NU 578 Unit 4 Exam: Advanced Pharmacology –
Real Questions plus Scenario-Based Questions
with Answers & Explanations | Diabetes,
Endocrine, Steroids, Gout, Rheumatoid Arthritis |
University of South Alabama
Section 1: Diabetes & Insulin Management Scenarios (Questions 1–35)
1. A 45-year-old male with type 2 diabetes presents with complaints of nausea, diarrhea, and
abdominal discomfort since starting a new medication two weeks ago. His blood glucose has
improved from 180 mg/dL to 130 mg/dL. He has lost 3 pounds. Which medication is most likely
causing his symptoms?
a) Glipizide
b) Pioglitazone
c) Sitagliptin
d) Metformin
Metformin commonly causes GI upset (nausea, diarrhea, abdominal discomfort) especially when first
initiated. These symptoms often improve over time. The weight loss is also consistent with metformin
(unlike sulfonylureas which cause weight gain).
2. A 60-year-old female with type 2 diabetes and chronic kidney disease (CrCl 35 mL/min) is being
treated for a urinary tract infection. Her primary care provider prescribed iodinated contrast for a CT
scan. What should be done with her metformin?
a) Continue metformin as usual
b) Double the metformin dose
c) Hold metformin for 24 hours after the procedure only
,d) Discontinue metformin before the procedure and withhold for 48 hours after, then restart based
on renal function
Metformin should be discontinued before using iodinated radio contrast media and withheld for 48 hours
after the procedure to prevent lactic acidosis. Renal function should be evaluated before restarting
metformin. This patient already has CKD, increasing her risk.
3. A 55-year-old male with type 2 diabetes is started on glipizide. He calls the clinic reporting that he
felt shaky, sweaty, and confused about 2 hours after lunch today. He ate his usual meal and took
his medication. What is the most likely cause?
a) Diabetic ketoacidosis
b) Hyperglycemia
c) Allergic reaction
d) Hypoglycemia from sulfonylurea
Sulfonylureas (glipizide) stimulate insulin release regardless of glucose level and can cause hypoglycemia.
Symptoms of hypoglycemia include shakiness, sweating, confusion, and hunger. This patient needs
education on recognizing and treating hypoglycemia (rule of 15).
4. A 62-year-old female with type 2 diabetes and heart failure with reduced ejection fraction (HFrEF)
is being evaluated for additional diabetes therapy. Which SGLT-2 inhibitor has been shown to
reduce cardiovascular death and hospitalization for heart failure?
a) Canagliflozin
b) Empagliflozin
c) Dapagliflozin
d) Ertugliflozin
*Empagliflozin has been shown to reduce cardiovascular death and hospitalization for heart failure in
patients with type 2 diabetes and established cardiovascular disease. This is a class effect for SGLT-2
inhibitors, but empagliflozin has the strongest evidence for HFrEF.*
5. A 38-year-old obese female with type 2 diabetes has poorly controlled blood glucose (HbA1c
8.5%) despite metformin 2000 mg daily. She is very concerned about weight gain. Which medication
would be most appropriate to add?
a) Glipizide
b) Pioglitazone
,c) Insulin glargine
d) Semaglutide (GLP-1 receptor agonist)
*GLP-1 receptor agonists (semaglutide, liraglutide) promote weight loss in addition to glycemic control.
Sulfonylureas, thiazolidinediones, and insulin cause weight gain. This patient's concern about weight
makes a GLP-1 agonist the best choice.*
6. A 25-year-old male with type 1 diabetes is taking insulin lispro and insulin glargine. He reports
that his blood glucose is often high after meals but normal before meals. What adjustment is most
appropriate?
a) Increase insulin glargine dose
b) Add metformin
c) Decrease insulin lispro dose
d) Adjust mealtime insulin (lispro) timing or dose
High postprandial glucose indicates inadequate mealtime insulin coverage. Insulin lispro (rapid-acting)
should be adjusted to cover carbohydrate intake. Basal insulin (glargine) controls fasting and between-meal
glucose, which is normal in this patient.
