high-yield conditions Flashcards
DPP4i
sitagliptin, linagliptin
used in T2DM
inhibits dipeptidylpeptidase-4 which inactivates incretins (glucagon-like peptide-1 [GLP-1] and glucose-dependent insulinotropic peptide [GIP]) which are released by intestines all day in response to food and prmote insulin secretion and suppress release of glucagon.
GI upset, headache, nasopharyngitis or peripheral oedema. Hypoglycaemia (less than in SUs) esp with other meds.
a small risk of acute pancreatitis, affecting 0.1–1% people taking the drugs. This should be suspected in patients experiencing persistent abdominal pain and usually resolves on stopping the drug.
CI: ✗type 1 diabetes or ✗ketoacidosis ✗pregnancy or ✗breastfeeding
do not reduce risk of vascular complications
β-blockers may mask symptoms of hypoglycaemia.
metformin
t2DM
biguanide. reduces hepatic glucose output by reducing glycogenolysis and gluconeogenesis and, to a lesser extent, increases glucose uptake and utilisation by skeletal muscle. can cause modest weight loss
GI upset, including nausea, vomiting, taste disturbance, anorexia and diarrhoea.
Lactic acidosis mainly in ppl with an intercurrent illness that causes metformin accumulation (e.g. renal impairment), increased lactate production (e.g. sepsis, hypoxia) or reduced lactate metabolism (e.g. liver failure).
dosage reduction required if the estimated glomerular filtration rate (eGFR) is <45 mL/min per 1.73 m2 and the drug stopped if eGFR falls below 30 mL/min per 1.73 m2.
CI: ✗acute kidney injury or ✗severe tissue hypoxia, e.g. in sepsis, cardiac or respiratory failure, or myocardial infarction.
withheld during ▴acute alcohol intoxication
Metformin must be withheld before and for 48 hours after injection of ▴IV contrast media
swallow tablets whole with a glass of water with or after food to minimise GI side effects.
SU
gliclazide
t2DM
Sulphonylureas lower blood glucose by stimulating pancreatic insulin secretion
associated with weight gain.
Dose-related side effects such as GI upset (nausea, vomiting, diarrhoea, constipation) are usually mild and infrequent.
Hypoglycaemia
Rare hypersensitivity reactions include hepatic toxicity (e.g. cholestatic jaundice), drug hypersensitivity syndrome (rash, fever, internal organ involvement) and haematological abnormalities (e.g. agranulocytosis).
Sulphonylureas should be taken with meals
β-blockers may mask symptoms of hypoglycaemia
insulin
t1dm
t2dm where oral therapy inadequate
diff choices -
rapid acting (immediate onset, short duration) – e.g. NovoRapid® (insulin aspart); short acting (early onset - 2-3 hrs delay in peak efffect, short duration) – e.g. Actrapid® (soluble insulin); intermediate acting (intermediate onset and duration) – e.g. Humulin I® (isophane or NPH insulin); and long acting (flat profile with regular administration) – e.g. Lantus® (insulin glargine), Levemir® (insulin detemir). Biphasic insulin preparations contain a mixture of rapid- and intermediate-acting insulins, e.g. NovoMix® 30 (30% insulin aspart, 70% insulin aspart protamine). Where IV insulin is required (hyperkalaemia, diabetic emergencies, peri-operative glucose control), soluble insulin (Actrapid®) is used.
hypoglycaemia - coma and death
When administered by repeated SC injection at the same site, insulin can cause fat overgrowth (lipohypertrophy)
Insulin regimens need to provide ‘peaks’ of insulin to deal with the glucose absorbed at mealtimes, and lower ‘basal’ levels in between. Examples include ‘basal–bolus’ regimens, e.g. Lantus® (glargine; long acting) taken once daily and NovoRapid® (insulin aspart; rapid acting) with meals and snacks; and twice-daily regimens, e.g. NovoMix® 30 (biphasic insulin). SC insulin is best prescribed by brand name.
rapid-acting: give immediately before meals.
biphasic insulin - administer immediately before a meal
Try to avoid giving ‘correction’ doses of insulin to treat hyperglycaemia in inpatients. It is generally better to tolerate transient, mild hyperglycaemia and instead adjust the patient’s scheduled insulin doses to avoid recurrence the next day. Correction doses add instability and can make titration of scheduled insulin more difficult.
t1dm -
1st line: multiple daily SC injection basal-bolus insulin regimens as the first line choice.Twice-daily or once daily insulin detemir should be offered as the long-acting basal insulin therapy, unless the patient is already meeting their agreed treatment goals on another insulin regimen. A rapid-acting insulin analogue is recommended as the mealtime insulin replacement eg insulin aspart (Novorapid)
cross-sensitivity within the beta lactams class of abx -
For carbapenems - CI in history of immediate hypersensitivity reaction to beta-lactam antibacterials.
