Chapter 30: Endocrine and Metabolic Disorders

Population

• –Adults.

Recommendations

AACE 2009

• –Recommends clinical, biochemical, and radiographic evaluation for evidence of hypercortisolism, aldosteronism, the presence of pheochromocytoma, or a malignant tumor.

• –Patients who will be managed expectantly should have reevaluation at 3–6 mo and then annually for 1–2 y.

Source

• –https://www.aace.com/files/adrenal-guidelines.pdf

Comments

1. A 1-mg overnight dexamethasone suppression test can be used to screen for hypercortisolism.

2. Measure plasma-fractionated metanephrines and normetanephrines to screen for pheochromocytoma.

3. Measure plasma renin activity and aldosterone concentration to assess for primary or secondary aldosteronism.

Population

• –Adult men.

Recommendations

Endocrine Society 2018

• –Obtain an AM total testosterone level for men with symptoms and signs of androgen deficiency.^a

• –Confirm diagnosis with a second AM total testosterone level.

• –Measure a serum luteinizing hormone (LH) and follicular stimulating hormone (FSH) in all men with testosterone deficiency to distinguish between primary and secondary hypogonadism.

• –Obtain a dual-energy x-ray absorptiometry (DEXA) scan for all men with severe androgen deficiency.

• –Testosterone therapy is indicated for androgen deficiency syndromes unless contraindications exist.^b

Source

• –https://academic.oup.com/jcem/article/103/5/1715/4939465

Comment

1. Testosterone therapy options: (treatment goal is to obtain a total testosterone level in mid-normal range)

   1. Testosterone enanthate or cypionate: 150–200 mg IM every 2 wk, or 75–100 mg IM weekly.

   2. Testosterone transdermal patch: 4–6 mg daily.

   3. Testosterone 1% gel: 50–100 mg daily.

   4. Testosterone 2% gel: 10–70 mg daily.

   5. Testosterone 2% solution: 60–120 mg (2–4 pumps or twists) applied to the axillae daily.

   6. Testosterone buccal bioadhesive tablets: 30 mg to buccal mucosa q12h.

   7. Testosterone nasal gel: 11 mg (2 pump actuations, 1 actuation per nostril) TID.

Population

• –Pediatric and adult patients with Cushing’s syndrome.

Recommendations

Endocrine Society 2015

• –Treatment goals for Cushing’s syndrome

  • Normalize cortisol levels to eliminate the signs and symptoms of CS.

  • Monitor and treat cortisol-dependent comorbidities

• –Recommend vaccinations against:

  • Influenza, herpes zoster, pneumococcus

• –Recommend perioperative thromboprophylaxis for venous thromboembolism.

• –Recommend surgical resection of primary adrenal or ectopic focus underlying CS.

• –Assess postoperative serum cortisol levels.

Source

• –www.endocrine.org/guidelines-and-clinical-practice/clinical-practice-guidelines/treatment-of-cushing-syndrome

Population

• –Hospitalized adults older than 18 y with diabetic foot problems.

Recommendations

IDF 2017: Diabetic Foot Infections

• –Assess arterial perfusion and need for revascularization.

• –Debride callus and necrotic tissue to fully visualize wound, measure depth and extent.

• –Obtain cultures: tissue or bone specimen preferred; deep swab only after debriding wound.

• –Obtain x-ray of all new diabetic foot infections.

• –Obtain MRI if osteomyelitis suspected and plain film is not diagnostic.

• –Request surgical consult for deep abscesses, compartment syndrome, and necrotizing soft tissue infection.

• –Treat clinically infected wounds with antibiotics:

  • 1–2 wk for mild-to-moderate infections.

  • 3 wk for more serious skin and soft tissue infections.

  • 6 wk for osteomyelitis.

Source

–https://www.idf.org/e-library/guidelines/119-idf-clinical-practice-recommendations-on-diabetic-foot-2017.html

Comment

1. A deep space infection may have deceptively few superficial signs.

NICE 2016

• –Every hospital should have a multidisciplinary foot care team to assess and treat any diabetic patient with foot problems.

• –Every patient with a diabetic foot problem should undergo an assessment for:

  • Need for debridement, pressure off-loading.

