Diabetes & Thyroid Treatment Guide PDF

Here's the converted markdown format of the text in the images. ### Glycemic Targets: * HgbA1C <7.0% for most non-pregnant adults * Pre-prandial capillary plasma glucose 80–130 mg/dL * Peak postprandial capillary plasma glucose (1-2 hours after meals),<180 mg/dL * more stringent A1C goals (...

Here's the converted markdown format of the text in the images. ### Glycemic Targets: * HgbA1C <7.0% for most non-pregnant adults * Pre-prandial capillary plasma glucose 80–130 mg/dL * Peak postprandial capillary plasma glucose (1-2 hours after meals),<180 mg/dL * more stringent A1C goals (such as 6.5%) for selected individual patients if this can be achieved without significant hypoglycemia or other adverse effects of treatment * short duration of diabetes, type 2 diabetes treated with lifestyle or metformin only, long life expectancy, or no significant cardiovascular disease. * Less stringent A1C goals (such as 8%) may be appropriate for patients with a history of severe hypoglycemia, limited life expectancy, advanced microvascular or macrovascular complications, extensive comorbid conditions, or long-standing diabetes in whom the general goal is difficult to attain despite diabetes self-management education, appropriate glucose monitoring, and effective doses of multiple glucose-lowering agents including insulin. * C peptide * 0.51-2.72 ng/dl normal * <0.51 ng/dl T1DM * >2.72 ng/dl T2DM ### Prediabetes: * Serum glucose random or fasting: 100-125mg/dl prediabetes * Hba1C: 5.7-6.4% prediabetes * Oral Glucose Tolerance test: 140-199mg/dl prediabetes ### Medications For type 2 | Effect | Biguanide (Metformin) | SGLT2 Inhibitor canagliflozin (Invokana) | DPP-4 Inhibitor - sitagliptin (Januvia) | TZD pioglitazone (Actos) | SU glimepiride (Amaryl) | GLP-1 RA semaglutide (Onglyza) | Glinides nateglinide (Starlix) | | :-------------------- | :-------------------- | :--------------------------------------- | :-------------------------------------- | :---------------------- | :--------------------- | :----------------------------- | :----------------------------- | | Typical A1C reduction, % | 1.0-2.0 | <1.0 | 0.5-0.8 | 0.5-1.0 | 1.0-2.0 | 0.6-1.5 | 0.4-0.9 | | Efficacy | High | Moderate | Moderate | Moderate | High | High | High | | Hypo Risk | No | No | No | Yes | Yes | No | Yes | | Weight | Neutral | Loss | Neutral | *Gain | *Gain | Loss | *Gain | * After monotherapy is initiated, additional treatments are added in a step-wish approach, if patients do not achieve their AIC goals. * Combination therapy can be considered as initial therapy in patients with AIC greater or equal to 9. or greater than 7 with monotherapy. ***BE CAREFUL NOT TO BRING GLUCOSE DOWN TOO FAST AND CAUSE HYPOGLYCEMIA * Choice of medication is based on patient co-morbidities and cost * Sulfonaurea's are cheap but have a high association with hypoglycemia and weight gain * Treatment responses should be evaluated every 3 months. * Early, aggressive treatment is supported by clinical data showing that intensive intervention early in DM-2 leads to reduction in micro and macro vascular risks. * Treatment must address both Fasting Plasma (FPG) and post prandial Glucose (PPG) if patients are to achieve their A1C goals. * At higher A1C levels, the predominant driver of hyperglycemia is FPG, but as AIC drops below 7.5%, PPG predominates. * Basal insulin largely targets FPG, once patients with DM-2 are using 50 to 60 units/day of basal insulin, they are likely to get further improvement in FPG. Normal level of TSH =0.4 -4 mIU/L Normal level of Free T4 = 0.8 to 1.8 ng/dL Total T3 = 75 to 195 ng/dL (used for hyperthyroidism) ### Hypothyroidism Treatment: * **PHARMACOLOGIC** * Levothyroxine sodium (synthetic thyroxine, T4) \[Synthroid, Levoxyl] * Young, healthy, non-pregnant adults → 1.6 mcg/kg PO daily * Adults > 50-60 yrs or with CHD → 25 to 50 mcg PO daily * Adults > 50-60 yrs and with CHD → 12.5 to 25 mcg PO daily * **NON-PHARMACOLOGIC/EDUCATION** * Educate about need for lifelong therapy * Monitor for adverse effects, which may mimic s/s of hyperthyroidism * Patients should take 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** * Monitor serum TSH 4-8 weeks after initiation of therapy or after dosage adjustments * Periodic TSH measurements at 6 months & then 12 month intervals, unless symptomatic Myxydema Coma * Condition of severe, life-threatening, and decompensated hypothyroidism in which thyroid hormone levels are dangerously low. * Common in elderly women with long-standing preexisting hypothyroidism. * Triggers may include cold temperature (more common during winter months) * precipitating comorbidities, such as infection, stroke, and heart failure or the use of sedative, analgesic, antidepressant , hypnotic, antipsychotic, or anesthetic medications. * Patients with preexisting hypothyroidism may also present with myxedema coma following a period of prolonged noncompliance with thyroid hormone replacement. * Signs and symptoms are exacerbations of the typical manifestations of hypothyroidism and