Diabetes ACCP/ASHP 2025 Ambulatory Care Pharmacy Preparatory Review and Recertification Course

130 Q&A style flashcards based on the Diabetes ACCP/ASHP 2025 lecture notes.

What does T1D stand for?

Type 1 diabetes.

What percent of all diabetes cases are Type 1 (T1D)?

About 5%–10%.

What percent of diabetes cases are Type 2 (T2D)?

About 90%–95%.

What does GD stand for in diabetes?

Gestational diabetes.

Which condition is diagnosed based on autoimmune destruction of β cells leading to insulin deficiency?

Type 1 diabetes (T1D).

What is predibetes in terms of HbA1c range?

HbA1c 5.7%–6.4%.

What is the FPG range for prediabetes?

100–125 mg/dL.

What OGTT 2-hour value defines diabetes?

≥200 mg/dL.

What HbA1c threshold defines diabetes?

HbA1c ≥6.5%.

What HbA1c range defines prediabetes?

HbA1c 5.7%–6.4%.

List the three stages of Type 1 diabetes (T1D).

Stage 1 autoimmune normoglycemic; Stage 2 autoimmune with dysglycemia; Stage 3 hyperglycemic and symptomatic.

What is the primary pathophysiology of Type 2 diabetes (T2D)?

Insulin resistance with progressive insulin deficiency.

Name a major nonpharmacologic goal in prediabetes care.

Sustained weight loss (about 7%).

How many minutes per week of moderate-intensity activity is recommended for diabetes patients?

At least 150 minutes per week.

What BMI threshold prompts consideration of metabolic (bariatric) surgery for diabetes?

BMI ≥30 kg/m2 (≥27.5 kg/m2 for Asian Americans) with comorbidities, or BMI ≥35 kg/m2 (≥37.5 for Asian Americans) with weight-related problems.

What is the general HbA1c goal for most nonpregnant adults with diabetes per ADA/AACE guidance?

HbA1c less than 7% (with consideration for tighter or less stringent goals based on individual factors).

What is a key goal for time-in-range (TIR) for most people with T1D or T2D?

Greater than 70% time in range (70–180 mg/dL) with less than 4% below range and less than 25% above range.

What is a more stringent time-in-range goal for pregnancy with preexisting diabetes?

Greater than 70% time in range of 63–140 mg/dL with <4% below and <25% above; no consensus for GD.

What fasting plasma glucose (FPG) value defines diabetes?

126 mg/dL or higher (after fasting for at least 8 hours).

What is the diagnostic criterion for diabetes using a 75-g OGTT?

2-hour plasma glucose ≥200 mg/dL.

What is the diagnostic criterion for prediabetes using OGTT?

2-hour OGTT 140–199 mg/dL.

What is the role of DSMES in diabetes care?

Diabetes self-management education and support to improve knowledge and skills for self-care.

What is the role of a CDCES?

Certified Diabetes Care and Education Specialist who provides DSMES; often a nurse, pharmacist, dietitian, etc.

What is the primary metabolic action of metformin (Biguanide)?

Primarily inhibits hepatic glucose production; may improve peripheral insulin resistance and decrease intestinal glucose absorption.

What HbA1c reduction is typically achieved with metformin?

About 1%–2%.

What is a key renal contraindication for starting metformin?

eGFR less than 30 mL/min/1.73 m2.

What is a common metformin adverse effect and its serious, rare risk?

GI upset is common; rare risk of lactic acidosis.

What monitoring is recommended with metformin use?

HbA1c, renal function, and vitamin B12 levels.

What are the main actions of GLP-1 receptor agonists (GLP-1 RAs)?

Glucose-dependent increase in insulin, glucose-dependent suppression of glucagon, slowed gastric emptying, and increased satiety.

What is a major clinical advantage of GLP-1 RAs beyond glucose control?

Weight loss and CV benefits in many agents.

Name a GLP-1 RA contraindication that is class-specific for some agents.

Personal or family history of medullary thyroid carcinoma or MEN2 (for certain agents like liraglutide, dulaglutide, semaglutide, exenatide ER).

Which GLP-1 RA formulations are available in weekly dosing?

Dulaglutide, semaglutide (subcutaneous), and others; weekly options include dulaglutide and semaglutide products.

What are common adverse effects of GLP-1 RAs?

Nausea, vomiting, diarrhea; risk of pancreatitis and rare retinopathy concerns.

Which agents are DPP-4 inhibitors?

Sitagliptin, saxagliptin, linagliptin, alogliptin.

What is the general effect of DPP-4 inhibitors on weight?

Weight neutral.

What is a notable safety concern with some DPP-4 inhibitors?

Risk of heart failure with saxagliptin and alogliptin in some trials.

What is the typical sitagliptin dose for adults and how is it adjusted for renal function?

100 mg once daily; reduce to 50 mg/day for eGFR 30–50, 25 mg/day for eGFR <30.

