Metabolic disorders Flashcards
What skin condition is associated with insulin resistance?
Acanthosis nigricans
A calorie deficit of 500-1,000 cal/day produces what weekly weight loss?
Decreasing calories by 500-1,000 a day typically leads to 1-2lbs loss a week
What non-pharmacological interventions are best for weight loss and weight management?
- Weight loss: diet
- Weight management: exercise
Which medication for obesity is NOT an anorexiant?
Orlistat => inhibits the absorption of dietary fat
What is the mechanism of action of anorexiant medications?
Increase satiation, satiety, or both by increasing norepinephrine release or inhibiting reuptake
At what BMI would a patient be a candidate for bariatric surgery?
- BMI >40 or >35 with comorbid condition
What are the criteria for metabolic syndrome?
- Abdominal obesity [ waist circumference in men >40inch and 35inch in women]
- Serum triglycerides greater than or equal to 150mg/dL
- Serum HDL less than 40mg/dL in men and 50 in women
- Blood pressure >130/85
- Fasting plasma glucose >110mg/dL
What further testing should be done in patients with high cholesterol?
- blood glucose
- creatinine
- liver function tests
- TSH
After how long might a patient with hyperlipidemia expect to see decreases in cholesterol if they exercise?
- 6 weeks to recheck lipid panel
How often and at what age should a lipid panel be tested?
- Every 5 years starting at age 20
What factors determine the LDL goal of an individual?
- Cigarette smoking
- hypertension
- low HDL
- Age >45 for men; >55 for women
- Family history of premature coronary heart disease
What is the LDL goal for someone with CHD or a CHD risk equivalent (greater than 20%)?
- 100mg/dL or less
What is the LDL goal for someone with 0-1 identified risks?
- 160 mg/dL or less
What is the LDL goal for someone with 2 or more risk factors and an individual risk of 10-20%?
- 130 mg/DL or less
What are secondary causes of hyperlipidemia?
- diabetes
- hypothyroidism
- obstructive liver disease
- chronic renal failure
What medications can cause an increase in cholesterol?
- progestins
- anabolic steroids
- corticosteroids
At what point should drug intervention be considered in the management of hyperlipidemia?
- After 3 visits where therapeutic lifestyle changes have been initiated/discussed
What are the percent cholesterol reduction of statins?
- LDL decrease by 18-55%
- HDL increase of 5-15%
- Triglyceride decrease by 7-30%
What are the major side effects of statins?
- myopathy
- myalgia
- increased liver enzymes
What are contraindications to statins?
- liver disease
- cytochrome p450 inhibitors
- cyclosporine
- macrolindes
- antifungals
What are the bile acid sequestrants and which lipoprotein do they mostly effect?
- Cholestyramine, colestipol, colesevelam
- Most decrease LDL
What are the major side effects of bile acid sequestrants?
- GI distress
- constipation
- decreased absorption of other meds
What is a contraindication to bile acid sequestrant use?
- Triglycerides >400
What lipoproteins are the nicotinic acids/niacin primarily known to change?
- LDL 5-25%
- HDL increase by 15-35%
- TG decrease 20-50%
What are the main side effects of niacin/nicotinic acids?
- flushing
- hyperglycemia (don’t give in diabetics)
- hyperuricemia
- GI distress
- hepatotoxicity
What are the contraindications to nicotinic acids/niacin?
- chronic liver disease
- gout
- diabetes
- hyperuricemia
- peptic ulcer disease
What are the fibric acids/fibrates and what component of cholesterol do they have the greatest effect on?
- Femfibrozil, fenofibrate, clofibrate
- decrease TG by 20-50%
What side effects are associated with fibric acids/fibrates?
- dyspepsia
- gallstones
- myopathy
- unexplained non CHD deaths
What are the contraindications to fibrates?
- Severe renal disease
- severe hepatic disease
What lipoprotein does Ezetimibe have the greatest effect on?
- Exetimibe ( cholesterol absorption blocker) reduces LDL by 13-25%
What are the major side effects of Ezetimibe?
- abdominal pain
- diarrhea
What are the contraindications to ezetimibe?
- hepatic insufficiency or disease
How often should liver enzymes be monitored in patients on statins?
- 6-12 weeks after initiation or dosage change
- 6-12 months thereafter
What diagnostic studies and follow up studies should be done for newly diagnosed diabetic patients?
- Blood glucose measurement
- Electrolytes
- BUN
- Creatinine
- Fasting lipids
- Urine microalbumin:creatinine ratio
- HgA1C
Apart from increased thirst/urination what is another presenting sign of diabetes?
- Difficult to treat or recurrent fungal infections
- Other immune deficient states should also be considered
How is diabetic ketoacidosis different from nonketotic hyperosmolar syndrome?
- Diabetic ketoacidosis: Seen in type 1 diabetics; syndrome characterized by hyperglycemia, high levels of serum acetone and an anion gap metabolic acidosis. Due to a propensity to metabolize fats into ketones
- Nonketotic hyperosmolar syndrome: blood sugar levels become highly elevated and the patient has a large fluid deficit. In severe cases coma or death can occur
What demographic of women should be screened for gestational diabetes?
ALL WOMEN
What are the diagnostic criteria for diabetes?
1) Random glucose >200 along with polydipsia, polyuria, polyphagia, frequent infections, weight loss
2) Fasting glucose more than 125 on more than 2 occasions
3) 2 Hour plasma glucose 200 or more after a 75g glucose load
What is the mechanism of action of metformin?
- Metformin is the first line treatment for DM2: decreases glucose output during gluconeogenesis and improves insulin sensitivity in the liver and muscle with no hypoglycemia
What is the most dangerous side effect of metformin?
- Lactic acidosis especially with renal insufficiency (contraindicated in patients with creatinine >1.5, hepatic insufficiency, or congestive heart failure)
- Other side effects include nausea and diarrhea
What is the mechanism of action of the sulfonylureas?
- Stimulate beta cells in the pancreas to secrete insulin
- some risk of hypoglycemia
What are the best validated second line drugs in the treatment of DM2?
- Sulfonylureas (Glibenclamide, Glimepiride, Glipizide, Tolbutamide)
- Insulin
What is the mechanism of action of thiazolidinediones?
- Glitazones improve insulin sensitivity in muscle and adipose tissue, they also decrease hepatic gluconeogenesis and increase peripheral glucose utilization
- Glitazones also decrease triglycerides and increase HDL
- Metabolized in the liver and can be used by patients with renal impairment
What are common causes of hypoglycemia?
- fasting, exogenous insulin, autoimmunity, sulfonylurea abuse, hormonal deficiency (hypoadrenalism, hypopituitary, glucagon deficiency)
What is the most effective way to treat hypoglycemia in an UNCONSCIOUS patient outside the hospital setting?
- Glucagon
How is hypoglycemia treated in an inpatient setting?
- IV dextrose
