Rationale of the Week | Best fix for hyperglycemic spike?

For our February 16th Question of the Week, over 76% of respondents chose the best answer!

Before we start though, if you don’t want any spoilers and haven’t tried the question yet, you can answer below: Answer Question

Question: LS is 79 years old and their most recent A1c is 7.4%.  LS takes metformin 1000 mg twice daily and sitagliptin (Januvia) plus 14 units of basaglar at before sleep at 2am.  LS is excited that they started using a Freestyle Libre sensor and shows you the glucose trends.  You notice that glucose levels rise to 250 – 350 in between noon to 4pm.

What is the next best action? 

Answer Choices:

  1. Start bolus insulin at breakfast
  2. Increase basal insulin by 20%
  3. Add a low dose sulfonylurea
  4. Assess food timing and content

As shown above, the most common choice was option 4, the second most common answer was option 2, then option 1, and finally option 3.

Getting to the Best Answer

If you are thinking about taking the certification exam, the content of this practice test question will set you up for success. The exam often present vignettes that compel test takers to weed through the details and figure out the key intent of the question and chose the BEST answer.

Answers & Rationale

Answer 1 is incorrect, 9.23% chose this answer. “Start bolus insulin at breakfast”. Giving bolus insulin at breakfast would not prevent the glucose elevations from 12pm to 4pm. If we were to start bolus insulin to help with these afternoon spikes, we would need to give it before lunch to match post lunch glucose elevations.

Answer 2 is incorrect, 9.83% of you chose this answer. “Increase basal insulin by 20%”. Basal insulin helps to manage overnight and between-meal blood glucose levels. It is not effective at preventing post-prandial hyperglycemia. We evaluate if a person is taking enough basal insulin by seeing if fasting blood glucose is in the 80-130 mg/dl range.

Answer 3 is incorrect, 4.84% of you chose this answer “Add a low dose sulfonylurea”. Generally speaking, if a person is on basal insulin we are reluctant to add a sulfonylurea, since it can potentiate hypoglycemia (LS’s A1c is 7.4%) and may not address this specific issue of lunch time post-prandial spike. In addition, since the A1c is so close to target, it might be a good idea to take a closer look at food intake and activity and it’s impact on post lunch blood sugars.

Answer 4 is correct, 76.10% of you chose this answer. “Assess food timing and content”. GREAT JOB team. Most of you chose the best answer. As it turns out, LS was eating cereal and “mini” bagels for lunch. This explained the post meal spike. By helping LS understand which foods are carbohydrates and their impact on blood glucose, LS was eager to make adjustments at lunch to get blood sugar to target.

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!


Test Taking Practice Exam Toolkit Webinar
20 Sample Practice Questions

You’re invited! FREE Live Webinar Friday, Feb 26th at 11:30 AM

You are invited to join Coach Beverly for this FREE Webinar. And, if you want to have access to an additional 220+ sample practice online questions, you can purchase the complete Test Taking Toolkit.

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She will explain how to dissect the question, eliminate wrong answers and avoid getting lured in by juicy answers.

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