtime glargine to 65 units.
D. Increase her prelunch aspart to 9 units.

Answer: B For insulin adjustments, determine which BG readings are at goal and which
ones are not. For those consistently not at goal, determine which insulin is most affecting
the BG readings. In this case, the patient’s BG readings are consistently elevated at
bedtime, which is probably caused by insufficient predinner prandial (a.k.a. bolus) insulin.
Changing the rapid-acting insulin at other times of the day would not help; hence, Answer
A and Answer D are incorrect. Changing her basal insulin (glargine in this case) would
not likely help her bedtime BG and, because her FBG readings have been well
controlled, could lead to hypoglycemia (Answer C).

A 34-year-old woman has a BMI of 33 kg/m2. With dietary changes, she has lost 2 lb in 6
months. She exercises regularly but is unable to do more because
she has two jobs and young children. She has a history significant for depression, type 2
DM, and substance abuse. Her current medications include metformin 1000 mg twice
daily, aspirin 81 mg once daily, and sertraline 100 mg once daily. She is most concerned
about weight loss. Which would be the best recommendation to help her lose weight?
A. Continue her diet and exercise routine; additional intervention is unwarranted.
B. Initiate lorcaserin 10 mg twice daily.
C. Initiate phentermine/topiramate 3.75/23 mg once daily.
D. Initiate orlistat 120 mg three times/day with meals.

Answer: D This patient weighs 50 kg (110 lb). 0.4 unit/kg/day x 50 kg = 20 units of TDI.
When using insulin analogs, 50% of the TDI dose should be used as an initial estimate of
the patient’s basal insulin needs; hence, 10 units will be required. Glargine is a once-daily
long-acting basal insulin. Answer A and Answer B, although they use basal insulin, are
incorrect because of the higher-than-estimated dosage. Answer C is incorrect because
insulin aspart is used for bolus insulin dosing, not for basal therapy, unless the patient is
using an insulin pump.

What is the most accurate assessment of evidence-based literature evaluating

conventional glucose control (glucose levels less than 180 mg/dL) versus intensive
glucose control (glucose levels less than 110 mg/dL) in critically ill patients with severe
sepsis and hyperglycemia?
A. Targeting glucose levels less than 180 mg/dL can reduce complications of
hyperglycemia while minimizing risks of hypoglycemia.
B. Targeting glucose levels less than 180 mg/dL has consistently resulted in increased
mortality in septic patients with hyperglycemia.
C. Targeting glucose levels less than 110 mg/dL has consistently resulted in increased
mortality in septic patients with hyperglycemia.
D. Targeting glucose levels less than 110 mg/dL can reduce complications of
hyperglycemia but will provide no mortality benefit.
Answer : A

A patient was recently initiated on thyroid replacement therapy to treat hypothyroidism.

When would be the best time to recommend checking thyroid lab studies to assess
maximum effects of this therapy?
A. 1 or 2 days
B. 1–2 weeks
C. 2–3 weeks
D. 6–8 weeks
Answer D. 6–8 weeks
To allow maximal effects in initiating thyroid replacement therapy, such as levothyroxine,
the recommended follow-up time to assess thyroid laboratory studies is about 6–8
weeks; therefore, Answer D is correct.
A 60 year old woman has received radioactive iodine over five years ago. She now
comes for her annual thyroid function assessment. Her results reveal: Free Thyroxine 11
pmol/l (9.8-23), TSH 14 mU/l (0.5-4.5 mU/l), Total cholesterol 6.5 mmol/l (<5 mmol/l),
Plasma triglycerides 2.1 mmol/l (<2 mmol/l). What is the most appropriate treatment for
this patient's dyslipidaemia?
A- Hormone replacement therapy
B- Simvastatin
C- Thyroxine
D- Carbimazole
E- Fibrate

Answer: C- The patient has subclinical hypothyroidism as reflected by a normal T4 but

elevated TSH. A hypercholesterolaemia or hypertriglyceridaemia is frequently associated
due impaired lipoprotein lipase function. Treatment should be with thyroxine replacement
first as hypercholesterolaemia should resolve.

