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Metformin add-ons to decrease heart complications:

Elevated early morning testosterone is most often associated with PCOS.

tags: PCOS work up, pregnancy testing, prolactin, DHEA-S, early morning 17-hydroxyprogesterone, Cushing syndrome, thyroid disease, acromegaly, pelvic ultrasound.

Question 10 of 10
Metformin (Glucophage) should be stopped prior to which one of the following, and withheld until 48 hours after completion of the test?   (check one)
 A. An upper GI series 
 B. Abdominal ultrasonography 
 C. CT angiography 
 D. MRI of the brain 
 E. Colonoscopy 
Since even a temporary reduction in renal function, such as occurs after pyelography or angiography, can cause lactic acidosis in patients taking metformin, the drug should be discontinued 48 hours before such procedures (SOR C) and restarted 48 hours after the procedure if renal function is normal. The other procedures listed are not indications for stopping metformin.

Ref: Stacul F, Adam A, Becker CR, et al: Strategies to reduce the risk of contrast-induced nephropathy. Am J Cardiol 2006;98(suppl 6A):59k-77k.

In DM2 intensive glycemic control is not beneficial for cardiovascular disease. REF

Some of the atypical agents, notably olanzapine and clozapine, have been associated with hyperglycemia and the development of type 2 diabetes mellitus. REF

State the insulin regimen that most closely mimics the normal pattern. REF

Beneficial dietary changes in persons with diabetic nephropathy ? REF

Both rosiglitazone and pioglitazone are indicated either as monotherapy or in combination with a sulfonylurea, metformin, or insulin when diet, exercise, and a single agent do not result in adequate

The classic dyslipidemia in both DM and PCOS is hypertriglyceridemia and low HLD. (K.S.)

Renal function and hypoglycemics: REF
1. Metformin is contraindicated in CKD: Stop in females w/ Cr ≥1.4  and in males w/ Cr ≥1.5 mg/dL. If creatinine clearance is <70 mL/min, metformin should not be prescribed (Cr is inaccurate for elderly - 80 yo).
2. Acarbose is contraindicated in pts w/ cirrhosis or a Cr  >2.0 mg/dL.
3. Exenatide is contraindicated in pts w/ CrCL <30 mL/min.
4. Pioglitazone is contraindicated in hepatic disease.
5. Glargine can be used in pts w/ disease at any stage, but the dosage may need to be decreased.

General mechanisms of action: REF
1. Biguanides and thiazolidinediones (rosi) - Incr insulin sensitivity. Biguanides decr hepatic production.
2. Sulfonylureas and meglitinides (repaglinide) stimulate pancreatic insulin secretion.
3. DPP-4 inhibitors (sitagliptin) prevent GLP-1 breakdown and slow the breakdown of some sugars.
4. GLP-1 mimetics (Exenatide) incr insulin secr, decr glucagon secr, promote β-cell production, delay gastric emptying.
5. Amylin analogues (Pramlintide) also delay gastric emptying. Another REF

Verapamil and Diltiazem decrease proteinuria. (PGYII Focus)

Statins are plaque stabilizers and decrease risk of ACS. (PGYII Focus)

Monofilament test - best test to assess for ulcer risk in DMII. (PGYII Focus)

Exenatide is most associated with weight loss (more so than Metformin). (PGYII Focus)

ACEIs should be used for HTN in DMII. Read the referenced paper sometime. REF

So in diabetic gastroparesis which DMII meds should be stopped ? REF

UWIM8506 - Exenatide and Saxagliptin both decr postprandial BGL and both decr A1c < 1%.

Exenatide is not recommended for the frail and elderly due to weight loss & nausea. REF
Pioglitiazone is contraindicated in heart failure.
Metformin is contraindicated in renal failure.

Pioglitazone for 24 months may raise risk of bladder cancer.  REF

Pioglitazone decreases A1c by 1 - 1.5 %.

Pioglitazone is contraindicated in NYHA Class III or IV heart failure.

What is more likely to cause hypoglycemia ? REF

How do you initiate insulin therapy ? REF

I don't believe this is true: REF

What are the fasting and post-prandial glucose goals in pregnancy ? REF

Amylin (Pramlinitde) analogs act with insulin to delay gastric emptying and inh glucagon release.  REF

Which organ system is not benefited by intensive glycemic control ? You won't believe this.  REF

2nd-generation (“atypical”) antipsychotics are assoc w/ wt gain, elevated triglycerides & DMII.  REF

In a DM2 which antihypoglycemics provide better lipid control ? REF
 In diabetics, metformin and thiazolidinediones (e.g., rosiglitazone) are more likely to improve lipid levels than are sulfonylureas.
Cholestyramine will raise triglyceride levels.

What does Colestyramine do that is bad in lipid control ? How about Niacin ? REF

What are the only 2 agents approved for DMII treatment in children ? REF

Which of the above delay gastric emptying ? GLP-1 mimetics (Ex) and Amylin analogs (Pramlinitide).

PCOS treatments ? REF

Intense glycemic control reduces risk for what ? REF

Nutritional reccs for those with diabetic nephropathy ? REF

BGL self-monitoring associated with ? REF

Pregnant diabetics should use what ? REF - Note - all oral hypoglycemics cross the placenta.

Metformin is the only hypoglycemic shown to reduce mortality rates in DMIIs. REF

Which anti-glycemics best improve lipid levels ? REF

Liraglutide is helpful in hypertriglyceridemia.  

Tx hypoglycemia in a 3yo DM peds IP:  2 cc / kg of D10W, OP use glucagon. Oral preferred if conscious.

Tx hypoglycemia in a newborn of a mother with DMII who has BGL = 28 mg/dl: D5W 4-8 mg/kg/hr.

In obese kids 1,5-anhydroglucitol predicts DMII b/c Ks can't absorb it where there is hyperglycemia. 

Biguanides - metformin
Thiazolidinediones - pioglitazone, rosiglitazone
Sulfonylureas - Glyburide
Meglitinides - Repglinide
DPP-4 inhibitors - Sitagliptin
GLP-1 mimetics - Byetta
Amylin analogs - Pramlintide

Annual Examination:

Insulin Regimen:
30 Units Lantus daily at 1600.
1 U aspart for every 7 carbs.
Measure glucose every 3 hours.
Touch up: Take 1U aspart for every 30 mg/dl glucose over 120.
For example: 
if glucose 150 give 1 U aspart
If glucose 180 give 2 U asport
If glucose 210 give 3 U aspart
If glucose 240 give 4 U aspart
If glucose 270 give 5 U aspart
If glucose 300 give 6 U aspart

If glucose is greater than 300 2 times in a row call the diabetes clinic at Children's Hospital.
Marc Curvin,
Mar 6, 2013, 2:59 PM
Marc Curvin,
Mar 6, 2013, 2:59 PM
Marc Curvin,
Mar 6, 2013, 3:00 PM
Marc Curvin,
Mar 6, 2013, 3:01 PM