endocrine med 2010 step2
TRANSCRIPT
Endocrine DiseaseEndocrine Disease
ApiradeeApiradee SriwijitkamolSriwijitkamol, MD, MDDivision of Endocrinology and MetabolismDivision of Endocrinology and Metabolism
Department of MedicineDepartment of MedicineFaculty of Medicine Faculty of Medicine SirirajSiriraj HospitalHospital
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TopicTopic
Thyroid diseaseThyroid diseaseDMDM
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TopicTopic
Thyroid diseaseThyroid diseaseDMDM
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Hypothalamus
TRH
Pituitary
TSH
Thyroid
T4 T3T4-TBG T3-TBG
+
-
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Case 1Case 1
•• 66 year old lady66 year old lady•• Presents with:Presents with:
•• DepressionDepression•• MyalgiaMyalgia•• Weight gainWeight gain
•• On Examination:On Examination:•• Slow relaxing reflexesSlow relaxing reflexes•• Sinus Sinus bradycardiabradycardia•• BMI 32BMI 32•• Swelling on the anterior aspect of the neckSwelling on the anterior aspect of the neck
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Case 1Case 1
•• What is the diagnosis?What is the diagnosis?
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Case 2Case 2
•• 36 year old lady36 year old lady•• Presents with:Presents with:
•• Weight lossWeight loss•• DyspneaDyspnea on exertionon exertion•• PalpitationPalpitation
•• On Examination:On Examination:•• Diffuse thyroid enlargementDiffuse thyroid enlargement•• Sinus tachycardia, warm moist skinSinus tachycardia, warm moist skin•• ExophthalmosExophthalmos
For 6 months
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Case 2Case 2
•• What is the diagnosis?What is the diagnosis?
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Case 3Case 3
•• 36 year old lady36 year old lady•• Presents with:Presents with:
•• Weight lossWeight loss•• DyspneaDyspnea on exertionon exertion•• PalpitationPalpitation
•• On Examination:On Examination:•• Thyroid nodule 2 cm at right lobeThyroid nodule 2 cm at right lobe•• Sinus tachycardia, warm moist skinSinus tachycardia, warm moist skin•• No No exophthalmosexophthalmos, no , no pretibialpretibial myxedmeamyxedmea
For 2 months
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Case 3Case 3
•• What is the diagnosis?What is the diagnosis?
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Tiredness / malaiseMental slownessReduced appetiteConstipationSensitivity to drugs Cold intolerance
/ Hypothermia
Change in appearanceAnaemiaHeart failureHypertensionBradycardiaDyspnoea
HYPOTHYROIDISM
Signs & Symptoms :-
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Aetiology
Thyroid TissueLoss or Atrophy
AutoimmunePost SurgeryPost IrradiationInfiltration
Decreased HormoneSynthesisDecreased Thyroxin Production
Primary (90%)
Dysfunction ofPituitary Gland
Tumour orsurgery
Decreased TSHProduction
Secondary (<10%)
Dysfunction ofHypothalamus
Decreased TRHProduction
Tertiary (Rare)
HYPOTHYROIDISM
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Serum T4 or fT4
Below Normal
Primary HypothyroidismSecondary HypothyroidismTertiary Hypothyroidism
DIAGNOSIS
HYPOTHYROIDISM
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Serum TSH
Above Normal
Primary Hypothyroidism Secondary HypothyroidismTertiary Hypothyroidism
Below Normal
DIAGNOSIS
HYPOTHYROIDISM
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Thyroxin replacementGoal:
Primary hypothyroidism:Normalized TSH
Secondary hypothyroidism:T4 in upper half of normal limit
HYPOTHYROIDISM
Treatment
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Highly successful in bringing patients back to normal metabolic stateTherapy continues for lifeCaution when commencing treatment- risk of MI
Patients observed for signs of• Angina• ECG changes• Dyspnoea• Palpitations• Arrythmias
HYPOTHYROIDISM
Treatment
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Weight loss (but normal appetite)
Sweating; heat intoleranceFatiguePalpitation; sinus
tachycardia or atrial fibrilationAngina; Heart failure (high
output)Agitation; tremor
THYROTOXICOSIS
Generalised muscle weakness
DiarrhoeaRapid bounding pulseShortness of breathWarm moist skinInsomnia
Signs & Symptoms :-
Excess of the thyroid hormone resulting in an hypermetabolic state
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THYROTOXICOSIS
Hyperthyroidism Other causes ofthyrotoxicosis
-Graves’ disease-Toxic multinodular goiter
Increase uptake
Antithyroid drug+Ablative treatment
-Subacute thyroiditis-Excessive iodine intake-Thyrotoxicosis factitious-Struma ovarii
Decrease uptake
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Definition:-
"Excessive secretion of the thyroid hormone resulting in an hypermetabolic state.....".
