Group 2 Flashcards
how is pre-diabetes defined
FPG 100-125 mg/dL
recommended therapeutic approach for pre-diabetes
Diet, exercise (150 min/week), limit alcohol consumption, avoidance of tobacco, stress reduction, plus
alternative medicine support, and sufficient sleep.
diabetes type 2 diagnostic criteria
• FPG concentration (after 8 or more hours of no caloric intake) of 126 mg/dL or greater or
• Plasma glucose concentration of 200 mg/dL or greater 2 hours after ingesting 75-g oral glucose
load in the morning after an overnight fast of at least 8 hours, or
• Symptoms of uncontrolled hyperglycemia (e.g., polyuria, polydipsia, polyphagia) and a random
(casual, non-fasting) plasma glucose concentration of 200 mg/dL or greater or
• A1C level of 6.5% or higher
evaluation and managment recommendations for type 2 diabetes
Evaluation and Management Recommendations: Each visit should include: • Monofilament testing • Blood Pressure • Foot exam • Peripheral blood flow • BMI, waist circumference Quarterly: • A1C (if not on target) • CMP (if not on target) • UA (if not on target) • Lipids (if not on target) Semi-annually: • A1C (if on target) • Neurological exam (if not on target) Annual: • dilated eye exam (refer out) • micro albumin • Lipids • CMP (if on target)
treatment for type 2 diabetes
• Target Glucose Control : A1C≤ 6.5%, FPG <110 mg/dL, peak postprandial PG <140 mg/dL
Blood pressure: < 130/80mmHg,
• Lipids: LDL <100, <70 mg/dL in patients with CAD, HDL: >40 mg/dL men, >50 mg/dL women, TG:
<150 mg/dL)
Current guidelines now recommend that drug therapy be initiated in all patients as soon as the diagnosis
of diabetes is established to prevent the deterioration of glycemic control. The American Association of
Clinical Endocrinologists guidelines aim for an HbA1c ≤6.5%, and the American Diabetes
Association guidelines aim for an HbA1c ≤7.0%
type 2 diabetes : NUNM Health Center Guidelines- to be used in conjunction with AACE guidelines below.
If there is a FPG of 126-139 mg/dL, without risk factors (Hypertension, Hyperlipidemia, ethnic
background, peripheral vascular disease, obesity, family history) we may treat for three months with
pre-diabetes therapeutic recommendations. The patient will have a clear understanding that if followup readings still meet diagnostic criteria for diabetes after three months, we will start metformin and/or
other DM medication.
FPG 140 mg/dL or greater &/or A1C of 6.5% or greater, initiate pharmaceutical treatment in
conjunction with natural therapies and lifestyle modification.
American Association of Clinical Endocrinologists guidelines tyoe 2 diabetes
Monitor the patient and adjust the treatment regimen over a 2- to 3-month period to achieve a goal
HbA1c ≤6.5%. If the HbA1c is still >6.5% after 3 months, intensify lifestyle modifications, and adjust the
medication regimen as follows, again depending on the patient’s HbA1c:
• In patients with an HbA1c <6.5%, continue the current regimen. Monitor fasting and
postprandial glucose levels, and adjust the regimen to maximize glycemic control
• In patients with an HbA1c of 6.5% to 8.5% on monotherapy, initiate combination therapy with
oral agents or basal insulin plus an oral agent. See the complete guideline for details
• In patients with an HbA1c of 6.5% to 8.5% on combination therapy, maximize the combination
oral medication and/or insulin regimen, and address fasting or postprandial hyperglycemia with
adjustments in basal and/or prandial insulin, respectively. See the complete guideline for details
• In patients with an HbA1c >8.5%, initiate or intensify insulin therapy, using basal and prandial
insulin or premixed preparations
The recommended order of therapies is based on expert opinion of the Diabetes Mellitus Clinical
Practice Guidelines Task Force. The initial medication regimen depends on the patient’s initial HbA1c:
• In patients with an HbA1c of 6.5% to 7%, initiate treatment with metformin,
a thiazolidinedione, acarbose, or sitagliptin. Metformin is the preferred first-line agent in most
patients. Alternatives include a low-dose sulfonylurea, a meglitinide, or prandial insulin (a rapidacting insulin analog or regular insulin)
• In patients with an HbA1c of 7% to 8%, initiate treatment with a combination of two or more of
the following agents: metformin, a thiazolidinedione, acarbose, a sulfonylurea, sitagliptin, or a
meglitinide. There are many commercially available combinations of oral agents that improve
patient compliance with dosing regimens. Prandial, premixed, or basal insulin analog (insulin
glargine or insulin detemir) regimens may be considered as an alternative
A1C of greater than 8.5%- after 3 months of medication , initiate insulin therapy through referral unless
trained in insulin therapy management.
