Treatment Flashcards
What is the management for MI?
Initial drug therapy
aspirin 300mg
oxygen should only be given if the patient has oxygen saturations < 94% in keeping with British Thoracic Society oxygen therapy guidelines
morphine should only be given for patients with severe pain
nitrates- can be given either sublingually or intravenously useful if the patient has ongoing chest pain or hypertension should be used in caution if patient hypotensive
Primary percutaneous coronary intervention (PCI) has emerged as the gold-standard treatment for STEMI Thrombolysis should be performed in patients without access to primary PCI
aspirin
P2Y12-receptor antagonist. Clopidogrel was the first P2Y12-receptor antagonist to be widely used but now ticagrelor is often favoured as studies have shown improved outcomes compared to clopidogrel, but at the expense of slightly higher rates of bleeding. This approached is supported in SIGN’s 2016 guidelines. They also recommend that prasugrel (another P2Y12-receptor antagonist) could be considered if the patient is going to have a percutaneous coronary intervention
unfractionated heparin is usually given for patients who’re are going to have a PCI. Alternatives include low-molecular weight heparin
Secondary prevention - 6As
Aspirin 75g
Another anti-platelet- clopdigrel
Atorvastatin 80mg
Atenol/bisoprolol
Adosterone antagonist - (epelorone)
What is the management for AF?
There are two key parts of managing patients with AF:
1. Rate/rhythm control
2. Reducing stroke risk
Rate vs. rhythm control
There are two main strategies employed in dealing with the arrhythmia element of atrial fibrillation:
rate control: accept that the pulse will be irregular, but slow the rate down to avoid negative effects on cardiac function
rhythm control: try to get the patient back into, and maintain, normal sinus rhythm. This is termed cardioversion. Drugs (pharmacological cardioversion) and synchronised DC electrical shocks (electrical cardioversion) may be used for this purpose
Rate control
A beta-blocker or a rate-limiting calcium channel blocker (e.g. diltiazem) is used first-line to control the rate in AF.
If one drug does not control the rate adequately NICE recommend combination therapy with any 2 of the following:
a betablocker
diltiazem
digoxin
Rhythm control
As mentioned above there are a subgroup of patients for whom a rhythm control strategy should be tried first. Other patients may have had a rate control strategy initially but switch to rhythm control if symptoms/heart rate fails to settle.
When considering cardioversion it is very important to remember that the moment a patient switches from AF to sinus rhythm presents the highest risk for embolism leading to stroke. Imagine the thrombus formed in the fibrillating atrium suddenly being pushed out when sinus rhythm is restored. For this reason patients must either have had a short duration of symptoms (less than 48 hours) or be anticoagulated for a period of time prior to attempting cardioversion.
Reducing stroke risk
Some patients with AF are at a very low risk of stroke whilst others are at a very significant risk. Clinicians use risk stratifying tools such as the CHA2DS2-VASc score to determine the most appropriate anticoagulation strategy.
Score Anticoagulation
0 No treatment
1 Males: Consider anticoagulation
Females: No treatment (this is because their score of 1 is only reached due to their gender)
2 or more Offer anticoagulation
Betablocker c
calcium channel blockers
2nd line Digoxin
Haem unstable
DC cardioversion
Haem stable
First line- Rate control except if
AF has reversible cause
If they have heart failure caused by AF
New onset AF <48hrs
What to do if DC cardioversion
If symptons under 48 - immediately- after 3 weeks of anti coag rate control them
Pharmacoligic
First line - beta blockers
Dronedarone 2nd line if successful cardioversion
Amiafdarone if heart failure LV dysfunction
If over DC cardioversion
If 0 do ECHO exclude valvular disease
What is the management for DVT?
apixaban or rivaroxaban (both DOACs) should be offered first-line following the diagnosis of a DVT
if renal impairment is severe (e.g. < 15/min) then LMWH, unfractionated heparin or LMWH followed by a VKA
if the VTE was provoked the treatment is typically stopped after the initial 3 months (3 to 6 months for people with active cancer)
if the VTE was unprovoked then treatment is typically continued for up to 3 further months (i.e. 6 months in total)
What is the management for infective endocarditis?