Incidence:-
2 - 5% of all females between age of 30-50 yrsMale / female: 1 : 7Can be precipitated by a life 'crisis'
HYPERTHYROIDISM
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Aetiology
HYPERTHYROIDISM
Secondary (Rare)
Over Secretion by Pituitary Tumor
Increased TSHProduction
Increased ThyroxinProduction
Thyroid TissueDisease
Autoimmune(Graves’ Disease)
Thyroid Stimulating Antibodies
IncreasedStimulation of TSH Receptors
Increased ThyroxinProduction
Primary (99%)
Thyroid nodule(Toxic adenoma)
Autonomous
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HyperthyroidismHyperthyroidism
Weight loss (but normal appetite)
Sweating; heat intoleranceFatiguePalpitation; sinus
tachycardia or atrial fibrilationAngina; Heart failure (high
output)Agitation; tremor
Generalised muscle weakness
DiarrhoeaRapid bounding pulseShortness of breathWarm moist skinInsomnia
Signs & Symptoms :-
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Thyroid Acropachy
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Lid Lag
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GravesGraves’’ Disease Disease -- EyesEyes
ExopthalmosProptosisSIRIRA
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Periorbital MyxoedemaSIRIRA
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Pretibial Myxedema
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Serum T3, T4 and free T3,T4
Above Normal
Primary HyperthyroidismSecondary Hyperthyroidism
Diagnosis
HYPERTHYROIDISM
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Serum TSH
Below Normal
Primary Hyperthyroidism
Secondary Hyperthyroidism
Above Normal
Diagnosis
HYPERTHYROIDISM
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Treatment :-
Highly successful in bringing patients back to normal metabolic state
Long term follow-upTreatment:
Anti-Thyroid drugsRadioiodineThyroidectomy
PartialTotal
HYPERTHYROIDISM
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Treatment :-
Anti-Thyroid drugsDose:
Start: PTU 150-300 mg/day or Methimazole 15-30 mg/day
Maintain: taper dose as clinical and laboratory results
Duration: 1 ½ - 2 yearsSide effects
Minor: RashMajor: Agranulocytosis, hepatitis
HYPERTHYROIDISM
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Treatment :-
Ablative treatmentIndication:
Failure to medicationRelapse or recurrentMajor drug adverse reactionPatient with underlying heart diseaseToxic adenoma
Options:Radioactive iodineSurgery
HYPERTHYROIDISM
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THYROIDTHYROIDNODULENODULE
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FINE NEEDLE ASPIRATION
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FINE NEEDLE ASPIRATION
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FINE NEEDLE ASPIRATION
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Case 1Case 1
•• 66 year old lady66 year old lady•• Presents with:Presents with:
•• DepressionDepression•• MyalgiaMyalgia•• Weight gainWeight gain
•• On Examination:On Examination:•• Slow relaxing reflexesSlow relaxing reflexes•• Sinus Sinus bradycardiabradycardia•• BMI 32BMI 32•• Swelling on the anterior aspect of the neckSwelling on the anterior aspect of the neck
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Case 1Case 1
•• What is the diagnosis?What is the diagnosis?
