Clinical Notes Flashcards
Pregnancy diabetes goals
63-140mg/dL
TIR 75-85%
A1C <6.5% prior to conception
New diabetes med C/I in pregnancy
SGLT2
C Telopeptide normal and target ranged
100-600normal
>300 think about restarting therapy for osteoporosis
When should you check 24hr Uribe calcium in osteoporosis?
Severe disease or not responding to therapy
How many units of insulin for black coffee?
1U
TURN OFF REVERSE CORRECTION
(Unless pump in manual mode)
Vit D target
30-60
How much but D to prescribe?
50,000 qd for 1wk if very low (teens)
Otherwise 50,000 weekly for 3mo and recheck
Frequency of A1C and CGM discrepancy
About 1/3 ppl
Pharmacodynamics of Byetta
Glp1
Very short 6hr 1/2 life
Consider using like bolus
Age of dx of T1DM
50% <21
25% 21-39
25% 40 & up
Percentage of patients on GLP1 w/o side effects
80%
Adjusting basal when starting pump
Usually 75% of prior dose
Calculate insulin in carb ration
500/TDD
*how many grams of carb are covered by 1 U insulin
Calculate insulin correction factor
Aka insulin sensitivity factor
1800/TDD
*how many points 1U of insulin will lower blood glucose
When changing a patient from MDI to a pump you should adjust insulin by:
Decreasing TDD by 25%
Ultra fast acting insulins
Fiasp and lyumjev
Diabetes distress survey
PAID score
Which insurance requires that pumps and CGMs be sent to a DME pharmacy?
Medicare
(Byram, CCS Medical, Wellstart, ADS)
SGLT2 inhibitors only work if your blood sugar is …
> 180
Typical TSH normal range
0.3-3.0
Pregnancy TSH target
<2.5
Adjusting levothyroxine dose in pregnancy
Increase by 20%
Extra tab 2 days a week
(Resume regular dose immediately after delivery)
EPI
Exocrine pancreatic insufficiency
Symptoms of EPI
Increased foul smelling gas and loose stool
Risk factors for EPI
Pancreatitis, pancreatic díctala carcinoma, cystic fibrosis, long-standing diabetes, prior intestinal surgery
Testing for EPI
Fecal elastase
<100mcg suggestive
GLP1 agonist meds have been around since…
2005
Metformin has been around in Europe since
1955
Consider ananolic meds for osteoporosis when T score is..
<-3
How do steroids impact TSH?
Could decrease TSH
How could low TSH impact liver enzymes?
Could increase AST & ALT due to myopathy
Neuropathy supplements
Alpha lipoid acid and B1 (thiamin)
LDL treatment for statin intolerant patients
PCSK9 therapy
Bempedoic acid 180mg daily
Zetia
Prescription fish oil (lovaza or omtryg 2caps twice daily)
Adjusting insulin for gestational diabetes post partum
Often insulin not needed 2 days post delivery
Insulin adjustment when going from long acting to ultra long acting
Decrease by 10%
Testosterone treatment lab monitor
1/2 time between shots check cbc, hepatic panel, and testosterone free and total q3-6mo
PSA also check annually -Medicare requires cpt for testosterone monitoring to cover
Switching from 1-2mg of ozempic to mounjaro
10mg
LDL goals in diabetics
<70
But <55 if heart disease or nephropathy
MEN III
Medullary thyroid carcinoma
Medulla of adrenal (pheo)
Mucosal neuroma
MEN II
Medullary thyroid carcinoma
Medulla of adrenal (pheo)
Parathyroid hyperplasia
MEN I
Pituitary tumors
Parathyroid hyperplasia
Pancreatic tumors (insulinoma and gastrinoma)
Metformin MOA
- Decrease liver glucose output
- Increase peripheral insulin sensitivity
How high does blood sugar have to be for SGLT2 inhibitors to work?
180
Weight stigma language
AVOID: diet, exercise, limit, restrict, ideal weight, extra large
USE: eating style/preferences, movement, physical activity, choose/experience, healthy weight, appropriate size
Pregnancy TSH goal
<2.5
Pregnancy levothyroxine adjustment
Increase by 20% or 2 pills per week
Resume normal dose immediately following delivery
Antihypertensive preferred in adrenal insufficiency
CCB
Which part of BP is more predictive of CV risk?
