Dr neil jaddou m. D board certified and professor of family medicine



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Answers:

1. c

2. c

3. d

4. d

5. b

6. c

7. e

8. E

9. B

10. A

11.A


Somerset Family Medicine Clinical Module

Bread & Butter of Family Medicine:

DIABETES

Clinical Pearls:

Normal fasting blood glucose (FBS) 60-99 mg/dL



  • Diabetes defined by any one of four criteria below:

    • FBS of ≥ 126 mg/dL on two occasions

    • RBS of > 200 mg/dL with classic symptoms of DM (polyuria, polydipsia, polyphagia)

    • Hemoglobin A1c ≥ 6.5%

    • Oral glucose tolerance test (OGTT): 2 hours post-prandial of ≥ 200 mg/dL (NOT USED in Office practices except in pregnancy)

  • Pre-diabetes:

    • FBS 100-125 mg/dL

    • RBS of 140-199 mg/dL with classic symptoms of DM (polyuria, polydipsia, polyphagia)

    • Hemoglobin A1c 5.7 to 6.4%

    • Oral glucose tolerance test (OGTT): 2 hours post-prandial of 140 to 199 mg/dL (NOT USED in Office practices except in pregnancy)

  • GOAL of Hgb A1C in diabetic is < 7%

  • Foot exam every visit for neuropathy, arterial insufficiency, and ulcers. Use the 10 g foot microfilament to check for peripheral neuropathy at least once a year

  • UA for microalbumin yearly

  • Eye exam yearly for retinopathy

    • Proliferative retinopathy = neovascularization or vitreal hemorrhages

    • Diabetic retinopathy can be prevented with tight glycemic control

    • Treatment of diabetic proliferative retinopathy is with laser photocoagulation. Intraocular injections with vascular endothelial growth factor (VEGF) inhibitors prevent further progression of diabetic retinopathy. Examples of VEGF inhibitors are bevacizumab and ranibuzimab

    • Diabetic Nephropathy=characterized by glomerular hyper filtration followed by microalbuminuria. preventive measures include ACE or angiotensin receptor blockers (ARB) and BP/glucose control.

  • Initial management of Type 2 diabetes is with diet, weight loss and exercise

  • Treatment of HTN in diabetes in non-African Americans should include thiazide diuretics, ACE-Is (or ARBs), or CCBs. (JNC 8)

  • Treatment of HTN in diabetes in African Americans should include thiazide diuretics or CCBs. (JNC 8)

  • Pharmacological treatment for BP in diabetes should start at a BP of 140/90 mm Hg (JNC 8) in the general population (JNC 8)

  • Goal of LDL-cholesterol in diabetes is < 100 mg/dL. Use statins.

  • Goal of LDL-cholesterol in diabetes and CAD is < 70 mg/dL. Use statins.

  • First line pharmacological treatment of diabetes is with metformin unless contraindicated (see table).

    • Add sulfonylureas or basal insulin (with or without preprandial insulin) if blood glucose is not well controlled with metformin.

    • Other oral agents may be used as first line treatment if there are contraindications to the use of metformin


Prevention:

Diabetes can often be prevented by following.

  • Maintain Normal body weight.

  • Physical exercise, and following a healthy diet.

  • Diet rich in whole grains and fiber.

  • Choosing good fats, such as Polyunsaturated fats found in nuts, vegetable oils, and fish.

  • Limiting sugary beverages and eating less red meat.



CLASS

MOA

NAMES

Clinical Info

CAUTION



Biguanides

Decreases hepatic glucose production, decreases intestinal absorption,

Metformin

(Glucophage)

500-1000mg BID-TID (also comes in 850)

2550mg QD



First line agent

Avoid situations that increase risk of lactic acidosis: renal insufficiency, radio-contrast agents,

Caution with CHF,



Causes Megaloblastic Anaemia

Sulfonylureas

Stimulates insulin secretion from beta cells in pancreas

Glipizide (Glucotrol XL) 2.5-10mg QD (dosage >10m max 20mg

Glyburide (Diabeta, Glynase, Micronase) 2.5-5mg QD, max 20/d

Glimepiride(Amaryl)