7. A 70-year-old male with type 2 diabetes is started on metformin. His creatinine is 1.4 mg/dL
(eGFR 55 mL/min). What is the appropriate action?
a) Start metformin at full dose
b) Double the starting dose
c) Hold metformin and start insulin
d) Start metformin at a reduced dose and monitor renal function
*Metformin can be used in patients with eGFR 30-60 mL/min at a reduced dose (typically 500 mg BID or
850 mg daily). Renal function should be monitored every 3-6 months. Metformin is contraindicated when
eGFR < 30 mL/min.*
8. A 48-year-old female with type 2 diabetes reports taking her metformin but still having morning
blood glucose of 180-200 mg/dL. Her A1c is 7.8%. She has no contraindications to additional
therapy. Which medication would be most appropriate to add?
a) Insulin glargine
b) Acarbose
, c) Repaglinide
d) Sitagliptin (DPP-4 inhibitor)
Sitagliptin is a reasonable add-on to metformin for patients not meeting glycemic goals. It has a low risk of
hypoglycemia and is weight neutral. Insulin glargine would be effective but is second-line after other oral
agents in most guidelines.
9. A 32-year-old female with type 1 diabetes is planning pregnancy. She asks about the safety of
insulin during pregnancy. What should the provider tell her?
a) Insulin is teratogenic and should be stopped
b) Insulin should be switched to oral agents
c) Insulin is safe only in the first trimester
d) Insulin is the treatment of choice for diabetes in pregnancy and is safe for the fetus
Insulin is the treatment of choice for diabetes in pregnancy (type 1, type 2, or gestational). It does not cross
the placenta in significant amounts and is safe for the fetus. Oral antidiabetic agents are generally not
recommended in pregnancy.
10. A 65-year-old male with type 2 diabetes and osteoarthritis takes ibuprofen daily for joint pain. He
is started on lisinopril for hypertension and glipizide for diabetes. What drug interaction should the
provider be concerned about?
a) Lisinopril and glipizide causing hyperglycemia
b) Ibuprofen and lisinopril causing hyperkalemia
c) Ibuprofen and glipizide causing hypoglycemia
d) Ibuprofen may increase the risk of hypoglycemia from glipizide by displacing protein binding
NSAIDs (ibuprofen) can displace sulfonylureas (glipizide) from protein-binding sites, increasing the risk of
hypoglycemia. Additionally, NSAIDs can reduce the antihypertensive effect of lisinopril and cause
nephrotoxicity.
11. A 50-year-old male with type 2 diabetes is started on empagliflozin. He returns to clinic 2 weeks
later reporting increased urination and a yeast infection. What is the most appropriate response?
a) Discontinue empagliflozin immediately
b) Add metformin to reduce the side effects
c) Switch to insulin
d) Treat the yeast infection and continue empagliflozin; educate patient on prevention
Real Questions plus Scenario-Based Questions
with Answers & Explanations | Diabetes,
Endocrine, Steroids, Gout, Rheumatoid Arthritis |
University of South Alabama
Section 1: Diabetes & Insulin Management Scenarios (Questions 1–35)
1. A 45-year-old male with type 2 diabetes presents with complaints of nausea, diarrhea, and
abdominal discomfort since starting a new medication two weeks ago. His blood glucose has
improved from 180 mg/dL to 130 mg/dL. He has lost 3 pounds. Which medication is most likely
causing his symptoms?
a) Glipizide
b) Pioglitazone
c) Sitagliptin
d) Metformin
Metformin commonly causes GI upset (nausea, diarrhea, abdominal discomfort) especially when first
initiated. These symptoms often improve over time. The weight loss is also consistent with metformin
(unlike sulfonylureas which cause weight gain).
2. A 60-year-old female with type 2 diabetes and chronic kidney disease (CrCl 35 mL/min) is being
treated for a urinary tract infection. Her primary care provider prescribed iodinated contrast for a CT
scan. What should be done with her metformin?
a) Continue metformin as usual
b) Double the metformin dose
c) Hold metformin for 24 hours after the procedure only
,d) Discontinue metformin before the procedure and withhold for 48 hours after, then restart based
on renal function
Metformin should be discontinued before using iodinated radio contrast media and withheld for 48 hours
after the procedure to prevent lactic acidosis. Renal function should be evaluated before restarting
metformin. This patient already has CKD, increasing her risk.
3. A 55-year-old male with type 2 diabetes is started on glipizide. He calls the clinic reporting that he
felt shaky, sweaty, and confused about 2 hours after lunch today. He ate his usual meal and took
his medication. What is the most likely cause?
a) Diabetic ketoacidosis
b) Hyperglycemia
c) Allergic reaction
d) Hypoglycemia from sulfonylurea
Sulfonylureas (glipizide) stimulate insulin release regardless of glucose level and can cause hypoglycemia.
Symptoms of hypoglycemia include shakiness, sweating, confusion, and hunger. This patient needs
education on recognizing and treating hypoglycemia (rule of 15).