Hypothyroidism
FT4 and TSHThyroid antibodySIR
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Case 2Case 2
•• 36 year old lady36 year old lady•• Presents with:Presents with:
•• Weight lossWeight loss•• DyspneaDyspnea on exertionon exertion•• PalpitationPalpitation
•• On Examination:On Examination:•• Diffuse thyroid enlargementDiffuse thyroid enlargement•• Sinus tachycardia, warm moist skinSinus tachycardia, warm moist skin•• ExophthalmosExophthalmos
For 6 months
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Case 2Case 2
•• What is the diagnosis?What is the diagnosis?
Hyperthyroidism: Graves’ disease
T3, T4 and TSH
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Case 3Case 3
•• 36 year old lady36 year old lady•• Presents with:Presents with:
•• Weight lossWeight loss•• DyspneaDyspnea on exertionon exertion•• PalpitationPalpitation
•• On Examination:On Examination:•• Thyroid nodule 3 cm at Thyroid nodule 3 cm at lefttleftt lobelobe•• Sinus tachycardia, warm moist skinSinus tachycardia, warm moist skin•• No No exophthalmosexophthalmos, no , no pretibialpretibial myxedmeamyxedmea
For 2 months
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Case 3Case 3
•• What is the diagnosis?What is the diagnosis?
Thyrotoxicosis: Toxic adenomaExogenous thyroid
T3, T4 and TSHThyroid scanSIR
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Thyroid scanThyroid scan
Toxic adenomaSIRIRA
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TopicTopic
Thyroid diseaseThyroid diseaseDMDM
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Diagnostic criteria for diabetesDiagnostic criteria for diabetes
≥≥20020022--h post glucose loadh post glucose load
Symptom of DM + Casual plasma Symptom of DM + Casual plasma ≥≥200200GlucoseGlucose
≥≥126126FastingFasting**Diabetes mellitusDiabetes mellitus
VenousVenous Plasma Glucose Plasma Glucose concentration, mg dlconcentration, mg dl--11
*Repeat in different day
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Classification of DiabetesClassification of Diabetes
Type 1 DiabetesType 1 DiabetesType 2 DiabetesType 2 DiabetesGestational DiabetesGestational DiabetesOther typesOther types–– Endocrine diseaseEndocrine disease–– Chronic pancreatitisChronic pancreatitis–– MalnutritionMalnutrition--related diabetes mellitus related diabetes mellitus
(MRDM)(MRDM)
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Case 1Case 1
3939--year old woman came to year old woman came to see you because see you because polyuriapolyuria, , polydipsiapolydipsia and and nocturianocturia 4 4 times/night.times/night.PE BP 130/90 mmHg, other PE BP 130/90 mmHg, other as in figureas in figureYou ordered BG stat (11am) You ordered BG stat (11am) and it was 230 mg/dland it was 230 mg/dl
Diagnosis Diabetes
Cause of DiabetesCushing’s syndromeSIR
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Advice
Blood pressure
Cholesterol
DN screening
Eye Examination
Feet Care
Guardian Drugs
Diabetes Care:Diabetes Care:THE ALPHABET STRATEGYTHE ALPHABET STRATEGY
AlphabetStrategy
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Conclusion:Conclusion:The Modified Alphabet StrategyThe Modified Alphabet Strategy
•• AAdvicedvice Smoking , diet , exerciseSmoking , diet , exercise•• BBlood pressure lood pressure << 130/80130/80•• CCholesterol holesterol LDL LDL ≤≤ 100100•• DDiabetes control iabetes control HbA1c HbA1c ≤≤ 7%7%•• DDN screeningN screening Annual examination Annual examination •• EEye examination ye examination Annual examinationAnnual examination•• FFeet examination eet examination Annual examinationAnnual examination•• GGuardian drugs uardian drugs Aspirin, ACEI, Aspirin, ACEI, statinsstatinsSIR
