PEBC Diabetes and Endocrine Practice Questions

Answer: D) Take with plain water 30 min before breakfast; stay upright

Oral bisphosphonates have very low bioavailability (under 1%) that is further reduced by food, juice, coffee, calcium and other medications, so alendronate is taken with a full glass of plain water at least 30 minutes before food or other drugs. Remaining upright for at least 30 minutes reduces the risk of esophagitis. Taking it with food or calcium markedly lowers absorption, and lying down increases esophageal injury.

Why the other options are wrong

• A) Food and juice greatly reduce absorption.
• B) Lying down increases the risk of esophageal injury.
• C) Calcium binds alendronate, and bedtime dosing risks esophagitis.

Key point: Bisphosphonates: plain water, empty stomach, upright 30 minutes.

Answer: D) Insulin regular

Insulin regular is a clear solution and is the standard insulin for IV infusion (e.g., 100 units in 100 mL NS for DKA). NPH is a suspension, which must never be given IV. Glargine depends on precipitating at the subcutaneous site and degludec on forming multihexamers under the skin; neither is intended for IV infusion.

Why the other options are wrong

• A) NPH is a suspension and must never be given IV.
• B) Glargine relies on precipitating under the skin; it is not intended for IV use.
• C) Degludec relies on forming multihexamers under the skin; it is not used IV.

Key point: Only clear, short-acting insulin (regular) goes in an IV insulin infusion. Never give suspensions IV.

Answer: B) 44 days

Each box: 5 pens x 3 mL x 100 units/mL = 1,500 units. Daily use: 32 + 2 = 34 units. 1,500 / 34 = 44.1, so about 44 days.

Why the other options are wrong

• A) 39 days uses too large a daily amount (about 38 units a day).
• C) 47 days ignores the priming dose altogether (1,500 ÷ 32 = 46.9).
• D) 50 days subtracts the 2 priming units instead of adding them (1,500 ÷ 30).

Key point: Insulin days supply: total units ÷ (daily dose + priming). Don't forget the priming.

Answer: A) Lifestyle program targeting 7% weight loss and 150 min/week of activity

Intensive lifestyle intervention (about 5-10% weight loss through diet and at least 150 minutes per week of moderate activity) reduced progression to type 2 diabetes by about 58% in the Diabetes Prevention Program, more than metformin (about 31%), and is the first-line approach recommended by Diabetes Canada. Vitamin D has not been shown to prevent diabetes, and monitoring alone does not alter risk.

Why the other options are wrong

• B) Vitamin D supplements have not been shown to prevent type 2 diabetes.
• C) Metformin reduced progression less (about 31%) than lifestyle change in the DPP.
• D) Monitoring alone finds diabetes later but does not lower the risk.

Key point: Prediabetes: intensive lifestyle change beats metformin for preventing type 2 diabetes.

Answer: D) 0.25 mg once weekly for 4 weeks, then 0.5 mg weekly

Semaglutide injection is started at 0.25 mg once weekly for 4 weeks to improve gastrointestinal tolerability (the 0.25 mg dose is not a maintenance dose), then increased to 0.5 mg weekly; further increases to 1 mg and then 2 mg occur at intervals of at least 4 weeks if needed. Starting at 1 mg increases nausea and vomiting, semaglutide injection is not dosed daily, and jumping from 0.5 to 2 mg skips the 1 mg step.

Why the other options are wrong

• A) Starting at 1 mg skips titration and causes more nausea and vomiting.
• B) Semaglutide injection is dosed once weekly, not daily.
• C) Starting at 0.5 mg skips the 0.25 mg step, and jumping to 2 mg skips 1 mg.

Key point: Ozempic: 0.25 mg weekly x 4 weeks, then 0.5 mg; increase every 4+ weeks.