  • Vascular inflow.

  • Infection of the foot.

  • Glycemic control.

  • Neuropathy.

• –If diabetic foot infection is suspected, obtain culture (soft tissue or bone sample preferred, or deep swab after debriding wound).

• –If osteomyelitis is suspected, obtain an x-ray; if x-ray is normal, obtain an MRI.

• –Provide off-loading for diabetic foot ulcers.

• –For mild diabetic foot infections, treat with empiric antibiotics that provide good coverage of gram-positive organisms.

• –For moderate-to-severe diabetic foot infections, treat with empiric antibiotics that provide coverage of gram-positive, gram-negative, and anaerobic bacteria.

Source

• –https://www.nice.org.uk/guidance/ng19

Comments

1. The diabetic foot care team should include:

   1. Diabetologist.

   2. Surgeon with expertise managing DM foot problems.

   3. DM nurse specialist.

   4. Podiatrist.

   5. Tissue viability nurse.

   6. Biomechanic and orthotic specialist.

2. Unless part of a clinical trial, do not treat diabetic foot ulcers with:

   1. electrical stimulation therapy, autologous platelet-rich plasma gel, regenerative wound matrices, dalteparin,

   2. growth factors,

   3. hyperbaric oxygen therapy.

Population

• –Pregnant women.

Recommendations

ACOG 2018

• –Treat all women with gestational diabetes with nutrition therapy and exercise.

• –For pharmacologic therapy of GDM, insulin is preferred (start at 0.7–1.0 units/kg/d); metformin may be a reasonable alternative.

• –Counsel women with GDM and estimated fetal weight of 4500 g or more regarding the option of scheduled cesarean delivery vs. vaginal trial of labor.

• –Instruct women with GDM to follow fasting and 1 h postprandial glucose levels.

• –Start antepartum fetal testing at 32 wk gestational age in women with poorly controlled or medication-requiring GDM and no other comorbidities. It may be reasonable to start surveillance earlier if other comorbidities are present.

• –Unless otherwise indicated, do not induce women with GDM who are well-controlled by diet and exercise (A1GDM) before 39 wk. Expectant management until 40-6/7 wk is appropriate; antepartum fetal testing may not be necessary unless other comorbidities are present.

• –Screen all women with GDM with a 75 g 2 h-GTT 4–12 wk after delivery.

Source

• –https://www.scribd.com/document/371228843/190-Gestational-Diabetes-Mellitus-Agog

Population

• –Nonpregnant adults.

Recommendations

American Thyroid Association 2016

• –The etiology of thyrotoxicosis should be determined. If the diagnosis is not apparent, consider obtaining a thyroid receptor antibody level (TRAb) +/− determination of the radioactive iodine uptake (RAIU).

• –Beta-adrenergic blockade is recommended in all patients with symptomatic thyrotoxicosis.

• –Patients with overt Graves’ hyperthyroidism should be treated with either radioiodine (RAI) therapy, antithyroid drugs (ATDs), or thyroidectomy.

• –A pregnancy test should be obtained within 48 h prior to treatment in any woman with childbearing potential who is to be treated with RAI.

• –Recheck a T4, T3, and TSH level in 4–8 wk after RAI therapy.

• –Prior to initiating ATD therapy for Graves’ disease (GD), we suggest that patients have a baseline complete blood count with differential (CBCD), and a liver profile.

• –Obtain a CBCD for patients on ATD therapy with a febrile illness or a sore throat.

• –If near-total or total thyroidectomy is chosen as treatment for GD, patients should be rendered euthyroid prior to the procedure with ATD pretreatment, with beta-adrenergic blockade. Potassium iodide should be given in the immediate preoperative period.

• –Wean beta-blockers following thyroidectomy.

• –Thyroid multinodular goiters or thyroid adenomas with hyperthyroidism should be treated with surgery or RAI.

• –Subclinical hyperthyroidism should be treated in all individuals ≥65 of age, and in patients with cardiac disease, osteoporosis, or symptoms of hyperthyroidism when the TSH is persistently <0.1 mU/L.

