Diabetes Treatment Guidelines 2019

Long time coming…


but I’m back. Will try using this site as place to collect clinical pearls and educational resources from around the internets. Up first- Diabetes.

There are many new treatments for DM, and I can’t keep the initials straight, so first up, my round-up of DM treatments.

Metformin- first line therapy along with lifestyle modification.

GLP-1 RA: end in “glutide”. These are all injectable, some now once weekly. Some have proven CVD reduction benefits. In order of CVD benefit: Liraglutide (Victoza/Saxenda), Semaglutide (Ozempic), Exanatide (Byetta/Byderon).

SGLT2i: end in “gliflozin” These also have been shown to reduce CVD events, along with heart failure and progression of CKD. Empagliflozin (Jardiance) and Canagliflozin (Invokana) are examples.

DPP-4i: “Gliptins” Work by increasing Incretin, which helps the body make insulin when needed, and decreases glucose creation in the liver. Sitagliptin (Januvia) and Saxagliptin (Onglyza) are examples.

 

These are the most updated Standards of Care in DM, published Jan 2019. Here are the AACE executive summary and slide decks. 

I am teaching about treatment of DM, so here are some of the most relevant figures. Smart people have also told me that there is a great app with these algorithms. Search AACE Type 2 Diabetes.

First and Second line Treatments

Adding Injectable Medicines

And because conflict is interesting, here are the ACP guidelines for DM published last year, which set off a bit of a firestorm between Internists and Endocrinologists. The main differences have to do with treatment targets. ACP recommends aiming for HbA1c between 7-8% for most patients, and even higher for patients with less than 10 years life expectancy, nursing home patients, or with other chronic diseases. They feel we should focus on limiting harms and avoiding hypoglycemia in this population.   The ADA suggests keeping HbA1c less than 7% for most patients, with tighter targets for healthier patients who are doing well with current treatment, or those with cardiovascular disease. They are OK with higher HbA1c targets (<8%) in those who have demonstrated hypoglycemia, limited life expectancy, or comorbidities.

Enjoy!!

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This or that… Asthma vs COPD

So how can you tell if your adult patient has asthma or COPD.  Sometimes you can’t, and sometimes it might be both.  But here are some clues.

helpful conceptualization from Medscape

Clinical course: The hallmark of asthma is intermittent episodes of obstruction or bronchospasm. These patients, particularly at onset, often have asymptomatic periods.  COPD, on the other hand, is slowly progressive and NOT reversible. Patients clearly have exacerbations, but are rarely completely symptom free.

Age at onset: Asthma patients tend to be younger. They may be able to identify specific triggers: allergens (pets), irritants (tobacco smoke), exercise, temperature. COPD is due to long-standing exposures, so patients are older, and almost always have a smoking history.

PFTs: Asthma and COPD both have an obstructive pattern on PFTs. Think low FEV1/FVC ratio, larger lung volumes. The difference is that the obstruction seen in asthmatics is REVERSIBLE with bronchodilators. The bronchodilator administration is necessary for the diagnosis of asthma. Specific criteria are that FEV1 increases more than 12% over baseline or Peak Flow increases > 20% over baseline with bronchodilator. Normal PFTs essentially rule out COPD, but PFTs can be normal in an asymptomatic asthmatic.

Wondering what else is in the differential?  Check out this post from 2013.

Itchy Skin

Inspired by last Friday’s AMR case, I thought I’d write an overview of the causes of pruritus, particularly the causes that DON”T go along with a rash (because I hate rashes? Nah).  You can organize these causes in a few ways, but I like to think of them based on the big categories of: dermatologic, systemic disease, neurologic, and psychogenic.

Only takes a few of these guys to set off some serious itching

Dermatologic

Most dermatologic etiologies are going to have an associated rash, but it may be subtle. Here are a few where you make have to look closely:

  • Xerosis: The most common cause of generalized pruritus, just plain old dry skin. Common in winter, often can tell skin is try just by feeling it.
  • Scabies: Regular scabies, not the Norwegian kind discussed in AMR, may not have much of a rash associated. Sometimes you can see a burrow, but rarely. I learned that the itching is a delayed hypersensitivity reaction, and may not appear for weeks after infestation.
  • Atopic Dermatitis: Think of this in a patient with other allergic phenomena (rhinitis, conjunctivitis), sx at an early age, and a family history of allergic disease. Patients also have allokinesis, when an innocuous stimuli, like temperature changes or clothing, induces itching.
  • Contact dermatitis: there are two kinds of contact dermatitis. Irritant contact dermatitis (like that caused by poison ivy) occurs when an irritant directly damages the skin.  There is often a rash in this instant.  Allergic contact dermatitis occurs when the irritant induces an allergic response. The rash here may be diffuse and obvious, or may be more subtle. Ask about anything that comes in contact with skin, including soaps, lotions, and laundry detergent.

Systemic Disease

  • Cholestasis: The first thing we think of, but pretty rare. Most commonly starts in the palms and soles before becoming more generalized. Disorders that cause cholestasis include: Primary biliary cirrhosis, cholestasis of pregnancy, viral hepatitis, and anything that causes obstructive jaundice.
  • Renal disease: We think about this in uremia, but it is actually common even in dialyzed patients. Worse at night or after a dialysis session,
  • Malignancy/hematologic disorders: More often with hematologic malignancies than with solid tumors. Think of: Hodgkin’s disease, Polycythemia vera (worse in water), Carcinoid (thank you, histamine), and cutaneous T cell lymphoma. Patients without a diagnosis for their pruritus may be at increased risk for malignancy.
  • Thyrotoxicosis: cause you can’t have a list without thyroid on it. Actually, a fairly common sx of Graves disease.  hypothyroidism can cause xerosis, which itches
  • Connective Tissue Disease: Common with dermatomyositis and scleroderma in particular.

Brachioradial pruritus

Neurologic

Small fiber neuropathy may be associated with pruritus, so anything that causes neuropathy could lead to itching, including diabetes.  These are typically localized to the affected area, however.

  • Post herpetic neuralgia: Up to 50% of patients with post herpetic neuralgia experience this as itching rather than pain.
  • Notalgia Paresthetica: Itching on the upper back, perhaps due to trapped nerve fibers in the T2-T6 nerve roots. Unilateral, near the medial or upper border of the scapula.
  • Brachioradial pruritis: Itching of the proximal dorsolateral forearm, but may extend up to the upper arm or even trunk. Feels better with ice application. Similar to notalgia paresthetica, this may be related to nerve root entrapment in C5-C8, but also may have something to do with sun exposure.
  • MS: Compared to the rest on this list, MS is more likely to cause generalized pruritus. Typically a relapsing, remitting type course that mirrors the rest of the disease.

Psychogenic 

  • Psychogenic excoriation: Skin is normal, but affected individuals pick and scratch at it. Lesions are all within reach of the patient, and may be precipitated by psychologic stressors.
  • Delusional parasitosis: Patients experience a firm, fixed belief that they are infested by parasites, despite a lack of evidence of infestation.  This may be secondary to another psychiatric disorder, or may be the primary disorder itself.
  • No matter the underlying etiology, pruritus may get worse under emotional stress.

For many, the itching itself causes emotional stress. It impacts sleep, work, relationships. Relief can really improve your patient’s quality of life, plus you may uncover a systemic disease earlier.

If you are itching after reading this post, that is probably psychogenic itching. Good luck!