Take 30 min before meals
Reduce drug clearance in renal failure

Causes Hypoglycemia, weight gain and SIADH

Thiazolidinediones

Decreases insulin resistance in the periphery and liver

Pioglitazone (Actos) 15-45mg QD

Monitor serum transaminase when starting

Contraindicated for liver disease and symptomatic heart failure
May cause or exacerbate CHF and MI, bladder cancer

Dipepidyl peptidase-4 inhibitor

Enhance incretin hormones

Januvia (Sitagliptin) 100mg QD

Saxagliptin

Possible increased risk of pancreatitis

Nausea, skin rashes, increased risk of infections

Glucagon-like peptide-1 receptor agonists - act as incretin which increase insulin

Mimics the enhancement of glucose dependent insulin secretion

Byetta (Exenatide), Victoza (Liraglutide) shots

Both promote weight loss,




Amylinomimetics (pramlintide). Acts as a synthetic analogue of amylin

Amylin is an endogenous pancreatic hormone that helps to slow gastric emptying, suppress glucagon, and regulate appetite

Symlin, SymlinPen 120, SymlinPen 60. Given subcutaneously.




Nausea, vomiting. Hypoglycemia

Meglitinides

↑ insulin secretion from pancreatic β cells

Repaglinide (Prandin), Nateglinide (Starlix)

Similar to sulfonylureas

Weight gain, hypoglycemia

Insulin

Binds to insulin receptors

Short: Regular or apidra before each meal (sliding scale)
Intermediate: NPH
Long (24hr): Glargine (Lantus), (Levimir)

Once QHS


May be used in combo with oral agents

Used when oral agents fail


Levemir or glargine (Lantus)

Start with 10 U SC QHS then increase by 1 U daily until FPG <100







Board Pearls:


  • Insulin is safe to use in Gestational Diabetes.

  • Microalbuminuria Cannot be detected on routine UA protein dipstick.

  • Afrezza (Inhalable Insulin) was approved by the FDA for general sale in June 2014.

  • Coronary artery bypass should be performed in a diabetic patient even if there is only two vessel coronary disease.

  • Hyper osmolar nonketotic coma(HONK) is a syndrome that occurs predominantly in patients with type 2 diabetes and is characterized by severe hyperglycemia in the absence of significant ketosis.

  • the SOMOGYI effect is rebound hyperglycemia in the morning because of counter regulatory hormone release after an episode of hypoglycemia in the middle of the night.

  • Frozen Shoulder is the most common risk factor In DM.It is an idiopathic condition, symptoms are Loss of active and passive shoulder rotation with severe pain.



Practice Questions:


  1. A 49-year-old woman presents to her physician’s office with a long-standing history of polydipsia, polyuria, central obesity, and hyperlipidemia. She is currently taking metformin, a sulfonylureas, and an ACE inhibitor. ACE inhibitors are most beneficial in preventing or slowing the progression of which of the follow- ing diabetic complications?
    a. Diabetic ketoacidosis
    b. Diabetic nephropathy
    c. Diabetic neuropathy
    d. Diabetic retinopathy
    e. Peripheral vascular disease

2. A 42-year-old man with a long-standing history of diabetes mellitus type 1 presents to his physician for his yearly checkup. On examination, the physician notes decreased sensation in both of his feet. Although he insists other- wise, the physician suspects that he has not been adequately monitoring and controlling his blood glucose level. Which of the following tests would be best for letting the physician know how well the patient’s blood glucose has been controlled over the past 3 months?


a. Dilated eye examination
b. Fasting blood glucose level

c. Hemoglobin A1C

d. Microalbumin Screening

e. Random blood glucose level



3. Diabetic neuropathies are diagnosed using all of the following except?

a.Nerve conduction studies or electromyography

b.Ultrasound

c. Foot examinations

d. Minnesota Mutiphasic Personality inventory (MMPI)

4. Which of the following regimens offers the best blood glucose control for persons with

type 1 diabetes?

a. A single anti-diabetes drugs

b. Once daily insulin injections

c. A combination of oral anti-diabetic medications

d. Three or four injections per day of different types of insulin.

5. Which of the following diabetes drugs acts by decreasing the amount of glucose produced

by the liver?

a. Sulfonylureas

b. Meglitinides

c. Biguanides

d. Alpha-glucosidase inhibitors

6. Proliferative retinopathy is often treated using:

a. Tonometry

b. Fluorescein angiogram

c. Antibiotics

d. Laser surgery

Answers:
1. The answer is B. ACE inhibitors such as captopril have been shown to decrease blood pressure and prevent and slow the progression of diabetic nephropathy in patients with diabetes. It is believed that ACE inhibitors play a renoprotective role by reducing glomerular filtration rate and reducing macro- proteinuria.