Source

• –2016 American Thyroid Association guidelines for diagnosis and management of hyperthyroidism and other causes of thyrotoxicosis.Thyroid. 2016;26(10):1343-1421.

AACE 2013

• –Radioactive iodine uptake scan should be performed when the etiology of thyrotoxicosis is unclear.

• –β-blockade should be prescribed to elderly patients and considered for all patients with symptomatic thyrotoxicosis.

• –Graves’ disease.

  • Options for Graves’ disease treatment:

    • ¹³¹I therapy.

    • Antithyroid medications.

    • Thyroidectomy.

• –Patients with Graves’ disease and increased risk of complications should be pretreated with beta-blockers and possibly methimazole prior to¹³¹I therapy.

  • Advise smoking cessation.

  • Graves’ ophthalmopathy should have steroids and ¹³¹I therapy.

• –¹³¹I therapy.

  • Verify a negative pregnancy test on female patients within 48 h of administering ¹³¹I therapy.

  • Assess patients 1–2 mo after ¹³¹I therapy with a free T₄and total triiodothyronine (T₃) level; repeat q 4–6 wk if thyrotoxicosis persists.

  • Consider retreatment with ¹³¹I therapy if hyperthyroidism persists 6 mo after ¹³¹I treatment.

• –Antithyroid drug therapy.

  • Methimazole is the preferred antithyroid drug except during the first trimester of pregnancy.

  • Obtain a CBD with differential and hepatic function panel prior to initiating ATD therapy.

  • Educate patients on the signs and symptoms of agranulocytosis and hepatic injury.

  • Obtain a CBC with differential whenever a patient taking antithyroid drugs develops a febrile illness or pharyngitis.

  • Recommend measurement of TSH receptor antibody level prior to stopping antithyroid drug therapy.

• –Thyroidectomy.

  • Indicated for toxic multinodular goiter or toxic adenoma.

  • Render patient euthyroid with methimazole prior to thyroidectomy.

  • Wean beta-blockers postoperatively.

  • Follow serial calcium or intact PTH levels postoperatively.

  • Start levothyroxine 1.6 μg/kg/d immediately postoperatively.

  • Check a serum TSH level 6–8 wk postoperatively.

• –Thyroid storm should be treated in the ICU with β-blockers, antithyroid drugs, inorganic iodide, corticosteroid therapy, volume resuscitation, and aggressive cooling with acetaminophen and cooling blankets.

Source

• –https://www.aace.com/files/hyperguidelinesapril2013.pdf

Population

–Nonpregnant adults.

Recommendations

AACE 2012

• –Replacement dosing of levothyroxine is 1.6 μg/kg/d.

  • Initiate replacement with 50 μg/d in patients over 50–60 y without CAD.

• –Check antithyroid peroxidase antibodies (TPOAb) in patients with subclinical hypothyroidism or recurrent miscarriages.

• –Treat hypothyroid patients with levothyroxine if:

  • TSH >10 mIU/L.

  • TSH < 10 mIU/L and:

    • Symptomatic.

    • Positive TPOAb.

    • History of ASCVD or at high risk for these conditions.

• –Avoid overtreatment with levothyroxine to minimize risk of cardiovascular, skeletal, or affective disturbances.

• –Monitor TSH 4–8 wk after starting levothyroxine or adjusting dose, then q 6–12 mo once euthyroid.

• –Levothyroxine monotherapy is recommended.

• –Do not use levothyroxine to treat obesity or depression in euthyroid patients.

Source

• –https://www.aace.com/files/hypothyroidism_guidelines.pdf

Population

• –Adults.

Recommendations

EAU 2018

• –Testosterone testing should be considered in men with:

• • Pituitary masses.

  • Obesity.

  • Metabolic syndrome.

  • Moderate-to-severe COPD.

  • Infertility.

  • Osteoporosis.

  • HIV infection.

  • DM type 2.

  • Chronic use of corticosteroids and/or opiates.

  • Signs and symptoms of hypogonadism

    • Reduced testis volume.

    • Gynecomastia.

    • Decreased lean body mass and muscle strength.

    • Decreased body/facial hair.

    • Erectile dysfunction.