A 76-year-old woman recently given a diagnosis of Hashimoto’s disease presents with

mild symptoms of lethargy, weight gain, and intolerance to cold. Her thyroid-stimulating
hormone (TSH) is 12.2 mIU/L, and her free thyroxine (T4) is below normal
limits. Her current weight is 47 kg. She has a history of hypertension and coronary artery
bypass surgery 2 years ago. Which would be the most appropriate
initial treatment for this patient?
A. Levothyroxine 25 mcg once daily.
B. Levothyroxine 75 mcg once daily.
C. Liothyronine 25 mcg once daily.
D. Liothyronine 75 mcg once daily.
Answer: A An elderly woman with heart disease should be initiated on a lower initial
dose of levothyroxine. Answer B is the normal starting dose (i.e., 1.6 mcg/kg), but it is
likely too high an initial dose for an elderly patient with established heart disease. Answer
C and Answer D are incorrect because the drug of choice is levothyroxine, and
liothyronine is no longer recommended for this condition.

A 65-year-old man with type 2 DM for 6 years has been receiving metformin 1000 mg
twice daily for the past 2 years. His A1c today is 7.8%. His fasting morning BG readings
are consistently at goal. His after-meal glucose readings average 190–200 mg/dL. Which
option would be most appropriate for this patient?
A. Increase metformin to 1000 mg three times/day.
B. Add insulin glargine 10 units once daily.
C. Switch from metformin to insulin glargine 10 units once daily.
D. Add saxagliptin 5 mg once daily.

Answer: D This patient has good control of his fasting glucose but is experiencing
postprandial hyperglycemia. An agent that targets postprandial glucose (e.g., a DPP- 4
inhibitor) would be most appropriate. Answer A is incorrect because this would exceed
the maximal daily dose for metformin. Answer B is incorrect because insulin glargine is a
basal insulin that has an effect on FPG but little effect on postprandial glucose. Answer C
is incorrect, again because it is a basal insulin and also because it is more appropriate to
add medications than to switch to another agent unless the patient is experiencing
adverse effects with the first agent.

A 42-year-old woman with Type 1 diabetes and Addison disease presents to the family
practice clinic with symptoms of an upper respiratory infection. She has a low-grade
fever, nasal congestion, sinus pressure and a headache. Her medications include
Humalog 15 units at each meal, Lantus 50 units at bedtime, and hydrocortisone 15 mg
daily. An antibiotic is prescribed for sinusitis.
Which one of the following would be the best recommendation regarding her
steroid replacement at this time?
A. Increase dose of hydrocortisone.
B. Decrease dose of hydrocortisone.
C. Continue same dose of hydrocortisone.
D. Add fludrocortisone to hydrocortisone.
Answer A. Increase dose of hydrocortisone. Under times of stress, such as an infection,
patients with Addison disease may require an increase in their steroid replacement
dosage. Therefore, the correct answer is A.

A 22-year-old white woman who feels tired, is mentally sluggish, and has gained 10 lb
during the past few months. Physical examination reveals delayed deep tendon reflexes
and a firm, enlarged thyroid gland. Laboratory values at this clinic visit are as follows: free
thyroxine (FT4) 0.6 ng/dL; thyroid-stimulating hormone (TSH) 20 mIU/L; and positive for
thyroid antibodies: T.W.’s weight is 70 kg. She is given a diagnosis of Hashimoto
thyroiditis. Which would be the preferred therapy for this patient?
A. Liothyronine
B. Desiccated thyroid
C. Levothyroxine
D. Liotrix
Answer C. Levothyroxine, synthetic LT4, is the gold standard for the management of
hypothyroidism. Liothyronine, synthetic T3 (Answer A), is incorrect because it may cause
more toxicity than LT4

A 30-year-old white woman who received a diagnosis 2 months ago of hyperthyroidism

and is now 6 weeks pregnant. She has no other medical problems and has normal
kidney and liver function. Which would be the best therapy at this time?
A. Radioactive iodine
B. Levothyroxine
C. Lugol’s solution
D. Propylthiouracil
Answer D. .Propylthiouracil is the recommended antithyroid medication in the
management of hyperthyroidism and pregnancy, specifically first-trimester pregnancy.

A 66-year-old Hispanic man with a history of myocardial infarction, dyslipidemia, and

hypertension received a diagnosis of type 2 diabetes mellitus (DM). After 1 month of
exercise and dietary changes and no diabetic medications, his hemoglobin A1c (A1c)
and fasting glucose concentration today are 11.5% and 322 mg/dL, respectively. He
weighs 273 lb with a body mass index (BMI) of 42 kg/m2. Which set of drugs is best to
initiate?
A. Metformin and glipizide.
B. Glipizide and insulin glulisine.
C. Pioglitazone and acarbose.
D. Insulin detemir and glulisine.