Initial blind therapy-
Native valve
amoxicillin, consider adding low-dose gentamicin
If penicillin allergic, MRSA or severe sepsis
vancomycin + low-dose gentamicin
If prosthetic valve
vancomycin + rifampicin + low-dose gentamicin
Indications for surgery
severe valvular incompetence
aortic abscess (often indicated by a lengthening PR interval)
infections resistant to antibiotics/fungal infections
cardiac failure refractory to standard medical treatment
recurrent emboli after antibiotic therapy
What is the management for myocarditis?
Management
treatment of underlying cause e.g. antibiotics if bacterial cause
supportive treatment e.g. of heart failure or arrhythmias
What is the management for acute pericarditis?
a combination of NSAIDs and colchicine is now generally used for first-line for patients with acute idiopathic or viral pericarditis
Treat underlying cause if bacterial antibiotics
strenuous physical activity should be avoided until symptom resolution and normalisation of inflammatory markers
patients who have high-risk features such as fever > 38°C or elevated troponin should be managed as an inpatient
What is the management for PE?
apixaban or rivaroxaban (both DOACs) should be offered first-line following the diagnosis of a DVT
if renal impairment is severe (e.g. < 15/min) then LMWH, unfractionated heparin or LMWH followed by a VKA
if the VTE was provoked the treatment is typically stopped after the initial 3 months (3 to 6 months for people with active cancer)
if the VTE was unprovoked then treatment is typically continued for up to 3 further months
Thrombolysis
thrombolysis is now recommended as the first-line treatment for massive PE where there is circulatory failure (e.g. hypotension)
other invasive approaches should be considered where appropriate facilities exist
What is the management for biliary colic
elective laparoscopic cholecystectomy
What is the management for acute cholecystitis?
intravenous antibiotics
cholecystectomy
NICE now recommend early laparoscopic cholecystectomy, within 1 week of diagnosis
pregnant women should also proceed to early laparoscopic cholecystectomy - this reduces the chances of maternal-fetal complications
What is the management for Ascending cholangitis?
intravenous antibiotics
endoscopic retrograde cholangiopancreatography (ERCP) after 24-48 hours to relieve any obstruction
What is the management for acute pancreatitis?
Key aspects of care
fluid resuscitation
aggressive early hydration with crystalloids. In severe cases 3-6 litres of third space fluid loss may
occur
aim for a urine output of > 0.5mls/kg/hr
may also help relieve pain by reducing lactic acidosis
analgesia
pain may be severe so this is a key priority of care
intravenous opioids are normally required to adequately control the pain
nutrition
patients should not routinely be made ‘nil-by-mouth’ unless there is a clear reason e.g. the patient is vomiting
enteral nutrition should be offered to anyone with moderately severe or severe acute pancreatitis within 72 hours of presentation
parental nutrition should only be used if enteral nurition has failed or is contraindicated
role of antibiotics
NICE state the following: ‘Do not offer prophylactic antimicrobials to people with acute pancreatitis’
potential indications include infected pancreatic necrosis
Role of surgery
Patients with acute pancreatitis due to gallstones should undergo early cholecystectomy
Patients with obstructed biliary system due to stones should undergo early ERCP
Patients who fail to settle with necrosis and have worsening organ dysfunction may require debridement, fine needle aspiration is still used by some
Patients with infected necrosis should undergo either radiological drainage or surgical necrosectomy. The choice of procedure depends upon local expertise
What is the management for hepatitis B?
pegylated interferon-alpha used to be the only treatment available. It reduces viral replication in up to 30% of chronic carriers. whilst NICE still advocate the use of pegylated interferon firstl-line other antiviral medications are increasingly used with an aim to suppress viral replication tenofovir, entecavir and telbivudine
What is the management for anal fissure?