What is the primary mechanism of SGLT-2 inhibitors?

Inhibit renal glucose reabsorption, increasing urinary glucose excretion.

Name a major cardiovascular or kidney benefit class of SGLT-2 inhibitors.

CV risk reduction and CKD progression protection in various trials (e.g., CANVAS, DAPA-CKD, EMPA-REG, FLOW outcomes).

Which SGLT-2 inhibitor has demonstrated robust CKD outcomes in trials like CREDENCE and DAPA-CKD?

Canagliflozin (CREDENCE) and Dapagliflozin (DAPA-CKD).

What are common adverse effects of SGLT-2 inhibitors?

Genital mycotic infections, UTIs, volume depletion, orthostatic hypotension, DKA (euglycemic).

What is a notable safety warning with canagliflozin regarding bones?

Increased risk of decreased bone mineral density and fractures.

What is a common renal/urinary precaution before starting SGLT-2 inhibitors?

Hold or pause for surgery; risk of DKA; adjust around procedures.

What are common agents in the SGLT-2 class?

Canagliflozin, dapagliflozin, empagliflozin, ertugliflozin, bexagliflozin.

What is a major warning associated with tirzepatide (GLP-1/GIP RA)?

Black box warnings for thyroid C-cell tumors at high doses in animals; relatively new CV risk data awaiting long-term results.

What is the basic dosing pattern for tirzepatide (Mounjaro)?

Start at 2.5 mg weekly, increase every 4 weeks to 5, 7.5, 10, 12.5, then 15 mg weekly as needed.

What is a notable non-diabetes indication for tirzepatide?

Weight management (Zepbound) with a max dose of 15 mg weekly.

What is the mechanism of action of GLP-1/GIP receptor agonists like tirzepatide?

Dual incretin effect: glucose-dependent insulin secretion, suppression of glucagon, slowed gastric emptying, increased satiety.

What is the general dosing approach for GLP-1 RAs with CV benefit in patients with ASCVD or high CV risk?

Prefer GLP-1 RA or SGLT2 inhibitor with proven CV benefit independent of HbA1c.

What are SGLT-2 inhibitors’ effects on heart failure and CKD outcomes even at lower eGFR?

Continue to provide heart-failure and CKD benefits even with reduced eGFR.

Which DPP-4 inhibitors have CV safety data and what is their general CV risk profile?

All have CV safety data; most show neutral MACE; saxagliptin and alogliptin have HF risk signals.

What are some common categories of beta-cell–targeted agents besides metformin?

GLP-1 RAs, DPP-4 inhibitors, SGLT-2 inhibitors, meglitinides, sulfonylureas, TZDs, amylin analogs.

What is pramlintide’s role in diabetes management?

Amylin analog used with mealtime insulin to slow gastric emptying and suppress glucagon.

What is the recommended initiation of pramlintide dosing for T1D?

Start at 15 mcg with meals and titrate up to 60 mcg as tolerated (insulin dose reduced by 50%).

What is the dosing approach for pramlintide in T2D?

Start at 60 mcg with meals and titrate to 120 mcg with meals (insulin dose reduced by 50%).

Where are pramlintide injections administered?

Abdomen or thighs; avoid the arm.

What is a key safety effect of pramlintide?

Increased risk of hypoglycemia when used with mealtime insulin.

What are the main basal insulins and their general action?

Long-acting (glargine, detemir, deguldec) and intermediate-acting (NPH) analogs that reduce hepatic glucose production.

What is a common starting basal insulin dose for T2D?

0.1–0.2 units/kg/day or about 10 units per day to start.

What is the rule of 1800 for rapid-acting insulin?

1800 ÷ total daily insulin dose = mg/dL change per unit.

What is the rule of 1500 for regular insulin?

1500 ÷ total daily insulin dose = mg/dL change per unit.

What is the rule of 500 for insulin-to-carbohydrate ratio?

500 ÷ total daily insulin dose equals insulin-to-carbohydrate ratio (g of carbohydrate per unit insulin).

What are the components of a mixed/combined insulin therapy like Xultophy or Soliqua?

Xultophy: insulin degludec + liraglutide; Soliqua: insulin glargine + lixisenatide; both are fixed-ratio combinations.

What is a typical starting dose for Xultophy (deg/lia) in basal insulin–naïve patients?

Initial dose around 10 units (deg) with 0.36 mg liraglutide; titrate to target.

What is a typical starting dose for Soliqua (glargine + lixisenatide) in basal insulin–naïve patients?

Initial dose 15 units glargine/5 mcg lixisenatide; titrate to target.

What is a common maximal daily dose for Soliqua?

Maximum combined dose is 60 units glargine with 20 mcg lixisenatide.

What is the recommended management for severe hypoglycemia?

If unconscious, administer glucagon and call emergency services; place in recovery position.

What glucagon formulations are available for severe hypoglycemia?

