primary+care+management+of+metabolic+disease+made+ridiculously+simple

This page has been edited {$pagerevisions} times. The last modification was made by user:{$revisioneditor} on {$revisiondate} Chris Farnitano is totally responsible for this document 150/90: age 60+ __without__ DM or CKD (JNC8 2014) 140/90: all others (JNC8 2014) 120/90: age 50+ __without__ DM or hx of stroke but __with__ either known CVD, GFR<60, 10 year CVD risk >15% or age >75 (Modification based on Sprint 2015) 1 algorithm for all: Increase to Lisinopril/HCT 20/25 1 tab a day Increase to Lisinopril/HCT 20/25 2 tabs a day Increase amlodipine 10 mg 1 tab a day -most patients need more than one med Most patients need a diuretic as second med Fewer pills and doses improves compliance Lower doses of combo pills better tolerated than full doses of single agents Ethnic differences in responses to different classes are minimal once you are on multiple meds Adding spironolactone to patients on 3 drugs already decreases BP by mean of 22/10 Watch for gynecomastia in men with spironolactone Put in problem list “HTN, goal x/90” 1 algorithm for all: Atorvastatin 10-20 mg qd (moderate dose) Only high dose statins are atorvastatin 40+, rosuvastatin 20+ 80mg doses of all statins associated with higher rate of liver test abnormalities, no proven additional benefit over 40 mg atorvastatin Atorvastatin is cheap and covered and potent, no need for any other drug for most patients Rosuvastatin lowers numbers better but no proven mortality advantage, more expensive No non-statin drugs have any proven mortality benefit. Don’t use them. Put in problem list “hyperlipidemia, mod/high dose statin is/is not indicated”
 * Primary care management of metabolic disease made ridiculously simple 7.13.16**
 * Hypertension:**
 * Who to treat (Target BP goals):**
 * What to treat with:**
 * Lisinopril/Hydrochlorothiazide** 10/12.5 mg 1 tab a day
 * Add amlodipine** 5mg 1 tab a day
 * Add spironolactone** 25 mg a day (do not initiate if K+ Is high (>5.1), discontinue if K+ >6.0
 * Teaching points:**
 * Cholesterol:**
 * Who to treat (2013 guidelines):**
 * 1) LDL>190 and >21 years old: use high dose statin
 * 2) Known CVD:
 * 3) Age <75 high dose
 * 4) Age >75 mod dose
 * 5) DM age 40-75 and LDL>70
 * 6) If 10 year risk >/=7.5% high dose
 * 7) If 10 year risk <7.5% mod dose
 * 8) All others if LDL >70 __and__ age 45-75 then calculate 10 year CVD risk using Pooled Cohort Equations
 * 9) If 10 year risk >/=7.5% mod or high dose
 * What to treat with:**
 * Atorvastatin** 40 mg qd (high dose) or
 * Teaching points:**

Goal A1c<7 in young, healthy diabetics, <8 in others 1 algorithm for all (type 2): Metformin 500 mg bid ac, then Metformin 850 mg bid ac, then Metformin 1000 mg bid ac If fasting glucose <120 but A1c still >8 check post prandial glucose. Metformin only* hypoglycemic drug with proven mortality benefit. Do not use glyburide: higher risk of severe hypoglycemia due to renal excretion, long half life Metformin XL does not have fewer side effects, may actually have more Doesn’t matter when to give lantus, just same time each day Above does not apply to Type 1 DM. These are rare in your practice. Consider referring to internal medicine for management. Sliding scales have no role in ambulatory management of diabetes, especially in type 2s Put in problem list “DM2, goal A1c ,7/8”
 * Diabetes Type 2**
 * Who to treat:**
 * What to treat with:**
 * Metformin** 500 mg po qa dinner, increase no more often than weekly (to minimize GI upset):
 * Add glipizide** 5 mg qam, then Increase to 5 mg bid, Increase to 10 mg bid
 * Add long acting insulin** Lantus 10 u qday, increase by 10 units at a time until fasting glucose <120
 * Add short acting insulin** lispro to 1 meal each day where highest post prandial sugars are (or biggest meal). Give lantus and lispro at same time (but different syringes)
 * Consider*** for patients who are not controlled on 100+ units of lantus and or refuse to use insulin:
 * Adding Canagliflozin** (sodium-glucose co-transport inhibitor) as combo pill with metformin: Invokamet 50/1000 bid (covered by CCHP with PA)
 * Teaching points:**
 * One large study showed a mortality benefit with one sodium-glucose co-transport inhibitor (empaglifozin, not canagliflozin) with decreased death from any cause by 32% in patients with known CVD. Causes yeast infections, UTIs, dehydration, patient falls, ketoacidosis, lowers BP 5 points.