Endocrine/Metabolic Flashcards
Discuss the screening for Diabetes
- screen every 3 years for those over 40
FPG <5.6 or A1c <5.5% - normal rescreen in 3 years
FPG 5.6-6.6 and/or AIc 5.5-5.9% - no risk factors then rescreen more often
- risk factors then go to 75g OGTT
FPG 6.1-6.9 and/or A1c 6.0-6.4% - go to 75g OGTT
- fasting <6.1 and 2h <7.8
- if A1c <6% then rescreen more often
- if A1c 6-6.4% then prediabetes
- fasting <6.1 and 2h 7.8-11 then impaired glucose tolerance and prediabetes
- fasting 6.1-6.9 and 2h <7.8 then impaired fasting glucose and prediabetes
- fasting 6.1-6.9 and 2h 7.8-11 then prediabetes
- fasting >7 or 2h >11.1 then diabetes
FPG >7.0 and/pr A1c >6.5% then diabetes
- fasting <6.1 and 2h <7.8
Discuss the monitoring for diabetes
Fasting Blood Glucose - 4-7 2hr Post Prandial - 5-10 or 5-8 if not achieving A1c target - HbA1c <7.0% done every 3 months Blood Pressure - <130/80 Lipids - LDL <=2 or >=50% reduction - apoB <0.8 or non-HDL <=2.6 - done yearly Chronic Kidney Disease - Normal ACR <2.0 - normal eGFR >60 - type 1 screen at 5 year and then yearly - type 2 at diagnosis then yearly Retinopathy - type 1 5 years after diagnosis then yearly - type 2 at diagnosis then 1-2 years Neuropathy - screen with 10g monofilament (until bends) at 1st, 3rd, and 5th metarsal head and base of great toe - type 1 at 5 years then yearly - type 2 yearly Waist Circumference/BMI - Maintain WC <102cm in males and <88cm in females - BMI between 18.5-24.9 Lifestyle Modification - 150minutes/week of aerobic exercises
Discuss screening following adding antihyperglycemic agent
- make timely increase in dose or add drug from different class in order to reach A1C target in 3-6 months
- if A1c is <1.5 above target of 7% then begin with lifestyle for three months before switching to metformin
- if A1c is >1.5 above target of 7 begin metformin right away and possibly other drug
Discuss the pathophysiology, benefits, risks and dosing of biguanides
Pathophysiology - increase sensitivity of the cell to insulin Benefit - A1c lowering of 1-1.5% - low risk of hypoglycemia - improved cardiovascular risk Risks - contraindicated with eGFR <30 (increase risk of lactic acidosis) - GI side effects Dosing
Discuss the pathophysiology, benefits, risks and dosing of incretins
Pathophysiology - secreted in the gut and result in increased insulin secretion from the pancreas - glucagon like peptide-1 - glucose dependent insulinotrophic peptide Benefit - increase satiety and decrease gastric emptying which reduces weight gain - increase insulin secretion Benefits - A1c lowering of 1% - significant weight loss - low risk of hypoglycemia - some cardiovascular benefit Risks - GI side effects - subcutaneous injection required - rare cause of pancreatitis - increase parafollicular hyperplasia Dosing
Discuss the pathophysiology, benefits, risks and dosing of DDP-IV inhibitors
Pathophysiology - amplify incretin pathway by inhibiting breakdown of endogenous GLP and GIP Benefits - A1c lowering of 0.7% - low risk of hypoglycemia - improve post-prandial control - GI side effects Dosing
Discuss the pathophysiology, benefits, risks and dosing of SGL2-inhibitors
Pathophysiology
- block glucose transport in proximal renal tubule leading to urinary exretion
Benefits
- glycosuria:
- negative caloric balance and weight loss
- decrease A1c
- increase uric acid release
- natriuresis
- decrease blood pressure resulting in decrease arteriolar stiffness
- decrease plasma volume resulting in decreased myocardial stretch
- increase tubulo-glomerulo fedback and afferent arteriole constriction
Risks
- increase risk of UTI
- osmotic diuresis leading to hypotension
- ketoacidosis in euglycemic individual
Dosing
Discuss the pathophysiology, benefits, risks and dosing of sulfonylurea
Pathophsyiology - bind to sulfonylurea receptor inhibiting efflux of K -> depolarization and increase in Ca entry into cell -> increase insulin release Benefits - A1c lowering of 0.8% - rapid glucose lowering Risks - may cause hypoglycemia - weight gain
Discuss the pathophysiology, benefits, risks and dosing of meglitinide
Pathophysiology - same as sulfonylurea as is a secretague Benefit - A1c lowering of 0.7% - rapid glucose lowering with lower risk of hypoglycemia due to shorter half-life - safe with renal impairment Risks - weight gain - hypoglycemia - interaction with plavic
Discuss the pathophysiology, benefits, risks and dosing of acarbose-glucosidase inhibitor
Pathophysiology - inhibit intestinal enzymes alpha-glucosidase and pancreatic alpha-amylase resulting in reduced digestion of carbohydrates Benefits - A1c lowering of 0.6% - rare hypoglycemia - GI side effects
Discuss the pathophysiology, benefits, risks and dosing of thiazolidinediones
Pathophysiology - increase sensitivity of tissues to insulin by activation of ppar-gamma receptor Benefit - longer duration of monotherapy - Mild blood pressure lowering - A1c lowering 0.8% - low risk of hypoglycemia Risks - weight gain - increased peripheral edema and heart failure - increased risk of fractures