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Case 2Case 2Mr. M,46Mr. M,46--yr old man came to you for check upyr old man came to you for check upHe had no underlying disease without any He had no underlying disease without any symptoms of hyperglycemiasymptoms of hyperglycemiaSmoking and drinking occasionallySmoking and drinking occasionallyOn physical examination, his blood pressure On physical examination, his blood pressure was 130/90 mmHg and his BMI was 31 kg/m2, was 130/90 mmHg and his BMI was 31 kg/m2, others were unremarkableothers were unremarkableHis lab investigation were followed, FPG 155 His lab investigation were followed, FPG 155 mg/dl, CH 250 mg/dl, TG 200 mg/dl, HDL 40 mg/dl, CH 250 mg/dl, TG 200 mg/dl, HDL 40 mg/dl, LDL 170 mg/dlmg/dl, LDL 170 mg/dl1 week later, his FPG was 150 mg/dl, HbA1c 1 week later, his FPG was 150 mg/dl, HbA1c was 7.5%was 7.5%
Type 2 diabetes, HT, Combined dyslipidemia, Obesity
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Advice
Blood pressure
Cholesterol
DN screening
Eye Examination
Feet Care
Guardian Drugs
Diabetes Care:Diabetes Care:THE ALPHABET STRATEGYTHE ALPHABET STRATEGY
AlphabetStrategy
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Initiation of antihypertensive treatment
Lifestyle changes + drug treatment
Lifestyle changesDiabetes
Lifestyle changes + immediate drug treatment
Lifestyle changes + immediate drug treatment
Lifestyle changes + immediate drug treatment
Lifestyle changes + immediate drug treatment
Lifestyle changes + immediate drug treatment
Established CV or renal disease
Lifestyle changes + immediate drug treatment
Lifestyle changes + drug treatment
Lifestyle changes + drug treatment
Lifestyle changes and consider drug treatment
Lifestyle changes
3 or more risk factors, MS, OD or diabetes
Lifestyle changes + immediate drug treatment
Lifestyle changes for several weeks then drug treatment if BP uncontrolled
Lifestyle changes for several weeks then drug treatment if BP uncontrolled
Lifestyle changes
Lifestyle changes
1-2 risk factors
Lifestyle changes + immediate drug treatment
Lifestyle changes for several weeks then drug treatment if BP uncontrolled
Lifestyle changes for several months then drug treatment if BP uncontrolled
No BP intervention
No BP intervention
No other risk factors
Grade 3 HT SBP ≥180 or DBP ≥110
Grade 2 HTSBP 160-179 or DBP 100-109
Grade 1 HTSBP 140-159 or DBP 90-99
High normal SBP 130-139 or DBP 85-89
Normal SBP 120-129 or DBP 80-84
Other risk factors, OD or disease
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Antihypertensive Treatment: Preferred DrugsAntihypertensive Treatment: Preferred DrugsGeneral rules: lower SBP and DBP to goal. Use any effective agent at adequate doses, if useful in combination. Use long acting agents to lower BP throughout 24 hours. Avoid or minimize adverse effects.
Subclinical organ damage Left ventricular hypertrophy ACE inhibitors, calcium antagonists,
angiotensin receptor antagonists Asymptomatic atherosclerosis Calcium antagonists, ACE inhibitors Microalbuminuria ACE inhibitors, angiotensin receptor antagonists Renal dysfunction ACE inhibitors, angiotensin receptor antagonists
Clinical event Previous stroke Any BP lowering agent Previous MI β-blockers, ACE inhibitors, angiotensin receptor antagonistsAngina pectoris β-blockers, calcium antagonists
Heart failure diuretics, β-blockers, ACE inhibitors, angiotensin receptor antagonists, antialdosterone agents
Atrial fibrillation Recurrent ACE inhibitors, angiotensin receptor antagonists Continuous β-blockers, non-dihydropiridine calcium antagonists
Renal failure/proteinuria ACE inhibitors, angiotensin receptor antagonists, loop diureticsPeripheral artery disease Calcium antagonists
Condition Isolated systolic hypertension (elderly) Duretics, calcium antagonists Metabolic syndrome ACE inhibitors, angiotensin receptor antagonists, calcium
antagonists Diabetes mellitus ACE inhibitors, angiotensin receptor blockerPregnancy calcium antagonists, methyldopa, β-blockers Blacks diuretics, calcium antagonistsSIR
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Diabetes Control
Advice
Blood pressure
Cholesterol
DN screening
Eye Examination
Feet Care
Guardian Drugs
Diabetes Care:Diabetes Care:THE ALPHABET STRATEGYTHE ALPHABET STRATEGY
AlphabetStrategy
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NCEP ATP III: LDLNCEP ATP III: LDL--C GoalsC Goals(2004 Modifications)(2004 Modifications)
Grundy SM et al. Circulation 2004;110:227-239.