Nasal glucagon (Baqsimi); injectable glucagon (Gvoke/dasiglucagon) and glucagon emergency kit.

What is the general management of hypoglycemia in a conscious patient?

Give 15 g of fast-acting carbohydrate and recheck in 15 minutes; repeat if needed.

What do you do if hypoglycemia persists more than an hour before the next meal?

Provide a longer-acting carbohydrate (e.g., half a peanut butter sandwich).

What is the primary CV risk reduction strategy in T2D?

Select agents with proven CV benefit (GLP-1 RA with CV benefit or SGLT2 inhibitor with CV benefit) and address ASCVD risk factors.

What is finerenone (Kerendia) used for in diabetes care?

Nonsteroidal mineralocorticoid receptor antagonist to reduce CKD progression and CV events in CKD with T2D.

What is the recommended monitoring for CKD and albuminuria in diabetes?

Annual urine albumin-to-creatinine ratio; treat persistent albuminuria with ACEI/ARB; consider finerenone for CKD with T2D.

When should ACE inhibitors or ARBs be used in diabetic patients with albuminuria?

First-line for albuminuria (≥300 mg/g creatinine or 30–299 mg/g) or in presence of CVD risk.

Why is HbA1c not the sole marker for glycemic status?

Other metrics like time in range (CGM) and time in range data provide a more complete picture of glucose control.

What is GMI?

Glucose Management Indicator derived from CGM data; estimates A1c from CGM.

What is time in range (TIR) used for in CGM data interpretation?

The percentage of time glucose is in the target range (commonly 70–180 mg/dL).

Which CGM systems provide real-time readings with continuous alerts?

Dexcom G6/G7, Dexcom G7; Freestyle Libre is intermittently scanned unless linked; others include Guardian, Eversense.

What is the difference between real-time CGM and intermittently scanned CGM?

Real-time provides continuous data with alerts; intermittently scanned requires scanning to view readings.

Which CGM device is implantable and lasts 1 year?

Eversense.

What is the annual screening for diabetes complications?

Dilated eye exam, urinary albumin/creatinine ratio, lipid panel; HbA1c assessment at least annually.

What are 3 common microvascular complications of diabetes?

Retinopathy, nephropathy, and neuropathy.

What is the recommended annual eye exam for diabetes?

Comprehensive dilated eye exam by an ophthalmologist or optometrist.

What is the role of ACEI/ARB in diabetic kidney disease?

Reduce albuminuria and slow CKD progression.

What distinguishes MASLD and MASH in metabolic disease context?

MASLD/MASH relate to metabolic liver disease; GLP-1 RAs and pioglitazone may offer hepatic benefits.

What is teplizumab (Teplizumab) used for?

Delay progression from stage 2 to stage 3 Type 1 diabetes in at-risk patients.

What is a key adverse reaction to teplizumab?

Lymphopenia and rash; other immune-related effects.

What are the major components of a comprehensive diabetes medical evaluation?

Medical history, physical examination, medications, vaccination status, labs (HbA1c, lipids, kidney function), microvascular and macrovascular risk.

What is the ADA CV risk management guidance for T2D patients?

Use GLP-1 RA or SGLT2 inhibitors with proven CV benefit, especially with ASCVD or CKD risk.

What is the recommended first injectable agent in T2D when feasible?

A GLP-1 RA before starting insulin, when possible.

What is the ADA recommendation on BP targets in diabetes?

Target <130/80 mm Hg if safely attainable; GD targets around 110–135/85 mm Hg.

What is the general LDL goal for diabetics without ASCVD?

LDL <70 mg/dL if multiple risk factors; use high-intensity statin as indicated.

What is the typical lipid management approach for diabetics with ASCVD?

High-intensity statin; consider ezetimibe or PCSK9 inhibitors if goal not reached.

What vaccines are recommended for adults with diabetes?

Influenza annually; PCV20 or PCV15 with PPSV23 follow-up; Hepatitis B for 19–59; RSV; Shingrix for adults >50; COVID-19 vaccination.

What credentialing exists for diabetes care and education professionals?

CDCES (Certified Diabetes Care and Education Specialist) and BC-ADM (Board Certified in Advanced Diabetes Management).

What is the difference between a CDCES and BC-ADM credential?

CDCES focuses on diabetes education; BC-ADM focuses on advanced clinical management of diabetes.

What is a practical goal of DSMES engagement?

Reduce ED visits, hospitalizations, hypoglycemia, and mortality; improve HbA1c.

What is the recommended target HbA1c range for preconception or pregnancy?

Generally more stringent targets; discuss with obstetric team; pregnancy goals vary by trimester.

What is the best initial therapy for most adults with T2D?

Metformin unless contraindicated.

What is the go-to therapy for patients with ASCVD or CKD when adding a glucose-lowering agent?

GLP-1 RA with CV benefit or SGLT2 inhibitor with CV/CKD benefit.