Discuss when to initiate insulin therapy
Suboptimal control with oral agents Marked Hyperglycemia at Presentation - A1c >9% - require basal-bolus regimen Stress on Body - infection - pregnancy
List risk factors for diabetes
- First degree relative with type 2 diabetes
- history of prediabetes
- history of gestational diabetes
- metabolic syndrome
- PCOS
- aconthosis nigricans
- OSA
- glucorticoids
- atypical antipsychotics
- retroviral therapy
List factors that can alter A1c
Increase A1c - B12 or iron deficiency - chronic renal failure - hyperbilirubinemia - EtOH or opioids Decrease A1c - use of EPO, iron or B12 - reticulocystosis - ASA - Vitamin C or E - hemoglobinopathies - Splenomegaly - rheumatoid
Discuss screening for dyslipidemia
- men >40 and women >40 or post-menopausal Regardless of Age Conditions - evidence of arthersclerosis - AAA - diabetes - hypertension - cigarette smoking - stigmata of dyslipidemia (arcus cornea, xanthelasma or xanthoma) - Family history of cardiovascular disease or dysplipidemia - Chronic kidney disease - Obesity - IBD - HIV - Erectile dysfunction - COPD - hypertension in pregnancy
Discuss screening risk using Framingham Risk Score, LDL, Non-HDL and Apo-B screening
No Pharmacology - low risk: FRS <10% Primary Prevention - Intermediate risk: FRS 10-19% and LDL >=3.5 or Non-HDL >=4.3 or Apo-B >=1.2 or men >50, women >60 with one component of metabolic syndrome - High risk: FRS: >20% Statin-Indicated Condition - Clinical artherosclerosis - AAA - Diabetes: age >40, Age >30 with type 1 for >15 years, microvascular disease - Chronic kidney disease LDL >=5 (genetic)
Discuss dyslipidemia therapy and targets
Targets following Initiation of Statin - LDL <2.0 or >50% reduction or ApoB <0.8 or non-HDL <2.6 Target Not Achieved Add on - Ezetimibe 1st line - PCSK9 inhibitor as 2nd line Non Pharmacological Therapy - Smoking cessation - Diet - Exercise
Discuss valid blood pressure check in clinic
Patient - back and arm supported - seated comfortably with legs uncrossed, feet on ground shoulder width apart - no talking - sitting for 5 minutes Cuff - 3cm above elbow crease - width 40% of arm circumference - length 80-100% of arm circumference Measurement - inflate to 30 mmHg above radial pulse obliteration - deflate slowly for average of 2 readings 60 seconds apart
Discuss criteria for diagnosis of hypertension
First Visit
- BP >180/110 then hypertension
- BP automatic >135/85 or office >140/90 then move to second visit
At Home Automatic Blood Pressure
- daytime automatic is >135/85 then hypertension
- if no home monitoring available and BP >140/90 then hypertension
List the target blood pressures
- <140/90
- <130/80 for diabetes
- <150/90 for elderly
Discuss lifestyle modifications for hypertension
Diet - DASH diet - limit sodium to 1.5-2.3g Exercise - 30-60min 4-7x/week Smoking Cessation Relaxation and Stress Management Healthy BMI and Waist Circumference
Discuss the indications to begin medication for hypertensions
- diastolic >90 with target organ damage or cardiovascular risk factors
- diastolic >100 or systolic >160
- systolic >140 with end organ damage
Discuss the medications used for hypertension
1st Line - Thiazide diuretics - ACE inhibitors - ARB - Long acting calcium channel blockers - Beta blockers Add-On - caution CCB and BB - caution ACEi and ARB - caution hypokalemia with thiazides
Discuss secondary causes of hypertension and potential investigations
Hyperthyroidism - TSH Aortic Coartation - CXR - CT angiogram Cushing Syndrome - 24-hr urine cortisol Obstructive Sleep Apnea - Overnight polysomnogram Renal Disease - Renal ultrasound Pheochromocytoma - 24hr urine fractionated metanephrines and catecholamines Medications - NSAIDs - OCP - Steroids - Cocaine
Discuss the Framingham risk score
- completed every 3-5 years in those 40-75 Components - Gender - Age - HDL-C - total cholesterol - SBP - Smoking - Diabetes Double - Family with cardiovascular disease in male <55 or female <55
Discuss the algorithm for starting insulin
- can be combined with oral agent
Basal (glargine or detemir) - start at 10 units or 0.2units/kg at bedtime
- check fasting glucose daily and increase by 2 units every 3 days until in in fasting range
- if FBG >10 then can increase by 4 units every 3 days
Second Injection - If A1c >=7% after 2-3 months then add bolus (lispart or aspart) at pre-lunch, -dinner, -bed
- if pre-lunch high then do at breakfast, etc - if after 2 months A1c still out of range then check 2h post-prandial
Discuss when to add additional therapy to diabetes
ACEI or ARB - clincal macrovascular disease - age >55 - age <55 and microvascular disease Statin - clinical macrovascular disease - age >=40 - age <40 and diabetes duration >15yr, microvascular complication or cardiovascular risk factor Low Dose ASA - for those with cardiovascular disease