High Risk
CHD or CHD risk equivalents
(10-yr risk >20%)
LD
L-C
level
100
160
130
190
Lower Risk
< 2 risk factors
Moderately High Risk
≥ 2 risk factors
(10-yr risk 10-20%) goal
160mg/dL
goal
130mg/dL
70 -
goal
100 mg/dL
Moderate Risk
≥ 2 risk factors
(10-yr risk <10%)
goal
130 mg/dL
Existing LDL-C goals
Proposed LDL-C goals
*CHD risk equivalents = DM, PAD, Stroke, CKD
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Major Risk FactorsMajor Risk Factors
Cigarette smokingCigarette smokingHT: BP HT: BP ≥≥140/90 mmHg or on antihypertensive agent140/90 mmHg or on antihypertensive agentLow HDLLow HDL--C (<40 mg/C (<40 mg/dLdL))††
Family history of premature CHDFamily history of premature CHD–– CHD in male first degree relative <55 yearsCHD in male first degree relative <55 years–– CHD in female first degree relative <65 yearsCHD in female first degree relative <65 years
Age (men Age (men ≥≥45 years; women 45 years; women ≥≥55 years)55 years)
† HDL-C ≥60 mg/dL counts as a “negative” risk factorSIRIRA
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or optional
70 mg/dL*
or optional
100 mg/dL*
NCEP ATP III: NCEP ATP III: 2004 Modifications2004 ModificationsHigh Risk
CHD or CHD risk equivalents
(10-yr risk >20%)
LD
L-C
level
100
160
130
190
Lower Risk
< 2 risk factors
Moderately High Risk
≥ 2 risk factors
(10-yr risk 10-20%) goal
160mg/dL
goal
130mg/dL
70 -
goal
100 mg/dL
Moderate Risk
≥ 2 risk factors
(10-yr risk <10%)
goal
130 mg/dL
Existing LDL-C goals
Proposed LDL-C goals
* And other clinical forms of atherosclerotic disease.# very high risk category = established CVD plus multiple major risk factors (especially diabetes), severe and poorly controlled risk factors (e.g. cigarette smoking), metabolic syndrome (TG > 200 mg/dL + non-HDL-C >130 mg/dL with HDL-C < 40 mg/dL]), and acute coronary syndromes.
