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• Glycemic targets for most non-pregnant adults include an HgbA1C of less than 7.0%
• Pre-prandial capillary plasma glucose should be 80–130 mg/dL
• Peak postprandial capillary plasma glucose (1-2 hours after meals) should be less than 180 mg/dL
• More stringent A1C goals (like 6.5%) are appropriate if achieved without significant hypoglycemia or adverse effects
• Short duration of diabetes, type 2 diabetes treated with lifestyle or metformin, long life expectancy, or no cardiovascular disease are factors for stict glycemic control
• Less stringent A1C goals (like 8%) may be considered for patients with severe hypoglycemia, limited life expectancy, advanced complications, comorbidities, or long-standing diabetes
• Normal C peptide levels are 0.51-2.72 ng/dl
• C peptide levels less than 0.51 ng/dl indicate T1DM
• C peptide levels greater than 2.72 ng/dl indicate T2DM
• Prediabetes diagnostic criteria include serum glucose (random or fasting) of 100-125mg/dl, Hba1C of 5.7-6.4%, and Oral Glucose Tolerance test result of 140-199mg/dl

Medications for Type 2 Diabetes

• Classes of medication for treating Type 2 diabetes include Biguanides, SGLT2 Inhibitors, DPP-4 Inhibitors, TZD's, SU's, GLP-1 RA's, and Glinides.

• A typical A1C reduction from Metformin typically ranges from 1.0-2.0% and carries a neutral weight risk

• SGLT2 Inhibitors like canagliflozin (Invokana) typically reduce A1C by <1.0% and may cause weight loss

• DPP-4 Inhibitors like sitagliptin (Januvia) typically reduce A1C by 0.5-0.8% and have a neutral impact on weight

• TZD's like pioglitazone (Actos) typically reduce A1C by 0.5-1.0%, and weight gain is an adverse effect

• SU's like glimepiride (Amaryl) typically reduce A1C by 1.0-2.0%, with a risk of hypoglycemia and weight gain.

• GLP-1 RA's like semaglutide (Ozempic/Rybelsus) typically reduce A1C by 0.6-1.5% and may lead to weight loss.

• Glinides like nateglinide (Starlix) typically reduce A1C by 0.4-0.9%, with a higher risk of hypoglycemia and weight gain.

• Additional treatment options are added if monotherapy does not meet A1C goals.

• Combination therapy can be considered initially for patients with A1C ≥ 9, or greater than 7 with monotherapy

• Choice of medication for glycemic control depends on patient co-morbidities and cost

• Sulfonaurea's are cheap but have a high association with hypoglycemia and weight gain

• Glycemic treatment response evaluation intervals are every 3 months.

• Treatements should address both Fasting Plasma (FPG) and post prandial Glucose (PPG) to achieve A1C goals.

• At higher A1C levels, FPG is the predominant driver of hyperglycemia; as AIC drops below 7.5%, PPG predominates

• Basal insulin largely targets FPG; patients with DM-2 using 50-60 units/day of basal insulin may improve with FPG target

• Normal TSH levels are 0.4 - 4 mIU/L

• Normal Free T4 levels are 0.8 to 1.8 ng/dL

• Total T3 levels (used for hyperthyroidism) are 75 to 195 ng/dL

Hypothyroidism Treatment

• Hypothyroidism treatment can either be pharmaceutic or non-pharmaceutic.
• Levothyroxine sodium (Synthroid, Levoxyl) may be used as pharmocologic treatment.
• Young, healthy, non-pregnant adults often require 1.6 mcg/kg of levothyroxine PO daily.
• Adults > 50-60 years or with CHD may require 25 to 50 mcg PO daily.
• Adults > 50-60 years AND with CHD may require 12.5 to 25 mcg PO daily.
• Non-pharmacologic includes educating about need for lifelong therapy and monitoring for adverse effects.
• Patients should take thyroid medication on empty stomach (30-60 mins before breakfast or 2-4 hours after last meal.
• Certain medications can interfere with absorption (ex. estrogen therapy, antacids, iron)

Follow Up for Thyroid Medication

• Monitor serum TSH 4-8 weeks after initiation of therapy or dosage adjustments
• Periodic TSH measurements are evaluated at 6 months and then 12 month intervals, unless symptomatic

Myxedema Coma

• Myxedema coma is a severe, life-threatening, decompensated hypothyroidism with dangerously low thyroid hormone levels.
• Myxedema Coma is common in elderly women with long-standing preexisting hypothyroidism.
• Triggers may include cold temperature (more common during winter months), comorbidities, or the use of certain medications.
• Signs and symptoms are exacerbations of the typical manifestations of hypothyroidism progressing to more severe problems.
• Management of myxedema coma should be considered as promptly as possible and can be started even before laboratory results.
• ICU setting is appropriate for treatment of myxedema coma.