may include extreme lethargy, which can progress to stupor or coma, hypothermia, respiratory depression, bradycardia, hyponatremia, and renal impairment. * Management of myxedema coma should be considered as promptly as possible, given the increased mortality of the disease (25%-60% despite treatment), and can be started even before laboratory results demonstrating abnormal serum TSH and T4 concentrations. * The treatment of myxedema coma should be in an intensive care unit (ICU) setting. ### Hyperthyroidism Treatment * **PHARMACOLOGIC** * Beta-blockers → to reduce symptoms associated with hyperthyroidism * Propanolol 10-40 mg PO 3-4 times per day * Atenolol 25-100 mg PO 1-2 times per day * \*Caution in patients with asthma or CHF * Antithyroid drugs (thionamides) → to decrease thyroid hormone synthesis * 1st line: Methimazole (Tapazole) initial 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 prior to initiation of therapy; Monitor for rare, serious side effects of agranulocytosis & hepatotoxicity. ### Thyroid Storm * Decompensated, severe form of hyperthyroidism, associated with increased morbidity and mortality * elevated serum thyroid hormone concentrations, resulting in the extreme alteration of usual hyperthyroid symptoms. * The diagnosis can happen in patients with or without preexisting hyperthyroidism. * It is a rare diagnosis and typically triggered by precipitants such as trauma, myocardial infarction, surgery (including thyroid surgery for hyperthyroidism or other surgeries in general), or infection. * In some cases, acute exposure to excess iodine (administration of iodinated contrast radiographic scan) may result in iodine-induced hyperthyroidism to trigger thyroid storm. * Patients with known severe hyperthyroidism who are noncompliant with prescribed antithyroid medications may also form thyroid storm. * Rapid recognition of thyroid storm is necessary to start management, which should be performed in an ICU setting. * Clinical manifestations include fever, cardiac arrhythmias, vomiting, and impaired mental status. | Condition | TSH | Free T4 | T3 | Other thyroid labs | | :----------------------- | :---- | :------ | :---- | :----------------- | | Normal | normal| normal | Normal| negative | | Primary Hypothyroid | High | Low | | | | Subclinical Hypothyroid | High | Normal | | | | Hashimotos | High | Low | | + anti-TPO antibody| | Primary Hyperthyroid | Low | High | High | Elevated TSI Graves| | Subclinical Hyperthyroid | Low | Normal | Normal| | **Table 1: Diagnostic criteria for metabolic syndrome** | Criterion | Clinical value | | :-------------------- | :-------------------------------------------------------- | | Abdominal obesity | Waist circumference >40 inches (men) or >35 inches (women) | | Hypertriglyceridemia | ≥150 mg/dL | | Low HDL cholesterol | <40 mg/dL in men | | | <50 mg/dL in women | | Hypertension | Blood pressure ≥130/85 mm Hg | | High fasting glucose | ≥110 mg/dL | aDiagnosis of metabolic syndrome is based on the presence of any 3 of the above 5 features HDL: high-density lipoprotein Source: Reference 4 ### Obesity Tratment * Short-term medication * Phentermine- sympathomimetic/increases satiety * 13 weeks * Dose: 15-37.5 mg PO daily * Side effects: tachycardia, HTN, psychosis * Chronic Medications * Orlistat (Xenical)- blocks the digestion and absorption of fat in the stomach and intestines * Dose: 120 mg PO TID during meals or 1 hour after meals containing fat content * Side effects: flatus w/oily discharge, fecal urgency, fatty stools, fecal incontinence * Lorcaserin (Belviq)- activates 5-HT2C receptors * Dose: 10 mg PO BID * Side effects: hypoglycemia (in diabetic pts), hyperprolactinemia, diarrhea, musculoskeletal pain * Phentermine-topiramate (Qsymia)- sympathomimetic and neurostibilizer; promotes satiety * Dose: 7.5 mg/46 mg PO QAM (start w/half dose x 2 weeks, then increase to prescribed dose) * D/C if less than 5% weight loss after 12 weeks on max dose, taper if at max dose * Naltrexone-bupropion (Contrave) - opioid antagonist and anti- depressant; promotes satiety and suppresses cravings * Dose: 8 mg/90 mg ER 2 tabs PO BID * Depression/suicide screen * Glucagon like peptide-1 agonist (GLP-1) * promotes satiety * Liraglutide (Saxenda) * Dose: Titrated 0.6 mg to 3mg SQ daily SC daily * Tirzepatide (Zepbound) * Dose: Titrated from 2.5mg/wk to 15mg SQ/wk * Semaglutide (Wegovy) * Dose: Titrated from 0.25mg/wk to 2.4 mg SQ/wk * Insulin therapy: * Rapid acting: Lispro, Aspart (15 mins before meal) * Short acting: Regular(HumilinR/Novolin R) (30 mins before meal) * Intermediate acting: NPH (HumilinN/Novolin N) (works for about 16 hrs) taking between meals and at bed time. * Long acting: Gargline {Lantus, Levemir}, Toujeo works (20-24 hrs) * Degludec : Long Acting ( Taking at bed time) * Insulin pump:Humalog, Novolog, Apidra * 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**: administered before or at mealtimes (depending on the formulation) as a rapid-acting (eg, lispro, aspart, glulisine, insulin for inhalation) or short-acting (regular) insulin