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Eye Examination
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Diabetes Care:Diabetes Care:THE ALPHABET STRATEGYTHE ALPHABET STRATEGY
AlphabetStrategy
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Oral hypoglycemic drugsOral hypoglycemic drugsInsulin Insulin secretagoguesecretagogue–– Sulfonylurea: Sulfonylurea: glibenclamideglibenclamide, , glipizideglipizide, ,
gliclazidegliclazide–– GlinideGlinide groupgroupBiguanideBiguanide: : metforminmetforminαα--GlucosidaseGlucosidase InhibitorInhibitor: : acarboseacarbose, , voglibosevogliboseThiazolidinedionesThiazolidinediones: : RosiglitazoneRosiglitazone, , plioglitazoneplioglitazoneIncretinIncretin
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Glucose
Biguanides
Insulin
α-glucosidase inhibitors
Thiazolidinediones
Sulphonylureas and meglitinides
DPP-4
GLP-1
DPP-4 inhibitors
GLP-1 analogues
Primary sites of action of oral Primary sites of action of oral antianti--diabetic agentsdiabetic agents
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ITC-1. Annals of Int Med. 2007
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InsulinInsulinIntermediate actingIntermediate acting: NPH, : NPH, HumulinHumulin N, N, InsulatardInsulatardShort actingShort acting: RI, : RI, HumulinHumulin R, R, ActrapidActrapidPremixed insulinPremixed insulin: : HumulinHumulin 70/30, 70/30, MixtardMixtard 3030Rapid actingRapid acting: Insulin : Insulin lisprolispro, , aspartaspartLong acting insulinLong acting insulin: Insulin : Insulin glargineglargine, , determirdetermir
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ระยะเวลาหลังฉีดยาอินซูลิน (ชั่วโมง)4 8 12 16 20 24
RegularNPH
GlargineDetemir
AspartLispro
การออกฤทธิ์ของอินซูลินการออกฤทธิ์ของอินซูลิน
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ADA/EASD 2008 guidelineADA/EASD 2008 guideline
Nathan DM, et al. Diabetes care 2008; 31:1-11.
At diagnosisLifestyle
modification + metformin
Lifestyle + metformin+
basal insulin*HbA1c >8.5%
Lifestyle + metformin+
PioglitazoneNo hypoglycemiaCHF, Bone loss
Lifestyle + metformin+
Intensify insulin
Lifestyle + metformin+
GLP-1 agonistNo hypogly, Wt loss
Nausea vomitting
Lifestyle + metformin+
sulfonylurea
Step 1 Step 2 Step 3
Lifestyle + metformin+
basal insulin
Lifestyle + metformin+
Pioglitazone+
sulfonylurea
Tier 1: Well-validated core therapies
Tier 2: Lesswell-validatedtherapies
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ThaiThai’’s guideline for management of T2DMs guideline for management of T2DM
FPG <200 mg/dl orHbA1c <8%
FPG 200-300 mg/dl
FPG 250-350 mg/dl orHbA1c >9%
FPG >300 mg/dl orHbA1c >11% or
Symptomatic hyperglycemia
Lifestyle modification1-3 months
Life
styl
e m
odifi
catio
nC
oncu
rren
t with
med
icat
ion Monotherapy
Combination OHA
Insulin therapy
Metformin or SulfonylureaOther: TZDs, Glinide, AGI
or DPP-IV inhibitor
Basal or Premixed or MDI
Insulin resistance phenotype
Insulin defiiciencyphenotype
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Approach to patient with poor Approach to patient with poor glycemicglycemic controlcontrol
Diet historyDiet historyExercise historyExercise historyCompliance historyCompliance historyConcurrent medicationConcurrent medication–– Herbal medicineHerbal medicine–– SteroidSteroid–– Diuretics, betaDiuretics, beta--blockerblockerOccult infectionOccult infectionSIR
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Diabetes Control
Advice
Blood pressure
Cholesterol
DN screening
Eye Examination
Feet Care
Guardian Drugs
Diabetes Care:Diabetes Care:THE ALPHABET STRATEGYTHE ALPHABET STRATEGY