    • Reduced libido.

    • Changes in mood and/or cognitive function.

    • Fatigue, decreased stamina/endurance.

• –Diagnose hypogonadism if morning total testosterone level is less than 300 mg/dL on two separate occasions.

  • Measure LH and FSH to differentiate between primary and secondary hypogonadism.

• –Indications for testosterone treatment are patients with low testosterone and:

  • Symptoms of hypogonadism.

  • Delayed puberty.

  • Klinefelter syndrome.

  • Sexual dysfunction not responding to PDE5Is.

  • Low bone mass.

  • Hypopituitarism.

• –Contraindications to testosterone use:

  • Locally advanced or metastatic prostate cancer.

    • May consider treatment in men with symptomatic hypogonadism, treated for localized prostate cancer with no evidence of active disease.

  • Male breast cancer.

  • Men who desire fertility in the near term.

  • Hematocrit >54%.

  • Severe CHF (NYHA Class IV).

• –Monitor clinical response to therapy, testosterone level, PSA, digital prostate exam, and hematocrit 3, 6, and 12 mo after starting therapy, and annually thereafter.

Source–https://uroweb.org/guideline/male-hypogonadism/

AUA 2018

• –Diagnose hypogonadism when morning total testosterone level is less than 300 mg/dL on two separate occasions and patient has symptoms of hypogonadism.

• –Measure luteinizing hormone (LH) if testosterone level is low.

  • If LH is low/low-normal in the setting of low testosterone, check a prolactin level.

• –Measure serum estradiol in testosterone-deficient patients who present with breast symptoms or gynecomastia prior to the commencement of testosterone therapy.

• –Obtain a hemoglobin and hematocrit (and PSA in men over 40 y) prior to initiating testosterone therapy.

  • Educate patients about the risk of polycythemia.

• –Testosterone therapy should not be commenced for a period of 3–6 mo in patients with a history of cardiovascular events.

• –Adjust testosterone therapy dosing to achieve a total testosterone level in the middle tertile of the normal reference range.

• –Educate patients on the risk of transference with topical testosterone gels/creams.

• –Consider stopping testosterone therapy after 3–6 mo in patients who normalize total testosterone levels but fail to achieve improvement in clinical signs or symptoms.

Source

–http://www.auanet.org/guidelines/testosterone-deficiency-(2018)#x7697

Population

• –Menopausal women.

Recommendations

AACE 2017

• –Indications for menopausal hormone therapy:

  • Severe menopausal symptoms.

  • Severe vulvovaginal atrophy.

  • Treatment of osteoporosis.

• –Cautions with menopausal hormone therapy:

  • Avoid unopposed estrogen use in women with an intact uterus.

  • Micronized progesterone is considered the safer alternative for women needing progesterone.

  • Consider transdermal or topical estrogens which may reduce the risk of VTE.

  • Use hormonal therapy in the lowest effective dose for the shortest duration possible.

  • Custom-compounded bioidentical hormone therapy is not recommended.

  • Hormone replacement is not appropriate for prevention or treatment of dementia, diabetes, or cardiovascular disease (CVD).

  • Avoid if at high risk for VTE.

• –Contraindications of menopausal hormone therapy:

  • History of breast CA.

  • Suspected estrogen-sensitive malignancy.

  • Undiagnosed vaginal bleeding.

  • Endometrial hyperplasia.

  • History of VTE.

  • Untreated hypertension.

  • Active liver disease.

  • Porphyria cutanea tarda.

Source

• –www.aace.com/files/position-statements/ep171828ps.pdf

Comments

1. Use of hormone therapy should always occur after a thorough discussion of the risks, benefits, and alternatives of this treatment with the patient.

2. SSRIs or gabapentin may offer relief of menopausal symptoms for women at high risk from hormone replacement therapy.

   1. Do not use paroxetine or fluoxetine in breast cancer patients as they inhibit the effect of tamoxifen.

Recommendations

NICE 2015

• –Consider short-term (<5 y) hormone replacement therapy (HRT) for:

  • Severe vasomotor symptoms.

  • Menopause-related depression.

  • Poor libido.

  • Urogenital atrophy.

