Answer A is incorrect: 18.4% chose this answer, “Start AR on pioglitazone and recheck FIB-4 in 3 months.” Although pioglitazone is a recommended treatment for steatosis, since AR’s FIB- is greater than 2.67, this indicates AR is at high risk for advanced fibrosis and a referral to a liver specialist is warranted.

Answer B is incorrect: 15.11% chose this answer, “Encourage AR to see a RDN and stop consumption of alcohol immediately.” Seeing a RDN is very important for AR to evaluate and customize an eating plan to address their steatosis and support quality of life. However, since AR’s FIB- is greater than 2.67, this indicates AR is at high risk for advanced fibrosis and a referral to a liver specialist is warranted.

Answer C is incorrect: 18.4% chose this answer, “Suggest increased high intensity activity coupled with a GLP-1 to reduce body weight.” Strength training and activity, coupled with a GLP-1 for GLP-1/GIP are important strategies to address steatosis. However, since AR’s FIB- is greater than 2.67, this indicates AR is at high risk for advanced fibrosis and a referral to a liver specialist is warranted.

Answer D is correct: 48.09% chose this answer, “Refer AR to liver specialist for further evaluation.” Great job! AR will require intensive intervention to decrease their risk of worsening steatosis, including MNT, targeted activities, and a referral to a liver specialist to determine the best treatment approach.

We hope you appreciate this week’s rationale! Thank you so much for taking the time to answer our Question of the Week and participate in this fun learning activity!

Answer A is incorrect: 24.19% chose this answer, “Semaglutide (Ozempic).” The diabetes approved version of semaglutide (Ozempic) does not yet have FDA approval as a medication that is used for treatment of MASH.

Answer B is incorrect: 18.77% chose this answer, “Empagliflozin (Jardiance).” Although empagliflozin will reduce blood glucose and can help with weight loss, it is not FDA approved for treatment of MASH.

Answer C is incorrect: 23.29% chose this answer, “Tirzepatide (Mounjaro).” Tirzepatide (Mounjaro) is approved for treatment of diabetes, helps with weight loss and is FDA approved for sleep apnea. However it is not FDA approved for treatment of MASH.

Answer D is correct: 33.75% chose this answer, “Semaglutide (Wegovy).” The weight loss approved version of semaglutide (Wegovy) has FDA approval as a medication that is used for treatment of MASH.

Please see our new “Indications for GLP-1/GIP” Cheat Sheet for a complete run down.  

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Answer A is incorrect: 6.35% chose this answer, “No changes are needed because kidney function is within normal range.” A is incorrect. Although eGFR indicates stage 2 kidney disease, the elevated UACR, ≥30 mg/g, confirms moderately increased risk and recommendation to treat. Additionally, PJ’s blood pressure is also above the target. Intervention is needed to protect kidney and cardiovascular health.

Answer B is correct: 83% chose this answer, “Initiate an ACE inhibitor or ARB to reduce progression the of diabetic kidney disease.” PJ has a mildly decreased eGFR, but UACR is elevated above 30 mg/g, indicating a recommendation to treat. Additionally, intervention is needed to optimize blood pressure. According to the ADA Standards of Care in Diabetes, individuals with diabetes, hypertension, and moderately increased albuminuria should be treated with an ACE inhibitor or angiotensin receptor blocker. The use of sodium-glucose cotransporter 2 (SGLT2) inhibitors or glucagon-like peptide 1 agonists (GLP1-RA), with demonstrated benefits, could also be considered to reduce CKD progression.

Answer C is incorrect: 5.25% chose this answer, “Discontinue metformin due to the risk of kidney injury with reduced eGFR.” Metformin is safe to continue unless eGFR falls below 30 30 mL/min/1.73m². PJ’s kidney function is adequate for continued use. However, consideration to add a change to SGLT2 or GLP1 with kidney benefit could also promote additional A1c reduction.

Answer D is incorrect: 5.52% chose this answer, “Increase statin therapy to target albuminuria reduction.” Statins are recommended for ASCVD prevention, but they do not reduce albuminuria. Lipids are within normal range, and albuminuria should be addressed with an ACE inhibitor/ARB or potentially a SGLT2 inhibitor or GLP-1 RA.