Answer: D According to the ADA guidelines, individuals with this degree of

hyperglycemia should be initiated on insulin therapy, and Answer D provides an
appropriate basal/ bolus insulin combination. This patient’s A1C is greater than 10%, and
his fasting glucose is greater than 250 mg/ dL. Answer A and Answer C are not optimal
because dual therapy with oral agents is unlikely to bring this patient to his glycemic goal.
Answer B is also not optimal because the combination of a sulfonylurea and rapid-acting
insulin would increase the risk of hypoglycemia and would be unlikely to bring about a
sufficient reduction in A1C.

Regarding propylthiouracil (PTU) and methimazole in the treatment of hyperthyroidism,

which statement is most appropriate?
A. PTU is clinically superior in efficacy to methimazole.
B. PTU may be associated with increased liver toxicity compared with methimazole.
C. Both agents are equally efficacious in the treatment of Hashimoto’s disease.
D. Both medications should be administered three times/day.
Answer: B Unlike methimazole, PTU has a boxed warning regarding the risk of
hepatoxicity. Answer A is incorrect because neither agent is considered more efficacious
than the other. Answer C is incorrect because Hashimoto’s disease is a result of
hypothyroidism, not hyperthyroidism.
A patient with type 2 DM has a blood pressure reading of 152/84 mm Hg, a serum
creatinine of 1.8 mg/dL, and two recent spot urine albumin/creatinine
concentrations of 420 and 395 mg/g. Which class of drugs (barring any contraindications)
is best to initiate in this patient?
A. Thiazide diuretic.
B. Dihydropyridine calcium channel blocker.
C. Angiotensin receptor blocker (ARB).
D. Nondihydropyridine calcium channel blocker.

Answer: C This patient has an elevated blood pressure, poor renal function, and two
urine albumin/creatinine concentrations above 30 mg/g. According to the ADA and the
clinical literature, the best classes of medications for patients with this condition are
ARBs or ACE inhibitors. Answer A (thiazide diuretic) is not appropriate because this class
of medications is not more beneficial than agents that block the renin-angiotensin
system. Answer B, a dihydropyridine calcium channel blocker, is not best because this
class has not been shown to be beneficial in type 1 and type 2 DM and proteinuria.
Answer D, a nondihydropyridine calcium channel blocker, is an alternative to agents that
block the renin-angiotensin system, but it should not be used instead of these agents
unless a patient has contraindications to them.

A 26-year-old Hispanic woman with polycystic ovary syndrome (PCOS) has been trying
to become pregnant for more than 1 year. She has tried to lose weight during the past 6
months, and she is very concerned
about using medications because of the risk of multiple children during the pregnancy.
Which is the best drug to improve fertility in this patient?
A. Clomiphene citrate.
B. Recombinant follicle-stimulating hormone (FSH).
C. Metformin.
D. Spironolactone.
Answer: C Metformin improves fertility in patients with PCOS, but unlike clomiphene and
gonadotropin therapy (Answer A and Answer B), it does not significantly increase the risk
of multiple pregnancies. Although spironolactone (Answer D) may improve some of the
hyperandrogenic signs of PCOS (e.g., hirsutism), it has not been adequately studied for
its effects on infertility.
A patient discusses her options for the management of her Cushing’s syndrome with her
provider and chooses medical therapy. As the pharmacist working in the clinic, you
recommend ketoconazole 200 mg twice daily. In addition to monitoring symptom
response to therapy, which is most important to include in her routine monitoring plan
after starting ketoconazole?
A. Hypergonadism
B. Hepatic transaminase elevations
C. Hirsutism
D. Ataxia
Answer B. Hepatic transaminase elevations . Ketoconazole can cause hypogonadism
and gynecomastia. Other therapies can cause the other listed adverse effects, hirsutism
(metyrapone) or ataxia (mitotane). Ketoconazole can lead to mild elevations in hepatic
transaminase concentrations and, rarely, liver toxicity; therefore, liver monitoring is
recommended, and Answer B is correct.

