dosing Flashcards
DM goals in sg
HbA1cL <7 (7-8.5% for vulnerable)
FBG 5-7mmol/dL
PPG <10 mmol/dL
stringent goal
6-6.5%
□ Shorter disease duration
□ Long life expectancy
□ No significant CVS disease
Less stringent goal
7.5-8%
□ History of severe hypoglycemia
□ Limited life expectancy
□ Advanced complications
□ Extensive comorbid conditions
□ Unable to attain target even when:
-Intensive SMBG
- Repeated counselling
-Effective pharmacotherapy
diagnose DM in SG
2 abnormal test results from same blood sample may be used to diagnose T2DM
HbA1c >7
HbA1c 6.1-6.9%
+
FPG>7mmol/L
2hOGTT >11.1mmol/L
metformin
A1c: 1.5 - 2%
regular: 850mg TDS
extended: 1g BD
max 2550mg
metformin dose adj
GFR 30-45 = 50% dose reduction
GFR <30 = discontinue
SU A1c
A1c: 1.5-2%
TZD A1c
A1c: 0.5-1.4%
GLP1 RA ADV
ASCVD (benefits
CKD (minimal)
HF (neutral)
GLP1 A1c
0.7-1.5%
SGLT2i adv
Ascvd (CE)
CKD (D)
HF (DE)
SGLT2i dose
0.8 - 1%
dapaglifozin 5mg OD (max 10mg)
empagliflozin 10mg OD (25mg max)
canaglifozin 100mg OD (max 300mg)
CONTINUE EVEN IF <30mL/min unless not tolerated/ kidney repalcement therapy
a-glucosidase inhibitor A1c
acarbose
0.5-0.8%
DPP-4 agonist
0.5 - 0.9%
sitagliptin crcl 30-50
ESRD, severe renal impairment
linagliptin
- no renal adj
when to start insulin
Catabolism (weight loss)
symp of Hypergly
A1c > 10%
BGL > 16.7 mmol/L
start basal insulin
10 IU NPH ON
titrate basal insulin
incr 2 unit every 3 days
incr 4 units every 3 days (if FPG > 10mmol/l)
decr 10-20% if hypoglycemia
when to start prandial insulin
1) FBG at goal (5-7) but HbA1c above goal
2) basal dose maxed (0.5IU/kg)
initiate prandial insulin
1) 10% of basal insulin dose / 4U
2) split bedtime NPH (2/3 AM, 1/3 PM)
titrate basal when added prandial
if (A1c <8%)
reduce basal by 4IU/ or by 10%
dose conversion of insulin
decr 10-20% if pt hypoglycemic
decr 20% for
1) BD NPH –> OD glargine/ detemir
2) glargine-300 –> basal insulin
changes in regimen after adding insulin
SGLT2i (continue)
metformin (continue)
TZD (decr/ stop – hypogly)
SU (decr/ stop when basal added – if pt hypogly) (or can wait until prandial added)
DPP4i (stop if GLP1 added)
range for TH and TSH
T4: 0.8-2.7 ng/dL
TSH: 0.4-4.2 MIU/L
- goal for hypoTH (0.4-4mIU/L)
- goal for elderly TSH 6.9
screening of thyroid in which pop
ROUTINE TEST FOR: (risk developmental risk)
- Preg
- Pediatric pt
compelling indications for screening
1) Presence of autoimmune disease (T1DM, cystic fibrosis)
2) 1st degree relative w/ autoimmune thyroid disease (genetics)
3) Psychiatric disorders
- TH abnormality affects psychiatric
4) Take amiodarone/ lithium
5) History of head/ neck radiation for malignancies
- Radiation predisposes
6) Symptoms of hypo/ hyperthyroidism
diagnosis of hyperthyroidism labs
1* hypothyroidism
- HIGH TSH, LOW T4
- +ve Ab (TPO, ATgA)
Central hypothyroidism
- LOW TSH, LOW T4
diagnosis for hyperthyroidism labs
- HIGH FREE T4
- LOW TSH (except in TSH-secreting adenomas)
- RAIU (radioactive iodine uptake)
- Presence of TRAb, ATgA, TPO
Biopsy
RAIU meaning
Used to better see if the gland is ACTIVELY secreting TH
INCR UPTAKE:
○ Graves, TSH-secreting adenomas, toxic adenoma, multinodular goiter
DECR UPTAKE:
○ Thyroiditis, cancer
levothyroxine initiate dose
young, healthy: 1.5-1.6 mcg/kg/day
50-60 yo, no CVD: 50mg/day
50-60 yo, CVD: 12.5-25mcg/day
titrate levothyroxine doses
