What are the goals set by ACE /ACCE and are they written in stone for all patients?
Primary target for glycemic
control is HbA1C
Individualize HbA1C goal -
based on...Duration of
DMAge/life
expectancyComorbid
conditions
Known CVD or advanced
, comorbid
conditionsHypoglycemic
unawareness
Individual patient
considerations
If a medication is removed, consider that it probably will have to be replaced with a
reasonable alternative
,Give this one a try later!
Examples:
SSRIs are a potential cause of ED. A reasonable replacement might be
bupropion (assuming no contraindications)
Dutasteride (for BPH) is a common cause of ED. Tardenafil as a replacement
for or in combination with a 5-alpha reductase might be reasonable
(assuming no contraindications)
What would you recommend if a patient is taking Nexium and Plavix together?
Give this one a try later!
As we have seen through our discussions, there is a lot of information
(including an FDA issued statement in the package insert) describing the
drug interaction and reduced efficacy of clopidogrel if used with a PPI
(primarily omeprazole) (or in patients who are genetically slow CYP2C19
metabolizers); however there is also evidence based information indicating
the interaction is not as significant as originally thought. Bottom line:
Despite pharmacokinetic evidence that omeprazole interferes with
clopidogrel metabolism, COGENT trial found addition of omeprazole to
clopidogrel reduced gastrointestinal events without increasing
cardiovascular events.
Why are thyroid replacement drugs considered to have a narrow therapeutic index (
NTI )and what does that mean clinically?
Give this one a try later!
The therapeutic index (TI) is the range of doses at which a medication is
effective without unacceptable adverse events. Drugs with a narrow TI
(NTIs) have a narrow window between their effective doses and those at
which they produce adverse toxic effects. Oral Bioavailability: (erratic) 40-
80%brand vs generic Highly protein bound (99%)Half-lifeEuthyroid = 6-7
, daysHypothyroid = 9-10 daysSteady State: @ 6 weeks or 4-5 t1/2 's ... this is
the bases for monitoring @ six weeks from start or changes!
Consider changes such as brand to generic, different generics
manufactures, different pharmacies, etcAny such change will require repeat
lab monitoring @ ~ 6 weeks to confirm the same clinical response
Please note when transitioning from oral therapy for type II DM to insulin, metformin
is retained! Secretagogues are discontinued possibly when basal insulin is initiated,
but definitely when prandial (fast/rapid) insulin is to be added
Give this one a try later!
Options to add to basal insulin for prandial coverage...
Fast-acting insulin
DPP-4 inhibitors
Incretin mimetics
Glinides
Alpha-glucosidase inhibitors
Colesevelam
JA has multiple medical problems and is taking several drugs including theophylline,
warfarin and phenytoin. His conditions were well controlled, but recently he started
to experience some GI distress for which of his "well intentioned friends" gave him
some medication. He presents to you with toxic effects of all his other medications
and plasma levels of those medications elevated. What was most likely the medication
he took?
Give this one a try later!
Cimetidine
Primary target for glycemic
control is HbA1C
Individualize HbA1C goal -
based on...Duration of
DMAge/life
expectancyComorbid
conditions
Known CVD or advanced
, comorbid
conditionsHypoglycemic
unawareness
Individual patient
considerations
If a medication is removed, consider that it probably will have to be replaced with a
reasonable alternative
,Give this one a try later!
Examples:
SSRIs are a potential cause of ED. A reasonable replacement might be
bupropion (assuming no contraindications)
Dutasteride (for BPH) is a common cause of ED. Tardenafil as a replacement
for or in combination with a 5-alpha reductase might be reasonable
(assuming no contraindications)
What would you recommend if a patient is taking Nexium and Plavix together?
Give this one a try later!
As we have seen through our discussions, there is a lot of information
(including an FDA issued statement in the package insert) describing the
drug interaction and reduced efficacy of clopidogrel if used with a PPI
(primarily omeprazole) (or in patients who are genetically slow CYP2C19
metabolizers); however there is also evidence based information indicating
the interaction is not as significant as originally thought. Bottom line:
Despite pharmacokinetic evidence that omeprazole interferes with
clopidogrel metabolism, COGENT trial found addition of omeprazole to
clopidogrel reduced gastrointestinal events without increasing
cardiovascular events.
Why are thyroid replacement drugs considered to have a narrow therapeutic index (
NTI )and what does that mean clinically?
Give this one a try later!
The therapeutic index (TI) is the range of doses at which a medication is
effective without unacceptable adverse events. Drugs with a narrow TI
(NTIs) have a narrow window between their effective doses and those at
which they produce adverse toxic effects. Oral Bioavailability: (erratic) 40-
80%brand vs generic Highly protein bound (99%)Half-lifeEuthyroid = 6-7
, daysHypothyroid = 9-10 daysSteady State: @ 6 weeks or 4-5 t1/2 's ... this is
the bases for monitoring @ six weeks from start or changes!
Consider changes such as brand to generic, different generics
manufactures, different pharmacies, etcAny such change will require repeat
lab monitoring @ ~ 6 weeks to confirm the same clinical response
Please note when transitioning from oral therapy for type II DM to insulin, metformin
is retained! Secretagogues are discontinued possibly when basal insulin is initiated,
but definitely when prandial (fast/rapid) insulin is to be added
Give this one a try later!
Options to add to basal insulin for prandial coverage...
Fast-acting insulin
DPP-4 inhibitors
Incretin mimetics
Glinides
Alpha-glucosidase inhibitors
Colesevelam
JA has multiple medical problems and is taking several drugs including theophylline,
warfarin and phenytoin. His conditions were well controlled, but recently he started
to experience some GI distress for which of his "well intentioned friends" gave him
some medication. He presents to you with toxic effects of all his other medications
and plasma levels of those medications elevated. What was most likely the medication
he took?
Give this one a try later!
Cimetidine