Answer: C) Keep it at room temperature (up to 30 °C) away from heat and light; discard 28 days after first use

Unopened insulin glargine pens are stored in the refrigerator (2-8 °C), but the in-use pen should be kept at room temperature (up to 30 °C), protected from heat and light, and discarded 28 days after first use even if insulin remains. Refrigerating the in-use pen is not recommended by the manufacturer, freezing destroys insulin, and the printed expiry date does not apply once the pen is in use.

Why the other options are wrong

• A) The manufacturer does not recommend refrigerating the in-use pen, and the printed expiry stops applying once in use.
• B) Freezing destroys insulin.
• D) Room temperature is right, but the in-use pen must be discarded 28 days after first use, not at the printed expiry.

Key point: In-use glargine pen: room temperature up to 30 C, discard 28 days after first use.

Answer: B) Eat carbohydrate while drinking and check glucose overnight

Alcohol inhibits hepatic gluconeogenesis and can cause delayed hypoglycemia, sometimes up to 24 hours later, and its symptoms may be mistaken for intoxication. People using insulin should consume carbohydrate with alcohol, monitor glucose more frequently including before bed and overnight, and wear medical identification. Skipping basal insulin in type 1 diabetes risks DKA, and taking extra insulin with drinks increases hypoglycemia risk.

Why the other options are wrong

• A) Skipping basal insulin in type 1 diabetes risks diabetic ketoacidosis.
• C) Alcohol lowers glucose by blocking gluconeogenesis, so eating is needed, not avoided.
• D) Extra rapid-acting insulin with drinks increases the risk of severe hypoglycemia.

Key point: Alcohol with insulin: eat carbs, check glucose overnight; delayed lows up to 24 h.

Answer: B) 8 mL/hour

Dose = 0.1 units/kg/hour × 80 kg = 8 units/hour. The concentration is 100 units ÷ 100 mL = 1 unit/mL, so the rate is 8 mL/hour. 0.8 mL/hour and 80 mL/hour are tenfold errors, and 10 mL/hour does not match the weight-based dose.

Why the other options are wrong

• A) 0.8 mL/hour is a tenfold underdose.
• C) 10 mL/hour doesn't match 0.1 units/kg/hour for 80 kg.
• D) 80 mL/hour is a tenfold overdose.

Key point: Weight-based infusion: dose per hour ÷ concentration. Standard insulin infusions are often 1 unit/mL.

Answer: A) Propylthiouracil

Propylthiouracil is preferred during the first trimester because methimazole is associated with congenital malformations (e.g., aplasia cutis, choanal/esophageal atresia) when used during organogenesis; switching to methimazole is often considered after the first trimester because of PTU hepatotoxicity. Radioactive iodine is contraindicated in pregnancy. Levothyroxine treats hypothyroidism, not hyperthyroidism.

Why the other options are wrong

• B) Levothyroxine treats hypothyroidism, not Graves'.
• C) Methimazole is associated with congenital malformations in the first trimester.
• D) Radioactive iodine is contraindicated in pregnancy.

Key point: Hyperthyroidism in pregnancy: PTU in the first trimester, methimazole after.

Answer: A) Prednisone must be tapered gradually because of adrenal suppression

Adrenal suppression can occur with oral glucocorticoid doses above about 4 to 6 mg of prednisone daily taken for 3 to 4 weeks or longer, so 30 mg daily for 4 months certainly suppresses the hypothalamic-pituitary-adrenal axis. Abrupt discontinuation can cause acute adrenal insufficiency and disease flare, so the dose must be tapered gradually under prescriber guidance, more slowly near physiologic doses. Topical hydrocortisone does not replace systemic glucocorticoid, and suppression occurs far below 40 mg daily.

Why the other options are wrong

• B) Every-other-day dosing for a week isn't an adequate taper after 4 months.
• C) Topical hydrocortisone doesn't replace systemic steroids.
• D) Suppression can occur above about 4-6 mg/day of prednisone for 3-4 weeks, far below 40 mg.

Key point: Prednisone above about 5 mg/day for 3-4 weeks or longer: taper, don't stop abruptly.