Thank you to our pharmacists for a very informative lecture!
Lecture Video: see Class Capture
Lecture Powerpoints: GLP1 Receptor Agonists & DPP4 Inhibitors
When Do I Start These Medications?
Check out: AACE Algorithm for Adding/Intensifying Diabetes Medications
GLP1 Receptor Agonists
Ex: Liraglutide (Victoza®), Exenatide, Dulaglutide (Trulicity®), Abliglutide
- Target multiple organs, not just the pancreas.
- Improve HTN, HLD and can lead to weight loss!
- Low risk of hypoglycemia
- LEADER trial: Liraglutide significantly reduces MACE
- Decrease A1C by 0.5-1.8% on average.
- Long-acting, once weekly versions available
- These versions affect both prandial and basal glucose levels
- Dulaglutide is covered by Health Partners!
- Requires subcutaneous injection
- Can cause mild-moderate nausea (main side effect and the reason you uptitrate the medication)
- Ex: with Liraglutide, if patient misses 3 days, then must restart titration
- Exenatide injector is extremely confusing to use (go for Liraglutide or Dulaglutide instead)
- Contraindicated in patients with h/o pancreatitis, thyroid C cell tumors, significantly renal impairment (varies by drug), severe GI disease
- Expensive if not covered by insurance
DPP4 Inhibitors (the “gliptins”)
Ex: Sitagliptin (Januvia®), Saxagliptin, Linagliptin, Alogliptin
- Well tolerated, weight neutral, low risk of hypoglycemia
- Daily administration
- Lack the systemic effects seen by GLP1 RA
- Only decrease A1C by 0.5-0.9% on average
- Warning for patients with h/o CHF, pancreatitis. May also cause hepatotoxicity, joint pain, hypersensitivity
- Expensive (even the generic alogliptan is $3/dose)
Lecture Video: head to the Lecture Database and click ‘Class Capture’.
Thank you Ajay Rao for giving us an amazing lecture. Here are the highlights:
- Incidence of thyroid storm is less than 10% of patients hospitalized for thyrotoxicosis. Mortality rate can be as high as 20-30%.
- Scoring system- Wartosky/Burch can be used to determine possibility of thyroid storm. Signs/symptoms of weight loss, generalized weakness/fatigue, diarrhea, palpitations, psychosis/confusion. A wide pulse pressure
- Most common cause of thyroid storm is underlying Graves’ Disease.
- Precipitating event like surgery, trauma, MI, VTE, DKA, infection, discontinuation of anti-thyroid drugs can lead to thyroid storm.
- Management in the ICU:
- Halt synthesis: give anti-thyroid drugs, i.e. methimazole or PTU
- Halt release: give iodine therapy no sooner than 30-60 minutes AFTER anti-thyroid therapy
- Halt peripheral effects: beta- blockade
- Give steroids: inhibits peripheral conversion of T4 to T3
- Most patients with severe hypothyroidism present neither with myxedema or coma. Can present with progressive dysfunction of cardiovascular, respiratory and CNS systems.
- Common precipitants include, sepsis, trauma, and surgery.
- Findings include hypothermia, AMS, bradycardia, hypotension, and hyponatremia. Myxedema include swelling of the soft tissue associated with periorbital edema, ptosis, macroglossia or cool, dry skin.
- Careful IV volume repletion
- Hydrocortisone (if pituitary disease or adrenal insufficiency)
- Give a SINGLE high dose of T4 (300-600mcg IV)
- Daily T4 dosing (50-100mcg IV or PO)
Many thanks to Dr McNellis for another amazing lecture!
- BG >200
- Serum/urine ketones
- Ischemia (cerebral, myocardial, etc)
- Catecholamine surge (trauma, surgery, medications: steroids, pseudoephedrine)
- Volume status
- Precipitating causes