• In patients with an HbA1c of 8.5% to 9%, initiate treatment with a combination of the
aforementioned agents (with the exception of acarbose) and/or a prandial insulin, premixed
insulin, isophane (NPH) insulin, or basal insulin regimen
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• In patients with an HbA1c of 9% to 10%, initiate treatment with a combination of the
aforementioned agents (with the exception of acarbose, meglitinides, and sitagliptin) and/or a
prandial, premixed, NPH, or basal insulin regimen
• In patients with an HbA1c >10%, initiate intensive insulin therapy with either a basal insulin
analog, NPH insulin, prandial insulin, or premixed insulin preparations. Certain combinations of
oral agents may be effective in selected patients
type 2 diabetes criteria for hospitalization
- When there is an in-office blood glucose level of over 400 mg/dL.
- If patient is in DKA
immediate pharmacological intervention for type 2 diabetes
• In patients with triglyceride levels >1,000 mg/dL (11 mmol/L):
• Initiate therapy immediately to decrease triglyceride levels to <400 mg/dL (4.5 mmol/L) because
of the risk of pancreatitis and other manifestations of hyperchylomicronemia syndrome
• Patients with hypoglycemia who are receiving insulin or sulfonylurea therapy:
o Administer rapidly absorbed carbohydrate (e.g., glucose tablets, glucose drink, orange
juice, or cola) if the patient is alert and able to swallow without the risk of aspiration
o Administer glucagon, 1 mg subcutaneously, if the patient is obtunded or unresponsive.
This requires administration by a friend, relative, or emergency personnel. It is
important to note that glucagon will only increase blood glucose for approximately 45
minutes, so additional treatment is needed
o Consider administering 50% dextrose, 25 to 50 mL intravenously, for severe
hypoglycemia when the patient is under medical care and venous access can be
obtained
o Recognize that urgent admission to the hospital may be required
when is the Escharotic treatment considered?
Level 5 treatment
• Used in cases of CIN 2, 3 with an adequate colposcopy & (=) ECC (you will get to practice this in gyn
lab and clinic with supervision) & in some cases of persistent CIN 1 (> 2 yrs)
• May cause less scarring of the cx compared with other therapies, however clinical research is
needed. Research to provide evidence regarding recurrence, issues with fertility and obstetric
complications is needed. When recommending this therapy for patients it is important to inform
them of the lack of evidence and have them sign a consent to treat just like any other minor
surgery procedure.
• Treatment is C/I in pregnancy, if pt has cervicitis or other gynecological infection treat before
beginning escharotic treatment.
• Side Effects: cramping, spotting, d/c, and pain during the procedure and afterwards
definition of Escharotic protocol
Definition - agent used to destroy tissue and to cause sloughing which produces what is known as
eschar (a slough, esp. following a cauterization or burn). The agents are caustics.
step 1 of eschorotic tx
Bromelain32
• Powder that is applied to the cervix, the enzyme begins to break down the cell wall.
• It is left on the cervix for 15 minutes with light source to add in increasing the temperature
to activate the enzymatic action.
• In both in vitro and in vivo studies it has been shown that it can effectively debride fullthickness burns in pig skin in less than 24 hrs due to its enzymatic digestion.32
• It also edema and has anti-tumor effects.32,79
step 2 of escorotic tx
Calendula officinalis (marigold) Succus • Remove bromelain powder using a cotton swab saturated with succus.
step 3 of escorotic protocol
ZnCl – ¼ tsp/Sanguinaria – ¾ tsp mixture
• Sanguinaria candensis (bloodroot) has anti-tumor (by inducing apoptosis), antimicrobial,
antioxidant, irritant, has strong escharotic effects.82
• This preparation is the main escharotic in the treatment.
• It is applied to the cervix and left on for only 1 minute
• It is then removed with calendula succus.
step 4 or escorotic protocol
Vag Pack Suppositories
Contents:
Thuja, Berberine, Echinacea, vitamin A & E, Lomatium- Antimicrobial, specifically against HPV, healing
support for the mucosal membrane
• Insert 2 suppositories at end of each treatment
treatment schedule
Visits last about 30 minutes and should be done 2x/wk with at least 2 days between
treatments for a total of 10 treatments.
Suppositories following Escharotic tx or for CIN 1 without Escharotic tx (C/I in pregnancy)
ories following Escharotic tx or for CIN 1 without Escharotic tx (C/I in pregnancy)
• Vitamin A - insert PV qhs x 6 nights wks 1 & 3
• Herbal (Thuja, Lomatium, Vit A) – insert PV qhs x 6 nights wks 2 & 4
• Green Tea capsules - insert PV qhs 2x/wk - wks 5-12 weeks.