• –Consider adjuvant testosterone therapy for decreased libido despite HRT.

• –Offer vaginal estrogen cream for urogenital atrophy (even if already on systemic estrogen).

Source

• –https://www.nice.org.uk/guidance/ng23/chapter/Recommendations#managing-short-term-menopausal-symptoms

Comments

1. Review risks of HRT before initiating:

   1. Venous thromboembolism (VTE): the risk is greater for oral than transdermal preparations.

   2. HRT with estrogen and progestrogen may slightly increase risk of breast cancer, but declines after stopping HRT.

2. Review benefits of HRT:

   1. Risk of fragility fracture is decreased while taking HRT but this benefit decreases once treatment stops.

Recommendations

Endocrine Society 2015

• –Recommends HRT for severe vasomotor symptoms in women less than 60 y who do not have excess cardiovascular or breast cancer risk.

• –Recommends nonhormonal remedies for women at high risk of CVD or breast cancer.

  • Options include a SSRI, SNRI, gabapentin, or pregabalin.

  • Clonidine is an option for women with severe vasomotor symptoms who do not respond to or tolerate nonhormonal modalities.

• –For women at moderate risk of CVD, recommend transdermal estradiol and micronized progesterone for severe vasomotor symptoms.

• –Recommends vaginal estrogen cream for urogenital atrophy unless history of a hormone-dependent cancer.

• –Consider ospemifene trial for moderate-to-severe dyspareunia (except in women with a history of breast cancer).

Source

• –https://www.endocrine.org/guidelines-and-clinical-practice/clinical-practice-guidelines/treatment-of-menopause

Population

• –Children and adults with Type I DM

Recommendations

ADA 2018

• –Recommends intensive insulin therapy with >3 injections daily using either basal and prandial insulin or an insulin pump.

• –Self-monitoring of blood glucose (SMBG) at least 4 times daily in all patients using multiple insulin injections or an insulin pump.

• –Continuous glucose monitoring in both children and adults results in lower HbA1c levels.

• –Recommends assessment of psychological and social situation as part of diabetic evaluation.

• –Blood pressure goal in children is <90th percentile for age, sex, and height. Confirm elevated BP on 3 separate occasions. If not at goal within 3–6 mo of initiating lifestyle intervention, consider starting medication (angiotensin-converting enzyme inhibitors [ACEIs] or angiotensin receptor blockers [ARBs] are preferred).

• –Advise all patients not to smoke.

• –Begin screening at age 10, at onset of puberty, or after 5 y with Type 1 DM, whichever is earlier:

  • Urine albumin-to-creatinine ratio annually.

  • Dilated funduscopic exam q 1–2 y.

  • Monofilament screening for diabetic neuropathy annually.

  • Comprehensive foot examination at least annually.

• –Screen for other autoimmune conditions at time of diagnosis of Type 1 DM

  • Celiac disease: IgA tissue transglutaminase antibodies. If negative, rescreen 2 and 5 y after DM diagnosis.

  • Thyroid dysfunction: TSH, thyroperoxidase and thyroglobulin antibodies.

• –Fasting lipid panel at age 10 or at onset of puberty, whichever is earlier (consider as early as age 2 y for a strong family history of hyperlipidemia).

  • Repeat annually if results are abnormal or every 5 y if results are acceptable (LDL <100 mg/dL).

• –Consider statin therapy if age ≥10 y and LDL ≥160 mg/dL, or LDL ≥ 130 mg/dL and one or more CVD risk factors.

• –Aspirin 75–162 mg/d for adults with:

  • 10-yr risk of CVD >10% (primary prevention).

  • Pre-existing CVD (secondary prevention).

Source

• –http://care.diabetesjournals.org/content/41/Supplement_1/S126

Comments

1. Glycemic control recommendations for children and adolescents:

   1. Before meals, capillary blood glucose (CPG) 90–130 mg/dL.

   2. Bedtime, CPG 90–150 mg/dL.

   3. HgbA1c <7.5%.

Population

• –Adults with type 1 diabetes.

Recommendations

NICE 2016

• –Do not routinely confirm diagnosis of Type 1 DM by checking C-peptide levels or auto-antibody testing.