Management of an acute anal fissure (< 1 week)
soften stool
dietary advice: high-fibre diet with high fluid intake
bulk-forming laxatives are first-line - if not tolerated then lactulose should be tried
lubricants such as petroleum jelly may be tried before defecation
topical anaesthetics
analgesia
Management of a chronic anal fissure
the above techniques should be continued
topical glyceryl trinitrate (GTN) is first-line treatment for a chronic anal fissure
if topical GTN is not effective after 8 weeks then secondary care referral should be considered for surgery (sphincterotomy) or botulinum toxin
What is the management for acute appendicitis?
appendicectomy
can be performed via either an open or laparoscopic approach
laparoscopic appendicectomy is now the treatment of choice
administration of prophylactic intravenous antibiotics reduces wound infection rates
patients with perforated appendicitis (typical around 15-20%) require copious abdominal lavage.
What is the management for ascites?
reducing dietary sodium
fluid restriction is sometimes recommended if the sodium is < 125 mmol/L
aldosterone antagonists: e.g. spironolactone
loop diuretics are often added. Some authorities only add loop diuretics in patients who don’t respond to aldosterone agonists whereas other authorities suggest starting both types of diuretic on the first presentation of ascites
drainage if tense ascites (therapeutic abdominal paracentesis)
large-volume paracentesis for the treatment of ascites requires albumin ‘cover’. Evidence suggests this reduces paracentesis-induced circulatory dysfunction and mortality
paracentesis induced circulatory dysfunction can occur due to large volume paracentesis (> 5 litres). It is associated with a high rate of ascites recurrence, development of hepatorenal syndrome, dilutional hyponatraemia, and high mortality rate
prophylactic antibiotics to reduce the risk of spontaneous bacterial peritonitis. NICE recommend: ‘Offer prophylactic oral ciprofloxacin or norfloxacin for people with cirrhosis and ascites with an ascitic protein of 15 g/litre or less, until the ascites has resolved’
a transjugular intrahepatic portosystemic shunt (TIPS) may be considered in some patients
What is the management for coeliac disease?
gluten-free diet
Immunisation
Patients with coeliac disease often have a degree of functional hyposplenism
For this reason, all patients with coeliac disease are offered the pneumococcal vaccine
Coeliac UK recommends that everyone with coeliac disease is vaccinated against pneumococcal infection and has a booster every 5 years
Currrent guidelines suggest giving the influenza vaccine on an individual basis.
What is the management for colorectal cancer?
Surgery details on Passmed colorectal cancer treatment
What is the management for diverticular disease?
Increase dietary fibre intake unless diverticulitis
What is the management for diverticulitis?
mild cases of acute diverticulitis may be managed with oral antibiotics, liquid diet and analgesia CKS
if the symptoms don’t settle within 72 hours, or the patient initially presents with more severe symptoms, the patient should be admitted to hospital for IV antibiotics ceftriaxone+ metronidazole
Patients are made nil by mouth,
What is the management for gastric cancer?
surgical options depend on the extent and side but include:
endoscopic mucosal resection
partial gastrectomy
total gastrectomy
chemotherapy
What is the management for Gastro-oesophageal reflux disease?
Endoscopically proven oesophagitis
full dose proton pump inhibitor (PPI) for 1-2 months
if response then low dose treatment as required
if no response then double-dose PPI for 1 month
Endoscopically negative reflux disease
full dose PPI for 1 month
if response then offer low dose treatment, possibly on an as-required basis, with a limited number of repeat prescriptions
if no response then H2RA or prokinetic for one month
What is the management for Haemochromatosis?
venesection is the first-line treatment
monitoring adequacy of venesection: transferrin saturation should be kept below 50% and the serum ferritin concentration below 50 ug/l
desferrioxamine may be used second-line
What is the management for Haemorrhoids
soften stools: increase dietary fibre and fluid intake
topical local anaesthetics and steroids may be used to help symptoms
outpatient treatments: rubber band ligation is superior to injection sclerotherapy
surgery is reserved for large symptomatic haemorrhoids which do not respond to outpatient treatments
newer treatments: Doppler guided haemorrhoidal artery ligation, stapled haemorrhoidopexy
Acutely thrombosed external haemorrhoids
typically present with significant pain
examination reveals a purplish, oedematous, tender subcutaneous perianal mass
if patient presents within 72 hours then referral should be considered for excision. Otherwise patients can usually be managed with stool softeners, ice packs and analgesia. Symptoms usually settle within 10 days
What is the management for hiatus hernias?
all patients benefit from conservative management e.g. weight loss
medical management: proton pump inhibitor therapy
surgical management: only really has a role in symptomatic paraesophageal hernias
What is the management for inguinal hernias?