Use with caution in patients with sensitivity to beta-lactam antibacterials.
for cephalosporins - Cross-reactivity between penicillins and first and early second-generation cephalosporins has been reported to occur in up to 10%, and for third-generation cephalosporins in 2–3%, of penicillin-allergic patients. Patients with a history of immediate hypersensitivity to penicillin and other beta-lactams should not receive a cephalosporin. Cephalosporins should be used with caution in patients with sensitivity to penicillin and other beta-lactams.
broad spec abx (carbapenems and cephalosprins) and wararin interaction
Cephalosporins and carbapenems can enhance the anticoagulant effect of warfarin by killing normal gut flora that synthesise vitamin K.
symptoms of angina and stable vs unstable
typically constricting chest pain with or without radiation to jaw or arms. Angina is “stable” when symptoms are always relieved by rest or glyceryl trinitrate (GTN). It is “unstable” when the symptoms come on randomly whilst at rest, and this is considered as an Acute Coronary Syndrome.
diagnostic ix for stable angina? and other ix pts shd have when presenting with angina
CT coronary angiogram
Physical Examination (heart sounds, signs of heart failure, BMI) ECG FBC (check for anaemia) U&Es (prior to ACEi and other meds) LFTs (prior to statins) Lipid profile Thyroid function tests (check for hypo / hyper thyroid) HbA1C and fasting glucose (for diabetes)
Mx of stable angina
4 principles - RAMP
Refer to cardiology (urgently if unstable)
Advice regarding diagnosis, management and when to call an ambulance
Medical management
Procedural management
medical management:
immediate symptom control - sublingual GTN spray - as required during angina episodes. use once and wait 5 mins. if pain still there use again and wait 5 mins. if pain still there then call ambulance.
long term symptom control - either beta blocker or CCB (eg amlodipine)
Other options (not first line):
Long acting nitrates (e.g. isosorbide mononitrate) Ivabradine Nicorandil Ranolazine
2ndary prevention of CVD - aspirin 75mg, atorvastatin 80mg. ACEi, beta blocker (already on for LT symptom relief)
procedural interventions:
- PPCI - primary percutaneous intervention with coronary angioplasty IF proximal or extensive disease
- CABG - in pts with severe stenosis not suitable for PPCI.
look out for midline sternotomy scar, great saphenous vein harvesting scar and brachial artery and femoral artery access scars.
ACS pathophys
ACS is usually the result of a thrombus from atheroscelrotic plaque which ends up partially or completely blocking a coronary artery. it is aminly made of platelets hence antiplatets
RCA supplies
right atrium
right ventricle
posterior interventricular area
inferior aspect of left ventricle
circumflex supplies
left atrium
posterior aspect of left ventricle
LAD supplies
anterioir aspect of left ventricle
anterior interventricular septum/area
how to diagnose ACS?
ACS symptoms do ECG
- ST elevation or new LBBB - STEMI
- ST depression or T wave inversion or no ECG changes BUT raised troponins - NSTEMI
- troponin lvls normal - unstable angina or other diagnosis
symptoms of ACS`
symptoms shd typically last longer than 20 mins and NOT be relieved by rest -
central constricting chest pain along with possibly -
nausea and vomiting
sweating and being clammy
feeling of impending doom
SOB
palpitations
pain radiating/in neck,jaw/shoulders/arms
Diabetic patients may not experience typical chest pain during an acute coronary syndrome. This is often referred to as a “silent MI”.
areas affected by infarction and corresponding ECG leads and artery
i,aVL,v5 and v6 - lateral MI - circumflex
v1-v4 - anterior MI - LAD
i, avl, v1-v6 - anterolateral MI - left coronary artery
ii,iii,avf - inferior MI - right coronary artery
troponins and diagnosing MI
Diagnosis of MI typically requires serial troponins (e.g. at baseline and 6 or 12 hours after onset of symptoms). howevere they are not specific and there are other causes - PE myocarditis aortic dissection sepsis chronic renal failure