  • Consider doing so only if diagnosis is uncertain.

• –Provide all adults with DM 1 a structured education program.

• –Offer carbohydrate counting education.

• –Offer peer support groups.

• –Counsel women of childbearing potential on implications for pregnancy and family planning.

• –Measure glycohemoglobin every 3–6 mo.

  • Fructosamine level is an alternative test for anemic patients.

• –Recommend self-glucose monitoring at least 4 times daily.

• –Glucose targets are:

  • 90–126 mg/dL fasting.

  • 72–126 mg/dL before meals.

  • 90–162 mg/dL 90 min after meals.

  • HbA1c ≤ 6.5%.

• –Basal insulin

  • Insulin detemir bid is preferred.

  • Daily insulin glargine is acceptable if BID detemir isn’t acceptable or tolerated.

• –Recommend rapid-acting prandial insulin analogs (vs. human or animal insulin) before meals.

• –Educate patients on prevention and management of hypoglycemia and hyperglycemia, including DKA.

• –Consider referral for islet cell transplantation in those with recurrent severe hypoglycemia.

• –Screen adults with low BMI for celiac disease.

• –Measure a TSH annually.

• –Recommend therapy with ACEI or ARB for patients with hypertension or diabetic nephropathy.

• –Offer digital retinopathy screening annually.

• –Offer men with DM 1 and erectile dysfunction a phosphodiesterase-5 inhibitor.

• –Do not offer aspirin for primary prevention of CVD to adults with Type 1 DM.

Source

• –https://nice.org.uk/guidance/ng17

Population

• –Nonpregnant adults.

Recommendations

AACE/ACE 2018

• –Lifestyle optimization is essential for all patients with diabetes but should not delay starting pharmacotherapy.

• –Weight loss: reduced-calorie meal plan, physical activity, behavioral intervention, consider weight-loss medication.

• –HbA1c target ≤6.5% is optimal, but higher targets may be appropriate for patients who are older and with other serious illness.

• –Minimize the risk of hypoglycemia; individualize both fasting and post-prandial glucose targets.

• –Control lipids and blood pressure.

• –Metformin is first-line medication but combination therapy is usually necessary—choose agents with complementary mechanisms of action.

• –Monitor therapy Q 3 mo until stable (HbA1c, SMBG records, weight, BP, lipids).

Source

• –https://www.aace.com/sites/all/files/diabetes-algorithm-executive-summary.pdf

Population

• –Adults.

Recommendations

ADA 2018

• –Self-monitoring blood glucose ≥3 times daily in all patients using multiple insulin injections or an insulin pump.

• –Recommends HgbA1c every 3 mo if therapy has changed or if blood glucose control is inadequate.

• –Provide diabetes self-management education, including education about hypoglycemia management and adjustments during illness.

• –Provide family planning for women of reproductive age.

• –Provide medical nutrition therapy.

• –Weight loss is recommended for all overweight or obese diabetic patients.

• –Keep saturated fat intake <7% of total calories.

• –Reduction of protein intake to 0.8–1.0 g/kg/d for early stages of CKD and 0.8 g/kg/d for later stages of CKD.

• –Recommends at least 150 min/wk of moderate physical activity.

• –The glucose range for critically ill patients is 140–180 mg/dL.

• –The glucose range for noncritically ill patients in the hospital is <140 mg/dL premeal (<7.8 mmol/L) and random blood glucose <180 mg/dL (<10 mmol/L).

• –Recommends the following:

  • Immunizations

    • Annual influenza vaccination if age ≥6 mo.

    • Pneumococcal polysaccharide vaccine if age >2 y.

    • Revaccinate with pneumococcal polysaccharide vaccine when age ≥65 y and > 5 y since first dose.

    • Hepatitis B vaccination if unvaccinated and age 19–59 y.

  • Target BP <130/80 mm Hg.

  • Statin therapy if:

    • Overt CVD present.

    • Age >40 y and ≥1 CV risk factor.

    • LDL >100 mg/dL despite lifestyle modification.

    • LDL >70 mg/dL if DM2 and overt CVD.