incr/decr 12.5-25 mcg/day
10-20% of weekly dose
admin for levothyroxine
30-60mins before meal
4hr after dinner
2hrs apart from Ca, Milk, Fe, Antacid, Biphosphonate
monitor for hypoTH levothyroxine tx
2-3mnths for TSH to respond
2-3wk for sx relief
central hypo: monitor FT4
start tx for hypoTH
TSH > 10mIU/L (decr risk of CHD)
TSH 4.5 - 10 AND (sx of hypoTH/ TPO ab/ CVS risk)
inititate at 25-75 mcg of levothyroxine
monitor for hypoth euthyroid state
thyroid function test recommended semiannually to annually
in nonpreg adults pt
HYPOTH and preg
incr dose by 30-50% to counter for rise in TBG
1st trimester TSH: <2.5 MIU/L
2nd trimester TSH: <3 MIU/L
3rd trimester TSH: <3.5 MIU/L
monitor and titrate carbimazole, propylthiouracil by
monitor: 4-6mnth for max sx effect.
thyroid size, TSH levels
monthly dose titrate as needed based on FT4, Sx
why not monitor TSH in hyperthyroidism
TSH remains suppressed for many mnths (1-2yrs)
why slow onset in reducing sx
max effect takes 4-6mnths
- needs to deplete stored T4 lvls
remission in hyperTH means
decr size, normal TSH and T4 for 1yr after discontinuation of antithyroid therapy
iodides for hyperTH
1) Before surgery (7-10 days) = shrink
2) After ablation (3-7days) = inhibit thyroiditis mediated release of stored TH (BURST)
3) Thyroid storm (too much TH)
PRE-ECLAMPSIA End organ damage
LFT > 2x UNL
SCr 2x
PLT <100
Pul oedema
Neurological complications
PRE-ECLAMPSIA proteinuria
24h urinary portein > 300mg
Dipstick > 2+
Urine Cr > 0.3 mg/dl
estrogen dosing
High dose: 50ug
Mod, standard 30-35
Favour lower (20-25mcg)
Low dose: 15-20ug
prevent pre-eclampsia
Low dose aspirin 100mg PO
12-16wks, until delivery
- High risk pt
- HTn previous preg
- Multifestation preg
- Autoimmune disease
- CKD, DM
Favour lower (20-25mcg)
○ Adolescene
○ Underweight <50kg
○ Age > 35yrs
○ Peri-menopause
○ Fewer ADR
High dose: 50ug
○ Obese, >70.5kg
○ Early-mid cycle breakthrough bleed, spot
○ Non adherence
○ ADR: vascular embolic events, Cancers
menopause PO (uterus intact)
1) Continuous cyclic
□ Prog added on either 1st/ 15th of mnth for 10-14days only
-Only if perimenopausal stage
2) Continuous-combined
□ Estrogen & progestin daily
- Amenorrhea take place after several mnths
initiate HRT must monitor for
- Annual mammography
- Endometrial surveillance
○ Unopposed estrogen: any vag bleeding
○ Continuous cyclic (E/P off)
§ If bleed occur when P on○ Continuous-combine (E/P) § If bleed prolonged § heavier than normal § freq § persists after treatment for > 10mnths
Assessment of BPH (7)
Digital rectal exam
Ultrasonography
Max urinary flow rate (Qmax)
Prostate size (<25g)
Prostate specific antigen (PSA) > 1.5ng/mL
post void residual >200mL
AUA-SSI
Tadalafil
(5mg PO daily)
36hr before intercourse
Can be taken DAILY
* Onset: 15min-2hr
* Duration of action: 36h
* Consideration
○ Regardless of food
Hep, renal adj
meds that affect BPH
- Anticholinergics
- Decr bladder musc contractibility
○ Antihist, tricyclic antidepressants (TCAs)
- Decr bladder musc contractibility
- A1 adrenergic AGONIST
- Contract prostate smooth muscles
- Decongestants (Pseudoepinephrine)
- Opioid analgesic
- Incr urinary retention
- Diuretic
- Incr urinary frew
- Testosterone
*Stimulate prostate growth
Medication induced ED
BP – clonidine, methyldopa, BB (Xnevibolol), thiazide diuretic
