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Family Medicine > Endocrine/Metabolic > Flashcards

Endocrine/Metabolic Flashcards

1
Q

Discuss the screening for Diabetes

A
  • 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
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2
Q

Discuss the monitoring for diabetes

A 
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
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3
Q

Discuss screening following adding antihyperglycemic agent

A
  • 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
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4
Q

Discuss the pathophysiology, benefits, risks and dosing of biguanides

A 
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
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5
Q

Discuss the pathophysiology, benefits, risks and dosing of incretins

A 
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
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6
Q

Discuss the pathophysiology, benefits, risks and dosing of DDP-IV inhibitors

A 
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
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7
Q

Discuss the pathophysiology, benefits, risks and dosing of SGL2-inhibitors

A

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

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8
Q

Discuss the pathophysiology, benefits, risks and dosing of sulfonylurea

A 
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
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9
Q

Discuss the pathophysiology, benefits, risks and dosing of meglitinide

A 
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
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10
Q

Discuss the pathophysiology, benefits, risks and dosing of acarbose-glucosidase inhibitor

A 
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
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11
Q

Discuss the pathophysiology, benefits, risks and dosing of thiazolidinediones

A 
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
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12
Q

Discuss when to initiate insulin therapy

A 
Suboptimal control with oral agents
Marked Hyperglycemia at Presentation
- A1c >9%
- require basal-bolus regimen
Stress on Body
- infection
- pregnancy
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13
Q

List risk factors for diabetes

A
  • 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
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14
Q

List factors that can alter A1c

A 
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
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15
Q

Discuss screening for dyslipidemia

A 
- 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
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16
Q

Discuss screening risk using Framingham Risk Score, LDL, Non-HDL and Apo-B screening

A 
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)
17
Q

Discuss dyslipidemia therapy and targets

A 
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
18
Q

Discuss valid blood pressure check in clinic

A 
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
19
Q

Discuss criteria for diagnosis of hypertension

A

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

20
Q

List the target blood pressures

A
  • <140/90
  • <130/80 for diabetes
  • <150/90 for elderly
21
Q

Discuss lifestyle modifications for hypertension

A 
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
22
Q

Discuss the indications to begin medication for hypertensions

A
  • diastolic >90 with target organ damage or cardiovascular risk factors
  • diastolic >100 or systolic >160
  • systolic >140 with end organ damage
23
Q

Discuss the medications used for hypertension

A 
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
24
Q

Discuss secondary causes of hypertension and potential investigations

A 
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
25
Q

Discuss the Framingham risk score

A 
- 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
26
Q

Discuss the algorithm for starting insulin

A
  • 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
27
Q

Discuss when to add additional therapy to diabetes

A 
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

Family Medicine (12 decks)

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