2. The answer is C. When hemoglobin is exposed to increased levels of glucose circulating in the blood, a higher percentage of glucose binds to the hemoglobin. This glycosylated hemoglobin can be measured with the HbA1c blood test. Target HbA1C levels for diabetics are 7.0% to 6.5% in diabetic patients. Because the average lifetime of an RBC is 120 days, this test is best for determining average blood glucose levels over the previous 34 months.

3. The answer is D. Nerve conduction studies assess transmission of electrical signals through nerves and electromyography evaluates nerve transmission to muscles. Ultrasound can assess the responsivity and function of internal organs that may be compromised by neurological damage. Foot exams help to assess peripheral neuropathy and to ensure the integrity of skin. The MMPI is a psychological test and is not used to assess diabetic neuropathy.

4. The answer is D. Because persons with type 1 diabetes do not produce insulin, they require insulin and cannot be treated with oral anti-diabetic drugs. Several injections of insulin per day, calibrated to respond to measured blood glucose levels, offer the best blood glucose control and may prevent or postpone the retinal, renal, and neurological complications of diabetes.

5. The answer is C. Biguanides, such as metformin, lower blood glucose by reducing the amount of glucose produced by the liver. Sulfonylureas and Meglitinides stimulate the beta cells of the pancreas to produce more insulin. Alpha-glucosidase inhibitors block the breakdown of starches and some sugars, which helps to reduce blood glucose levels.

6. The answer is D. Scatter laser treatment is used to shrink abnormal blood vessels in an effort to preserve vision. When there is significant bleeding in the eye, it is removed in a procedure known as vitrectomy. Tonometry is a diagnostic test that measures pressure inside the eye. A fluorescein angiogram is a diagnostic test that traces the flow of dye through the blood vessels in the retina; it is used to detect macular edema.

Somerset Family Medicine Clinical Module

Bread & Butter of Family Medicine:

Blood Cholesterol and Atherosclerotic Cardiovascular Disease (ASCVD)
Introduction

In the United States, atherosclerotic cardiovascular disease (ASCVD) is the leading cause of:



  • Death

  • Decreased quality of life, and

  • Medical cost

The Adult Treatment Panel (ATP) IV was first released by the National Heart, Lung, and Blood Institute (NHLBI) in 2008. The panel used evidence from randomized control trials including meta-analyses to update the 2001 ATP III guidelines. In November 2013, the American College of Cardiology and American Heart Association (ACC/AHA) released the “Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Disease (ASCVD) in Adults.”

The guideline addressed the goals of low density lipoprotein cholesterol (LDL-C) and non-high density lipoprotein cholesterol (HDL-C) in both secondary and primary prevention, as well as the efficacy and safety of cholesterol lowering medications. One major shift from ATP III to the current guideline is that the 2013 ACC/AHA recommendation does not favor treating hyperlipidemia to specific target goal.


Treatment Recommendation

ACC/AHA highly recommends lifestyle modification as being critical to health promotion and ASCVD risk reduction, both prior to and in concert with the use of cholesterol lowering



drug therapies. Measures include:

  • Adhering to a heart healthy diet

  • Regular exercise habits

  • Avoidance of tobacco product

  • Maintenance of a healthy weight

According to the guideline, there are four 4 major statin benefit groups:

  1. Individuals with clinical ASCVD

  2. Individuals with primary elevations of LDL–C >190 mg/dL

  3. Individuals with diabetes aged 40 to 75 years with LDL–C 70 to189 mg/dL and without clinical ASCVD

  4. Individuals without clinical ASCVD or diabetes with LDL–C 70 to189 mg/dL and estimated 10-year ASCVD risk >7.5%



Clinical ASCVD is defined by the inclusion criteria for the secondary prevention statin RCTs (acute

coronary syndromes, or a history of MI, stable or unstable angina, coronary or other arterial

revascularization, stroke, TIA, or peripheral arterial disease presumed to be of atherosclerotic origin).
Statins for Treatment of ASCVD$

