NAPLEX Question of the Week: Diabetes Dilemma

Our dilemma this week is the following: Can you get this question 100% correct. It will test your comprehensive knowledge base regarding diabetes pharmacotherapy!
NAPLEX Question of the Week: Diabetes Dilemma

You have been tasked with providing a pharmacotherapy presentation for an internal medicine residency grand rounds on diabetes mellitus management. In preparation for the lecture, you are gathering the most up-to-date information which you believe would be practical for the audience. Which of the following statements are true and would be appropriate to include in the presentation? Select all that apply.  

A. Afrezza therapy is contraindicated in patients with uncontrolled hypertension.

B. All FDA-approved GLP-1 agonists for diabetes management are injectables.  

C. Invokana can cause genital yeast infections. 

D. Actos is recommended primarily for diabetes patients with heart failure.  

E. Concomitant use of Victoza and Januvia may lead to increased risk of pancreatitis.  

F. Certain SGLT2 inhibitors have proven benefits in heart failure, CKD and CVD. 

G. The rapid acting insulins include Lantus, Levemir, and Tresiba.  


Correct Answers: C, E, F 


Answer choice A is false. Afrezza is inhaled insulin and is contraindicated in several pulmonary diseases such as asthma and COPD.

Answer choice B is also false. Semaglutide comes as both an injectable (Ozempic) and an oral tablet (Rybelsus). Rybelsus is initiated at 3 mg daily x 30 days, and then titrated to 7mg daily.  The dose can be titrated to 14 mg daily if control is not adequate. It should also be taken on an empty stomach with plain water upon awakening, and other medications/food should be held for at least 30 minutes after taking Rybelsus.  

Answer choice C is true. SGLT2 inhibitors like Invokana (canagliflozin) work by increasing urinary excretion of glucose which can lead to increased risk of bacterial and yeast infections.

Answer choice D is false because Actos (pioglitazone) is contraindicated in patients with heart failure. There is a boxed warning on this drug as well as rosiglitazone for their use in heart failure. These drugs are thiazolidinediones (TZDs) which can cause fluid retention and edema which exacerbates heart failure.

Answer choice E is true. GLP-1 agonists (Ex: liraglutide (Victoza), semaglutide (Ozempic), dulaglutide (Trulicity)) and DPP-4 inhibitors (Ex: sitagliptin (Januvia), saxagliptin (Onglyza), linagliptin (Trajenta) both carry the risk of pancreatitis as an adverse reaction and therefore should not be used together.  

Answer choice F is also true. Canagliflozin (Invokana), empagliflozin (Jardiance) and dapagliflozin (Farxiga) have been shown to reduce heart failure as well as progression of CKD. Dapagliflozin has also been proven to reduce hospitalizations due to heart failure. In addition, empagliflozin and canagliflozin have specifically received FDA approval as agents that reduce cardiovascular risk in patients with established CVD.

Answer choice G is false because these are the long-acting/basal insulins (Lantus (insulin glargine), Levemir (insulin detemir), and Tresiba (insulin degludec)). The rapid acting insulins that are used for bolus/mealtime coverage are Novolog (insulin aspart), Humalog (insulin lispro) and Apidra (insulin glulisine).  

Exam Competencies Covered: Area 2 – Identify Drug Characteristics: 2.1 – Pharmacology, mechanism of action, or therapeutic class, 2.2 – Commercial availability; prescription or non-prescription status; brand, generic, or biosimilar names; physical descriptions; or how supplied, 2.3 – Boxed warnings or REMS 

Congrats to all who have passed. For those about to take the exam, keep working hard! It is about to pay off! 


Dr. B

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