Below are listed the recommendations of how and when to measure baseline lipid levels. The main determinants are the expected triglyceride values, and family history of premature cardiovascular disease or genetic lipid disorders.
I am happy to contribute to the editorial by Lisa Eramo published in Medical Economics, January 2018. The article is important as it raises physician awareness of Merit-based Incentive Payment System (MIPS) under which hypertension management falls. MIPS, part of 2015 MACRA, will go into effect in 2019.
This meta-analysis of four major clinical trials (ELIXA, LEADER, SUSTAIN 6, EXSCEL) reveals safety of GLP-1 agonists, bur more importantly their cardiovascular benefits on mortality, myocardial infarction and stroke in adults with type 2 diabetes.
The next natural step would be the quest for oral version of GLP-1 agonist given its positive profile on appetite, glucagon, insulin, glucose metabolism, proteinuria and cardiovascular system.
Although current guidelines are an honest attempt in reflecting complex medical evidence from clinical trials, they may not be very practical or user-friendly to general practitioners.
A simplified but reasonable approach to lipid management for secondary ASCVD prevention would be:
Patients with established clinical ASCVD should achieve LDL-cholesterol <70 mg/dL by using statins ± ezetimibe ± PCSK9 inhibitors.
This is an update of previous guidelines published in 2010.
We recommend T therapy for men with symptomatic T deficiency to induce and maintain secondary sex characteristics and correct symptoms of hypogonadism after discussing the potential benefits and risks of therapy and involving the patient in decision making.
We suggest that when clinicians institute T therapy, they aim at achieving T concentrations in the mid-normal range during treatment with any of the approved formulations.
Clinicians should monitor men receiving T therapy using a standardized plan that includes: evaluating symptoms, adverse effects, and compliance; measuring serum T and hematocrit concentrations; and evaluating prostate cancer risk during the first year after initiating T therapy.
Cardiovascular disease is the leading cause of death in the United States. Cholesterol anomaly, or dyslipidemia, is a major contributor to atherosclerosis morbidity and mortality. Multi-society new cholesterol guidelines were recently published. They were contributed and endorsed by ACC, AHA, ADA, and NLA, among other national associations. You can find below the key recommendations published in the journal of Circulation, November 2018.
ADA recommendations are released each January. Below is a succinct ACP review of guidelines in screening, treatment goals, lifestyle intervention, and drug approach to dyslipidemia in the setting of diabetes mellitus. LDL-cholesterol is still a main target. Charts depict indications and doses of statins, the mainstay therapy to diabetic lipid disorders.
ADA standards are released each January. Here is a succinct ACP review of guidelines in screening, diagnosis, treatment goals, lifestyle intervention, and drug approach to hypertension in the setting of diabetes mellitus. The chart depicts nicely the flow process of how to initiate and intensify the pharmacological therapy.
This is a nice summary of the latest guidelines on diagnosis and management of mineral bone disease induced by chronic kidney disease. Kidney anomaly can be classified functionally via estimated GFR or structurally via proteinuria.
Guidelines emphasize the need for bone density scan, bone biopsy, parathyroid hormone, calcium and phosphorus measures in the right context. Vitamin D analogs and phosphate binders are also discussed. See below for detailed recommendations.
Unlike previous guidelines, the 2017 guideline emphasizes individualized cardiovascular risk assessment and aggressive management of blood pressure at levels of 140/90 mm Hg or higher in patients with a 10-year risk of cardiovascular events of >10%.
Absolute risk is an important determinant of the need for treatment. It’s reasonable to consider more aggressive treatment goals in the highest-risk patients, as SPRINT showed. But while a blood-pressure treatment target of <130/80 mmHg makes sense for high-risk patients, for everyone else it seems more reasonable to continue defining hypertension as a blood pressure of 140/90 mm Hg or higher.
New targets for treatment:
Below are listed recommendations on when to consider metabolic surgery for type 2 diabetes. Decisions making would depend on BMI severity and glycemic control.
