You can find below ADA recommendations on type 2 diabetes prevention. Weight loss, exercise and metformin are key. Cardiovascular risk factors need to be identified and addressed.
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.
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.
Functional hypothalamic amenorrhea stems from decreased action and release of GnRH, LH and FSH; in turn leading to lower estrogen production and inability to ovulate.
Long term consequences are low bone mass and infertility. Functional hypothalamic amenorrhea is a diagnosis of exclusion, and thus no specific cause can be found. Main culprits are excessive exercise, weight loss and stress.
Updated ADA guidelines were recently published in Annals of Internal Medicine April 2017. First line therapy is still metformin, while the second and third line agent would depend on an open discussion between the patient and physician; regarding side effects, cost, convenience, hypoglycemia risk, route of delivery, as well as secondary benefits like weight loss, and improved CVD and blood pressure profile. This clinical modality is often called a "shared decision making" and "patient-centered" approach.
The recent ACP update on osteoporosis guidelines is shown below. Interestingly, American College of Physicians recommends against the use of DEXA/bone scans for treatment surveillance; although evidence quality is low for such an advice. Recommendations are listed with slight modified wording for easier and succinct reading.
Please find below the definition and the NLA approach to Metabolic Syndrome. MS or Syndrome X is a significant contributor to cardiovascular disease and type 2 diabetes. Its prevalence often parallels obesity epidemic.
Guidelines were published in April 2015. Text has been slightly modified for easier and succinct reading.
Primary hyperparathyroidism is a common disorder that arises from autonomous overproduction of parathyroid hormone by abnormal parathyroid glands. The disease is characterized by the persistent elevation of total serum calcium levels with corresponding elevated or inappropriately normal PTH levels.
The diagnosis of pHPT is biochemical. The clinical presentation is heterogeneous, and the associated symptoms overlap with those of aging and disease. Patients with symptomatic pHPT have overt signs and symptoms; however, the definition of symptomatic disease is still evolving. Patients with asymptomatic pHPT have no disease-specific symptoms.
Normocalcemic pHPT is a recently recognized, incompletely characterized variant that presents with high PTH levels and normal total and ionized serum calcium levels. Some, but not all, patients may progress over time to hypercalcemic pHPT.
"Pediatric obesity remains an ongoing serious international health concern affecting ∼17% of US children and adolescents, threatening their adult health and longevity. Pediatric obesity has its basis in genetic susceptibilities influenced by a permissive environment starting in utero and extending through childhood and adolescence.
Endocrine etiologies for obesity are rare and usually are accompanied by attenuated growth patterns. Pediatric comorbidities are common and long-term health complications often result; screening for comorbidities of obesity should be applied in a hierarchal, logical manner for early identification before more serious complications result.
Genetic screening for rare syndromes is indicated only in the presence of specific historical or physical features. The psychological toll of pediatric obesity on the individual and family necessitates screening for mental health issues and counseling as indicated."
J C E M
Epidemiologically, HDL-Cholesterol has been found to correlate inversely with CAD events. Unfortunately interventional trials have not found that increasing HDL is clinically beneficial. Interesting to see the exponential rise in published HDL articles since mid 1970s (graph).
Please find below the NLA approach to HDL-Cholesterol. Guidelines were published in April 2015. Text has been slightly modified for easier and succinct reading.
High triglycerides are commonly seen in clinical practice. It can increase the risk of cardiovascular disease and certainly cause pancreatitis at extreme levels.
Please find below NLA recommendations on how to approach hypertriglyceridemia. Guidelines were published in April 2015. Text has been slightly modified for easier and succinct reading.
Please find below main recommendations and rationales on apolipoprotein B (Apo B) as a useful tool in assessing and monitoring dyslipidemia.
Apo B is becoming an important factor in evaluating complex lipid disorders. I anticipate greater use in the future.
Text has been slightly modified for easier and succinct reading. Part 1 of guidelines were published by National Lipids Association in April 2015.
Low ADH production by the posterior pituitary can cause excessive urination, severe dehydration and high sodium measures. The natural response is increased thirst leading to additional water intake. Polyuria could be so advanced that drinking alone would not correct dehydration or sodium anomalies. Supplementation with ADH hormone is needed in these cases.
Please find below excerpts from Endocrine Society guidelines on central diabetes insipidus published in November 2016.
Amiodarone induced thyrotoxicosis could be productive or destructive, called AIT1 and AIT2 respectively. AIT1 hyperthyroidism is primarily due to excessive iodine supplied by the amiodarone, whereas AIT2 is secondary to thyroid inflammation leading to uncontrolled release of preformed hormone. Distinguishing between the two types clinically, biochemically or by imaging studies is often difficult. Common treatments are methimazole, prednisone, surgery or a combination of the three. Amiodarone could also be discontinued if approved by the heart specialist.
In 2016, American Thyroid Association published guidelines on diagnosis and management of hyperthyroidism, including the amiodarone scenario. The publication provides great explanations and rationales on how to approach amiodarone induced thyrotoxicosis. Please read recommendations and excerpts below for more details.