<50yr diastolic
>50yr systolic
Severity of hypoglycemia
Mild if <70
Moderate if < 55
Severe if altered mental status
How does acute illness impact DM2?
Increased insulin resistance that can last up to 2wk
Hypothyroidism in pregnancy
- Increase dose by 20% or 2pills weekly
2.Monitor T4 and TSH ever 1-2mo. Keep TSH <2.5 - Resume regular dose immediately after delivery
- Check for thyroiditis 6wk pp
Possible medication for post bariatric hypoglycemia
Acarbose
DME companies for insulin pumps
Byrum
ADS
Performance medical
Wellstart
Most common cause of ectopic cushings
50% small cell lung cancer
Treatment if hypercalcemia if malignancy
Hydration
IV BP or prolia
Calcimimetic
Hormones released by adrenal medulla
Epinephrine
Norepinephrine
Dopamine
Hormones released by adrenal cortex zona glomerulosa
Mineralicorticoids: Aldosterone
Hormones released by adrenal cortex zona fasiciculata
Glucocorticoids : cortisol, cortisone, and corticosterone
Hormones released by adrenal cortex zona reticularis
Androgens, estrogen, aldosterone, and DHEAS
Trans women biochemical treatment goals
Estradiol in 100s
Testosterone in low range/female range
LH & FSH suppressed
Satiety hormone released by pancrease
Amylin
(Some t1dm are deficient)
Supplements for neuropathy
B1 (benfotiamine/thiamine)
Alpha lipoic acid
Pseudohypoparathyroidism can be caused by this electrolyte abnormality
Hypomagnesemia
Dx labs with hypoparathyroidism
Low calcium, PTH, urinary calcium, and vit D
High or normal phosphate
Treatment for symptomatic hypocalcemia
IV calcium gluconate in DSW
Tx for hypoparathyroidism
Calcium citrate or carbonate
Calcitriol
Vit D
Thiazide if hypercalciuric
Phosphate binder possibly
New PTH analog if refreactory
Hypoparathyroidism in pregnancy
Monitor q 3-4wk
Adjustment up and down often needed
8 most common complications of hypoparathyroidism
Cataracts
Infection
Nephrolithuasis/calcinosis
Renal insufficiency
Arrhythmia (QT prolongation)
Ischemic heart dz
Depression
Seizures
Palopectaryparotide
PTH analong - prodrug conjugated to carrier molecule
Calcium supplementation while on PPI
Can not use carbonate
Use citrate instead
Tx hyperphosphatemia
Take calcium supplement with meal
Low phosphate diet
Consider phosphate binder
Preferred HTN tx with adrenal insufficiency
CCB
Affect of Crestor on LDL with weekly administration
20% per DrCW
Lab that needs to be monitored with benpodoic acid tx
Uric acid
TSH goal with pregnancy and pregnancy planning
<2.5 prior to conception
0.2-2.5 1st trimester
0.3-3.5 2nd and 3rd trimester
This electrolyte deficiency can cause pseudohypoparathyroidism
Magnesium
Supplements for neuropathy
B1 - thiamine/benfotiamine (300-600mg)
Alpha lipoic acid (600-1200mg)
Labs with hypoparathyroidism
LOW: PTH, serum and urine Calcium, vit d
HIGH to norm: phosphate
This lab predicts Cushings dz recurrence best
ACTH
Cushings Dz treatment
Transphenoidal tumor resection
Radiation
Medication
Bilateral adrenalectomy
Crushings disease medications
Antitumor: pasireotide or cabergoline
Glucocorticoid receptor blocker: mifepristone
Steroidogenesis inhibitor: ketoconazole, lovelkeyonkonazoke, metryapone, osilodrostat
Thyroglobulin monitoring
Every 6mi for 2yr then annually
Central diabetes insipidus tx
DDAVP
Nephrogenic diabetes insipidus tx
Thiazide or acetazolamide as needed for hypernatremia
