Medical Concepts

  ASTHMA Definition: According to WHO: "It is a disease characterized by recurring attacks of breathlessness and wheezing which vary in frequency according to the nature of allergen and these symptoms vary from hour to hour or day to day". According to Principle & Practice of Medicines by Davidson: "It is chronic inflammatory disorder of airways associated with airway hyper-responsiveness that leads to recurrent episodes of wheezing, breathlessness or coughing particularly at night or early in the morning". Etiology: Hyperresponsiveness -exaggerated response of airway to any non-specific stimulus which results in airway obstruction. Broncho-constriction- Breathlessness or spasm due to construction of bronchioles in airway stimulus. Allergens: Industrial chemicals such as paints, hairsprays or resins Drugs such as NSAIDs, Beta-blockers Food products such as dairy products, fish, etc. Environmental pollutants such as cigarette, smoke Industrial triggers such as w

SITUATIONS REQUIRING HOSPITALIZED CARE The NICE-SUGAR (Intensive versus conventional glucose in critically ill patients) trial compared intensive (81-108 mg/dL) with conventional glucose control using IV Insulin in 6104 intensive care unit patients. At 90 days, intensively controlled patients had an increased absolute risk of death of 2.6%. Significantly, more hypoglycemia was observed in intensively controlled group. Recommendations: Current recommendations call for critically ill patients to be started on IV Insulin therapy at a threshold of 180mg/dL. A goal range of 140-180mg/dL is recommended for majority of patients. More stringent goals may be considered for selected critically ill patients, but only if hypoglycemia can be avoided. Scheduled SC insulin regimens with basal, nutritional and correction components are recommended for patients who are not critically ill. Goals of less than 140mg/dL for fasting glucose and less than 180mg/dL for random glucose are recommended for non-

  TREATMENT OF CONCOMINANT CONDITIONS RELATED TO DIABETES MELLITUS Coronary Heart Disease Dyslipidemia Hypertension HIV and AIDS Antipsychotic Therapy Hypoglycemia Diabetic Ketoacidosis (DKA) Hyperosmolar Hyperglycemic state Retinopathy Neuropathy Foot Ulcers  TREATMENT OF LONG-TERM COMPLICATIONS 1. Retinopathy 2. Neuropathy 3.Microablumiuria 4. Foot Ulcers 9.RETINOPATHY Diabetic retinopathy is the leading cause of blindness in adults 20-74 years of age in the United States. Pathophysiology: Diabetic retinopathy occurs when the microvasculature that supplies blood to the retina becomes damaged. This damage permits leakage of blood components through the vessel walls. Etiology: The risk of retinopathy is increased in patients with longstanding DM, chronic hyperglycemia, hypertension and nephropathy. Glaucoma, cataracts and eye disorders are more frequent in pt. with DM. Treatment: The AD recommends that patients with DM receive a dilated eye examination annually by an ophthalmologist or

  TREATMENT OF CONCOMINANT CONDITIONS RELATED TO DIABETES MELLITUS Coronary Heart Disease Dyslipidemia Hypertension HIV and AIDS Antipsychotic Therapy Hypoglycemia Diabetic Ketoacidosis (DKA) Hyperosmolar Hyperglycemic state Retinopathy Neuropathy Foot Ulcers  The Acute Complications Include: Hypoglycemia DKA Hyperosmolar Hyperglycemic state 6. HYPOGLYCEMIA  "Hypoglycemia or low blood sugar can be defined clinically as a blood glucose level of less than 50mg/dL". Signs: Individuals with DM can experience symptoms of hypoglycemia at varying blood glucose levels. Patients who have regular blood glucose levels as high as 300-400mg/dL may experience symptoms of hypoglycemia when blood glucose levels are lowered to the middle to upper mg/dL range. Most people whose blood glucose levels are controlled adequately may experience symptoms when levels fall below 70mg/dL. Symptoms: Shakiness Sweating Fatigue Hunger Headaches Confusion *Patients experiencing symptoms of hypoglycemia shou

  TREATMENT OF CONCOMINANT CONDITIONS RELATED TO DIABETES MELLITUS Coronary Heart Disease Dyslipidemia Hypertension HIV and AIDS Antipsychotic Therapy Hypoglycemia Diabetic Ketoacidosis (DKA) Hyperosmolar Hyperglycemic state Retinopathy Neuropathy Foot Ulcers  3.HYPERTENSION Uncontrolled blood pressure plays a major role in the development of macrovascular events as well as microvascular complications, including retinopathy and nephropathy in patients with Diabetes Mellitus. Medications: There are several other principles regarding the treatment of hypertension in Diabetes patients. Angiotensin-converting enzyme (ACE) inhibitors or Angiotensin II receptor Blockers are recommended as initial therapy because of their beneficial effects on renal function. Combination therapy with ACE Inhibitor and Dihydropyridine calcium channel blockers has shown to reduce cardiovascular morbidity and mortality versus those receiving ACE Inhibitor therapy combined with Thiazide Diuretic. However, th

  TREATMENT OF CONCOMINANT CONDITIONS RELATED TO DIABETES MELLITUS Coronary Heart Disease Dyslipidemia Hypertension HIV and AIDS Antipsychotic Therapy Hypoglycemia Diabetic Ketoacidosis (DKA) Hyperosmolar Hyperglycemic state Retinopathy Neuropathy Foot Ulcers  1.CORONARY HEART DISEASE "Cardiovascular disease is the major cause of morbidity and mortality for patients with DM". Interventions: The interventions to manage CVS disease: Smoking cessation BP Control Lipid management Antiplatelet therapy Lifestyle modification Medications: All DM patients with a history of cardiovascular disease should be prescribed; Aspirin 75-125mg/day as a secondary prevention strategy or Clopidogrel 75mg/day. The ADA recommends that antiplatelet therapy should be considered for any patient with DM as a primary prevention strategy, if that patient is at risk of cardiovascular disease greater than 10% for over 10 years. This includes most men older than 50 years of age and most women older than 60

PHARMACOTHERAPY  NON-INSULIN INJECTABLE AGENTS 1.GLUCAGON-LIKE PEPTIDE 1 AGONSIT: GLP-1 Agonists enhance glucose dependent insulin secretion while suppressing inappropriately high glucagon secretion in the presence of elevated glucose, which results in reduced hepatic glucose production. Exenatide and Liraglutide are both indicated for the treatment of T2 DM to improve glycemic control. Pharmacokinetics: Plasma concentrations are detected up to 10hrs after injection, although pharmacodynamics action lasts for approximately 6hrs. Mechanism of Action: GLP-1 agonists lower blood glucose levels by producing glucose dependent insulin secretion, reducing post meal glucose secretion, which decreases post meal glucose output, increasing satiety which decreases food intake and regulating gastric emptying which allows nutrients to be absorbed into the circulation more smoothly. Clinical uses: In a 26 weeks head-to-tail trial in patients with T2DM with a baseline A1c between 7%-11% who were tak