AM is a 61-year-old, obese man with type 2 diabetes mellitus (diagnosed 4 years ago),
atrial fibrillation, dyslipidemia, and microalbuminuria. His present regimen of glyburide 10
mg provides an A1c of 8.2%. SMBG reveals fasting blood glucose and pre-dinner levels
averaging 159 mg/dl and 178 mg/dl, respectfully. DA’s diet is high in carbohydrates and
he seldom exercises. Which one of the following therapies should be considered?
(A) discontinue the glyburide and initiate metformin 500 mg daily
(B) discontinue the glyburide and initiate pioglitazone 15 mg daily
(C) add metformin 1000 mg daily
(D) add pioglitazone 15 mg daily
Answer: C. This obese patient has not achieved his glycemic goals on his current
therapy. Based on the ADA guidelines an A1c < 7% is desired. Recent guidelines
suggest targeting an A1c near normal at 6% as long as excessive hypoglycemia can be
avoided. This is based on the additional benefit in slowing the progression of
microvascular complications. Glyburide at an excellent first-line agent, but over time a
second agent is needed. This was clearly demonstrated in the UKPDS. Metformin and
pioglitazone have similar ability to lower the A1c as compared to sulfonylureas.
Therefore, switching to these agents will most likely not help this patient achieve the
desired A1c. Pioglitazone can be added to a sulfonylurea. A common side effect of the
glitazones is weight gain. Metformin would be the preferred agent to add in this obese
patient.
A 34-year-old woman has a BMI of 33 kg/m2. With dietary changes, she has lost 2 lb in 6
months. She exercises regularly but is unable to do more because
she has two jobs and young children. She has a history significant for depression, type 2
DM, and substance abuse. Her current medications include metformin 1000 mg twice
daily, aspirin 81 mg once daily, and sertraline 100 mg once daily. She is most concerned
about weight loss. Which would be the best recommendation to help her lose weight?
A. Continue her diet and exercise routine; additional intervention is unwarranted.
B. Initiate lorcaserin 10 mg twice daily.
C. Initiate phentermine/topiramate 3.75/23 mg once daily.
D. Initiate orlistat 120 mg three times/day with meals.
Answer D. This patient has tried dieting and some exercise, but these are failing to
control her weight; hence, her current routine alone is not appropriate, making Answer A
incorrect. Answer B, lorcaserin, is approved for the treatment of obesity but should be
avoided in patients taking serotonergic agents, in this case sertraline. Answer C is a
federally scheduled medication because of its abuse potential with phentermine, and
given this patient’s history of abuse, it is not the most favorable selection. Orlistat,
Answer D, is the only agent listed to which this patient does not have a specific
precaution or contraindication with its use.

When preparing to educate patients with diabetes, which statements regarding

hypoglycemia is the best educational advice a pharmacist can provide to the patient?
A. Patients with type 1 diabetes mellitus appear to have a lower risk of experiencing
hypoglycemia than patients with type 2 diabetes mellitus.
B. Patients should eat a candy bar each time they experience hypoglycemia.
C. Patients should wait 15 minutes and recheck blood glucose, and if hypoglycemia
continues, treat hypoglycemia.
D. Patients should treat hypoglycemia, wait 15 minutes to recheck blood glucose, and if
hypoglycemia continues, treat hypoglycemia again.
Answer D. Patients should treat hypoglycemia, wait 15 minutes to recheck blood glucose,
and if hypoglycemia continues, treat hypoglycemia again. Answer D is the appropriate
protocol to follow in managing hypoglycemia in a patient with diabetes.
A patient is currently taking insulin detemir 15 units at bedtime and insulin lispro 4 units
before breakfast and 6 units before both lunch and dinner each. Given the self-monitoring
blood glucose results below (in milligrams per deciliter), which one of the following
regimens would most appropriately address any abnormal blood glucose readings?
Morning Fasting | Prelunch | Predinner | Bedtime
Range: 92-126 | 112-150 | 102-142 | 182-246
Average: 116 | 132 | 122 | 220
A. Detemir 20 units before bedtime, 4 units of lispro before breakfast, and 6 units of lispro
before lunch and dinner.
B. Detemir 15 units before bedtime, 4 units of lispro before breakfast, 6 units of lispro
before lunch, and 8 units before dinner.
C. Detemir 20 units before bedtime, 4 units of lispro before breakfast, 6 units of lispro
before lunch, and 8 units before dinner.
D. Detemir 15 units before bedtime, 4 units of lispro before breakfast, 6 units of lispro
before lunch, and 4 units before dinner.
Answer B

Answer D. Somogyi effect; decrease dinner NPH

This patient is demonstrating nighttime hypoglycemia, which is leading to rebound
hyperglycemia in the early morning hours. This results in the liver releasing more
glucose, which causes elevated fasting glucose the next morning. This is called the
Somogyi effect. This can occur from having too much insulin the previous evening;
therefore, Answer D is the correct answer.