AlphabetStrategy
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Screening for Diabetic Screening for Diabetic NephropathyNephropathy
1American Diabetes Association: Nephropathy in Diabetes (Position Statement). Diabetes Care 27 (Suppl.1): S79-S83, 2007
Test When Normal Range
BloodPressure 1
Each office visit <130/80 mm/Hg
UrinaryAlbumin 1
Type 2: Annuallybeginning at diagnosisType 1: Annually, 5 -yearspost -diagnosis
<30 mg/day<30 μg/mg creatinine
CreatinineClearance1
Annually >90 ml/min per 1.73m2 BSA
GFR = ([140-age] X weight in kg) X 0.85 (if female)
(serum creatinine X 72)
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Definitions of abnormalities in Definitions of abnormalities in albumin secretionalbumin secretion
1American Diabetes Association: Nephropathy in Diabetes (Position Statement). Diabetes Care 28 (Suppl.1): S3-41, 2008
Category Spot collection
Normal <30
μg/mg creatinine
Microalbuminuria
Macroalbuminuria
30-299
>300
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Stage of CKDStage of CKD
1American Diabetes Association: Nephropathy in Diabetes (Position Statement). Diabetes Care 28 (Suppl.1): S3-41, 2008
Stage GFR
1
2
3
4
5
ml/min per 1.73m2 BSA
>90
60-89
30-59
15-29
<15 or dialysis
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Advice
Blood pressure
Cholesterol
DN screening
Eye Examination
Feet Care
Guardian Drugs
Diabetes Care:Diabetes Care:THE ALPHABET STRATEGYTHE ALPHABET STRATEGY
AlphabetStrategy
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Diabetic footDiabetic foot
Inspection:Inspection:–– DeformityDeformity–– Dryness or cracks in Dryness or cracks in
the skinthe skin–– WoundWound–– GangreneGangrene–– CallusCallus–– Toe nail Toe nail
Hallux valgusSIRIRA
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Diabetic footDiabetic foot
PulsePulse–– DorsalisDorsalis pedispedis pulse pulse –– Posterior Posterior tibialtibial pulsepulse–– PoplitealPopliteal–– FemoralFemoral
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Diabetic footDiabetic footMonofilament Monofilament –– โดยใหผูปวยหลับตาโดยใหผูปวยหลับตา กดปลายกดปลาย
monofilament monofilament ที่แขนผูปวยกอนที่แขนผูปวยกอนเพื่อใหผูปวยรูวาจะรูสึกอยางไรเพื่อใหผูปวยรูวาจะรูสึกอยางไร
–– ใหผูปวยหลับตาใหผูปวยหลับตา กดปลายกดปลาย monofilament monofilament ใหตั้งฉากกับฝาเทาใหตั้งฉากกับฝาเทา ใหให monofilamentmonofilament โคงงอเล็กนอยโคงงอเล็กนอยประมาณประมาณ 11--1.5 1.5 วินาทีวินาที
–– ตรวจครบตรวจครบ 10 10 จุดจุด ดังรูปดังรูป โดยตรวจโดยตรวจตําแหนงละตําแหนงละ 33 ครั้งครั้ง ((ถาตอบถูกถาตอบถูก 2 2 ในใน 3 3 ครั้งครั้ง == OKOK))
–– ถามวาผูปวยรูสกึหรือไมถามวาผูปวยรูสกึหรือไม
Loss of protective sense = จากการตรวจ monofilament ผูปวยไม
รูสึกถงึแรงกดมากกวา 4 จดุใน 10 จดุทีต่รวจ
Loss of protective sense = จากการตรวจ monofilament ผูปวยไม
รูสึกถงึแรงกดมากกวา 4 จดุใน 10 จดุทีต่รวจ SIRIRA
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Diabetic footDiabetic footVibrationVibration–– เลือกใชสอมเสียงขนาดเลือกใชสอมเสียงขนาด 128 Hz128 Hz
–– แสดงใหผูปวยทราบวาอาการสั่นเปนอยางไรแสดงใหผูปวยทราบวาอาการสั่นเปนอยางไร โดยวางโดยวางสอมเสียงที่ถูกทําใหสั่นที่กระดูกสอมเสียงที่ถูกทําใหสั่นที่กระดูก sternumsternum
–– ตรวจผูปวยขณะที่ผูปวยหลับตาตรวจผูปวยขณะที่ผูปวยหลับตา
–– วางสอมเสียงที่ปุมกระดูกวางสอมเสียงที่ปุมกระดูก distal distal interpharyngealinterpharyngeal joint joint ของนิ้วหัวแมเทาของนิ้วหัวแมเทา ตรวจทั้งตรวจทั้ง 22 ขางขาง
–– ถามผูปวยวารูสึกสั่นหรือไมถามผูปวยวารูสึกสั่นหรือไม และใหบอกทันทีเมื่อหยุดและใหบอกทันทีเมื่อหยุดสั่นสั่น จะไดจะได 2 2 คําตอบคําตอบ ทําขางละทําขางละ 2 2 ครั้งครั้ง นับเปนนับเปน 1 1 รอบรอบ เมื่อเมื่อทําครบทําครบ 1 1 รอบรอบ ใหทําซ้ําใหครบใหทําซ้ําใหครบ 2 2 รอบรอบ