  • ASA 75–162 mg/d if:

    • Primary prevention of CVD if 10-y risk of CAD >10%.

    • Secondary prevention of CVD.

  • Check annually:

    • Urine albumin-to-creatinine ratio.

    • Serum creatinine.

    • Fasting lipid profile.

    • Dilated funduscopic exam.

    • Monofilament screening for diabetic neuropathy.

    • Comprehensive foot exam.

• ​​​​Source

• –https://professional.diabetes.org/sites/professional.diabetes.org/files/media/dc_40_s1_final.pdf

Comments

1. Glycemic control recommendations:

   1. Preprandial glucose: 70–130 mg/dL.

   2. Postprandial glucose: <180 mg/dL (1–2 h postmeals).

   3. HgbA1c <7%.

2. Consider bariatric surgery if BMI ≥40 kg/m² (≥37.5 kg/m² in Asian Americans), or ≥35 kg/m² and diabetes is difficult to control with lifestyle modification and medications.

3. ACEIs or ARBs are first-line antihypertensives.

4. Second-line antihypertensives are a calcium channel blocker, or thiazide diuretic if GFR ≥30 mL/min/1.73 m² or a loop diuretic if GFR <30 mL/min/1.73 m².

5. Clopidogrel 75 mg/d is an alternative for persons ASA intolerant.

6. Nephrology referral indicated if GFR <60 mL/min/1.73 m², or if heavy proteinuria or structural kidney disease present.

7. Consider a serum TSH in women age >50 y.

8. Consider assessing patients for the following comorbidities that are increased with DM:

   1. Hearing impairment.

   2. Obstructive sleep apnea.

   3. Fatty liver disease.

   4. Low testosterone in men.

   5. Periodontal disease.

   6. Cognitive impairment.

Population

• –Adults older than 18 y.

Recommendations

International Diabetes Federation 2017

• –General target for HbA1c in Type 2 diabetes (T2D) is <7%; up to 8% may be appropriate in patients with <10 y life expectancy.

• –SMBG is mandatory for patients using insulin, and useful when adjusting medications, during acute illness, as an education tool for self-care.

• –Patient education is a cornerstone to diabetes management and should, at a minimum, involve the PCP, a trained diabetic educator, and a structured education program.

• –Lifestyle recommendations include: weight loss, exercise (150 min/wk), a high-fiber, low-glycemic index foods diet and smoking cessation.

• –Consider anti-obesity drugs in T2D patients with BMI ≥ 27 kg/m².

• –Encourage smoking cessation and limiting alcohol intake.

• –Consider referral to bariatric surgery in T2D patients with BMI ≥35 kg/m², or BMI 30–35 kg/m² who have not responded to regular treatment.

• –Pharmacotherapy:

  • Metformin is preferred choice for monotherapy.^a

  • Considering starting two agents if the HbA1c is 1%–2% or more above target.

    • Combination therapy should be metformin plus sulfonylurea (SU),^b DPP4 inhibitor, SGLT2 inhibitor,^c or GLP1 receptor agonist.^d

• –BP goal is 130–140/80; SBP of 130 is recommended in younger patients and those with CV risk or microvascular disease.

  • Start with an ACEI or ARB; add a calcium channel blocker or a thiazide diuretic if needed.

  • An ACEI or ARB should also be started if the patient has microalbuminuria in the absence of high BP.

• –Prescribe a high-intensity statin for patients with:

  • T2D and established CVD (secondary prevention).

  • T2D without CVD who are > 40 y with LDL > 100 mg/dL (primary prevention).

• –Start low-dose aspirin (75–350 mg/d) in patients with T2D and CVD (secondary prevention).

• –Additional recommendations:

  • Screen for depression (eg, PHQ-2).

  • Retina screening every 1–2 y with retinal photography.

  • Annual urine microalbumin-to-creatinine ratio.

    • Annual serum creatinine and eGFR if albuminuria or HTN is present.

  • Annual monofilament foot exam for peripheral neuropathy.

  • Frequent foot exams at office visits.

  • Screen for peripheral vascular disease by checking foot pulses and/or calculating the ankle/brachial index.