4. A 62-year-old female with type 2 diabetes and heart failure with reduced ejection fraction (HFrEF)
is being evaluated for additional diabetes therapy. Which SGLT-2 inhibitor has been shown to
reduce cardiovascular death and hospitalization for heart failure?
a) Canagliflozin
b) Empagliflozin
c) Dapagliflozin
d) Ertugliflozin
*Empagliflozin has been shown to reduce cardiovascular death and hospitalization for heart failure in
patients with type 2 diabetes and established cardiovascular disease. This is a class effect for SGLT-2
inhibitors, but empagliflozin has the strongest evidence for HFrEF.*
5. A 38-year-old obese female with type 2 diabetes has poorly controlled blood glucose (HbA1c
8.5%) despite metformin 2000 mg daily. She is very concerned about weight gain. Which medication
would be most appropriate to add?
a) Glipizide
b) Pioglitazone
,c) Insulin glargine
d) Semaglutide (GLP-1 receptor agonist)
*GLP-1 receptor agonists (semaglutide, liraglutide) promote weight loss in addition to glycemic control.
Sulfonylureas, thiazolidinediones, and insulin cause weight gain. This patient's concern about weight
makes a GLP-1 agonist the best choice.*
6. A 25-year-old male with type 1 diabetes is taking insulin lispro and insulin glargine. He reports
that his blood glucose is often high after meals but normal before meals. What adjustment is most
appropriate?
a) Increase insulin glargine dose
b) Add metformin
c) Decrease insulin lispro dose
d) Adjust mealtime insulin (lispro) timing or dose
High postprandial glucose indicates inadequate mealtime insulin coverage. Insulin lispro (rapid-acting)
should be adjusted to cover carbohydrate intake. Basal insulin (glargine) controls fasting and between-meal
glucose, which is normal in this patient.
7. A 70-year-old male with type 2 diabetes is started on metformin. His creatinine is 1.4 mg/dL
(eGFR 55 mL/min). What is the appropriate action?
a) Start metformin at full dose
b) Double the starting dose
c) Hold metformin and start insulin
d) Start metformin at a reduced dose and monitor renal function
*Metformin can be used in patients with eGFR 30-60 mL/min at a reduced dose (typically 500 mg BID or
850 mg daily). Renal function should be monitored every 3-6 months. Metformin is contraindicated when
eGFR < 30 mL/min.*
8. A 48-year-old female with type 2 diabetes reports taking her metformin but still having morning
blood glucose of 180-200 mg/dL. Her A1c is 7.8%. She has no contraindications to additional
therapy. Which medication would be most appropriate to add?
a) Insulin glargine
b) Acarbose
, c) Repaglinide
d) Sitagliptin (DPP-4 inhibitor)
Sitagliptin is a reasonable add-on to metformin for patients not meeting glycemic goals. It has a low risk of
hypoglycemia and is weight neutral. Insulin glargine would be effective but is second-line after other oral
agents in most guidelines.
9. A 32-year-old female with type 1 diabetes is planning pregnancy. She asks about the safety of
insulin during pregnancy. What should the provider tell her?
a) Insulin is teratogenic and should be stopped
b) Insulin should be switched to oral agents
c) Insulin is safe only in the first trimester
d) Insulin is the treatment of choice for diabetes in pregnancy and is safe for the fetus
Insulin is the treatment of choice for diabetes in pregnancy (type 1, type 2, or gestational). It does not cross
the placenta in significant amounts and is safe for the fetus. Oral antidiabetic agents are generally not
recommended in pregnancy.
10. A 65-year-old male with type 2 diabetes and osteoarthritis takes ibuprofen daily for joint pain. He
is started on lisinopril for hypertension and glipizide for diabetes. What drug interaction should the
provider be concerned about?
a) Lisinopril and glipizide causing hyperglycemia
b) Ibuprofen and lisinopril causing hyperkalemia
c) Ibuprofen and glipizide causing hypoglycemia
d) Ibuprofen may increase the risk of hypoglycemia from glipizide by displacing protein binding
NSAIDs (ibuprofen) can displace sulfonylureas (glipizide) from protein-binding sites, increasing the risk of
hypoglycemia. Additionally, NSAIDs can reduce the antihypertensive effect of lisinopril and cause
nephrotoxicity.
11. A 50-year-old male with type 2 diabetes is started on empagliflozin. He returns to clinic 2 weeks
later reporting increased urination and a yeast infection. What is the most appropriate response?
a) Discontinue empagliflozin immediately
b) Add metformin to reduce the side effects
c) Switch to insulin
d) Treat the yeast infection and continue empagliflozin; educate patient on prevention