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Answer A is incorrect: 1% chose this answer, “Stress with R.S. the importance of never missing his meal time lispro to prevent diabetes-related complications.” R.S. is aware that his glycemic control is important, and he is already aware of the risk of diabetes-related complications. Counseling him on this would not help him be successful with his insulin management.  

Answer B is correct: 96% chose this answer, “Using open-ended questions, explore R.S.’s routine, stressors, and support systems to understand the barriers to his insulin use.” R.S. is struggling with barriers to successful insulin management.  A holistic approach would be to ask open-ended questions about his current routine, stressors, and support systems to gain a better understanding of these barriers. This information can lead to a personalized plan of care to help improve glycemic control. 

Answer C is incorrect: 2% chose this answer, “Recommend R.S. switch to another non-insulin medication to make his regimen easier for him to manage.” He has already attempted other non-insulin therapies, and these were either ineffective or not tolerated. Changing his regimen would not be successful at improving his glycemic control and quality of life.

Answer D is incorrect: 1% chose this answer, “Since it appears R.S. did not understand how to take his insulin lispro, write out step-by-step instructions on how to take the insulin.” R.S. appears to understand how to take his insulin lispro at meals. Writing out the instructions would not improve his situation. It is not a lack of knowledge, but the multiple barriers in his life that are keeping him from being able to implement this new medication regimen.  

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Answer 1 is incorrect. 25.14% chose this answer, “It decreases cortisol synthesis in the adrenal cortex, lowering circulating cortisol levels.” As tempting as this answer is, mifepristone does not inhibit cortisol synthesis.

Answer 2 is incorrect. 15.21% of you chose this answer, “It reduces ACTH release from the pituitary, leading to decreased adrenal stimulation.” This medication does not directly reduce ACTH release from the pituatary.

Answer 3 is correct. About 48.73% of respondents chose this, “It blocks glucocorticoid receptors, preventing cortisol from exerting metabolic effects.” Mifepristone is a glucocorticoid receptor antagonist. By competitively binding to glucocorticoid receptors, it prevents cortisol from exerting downstream effects, including increased hepatic gluconeogenesis, peripheral insulin resistance, and lipolysis. This mechanism is particularly useful in people with hypercortisolism and concurrent type 2 diabetes, as it improves insulin sensitivity and lowers blood glucose without lowering circulating cortisol levels.

Finally, Answer 4 is incorrect. 10.99% chose this answer, “It directly enhances insulin secretion and sensitivity, independent of cortisol pathways.” This medication does not act directly on pancreatic β-cells or insulin receptors.

We hope you appreciate this week’s rationale! Thank you so much for taking the time to answer our Question of the Week and participate in this fun learning activity!

Answer 1 is incorrect. 9% chose this answer, “Individuals with type 2 diabetes should include regular meals throughout the day to support stabilize blood sugars and prevent hypoglycemia.” Random control trials have indicated that time-restricted eating is a safe and practical dietary approach for individuals with type 1 and type 2 diabetes. While assessment and prevention of hypoglycemia is a priority, MJ’s current medication regimen is of low risk. Even with higher risk medications, such as insulin or sulfonylureas modifications of medication, timing or dose can be made to support safety.

Answer 2 is correct. 86% of you chose this answer, “Review with MJ his motivations for the time-restricted eating plan and assess plan for dietary intake within the eating window.” Great Job! Time-restricted eating can be a safe and effective strategy for MJ. Reviewing motivation and current eating patterns may improve the ability to apply balanced meals within the eating window.

Answer 3 is incorrect. About 3% of respondents chose this, “Encourage a time-restricted eating plan, evidence indicates it is more effective than calorie reduction alone for weight loss and A1c reduction.” While time restricted eating may be a practical strategy, it has not been shown to be superior to continuous energy restricted dietary intake for weight loss and A1c outcomes.

Finally, Answer 4 is incorrect. About 2% chose this answer, “Recommend starting Incretin therapy, such as Ozempic or Mounjaro, to ensure effectiveness of time-restricted eating plan.” While we may consider addition of an incretin therapy to support A1c, weight and cardiovascular risk reduction, time-restricted eating does not require the addition of these medications to be effective.

We hope you appreciate this week’s rationale! Thank you so much for taking the time to answer our Question of the Week and participate in this fun learning activity!