Management
the clinical consensus is currently to treat medically fit patients even if they are asymptomatic
a hernia truss may be an option for patients not fit for surgery but probably has little role in other patients
mesh repair is associated with the lowest recurrence rate
unilateral inguinal hernias are generally repaired with an open approach
bilateral and recurrent inguinal hernias are generally repaired laparoscopically
The Department for Work and Pensions recommend that following an open repair patients return to non-manual work after 2-3 weeks and following laparoscopic repair after 1-2 weeks
What is the management for femoral hernias?
Surgical repair is a necessity, given the risk of strangulation, and can be carried out either laparoscopically or via a laparotomy
Hernia support belts/trusses should not be used for femoral hernias, again due to the risk of strangulation;
In an emergency situation, a laparotomy may be the only option
What is the management for ulcerative colitis?
Inducing remission
Treating mild-to-moderate ulcerative colitis
proctitis
topical (rectal) aminosalicylate: for distal colitis rectal mesalazine has been shown to be superior to rectal steroids and oral aminosalicylates
if remission is not achieved within 4 weeks, add an oral aminosalicylate
if remission still not achieved add topical or oral corticosteroid
proctosigmoiditis and left-sided ulcerative colitis
topical (rectal) aminosalicylate
if remission is not achieved within 4 weeks, add a high-dose oral aminosalicylate OR switch to a high-dose oral aminosalicylate and a topical corticosteroid
if remission still not achieved stop topical treatments and offer an oral aminosalicylate and an oral corticosteroid
extensive disease
topical (rectal) aminosalicylate and a high-dose oral aminosalicylate:
if remission is not achieved within 4 weeks, stop topical treatments and offer a high-dose oral aminosalicylate and an oral corticosteroid
Severe colitis
should be treated in hospital
intravenous steroids are usually given first-line
intravenous ciclosporin may be used if steroid are contraindicated
if after 72 hours there has been no improvement, consider adding intravenous ciclosporin to intravenous corticosteroids or consider surgery
Maintaining remission
Following a mild-to-moderate ulcerative colitis flare
proctitis and proctosigmoiditis
topical (rectal) aminosalicylate alone (daily or intermittent) or
an oral aminosalicylate plus a topical (rectal) aminosalicylate (daily or intermittent) or
an oral aminosalicylate by itself: this may not be effective as the other two options
left-sided and extensive ulcerative colitis
low maintenance dose of an oral aminosalicylate
Following a severe relapse or >=2 exacerbations in the past year
oral azathioprine or oral mercaptopurine
What is the management for Crohn’s disease?