• Vitamin D suppositories – 12,500 IU 3nights/week for 6 weeks – consider this for CIN 1 only
– study showed women with CIN 1 using this suppository - found good antidysplastic effects
– of the 20 follow-up pts 15 had improved pap at 2 yrs, 3 had CIN1, 1 had a CIN 2-3, and 1 had CIN 3.
Patients Requiring Immediate Referral (to an HIV specialist):
Pediatric patients
• Pregnant patients
• Patients with CD4 T-cells counts <350 cells/uL
• Patients with opportunistic infections
• Patients with concomitant Hepatitis B or Hepatitis C infections
• Patients with other HIV co-morbidities, including HIV-nephropathy, cardiovascular disease,
neurological disease, etc.
Baseline Evaluation: for HIV patients
Each HIV-infected patient entering care should have:
• Complete medical history, including:
o Substance abuse history
o Presence of social, psychiatric and other medical issues
o Social support
o Medical insurance status
o Exploration of factors that might inhibit proper treatment
• Physical examination
• Laboratory evaluation, including:
o HIV antibody testing (if prior documentation is not available or if HIV RNA is below the
assay’s limit of detection)
o CD4 T-cell count (with follow-up testing every 3-4 months)
o Plasma HIV RNA (viral load)
o CBC; CMP + lipids: including transaminase levels, BUN, creatinine, fasting glucose;
urinalysis
o Serology for Hepatitis A, B, C viruses
o Genotypic resistance testing at entry into care, regardless of whether ART will be
initiated immediately. For patients who have HIV RNA levels <500-1000 copies/mL,
amplification of virus for resistance testing may not always be successful.
o Testing for other STI’s if indicated by history
therapy initiation recommendations for HIV patients
In January 2011, the Department of Health and Human Services (DHHS) Panel on Antiretroviral
Guidelines for Adults and Adolescents issued updated guidelines on initiation of antiretroviral therapy,
as follows:
• Antiretroviral therapy should be initiated in all patients with a history of an AIDS-defining illness
or with a CD4 count below 350 cells/µL
• Antiretroviral therapy should be initiated regardless of CD4 count in pregnant patients, patients
with HIV-associated nephropathy, and those with hepatitis B virus co-infections when treatment
of hepatitis B virus infection is indicated
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• The panel was divided on the initiation of antiretroviral therapy in patients with CD4 counts
between 350 and 500 cells/µL: 55% of panel members considered this a strong
recommendation, while 45% considered it a moderate recommendation
The panel was also divided on initiation of antiretroviral therapy in patients with CD4 counts above 500
cells/µL: half of the panel members favored initiation in this setting, while the other half considered
treatment initiation as optional
Antiretroviral therapy should be managed by an infectious disease specialist
Guidelines for evaluation: HTN
Guidelines for evaluation:
• Bilateral readings - first visit
• 3 separate readings at least 1 day apart
• If first day reading is Stage 2:
o return for repeat reading within one week.
evaluation requirements: HTN
CBC, • CMP, • Lipids – consider CRP, • Urinalysis, • Fundoscopic exam, • Electrocardiogram (ECG), if stage 2
treatment L: HTN
• Over 60 years of age, and no chronic kidney disease (CKD) or diabetes (DM), goal is
<150/90
• Under 60 years of age or patients with CKD or DM, goal is <140/90
changes to JNC 8 guidelines ( HTN
First-line and later-line treatments should now be limited to 4 classes of medications:
thiazide-type diuretics, calcium channel blockers (CCBs), ACE inhibitors, and ARBs.
• Second- and third-line alternatives included higher doses or combinations of ACE
inhibitors, ARBs, thiazide-type diuretics, and CCBs. Several medications are now
designated as later-line alternatives, including the following: beta-blockers,
alphablockers, alpha1/beta-blockers (eg, carvedilo), vasodilating beta-blockers (eg,
nebivolol), central alpha2/-adrenergic agonists (eg, clonidine), direct vasodilators (eg,
hydralazine), loop diruretics (eg, furosemide), aldosterone antagoinsts (eg,
spironolactone), and peripherally acting adrenergic antagonists (eg, reserpine).
• When initiating therapy, patients of African descent without CKD should use CCBs and
thiazides instead of ACE inhibitors.
• Use of ACE inhibitors and ARBs is recommended in all patients with CKD regardless of
ethnic background, either as first-line therapy or in addition to first-line therapy.
• ACE inhibitors and ARBs should not be used in the same patient simultaneously.
• CCBs and thiazide-type diuretics should be used instead of ACE inhibitors and ARBs in
patients over the age of 75 years with impaired kidney function due to the risk of
hyperkalemia, increased creatinine, and further renal impairment.