anticholinergic – TCA, 1st gen antihist, phenothiazines
dopamine – metoclopramide
serotonin selective reuptake inhibitors
5a reductase inhibitors – finasteride, dutasteride
CNS depressants – benzodiazepines, anticonvulsants
Testosterone replacement
Restore serum testosterone lvl to normal range (300-1100 ng/dL; 10.4-38.2 nmol/L)
monitor for testosterone replacement
- 1-3mnths
- 6/12mn interval
Discontinue if no improvement after 3mn (high risk for SE)
when to take PDE5i
S - 1hr before, empty stomach
V - 1hr before, empty stomach
T - 36hr before, regardless of food
A - 30mins before, regardless of food
PDE5i ADR
hypotension, priapism, hearing loss
S - PDE6
V - PDE6, QTc
T - PDE11 muscle ache
A -
when can take nitrates + PDE5i
Avoided for 12hrs after avanafil
24hrs after sildenafil, vardenafil
48hrs after tadalafil
why is nitrite CI for PDE5i
NO acts as vasodilator, worsens hypotension with the use of PDE5i, which also inhibits degradation of cGMP, leads to smooth muscle relaxation, causing vasodilation
initiate low dose PDE5i
Low dose esp for:
○ Pt > 65yo
○ Alpha blockers
○ Renal failure pt
○ CYP3A4 inhibitors Incr serum conc of PDE5i
monitoring for PDE5i
Efficacy
○ Failure reported:
§ Admin w/ food
§ Time, freq of dosing
§ Sexual stimulation
§ Titration to max dose
Safety (BP, ADR, DDI – GTN, hypertensives, alcohol, CYP3A4i)
Change in cardiac health status
ADR of PDE5i
- Headache
- Rhinitis
- Flushing
- Muscle and back pain (PDE11)
- Dizziness
- Hypotension
- Prolonged erections, priapism
○ Blood trapped inside)
○ Seek ED if >4hrs - Sudden hearing loss
*Tinnitus and dizziness - S,V = Nonarteritic anterior ischemic optic neuropathy (NAION) PDE6
considerations of alprostadil
- (unlike PDE5i): no need sexual stimulation to work
- Fast onset: 5-10mins
- DDI: not used with PDE5i
- DF:
1) Intraurethral
2) Intracavernosal
tx considerations for ED
- PDE5i as 1st line agent
a. All have similar efficacy profile
b. Diff onset, duration of action, SE profile - Alprostadil
a. Avoided due to priapism & pain - Testosterone 1st line if
a. ED + symptomatic hypogonadism
b.Consider SE
meds that affect BPH
TOAAD
- testosterone
- opioid analgesic
- anticholinergics
- a1 adrenergic agonist
- diuretic
Anticholinergics
- Decr bladder musc contractibility
○ Antihist, tricyclic antidepressants (TCAs)
A1 adrenergic AGONIST
- Contract prostate smooth muscles
- Decongestants (Pseudoepinephrine)
- Opioid analgesic
- Incr urinary retention
Diuretic
- Incr urinary freq
Testosterone
*Stimulate prostate growth
Medication induced ED (organic)
anticholinergic
bp
CNS depressant
dopamine
serotonin selective reuptake inhibitor
5a reductase inhibitors
Anticholinergics
TCA, 1st gen antihist, phenothiazines
○ MOA: decr Ach activity
○ Alt: bupropion, trazodone, 2nd gen antihistamine, atypical antipsychotics 2nd gen
BP
clonidine, methyldopa, BB (Xnevibolol), thiazide diuretic
○ MOA: Decr penile blood flow
○ Alt: nebivolol, ACEi, ARB, loop diuretic
CNS depressants
(benzodiazepines, anticonvulsants)
○ MOA: suppress perception of psychic stimulus
○ Alt: anticonvulsant - valproic acid, gabapentin
dopamine
(metoclopramide)
○ MOA: decr ACh activity
○ Alt: PPI, erythromycin
SSRI
○ MOA: incr serotonin in brain, decr testosterone
○Alt: bupropion, trazodone
5a RI
(finasteride, dutasteride)
○ MOA: decr testosterone
○ Alt: (a-blockers) terazosin, alfuzosin