Hyperthyroidism Treatment

• Hyperthyroidism treatment can be pharmaceutic.
• Beta-blockers are used to reduce symptoms associated with hyperthyroidism.
• Propanolol dosage is 10-40 mg PO 3-4 times per day
• Atenolol dosage is 25-100 mg PO 1-2 times per day
• Caution is advised for Beta-blockers in patients with asthma or CHF.
• Antithyroid drugs (thionamides) helps decrease thyroid hormone synthesis.
• Methimazole (Tapazole) is a 1st line treatment with an initial dose of 10-30 mg PO daily; maintenance 5-10 mg PO daily.
• Propylthiouracil (PTU) 50-100 mg PO TID... Should ONLY be used in 1st trimester of pregnancy!
• Baseline CBC & LFTs is important before initiation of therapy; Monitor for rare, serious side effects of agranulocytosis & hepatotoxicity.

Thyroid Storm

• Thyroid storm is a decompensated, severe form of hyperthyroidism, associated with increased morbidity and mortality
• Elevated serum thyroid hormone concentrations, result in extreme alteration of usual hyperthyroid symptoms.
• Diagnosis can happen in patients with or without preexisting hyperthyroidism.
• Thyroid storm is rare and triggered by precipitants or acute exposure to excess iodine.
• Patients with known severe hyperthyroidism who are noncompliant can form thyroid storm.
• Rapid recognition of thyroid storm is necessary to start management in an ICU setting. Clinical manifestations include fever, cardiac arrhythmias, vomiting, and impaired mental status

Table for thyroid labs:

• Normal TSH, Free T4, and T3, results in a negative labs for other thyroid issues.
• Primary Hypothyroid presents High TSH with Low Free T4
• Subclinical Hypothyroid presents High TSH with Normal Free T4
• Hashimotos presents High TSH with Low Free T4 result in positive anti-TPO antibody
• Primary Hyperthyroid presents Low TSH with High Free T4 and High T3, this also will result in Elevated TSI Graves
• Subclinical Hyperthyroid presents Low TSH with Normal Free T4 and Normal T3

Diagnostic Criteria for Metabolic Syndrome

• Abdominal obesity is defined as a waist circumference >40 inches in men or >35 inches in women.
• Hypertriglyceridemia is defined as ≥150 mg/dL.
• Low HDL cholesterol is defined as <40 mg/dL in men or <50 mg/dL in women.
• Hypertension is defined as a blood pressure ≥130/85 mm Hg
• High fasting glucose is defined as ≥110 mg/dL
• Diagnosis of metabolic syndrome is based on the presence of any 3 of the above 5 features

Obesity Treatment

• Short-term medication with Phentermine is sympathomimetic that increases satiety
• 13 weeks is the treatment duration, with a dose of 15-37.5 mg PO daily, possible SE's are tachycardia, HTN, psychosis
• Chronic Medications can blocks the digestion and absorption of fat with Orlistat
• (Xenical) which has a dose of 120 mg PO TID during meals or 1 hour after meals containing fat content, possible SE are flatus w/oily discharge, fecal urgency, fatty stools, fecal incontinence
• Lorcaserin (Belviq) activates 5-HT2C receptors with a dose: of 10 mg PO BID, with possible SE's of hypoglycemia, hyperprolactinemia, diarrhea, musculoskeletal pain
• Phentermine-topiramate (Qsymia)'s role sympathomimetic and neurostibilizer and promotes satiety, the given dose 7.5 mg/46 mg PO QAM and can have side effects
• Naltrexone-bupropion (Contrave) is opioid antagonist and anti-depressant that can cause depression/suicide so monitor for risk
• Glucagon like peptide-1 agonist (GLP-1) promotes satiety.
• Liraglutide (Saxenda) with a dose that needs titrating 0.6 mg to 3mg SQ daily SC daily.
• Tirzepatide (Zepbound) dose needs to be titrated from 2.5mg/wk to 15mg SQ/wk
• Semaglutide (Wegovy) dose needs to be titrated from 0.25mg/wk to 2.4 mg SQ/wk

Insulin therapy:

• Rapid acting insulin, Lispro and Aspart should be taken 15 mins before meal
• Short acting insulin, Regular should be taken 30 mins before meal
• Intermediate acting insulin, NPH works for about 16 hrs taken between meals and at bedtime
• Long acting insulin, Gargline (Lantus, Levemir}, Toujeo works between 20-24 hrs.
• Degludec is long acting and Taken at bedtime
• Insulin pump, Humalog should be titrated following the physicians directions

Insulin Calculations

• Initial Total Daily Dose (TDD) : 0.4 to 0.5 u/kg/day.
• Usual Total Daily Dose (TDD) : 0.4 to 1 u/kg/day in divided doses
• Dosing is broken down to 50% basal and 50% prandial
• Basal insulin: intermediate (NPH) or long-acting (eg, glargine, degludec, detemir) in 1 to 2 daily injections.
• Bolus or prandial insulin is administered before or at mealtimes as a rapid-acting or short-acting insulin