The joint statement advises surgery for patients with class III obesity, and in those with class II but have high A1c. Consideration should be given to adults with controlled class II or uncontrolled class I obesity.
Standards are listed below with a slightly modified wording for easier and succinct reading:
Below you can find ADA recommendations on screening, cardiovascular risks, and treatment of dyslipidemia in the context of diabetes. As always improve lifestyle choices first. If ASCVD likelihood is still high then add medications. Statins are first-line, either of moderate or high intensity. Statin selection would depend on age, CVD status, and contributing factors.
Statin plus PCSK9 inhibitor or statin plus zetia could be used in adults with residual ASCVD risk. Statin plus fenofibrate is no longer advised unless special circumstances are present; severe hypertriglyceridemia or in men with profound metabolic syndrome. Statin plus niacin is also not recommended due to stroke concerns.
For more details, ADA standards are listed below with a slightly modified wording for easier and succinct reading:
PCSK9 inhibitors are a relatively new class of medications. They lower atherogenic cholesterol and cardiovascular disease significantly. Although effective, cost limits their use to persons at high risk for CVD in spite of being optimally manged with statins (mainly crestor or lipitor).
National Lipid Association recently published the updated guidelines on the use of PCSK9 inhibitors in patients with residual CVD risk, very high LDL-cholesterol and those with intolerance to statin therapy. Recommendations are listed below with slightly modified wording for easier and succinct reading:
Below you can find ADA standards on proper A1c targets, blood pressure range, retinopathy monitoring and medications used in preexisting and gestational diabetes. The preferred medications during pregnancy are insulin, metformin and glyburide.
Recommendations are listed below with slightly modified wording for easier and succinct reading:
Obesity is a pro-inflammatory state contributing to insulin resistance and type 2 diabetes. Starting with jejuno-ileal bypass in 1954 by Kremer and intestinal bypass in 1967 by Mason, various techniques of the malabsorption surgery have been developed, researched and applied over the decades. They have shown good results in reducing hyperglycemia, the number of diabetic medications and excessive body weight.
Guidance on the importance and indications of metabolic surgery for type 2 diabetes were published in Diabetes Care, January 2017. Recommendations are listed below with a slightly modified wording for easier and succinct reading:
High blood pressure is common in patients with diabetes. Both hypertension and diabetes are independent risk factors for poor cardiovascular outcomes. Obviously the concomitant presence of both HTN and DM in an individual magnifies the chance for CVD events. It is important to screen, diagnose and treat high blood pressure appropriately in someone with diabetes, particularly type 2.
ADA published a position statement on the subject in Diabetes Care, September 2017. The article is comprehensive in regard to proper diagnosis, clinic vs. home BP measurements, target blood pressure values, life style modifications, pharmacological agent initiation and titration, and barriers to therapy. Recommendations are listed below with slightly modified wording for easier and succinct reading:
AHA recently announced guidelines on the topic of syncope. Orthostatic hypotension is a cause in about 9% of afflicted individuals. A good portion of these patients have autonomic peripheral neuropathy from advanced diabetes mellitus. You can find below more details on syncope guidelines. Statements were published in Circulation March 2017
Last ADA standards were published in January 2017. You could find below the recommended glucose aims for patients with type 1 and type 2 diabetes. Guidelines offer flexibility on A1c targets from <6.5-8.0% depending on person's age, life expectancy, polypharmacy, disease duration, hypoglycemia frequency and comorbidities.
Lipodystrophy syndromes (LDS) are defined by severe deficiency in body fat in the absence of food restriction or starvation. They are very rare and could be classified as complete vs. partial or inherited vs. acquired.
Uncontrolled LDS could affect multiple organs including heart, liver, kidney and pancreas. Diabetes, hypertriglyceridemia, and fatty liver disease are common. Diet and exercise are the cornerstone therapies. In special cases Metreleptin could also be used.