General points
patients should be strongly advised to stop smoking
some studies suggest an increased risk of relapse secondary to NSAIDs and the combined oral contraceptive pill but the evidence is patchy
Inducing remission
glucocorticoids (oral, topical or intravenous) are generally used to induce remission. Budesonide is an alternative in a subgroup of patients
enteral feeding with an elemental diet may be used in addition to or instead of other measures to induce remission, particularly if there is concern regarding the side-effects of steroids (for example in young children)
5-ASA drugs (e.g. mesalazine) are used second-line to glucocorticoids but are not as effective
azathioprine or mercaptopurine* may be used as an add-on medication to induce remission but is not used as monotherapy. Methotrexate is an alternative to azathioprine
infliximab is useful in refractory disease and fistulating Crohn’s. Patients typically continue on azathioprine or methotrexate
metronidazole is often used for isolated peri-anal disease
Maintaining remission
as above, stopping smoking is a priority (remember: smoking makes Crohn’s worse, but may help ulcerative colitis)
azathioprine or mercaptopurine is used first-line to maintain remission
+TPMT activity should be assessed before starting
methotrexate is used second-line
Surgery
around 80% of patients with Crohn’s disease will eventually have surgery
stricturing terminal ileal disease → ileocaecal resection
segmental small bowel resections
stricturoplasty
perianal fistulae
an inflammatory tract or connection between the anal canal and the perianal skin
patients with symptomatic perianal fistulae are usually given oral metronidazole
anti-TNF agents such as infliximab may also be effective in closing and maintaining closure of perianal fistulas
a draining seton is used for complex fistulae
a seton is a piece of surgical thread that’s left in the fistula for several weeks to keep it open. This is useful because persisting fistula tracks after premature skin closure predispose to abscess formation
perianal abscess
requires incision and drainage combined with antibiotic therapy
a draining seton may also be placed if a tract is identified
What is the management for irritable bowel syndrome?
First-line pharmacological treatment - according to predominant symptom
pain: antispasmodic agents
constipation: laxatives but avoid lactulose
diarrhoea: loperamide is first-line
Second-line pharmacological treatment
low-dose tricyclic antidepressants (e.g. amitriptyline 5-10 mg) are used in preference to selective serotonin reuptake inhibitors
General dietary advice
have regular meals and take time to eat
avoid missing meals or leaving long gaps between eating
drink at least 8 cups of fluid per day, especially water or other non-caffeinated drinks such as herbal teas
restrict tea and coffee to 3 cups per day
reduce intake of alcohol and fizzy drinks
consider limiting intake of high-fibre food (for example, wholemeal or high-fibre flour and breads, cereals high in bran, and whole grains such as brown rice)
reduce intake of ‘resistant starch’ often found in processed foods
limit fresh fruit to 3 portions per day
for diarrhoea, avoid sorbitol
for wind and bloating consider increasing intake of oats (for example, oat-based breakfast cereal or porridge) and linseeds (up to one tablespoon per day).
What is the management for Oesophageal cancer ?
Treatment
Operable disease is best managed by surgical resection - the most common procedure is an Ivor-Lewis type oesophagectomy
The biggest surgical challenge is that of anastomotic leak, with an intrathoracic anastomosis resulting in mediastinitis
In addition to surgical resection many patients will be treated with adjuvant chemotherapy
What is the management for pancreatic cancer ?
Management
less than 20% are suitable for surgery at diagnosis
a Whipple’s resection (pancreaticoduodenectomy) is performed for resectable lesions in the head of pancreas. Side-effects of a Whipple’s include dumping syndrome and peptic ulcer disease
adjuvant chemotherapy is usually given following surgery
ERCP with stenting is often used for palliation
What is the management for peptic ulcer disease?
Uncomplicated-
if Helicobacter pylori is negative then proton pump inhibitors (PPIs) should be given until the ulcer is healed
if Helicobacter pylori is positive then eradication therapy should be given
Acute bleeding-
ABC approach as with any upper gastrointestinal haemorrhage
IV proton pump inhibitor
the first-line treatment is endoscopic intervention
if this fails (approximately 10% of patients) then either:
urgent interventional angiography with transarterial embolization or
surgery
What is the management for perianal abscess?
Treatment is usually surgical, with incision and drainage being first line, usually under local anaesthetic. The wound can then either be packed or left open, in which case it will heal in around 3-4 weeks;
Antibiotics can be of use, but are only usually employed if there is systemic upset secondary to the abscess, as they do not seem to help with healing of the wound after drainage.
What is the management for fistulae?
They will heal provided there is no underlying inflammatory bowel disease and no distal obstruction, so conservative measures may be the best option
Where there is skin involvement, protect the overlying skin, often using a well-fitted stoma bag- skin damage is difficult to treat
A high output fistula may be rendered more easily managed by the use of octreotide, this will tend to reduce the volume of pancreatic secretions.