Statin Therapy*

Daily Dose

High Intensity#

Moderate Intensity##

Low Intensity###

  • Atorvastatin (Lipitor)

(40†)-80 mg

10 (20) mg

-

  • Rosuvastatin (Crestor)

20 (40) mg

(5) 10 mg

-

  • Simvastatin (Zocor)

-

20-40 mg

10 mg

  • Pravastatin (Pravachol)

-

40 (80) mg

10-20 mg

  • Lovastatin

-

40 mg

20 mg

  • Fluvastatin

-

80 mg XL

20-40 mg

  • Fluvastatin

-

40 mg (twice daily)

-

  • Pitavastatin

-

2-4 mg

1 mg

Specific statins and doses are noted in bold that were evaluated in RCTs (17,18,46-48,64-67,69-78) included in CQ1,

CQ2 and the CTT 2010 meta-analysis included in CQ3 (20). All of these RCTs demonstrated a reduction in major

cardiovascular events. Statins and doses that are approved by the U.S. FDA but were not tested in the RCTs reviewed

are listed in italics.

*Individual responses to statin therapy varied in the RCTs and should be expected to vary in clinical practice. There

might be a biologic basis for a less-than-average response.



#Daily dose lowers LDLC on average, by approximately ≥50%

##Daily dose lowers LDLC on average, by approximately 30% to <50%

###Daily dose lowers LDLC on average, by approximately <30%

†Evidence from 1 RCT only: down-titration if unable to tolerate atorvastatin 80 mg in IDEAL (47).

‡Although simvastatin 80 mg was evaluated in RCTs, initiation of simvastatin 80 mg or titration to 80 mg is not

recommended by the FDA due to the increased risk of myopathy, including rhabdomyolysis.

XL – Extended release



$Adapted from Table 5 of Guideline
Recommendations of the Panel are summarized below&:


  • Healthy lifestyle habits should be encouraged for all persons.

  • The appropriate intensity of statin therapy should be initiated or continued:

1. Clinical ASCVD‡

a. Persons aged ≥75 y with no safety concerns: high-intensity statin (class I, level A)

b. Persons aged <75 y or with safety concerns: moderate-intensity statin (class I, level A)

2. Primary prevention: primary LDL-C level _190 mg/dL

a. Rule out secondary causes of hypercholesterolemia

b. Persons aged ≥21 y: high-intensity statin (class I, level B)

c. Achieve ≥50% reduction in LDL-C level (class IIa, level B)

d. May consider LDL-C–lowering non-statin therapy to further reduce LDL-C levels (class IIb, level C)

3. Primary prevention: persons with diabetes aged 40–75 y with an LDL-C level of 70–189 mg/dL

a. Moderate-intensity statin (class I, level A)

b. Consider high-intensity statin when 10-y ASCVD risk is ≥7.5% (class IIa, level B)

4. Primary prevention: persons aged 40–75 y without diabetes with an LDL-C level of 70–189 mg/dL

a. Estimate 10-y ASCVD risk (risk calculator based on Pooled Cohort Equations recommended)§ in those not receiving a statin; estimate risk every 4–6 y (class I, level B)

b. To determine whether to initiate a statin, engage in clinician–patient discussion of potential for ASCVD risk reduction, adverse effects, drug–drug interactions, and patient preferences (class IIa, level C). Reemphasize healthy lifestyle habits and address other risk factors. If statin therapy is chosen:

i. Persons with ≥7.5% 10-y ASCVD risk: moderate- or high-intensity statin (class I, level A)

ii. Persons with 5% to < 7.5% 10-y ASCVD risk: consider moderate-intensity statin (class IIa, level B)

iii. Other factors may be considered_: LDL-C level ≥160 mg/dL, family history of premature ASCVD, lifetime ASCVD risk, high-sensitivity C-reactive protein level of ≥2.0 mg/L, coronary artery calcification score ≥300 Agatston units, or ankle–brachial index <0.9 (class IIb, level C)

5. Primary prevention when LDL-C level is <190 mg/dL and person is aged <40 y or >75 y or has <5% 10-y ASCVD risk

a. Statin therapy may be considered in selected persons|| (class IIb, level C)

6. Statin initiation is not routinely recommended for persons with NYHA class II–IV heart failure or those who are receiving maintenance hemodialysis.


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