Triglycerides as a Factor in Residual ASCVD Risk
To treat patients with high TG and to lower ASCVD risk, always encourage diet and lifestyle first, manage diabetes (with Pioglitazone, SGLT2I, GLP1-RA), obesity, high BP. Statins are first-line in essentially all patients. If the TG is still >135 mg/dL fasting (or >150 non-fasting), add IPE, if possible, Rx DAW/brand only, generic IPE not indicated to decrease ASCVD or for TG
Pharmacotherapy For Weight Management
Newer agents introduced for weight management includes Phentermine/Topiramate, Buproprion/Naltrexone XR, Liraglutide, CelIulose/Citric acid, and Semaglutide. Studies have shown that semaglutide causes a significant reduction in body weight as compared to placebo over a period of 68 weeks and was able to achieve >20% of weight loss in comparison to placebo.
QOL Tool to Examine Fatigue in Subjects With DM
Norfolk QOL Tool analyses cognitive, physical, & emotional elements of fatigue. It is a 35-item self-administered questionnaire and responses graded 0-4 with higher scores indicating higher degree of fatigue symptom or functional limitation. In this tool, diabetic individuals were found to be more fatigued than healthy individuals and younger individuals reported the worst fatigue scores.
Indications for SGLT2i in Non-Diabetes Patients
Collaboration with non-endocrinologists regarding use of SGLT2Inhibitors:Understand each patient's indications for SGLT2I use; When titrating SGLT2i up or down, keep in mind the impact on numerous disease states; Collaboration using protocols, formularies, and patient specific cases; Co-management and communication
Management of Obesity Post Bariatric Surgery
Weight regain and insufficient weight loss after bariatric surgery is commonly caused by hormonal, nutritional or genetic factors. Anti-Obesity Medications (AOM) are used for WR & IR. The best time to start AOM appears to be when you reach your postsurgical nadir weight OR when you reach aweight plateau, and post-operative bariatric patients who were given two or more AOM lost more weight.
Use of Glucose Lowering Agents in Advanced CKD
GLP1 agents with CKD benefits are Dulaglutide, Semaglutide weekly, and Liraglutide daily. As per the AWARD study, Dulaglutide showed a 40% eGFR decline and ESKD. Insulin therapy is not exhibited to prevent the CKD development. Starting with lower doses (0.25 units daily dose), basal insulin + non-insulin agents, mixed insulin (70/30% or 75/25%) or BASAL - BOLUS should be the last option.
Glycemic Monitoring in Advanced Chronic Kidney Disease (CKD)
Insulin resistance and impared glucose metabolism increase risk of hyperglycemia in early CKD and hypoglycemia in advanced CKD/dialysis. An HbA1c target is recommended ranging from less than 6.5% to 8.0% in patients with diabetes & CKD not treated with dialysis. Linagliptin (no renal adjustment) or Sitagliptin is recommended for mild hyperglycemia.
CVD and T2D: Assessing Risks And Prioritizing Therapies
Current guidelines recommend SGLT2i such as dapagliflozin and empagliflozin and GLP1-Ra as first-line treatment in patients with T2DM and cardiovascular disease. Saxagliptin is not recommended in patients with T2DM and high risk of HF (class of recommendation III, level of evidence B) in international guidelines, whereas DPP4i as a pharmacological class can be used for glycaemic control.
Energy Metabolism in a Weight Reduced State
With moderate dietary restriction, physical activity can enhance short-term weight loss by 20-25%. If there is a severe dietary restriction, physical activity will have minimum effect on weight loss. People should get adequate amounts of sleep, decrease sedentary behavior and increase light, moderate and vigorous intensity physical activity including household, andoccupational activity.
Use of Sulfonylurea Based on Diet Recall
Sulfonylurea is the most potent diabetes agents and to avoid hypoglycaemia, sulfonylurea has to be selected based on diet composition and pattern of the patent. A study conducted by Panchal D revealed that the use of sulfonylurea drugs as per the diet pattern, particularly meal pattern and percent of carbohydrate achieve glycaemic control with minimum risk of hypoglycaemia in T2D patients.
Management of Primary Hyperparathyroidism
• Alendronate and Denosumab can be used to increase bone density • Cinacalcet can be used to reduce the serum calcium concentration into the normal range if there are no contraindications• Calcium intake/supplementation should follow the guidelines: 800 mg/day for women 70 years old.
Surgical Management of Primary Hyperparathyroidism (PHPT)
Surgery is recommended if Serum calcium is >1 mg/dL (0.25 mmol/L); Skeletal involvement: A fracture by VFA or vertebral X-ray or BMD by T-score < -2.5; Renal involvement: eGFR or creatinine clearance (>250 mg/day in women; >300 mg/day in men) or Nephrocalcinosis or nephrolithiasis by X-ray, or ultrasound, or Hypercalciuria (>250 mg/day in women; >300 mg/day in men).
Diagnosis of Hyperparathyroidism
PHPT can be evaluated with:Biochemical: Measure adjusted total serum calcium, phosphorus, intact PTH, 25OHD, creatinine.Skeletal: Three-site DXA; imaging for vertebral fractures; Trabecular Bone Score if available.Renal: eGFR, or creatinine clearance, 24-hour urinary calcium and biochemical risk factors for stones; imaging for nephrolithiasis/nephrocalcinosis.
Treatments for Non-alcoholic Fatty Liver Disease
Nonalcoholic steatohepatitis (NASH) treatment is recommended in intermediate and high risk patients. Current treatments for patients with NAFLD (not FDA approved but can be used for obese or diabetic patients) were lifestyle interventions, bariatric surgery, GLP-1RA and Pioglitazone. Studies have shown that Pioglitazone increases adiponectin, reduces fat, and lowers liver fibrosis risk in NASH.