Nutritional complications are common especially with high fistula (e.g. high jejunal or duodenal) these may necessitate the use of TPN to provide nutritional support together with the concomitant use of octreotide to reduce volume and protect skin.
When managing perianal fistulae surgeons should avoid probing the fistula where acute inflammation is present, this almost always worsens outcomes.
When perianal fistulae occur secondary to Crohn’s disease the best management option is often to drain acute sepsis and maintain that drainage through the judicious use of setons whilst medical management is implemented.
Always attempt to delineate the fistula anatomy, for abscesses and fistulae that have an intraabdominal source the use of barium and CT studies should show a track. For perianal fistulae, surgeons should recall Goodsall’s rule in relation to internal and external openings.
What is the management for peritonitis?
intravenous cefotaxime is usually given for Spontaneous bacterial peritonitis
What is the management for B12 deficiency?
if no neurological involvement 1 mg of IM hydroxocobalamin 3 times each week for 2 weeks, then once every 3 months
if a patient is also deficient in folic acid then it is important to treat the B12 deficiency first to avoid precipitating subacute combined degeneration of the cord
What is the management for sepsis?
Think Sepsis 6
oxygen, cultures, antibiotics, fluids, lactate measurement and urine output monitoring
What is the management for addison’s disease?
hydrocortisone: usually given in 2 or 3 divided doses. Patients typically require 20-30 mg per day, with the majority given in the first half of the day
fludrocortisone
Management of intercurrent illness
in simple terms the glucocorticoid dose should be doubled, with the fludrocortisone dose staying the same
What is management for Diabetes inspidus ?
nephrogenic diabetes insipidus
thiazides
low salt/protein diet
central diabetes insipidus can be treated with desmopressin
What is management for Diabetes mellitus type 1?
HbA1c
should be monitored every 3-6 months
adults should have a target of HbA1c level of 48 mmol/mol (6.5%) or lower. NICE do however recommend taking into account factors such as the person’s daily activities, aspirations, likelihood of complications, comorbidities, occupation and history of hypoglycaemia
Self-monitoring of blood glucose
recommend testing at least 4 times a day, including before each meal and before bed
more frequent monitoring is recommended if frequency of hypoglycaemic episodes increases; during periods of illness; before, during and after sport; when planning pregnancy, during pregnancy and while breastfeeding
Blood glucose targets
5-7 mmol/l on waking and
4-7 mmol/l before meals at other times of the day
Type of insulin
offer multiple daily injection basal–bolus insulin regimens, rather than twice‑daily mixed insulin regimens, as the insulin injection regimen of choice for all adults
twice‑daily insulin detemir is the regime of choice. Once-daily insulin glargine or insulin detemir is an alternative
offer rapid‑acting insulin analogues injected before meals, rather than rapid‑acting soluble human or animal insulins, for mealtime insulin replacement for adults with type 1 diabetes
Metformin
NICE recommend considering adding metformin if the BMI >= 25 kg/m²
What is management for Diabetes mellitus type 2?
Metformin remains the first-line drug of choice in type 2 diabetes mellitus.
metformin should be titrated up slowly to minimise the possibility of gastrointestinal upset
if standard-release metformin is not tolerated then modified-release metformin should be trialled
SGLT-2 inhibitors
should also be given in addition to metformin if any of the following apply:
the patient has a high risk of developing cardiovascular disease (CVD, e.g. QRISK ≥ 10%)
the patient has established CVD
the patient has chronic heart failure
metformin should be established and titrated up before introducing the SGLT-2 inhibitor
SGLT-2 inhibitors should also be started at any point if a patient develops CVD (e.g. is diagnosed with ischaemic heart disease), a QRISK ≥ 10% or chronic heart failure
If metformin is contraindicated
if the patient has a risk of CVD, established CVD or chronic heart failure:
SGLT-2 monotherapy
if the patient doesn’t have a risk of CVD, established CVD or chronic heart failure:
DPP‑4 inhibitor or pioglitazone or a sulfonylurea
SGLT-2 may be used if certain NICE criteria are met
Second-line therapy
Dual therapy - add one of the following:
metformin + DPP-4 inhibitor
metformin + pioglitazone
metformin + sulfonylurea
metformin + SGLT-2 inhibitor (if NICE criteria met)
Third-line therapy
If a patient does not achieve control on dual therapy then the following options are possible:
metformin + DPP-4 inhibitor + sulfonylurea
metformin + pioglitazone + sulfonylurea
metformin + (pioglitazone or sulfonylurea or DPP-4 inhibitor) + SGLT-2 if certain NICE criteria are met
insulin-based treatment
What is management for Diabetes ketoacidosis?