  • Routine screening for CAD is not recommended for asymptomatic patients.

  • T2D patients who observe Ramadan should interrupt their fast if SMBG is <70 or >300. High-risk patients are advised not to fast at all.

^aTitrate metformin from 500 to 2000 mg/d to minimize GI side effects.

^b When starting an SU, the patient must learn how to prevent, recognize, and treat hypoglycemia.

^c SGLT2 inhibitors reduce major cardiovascular events in patients with T2D and are preferred in patients with CVD.

^d GLP1 RA can be used if weight loss is a priority and the drug is affordable.

Source

• –International Diabetes Federation. Recommendations For Managing Type 2 Diabetes In Primary Care, 2017. www.idf.org/managing-type2-diabetes

Population

• –Hospitalized adults older than 18 y.

Recommendations

AAFP 2017

• –Avoid intensive insulin therapy in hospitalized patients (even if in SICU/MICU).

• –Recommends a target blood glucose level of 140–180 mg/dL if insulin therapy is used in hospitalized patients, especially those who are critically ill.

• –Either basal insulin or basal plus bolus correctional insulin may be used in the treatment of hospitalized patients; sliding scale regimens are no longer recommended.

Source

• https://www.aafp.org/journalpdfrestricted/afp/2017/1115/p648.pdf

Comment

1. Intensive insulin therapy in SICU/MICU patients does not improve mortality, but has a 5-fold increased risk of hypoglycemia.

Population

• –Children and adolescents with newly diagnosed DM2.

Recommendations

AAP 2013

• –Insulin therapy should be initiated for children with:

  • Diabetic ketoacidosis.

  • HbA1c >9%.

  • Random glucose >250 mg/dL.

• –Diet, exercise, and metformin are initial therapy for other situations.

• –Recommend moderate-to-vigorous exercise for 60 min daily.

• –Limit nonacademic screen time to <2 h/d.

• –Monitor HbA1c every 3 mo.

• –Desire HbA1c <7%.

Source

• –pediatrics.aappublications.org/content/131/2/364.full.pdf

–Prolonged metformin use can lead to vitamin B₁₂ deficiency. SGLT-2 inhibitors are favored over sulfonylureas as an add-on to metformin in terms of cardiovascular mortality.

Sources

• –https://professional.diabetes.org/sites/professional.diabetes.org/files/media/dc_40_s1_final.pdf and Inzucchi SE et al. Diabetes Care. 2015;38:140–149.

• –Qaseem A, Barry MJ, Humphrey LL, Forciea MA; Clinical Guidelines Committee of the American College of Physicians. Oral pharmacologic treatment of type 2 diabetes mellitus: a clinical practice guideline update from the American College of Physicians. Ann Intern Med. 2017;166(4):279-290.

Population

• –All patients with or suspected of having serum cobalamin and folate deficiency.

Recommendations

BCSH 2014

• –Serum cobalamin <200 ng/L is consistent with cobalamin deficiency.

• –Patients with normal cobalamin level but high suspicion of cobalamin and/or folate deficiency should have their methylmalonic acid (MMA) and total homocysteine (tHC) levels measured.

• –Patients with cobalamin deficiency or unexplained anemia, neuropathy, or glossitis (regardless of cobalamin level) should have an anti-intrinsic factor antibody test to rule out pernicious anemia.

• –Initial therapy for cobalamin deficiency is vitamin B₁₂ 1 mg IM TIW for 2 wk and then maintenance therapy.

• –Maintenance therapy is either 1 mg IM every 3 mo (if no neurologic symptoms) or every 2 mo (if neurologic symptoms) or vitamin B₁₂ 2 mg PO daily.

• –Serum folate level <7 nmol/L (<3 μg/L) indicates folate deficiency.

• –Treatment of folate deficiency is 1–5 mg po daily for 1–4 mo, or until folate level normalizes.

Source

• –onlinelibrary.wiley.com/doi/full/10.1111/bjh.12959

Comments

1. Recommends against anti-parietal cell antibody to test for pernicious anemia.

2. Both MMA and tHC will be elevated in cobalamin deficiency; normal MMA and elevated tHC are consistent with folate deficiency.