–– ถาตอบผิดมากกวาถาตอบผิดมากกวา 5 5 ในใน 8 8 ครั้งของแตละขางแสดงวาครั้งของแตละขางแสดงวาขางนั้นมีขางนั้นมี peripheral neuropathyperipheral neuropathy
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Advice foot careAdvice foot care
DailyDaily feetfeet inspectioninspection,, includingincluding areasareas betweenbetween thethetoestoesIfIf visionvision isis impairedimpaired,, peoplepeople withwith diabetesdiabetes shouldshould notnotattemptattempt theirtheir ownown footfoot carecareRegularRegular washingwashing ofof feetfeet withwith carefulcareful dryingdrying,, especiallyespeciallybetweenbetween thethe toestoesWaterWater temperaturetemperature –– alwaysalways belowbelow 37C37CDoDo notnot useuse a a heaterheater oror a a hothot--waterwater bottlebottle toto warmwarmyour feetyour feetUseUse ofof lubricatinglubricating oilsoils oror creamscreams forfor drydry skinskin -- butbut notnotbetweenbetween thethe toestoes
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Advice foot careAdvice foot care
AvoidanceAvoidance ofof barefootbarefoot walkingwalking indoorsindoors ororoutdoorsoutdoors andand ofof wearingwearing ofof shoesshoes withoutwithoutsockssocksDailyDaily inspectioninspection andand palpationpalpation ofof thethe insideinside ofofthethe shoesshoesDoDo notnot wearwear tighttight shoesshoes oror shoesshoes withwith roughroughedgesedgesDailyDaily changechange ofof sockssocksWearingWearing ofof stockingstocking withwith seamsseams insideinside outout ororpreferablypreferably withoutwithout anyany seamsseamsNeverNever wearwear tighttight oror kneeknee--highhigh sockssocks
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Advice foot careAdvice foot careCuttingCutting nailsnails straightstraight acrossacrossChemicalChemical agentsagents oror plastersplasters totoremoveremove cornscorns andand callusescalluses -- shouldshouldnotnot bebe usedusedCornsCorns andand callusescalluses -- shouldshould bebe cutcutbyby a a healthcarehealthcare providerproviderPatientPatient awarenessawareness ofof thethe needneed totoensureensure thatthat feetfeet areare examinedexaminedregularlyregularly byby a a healthcarehealthcare providerproviderNotifyingNotifying thethe healthcarehealthcare providerprovider atatonceonce ifif a a blisterblister,, cutcut,, scratchscratch oror soresorehashas developeddeveloped
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ConclusionConclusion
What type of diabetes he/she has?What type of diabetes he/she has?What is the goal for this patient?What is the goal for this patient?We should correct and take care everything We should correct and take care everything according to alphabet strategyaccording to alphabet strategyWhich medication suitable for this patient?Which medication suitable for this patient?According to guidelineAccording to guidelineDoes she/he have any contraDoes she/he have any contra--indication for this indication for this medication?medication?Lifestyle modification is the fundamental Lifestyle modification is the fundamental management of diabetesmanagement of diabetesSIR
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Diabetes Control
Advice
Blood pressure
Cholesterol
DN screening
Eye Examination
Feet Care
Guardian Drugs
Diabetes Care:Diabetes Care:THE ALPHABET STRATEGYTHE ALPHABET STRATEGY
AlphabetStrategy
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TopicTopic
Thyroid diseaseThyroid diseaseDMDMEndocrine emergencyEndocrine emergency
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Thank youThank youSIRIRA
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