fluid replacement
most patients with DKA are deplete around 5-8 litres
isotonic saline is used initially, even if the patient is severely acidotic
please see an example fluid regime below.
insulin
an intravenous infusion should be started at 0.1 unit/kg/hour
once blood glucose is < 14 mmol/l an infusion of 10% dextrose should be started at 125 mls/hr in addition to the 0.9% sodium chloride regime
correction of electrolyte disturbance
serum potassium is often high on admission despite total body potassium being low
this often falls quickly following treatment with insulin resulting in hypokalaemia
potassium may therefore need to be added to the replacement fluids
if the rate of potassium infusion is greater than 20 mmol/hour then cardiac monitoring may be required
long-acting insulin should be continued, short-acting insulin should be stopped
What is management for Diabetic nephropathy?
Management
dietary protein restriction
tight glycaemic control
BP control: aim for < 130/80 mmHg
ACE inhibitor or angiotensin-II receptor antagonist
should be start if urinary ACR of 3 mg/mmol or more
dual therapy with ACE inhibitors and angiotensin-II receptor antagonist should not be started
control dyslipidaemia e.g. Statins
What is management for Diabetic neuropathy?
first-line treatment: amitriptyline, duloxetine, gabapentin or pregabalin
if the first-line drug treatment does not work try one of the other 3 drugs
tramadol may be used as ‘rescue therapy’ for exacerbations of neuropathic pain
topical capsaicin may be used for localised neuropathic pain (e.g. post-herpetic neuralgia)
pain management clinics may be useful in patients with resistant problems
What is management for hyperlipidaemia?
Primary prevention : Atorvastatin 20mg OD should be offered first-line
Secondary prevention: Atorvastatin 20mg 80mg OD
What is management for Hyperosmolar hyperglycaemic state ?
Management
fluid replacement
fluid losses in HHS are estimated to be between 100 - 220 ml/kg
IV 0.9% sodium chloride solution
typically given at 0.5 - 1 L/hour depending on clinical assessment
potassium levels should be monitored and added to fluids depending on the level
insulin
should not be given unless blood glucose stops falling while giving IV fluids
venous thromboembolism prophylaxis
patients are at risk of thrombosis due to hyperviscosity
What is management for primary hyperparathyroidism?
the definitive management is total parathyroidectomy
conservative management may be offered if the calcium level is less than 0.25 mmol/L above the upper limit of normal AND the patient is > 50 years AND there is no evidence of end-organ damage
patients not suitable for surgery may be treated with cinacalcet, a calcimimetic
a calcimimetic ‘mimics’ the action of calcium on tissues by allosteric activation of the calcium-sensing receptor
What is management for hypoglycaemia?
the following guidelines are based on the BNF hypoglycaemia treatment summary.
in the community (for example, diabetes mellitus patients who inject insulin):
Initially, oral glucose 10-20g should be given in liquid, gel or tablet form
Alternatively, a propriety quick-acting carbohydrate may be given: GlucoGel or Dextrogel.
A ‘HypoKit’ may be prescribed which contains a syringe and vial of glucagon for IM or SC injection at home
in a hospital setting:
If the patient is alert, a quick-acting carbohydrate may be given (as above)
If the patient is unconscious or unable to swallow, subcutaneous or intramuscular injection glucagon may be given.
Alternatively, intravenous 20% glucose solution may be given through a large vein
What is management for osteomalacia?
vitamin D supplmentation
a loading dose is often needed initially
calcium supplementation if dietary calcium is inadequate
