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- Addison's (low cortisol and aldosterone): Cosyntropin stimulation tests - 250 mcg IV
then cortisol in 60 minutes
- Glucocorticoid excess: Dexamethosone suppression test
Screening
Unclear when asymptomatic persons should be screened. ADA wants to test at age 45 and
q3y thereafter -- seems a bit excessive. Screen if risk factors including: non-Euro (Euros
seem relatively resistant - possibly due to selection pressure), FH or hx GDM or
macrosomia, obesity.
Diagnosis and Classification.
See Diagnosis and
Classification of Diabetes Mellitus New Criteria - Oct 15, 1998 - AFP.
Any one of the following on two different days makes diagnosis. Screening criteria for
GDM is very controversial -- esp. what cutoff value to use.
| test |
normal |
diabetes |
impaired glucose tolerance |
gestational (GDM) |
| post-prandial (50 gm glu load) |
|
|
|
>= 140 indicates need for OGTT, some advocate a lower
threshhold of 130. Less than 130 rules out GDM -- consider using risk adjusted criteria. |
| random glucose (with symptoms?) |
|
> 200 |
|
|
| fasting glucose |
< 110 |
>= 126 mg/dl |
110-125 |
|
| post-prandial (75 gm glu load) |
< 140 |
>= 200 |
140-199 |
|
| post-prandial (50 gm glu load) |
|
|
|
>= 140 indicates need for OGTT, some advocate a lower
threshhold of 130. Less than 130 may r/o GDM -- consider using risk adjusted criteria.
Currently skip this and do OGTT if PMH GDM. |
| OGTT 100 gm (US) |
|
|
|
Exceed any two of four
- baseline: 105
- 1 hr: 190
- 2 hr: 165
- 3 hr: 145
|
| OGTT 75 gm (WHO) |
|
|
|
Exceed 165 2 hours after load. |
Oral Agents
Oral Agents in the Management of
Type 2 Diabetes Mellitus - May 2001 - AFP
Type II DM is in part a disorder of excessive insulin, but most treatments act to
increase insulin levels or activity. Only metformin (biguanide) lacks the side effect of
weight gain; arguably only it treats the real disorder.
biguanide - insulin sensitizer
- start with metformin (Glucophage)
- dominant initial agent, arguably first medication to treat underlying disorder in type
II DM
- no hypoglycemia when used as single agent
- rare s/e of lactic acidosis (phenformin, first in this class, removed from US market in
1970s). Seems to increase with renal failure, so must have Cr < 1.4, avoid use with dye
that might bump Cr.
- second generation: glipizide (Glucotrol), glyburide (Diabeta)
- first generation: chlorpropamide (Diabinase) - out of favor due to side effects, CV
worries -- rarely used
- greatest benefit at less than half maximal dose (no reason to exceed
that level), works only for about 25% of type II DM
- can combine with biguanide
meglitinides
- repaglinide (Prandin), nateglinide (Starlix -- some say Starlix is an amino acid
derivative)
- insulin secretagogues, very much like sulfonylureas
but shorter half-life (hence better suited to use with meals)
- can combine with sulfonylurea to really flog that pancreas
alpha-glucosidase inhibitors
- acarbose (Precose), miglitol (Glyset)
- diarrhea, bloating, flatulence, etc.
- not enormously popular with patients
thiazidalinediones
- pioglitazone (Actos), rosiglitazone (Avandia)
- insulin sensitizers, can be added to metformin, help with insulin resistance
- low risk of hypoglycemia
- side effect of weight gain, strange edema problems, worries about
hepatotoxicity - troglitazone pulled from market -- not first line drugs
Combined Oral/Insulin
- for patients who ‘just’ fail oral
- metformin with sulfonylurea or metformin with thiazidalinediones
- NPH insulin before bedtime (bw < 150% of ideal), or 70/30 before supper (bw > 150%
of ideal)
- start with insulin 10-15 units, increase 5-10 units q1-2 weeks
- 2005 goals are significantly tighter than 2000 goal. These may be as tight as we can
safely go -- tighter controls had poor results in 2007 studies:
- preprandial glu < 90-130
- postprandial < 180
Insulin Notes
- NPH and regular do not interact when mixed
- Lente insulins are stable when mixed in any ratio and do not interact with each other
- Regular and Lente insulins CANNOT be combined (they delay onset of action of regular)
Insulin Resistant Patients
- may get severe hypoglycemia with exercise (faster release of depot insulin): eat
beforehand!
Exercise Evaluation
| type |
synonyms |
comments |
| chronic lymphocytic |
Hashimoto's |
- most common cause goiter in US, 95% women, typical age 40, high level antithyroid
microsomal or peroxidase antibodies.
- not acute
|
| subacute lymphocytic |
postpartum, sporadic painless |
- postpartum: thyrotoxic phase at 6w to 6m postpartum, then hypothyroid 1 y pp. About 25%
remain hyopthyroid. High anti-mitochondrial antibody.
|
| subacute granulomatous |
de Quervain's |
- most common cause of diffusely swollen painful thyroid
- viral: EB, coxsackie, adeno -- usually preceded by URI, esp. women age 40-50 in
summer/fall
- T4>T3, initially hyperthyroid with low TSH
- RAIU is low vs Graves disease where RAIU is high
- thyroglobulin elevated
- pain for 3-6 weeks, then hypothyroid, 95% recover thyroid function
- can treat with prednisone if no improvement in 1 week (40-60 mg/day over 4-6 wks)
|
| microbial inflammatory (suppurative) |
suppurative, acute |
- rare, usually pt has pre-existing nodular goiter
- fine needle aspiration, Gram stain and culture
|
| invasive fibrous |
Riedel's struma |
|
- Inderal is primary initial therapy. Start with 20-40 mg PO q6h, effective dose may be @
80 mg PO q6h.
- Inderal's half-life may be too short for q6h dosing in this setting. Some instead dose
Inderal LA q6h.
Author: John G. Faughnan.
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