General Practice and beyond

Start with Metformin 500 mg once a day to maximum 1000 mg twice a day; take with meals; hold if CrCl< 30 ml/min/1.73 m2. If HbA1C target not reached after 3 months, add one of- - Sulfonylureas: Glimepiride 1 mg to max 4 mg/day, with breakfast or first main meal of the day. Beware in elderly patient as risk of hypoglycemia - SGLT2 inhibitor: Empagliflozin 10 mg once daily in the morning, with or without food. Prefer in patients with ASCVD, heart failure or diabetic kidney disease. - DPP-4 Inhibitor: Linagliptin 5 mg once daily, may be administered with or without food. Linagliptin can be used without dose adjustment in renal impairment, including ESRD. - Thiazolidinediones: Pioglitazone 15 to 30 mg once daily; may be administered without regards to meal; beneficial in NAFLD. Serious side effects include worsening heart failure, increase bone fracture risk.  If HbA1C target not reached after 3 months, add another drug of different group from the above list as per patient comorbidi...

 Non-critically ill patient Hyperglycemia if blood glucose > 140 mg/dl Treatment recommended if glucose levels persistently >=180 mg/dl HbA1c needed for all admitted patients with diabetes or hyperglycemia ( blood glucose >= 140 mg/dl ) if not performed in the prior 3 months.  Oral anti-diabetic agents typically discontinued during acute illness Sliding Scale insulin alone is not appropriate to treat sustained hyperglycemia Basal Bolus regimen- a. Basal insulin ( long acting )                                                 b. Mealtime prandial bolus insulin ( short acting)                                              c. Correction insulin Initial Dosing: - 1st step is to estimate pa...

Insulin Indication : Patients with DM-2 with HbA1c >10% or on 3 medicines with HbA1c > goal on 2 occasions, 3 months apart  HbA1C goal- Generally < 7%, but consider < 8% if old age, decreased life expectancy, risk of hypoglycemia   Initiation - Start basal insulin ( 0.1-0.2 mg/kg/day ), safe to start Glargine 10 units HS, increase by 2 units every 3rd night until Fasting Blood sugar < 130 mg/dl The patient can be started with basal insulin 20 units if BMI > 30 and all blood sugars > 200 mg/dl ( Continue Metformin or other agents based on cost, complexity ) If basal insulin required is > 0.5 units/kg/day,  or HbA1C > goal and postprandial hyperglycemia despite fasting sugar at goal,   1. Add 1 rapid acting insulin injection before largest meal: 4 units insulin/meal, increase by 2 units   every 3rd day until postprandial blood glucose < 180 mg/dl. ( Discontinue sulfonylurea before starting prandial insulin ). Add prandial glucose...

  Primary prevention  - Make treatment decisions based on 10 year ASCVD clinical risk calculation ( http://tools.acc.org/ASCVD-Risk-Estimator-Plus ) -  In all patients of Diabetes aged 40 to 75 years, start a moderate dose statin regardless of estimated 10 year risk. - In age 40-75 years without diabetes, if LDL-C ≥ 70 mg/dl at ASCVD risk >7.5%, start moderate intensity statin therapy. - In age 20-75 years with LDL-C ≥ 190 mg/dl, offer maximally tolerated statin therapy - Add Ezetimibe to maximally tolerated statin therapy in adults who have diabetes and a 10-year risk of ≥ 20% to reduce LDL-C levels by ≥ 50% -Add PCSK9 inhibitor in 40 to 75 years of age with baseline LDL-C level  ≥ 220 mg per dL and who achieve an on-treatment LDL-C level of ≥ 130 mg per dL while receiving maximally tolerated statin and ezetimibe therapy/   Secondary Prevention - For secondary prevention, use at least a moderate-dose statin as the mainstay of treatment - Initiate or cont...

Common Brands in Nepal : Sunaulo Gulab, Ovral L, Nilocon White Standard Composition :  Levonorgestrel 0.15 mg/ Ethinyl Estradiol 0.03 mg . One cycle contains 21 hormonal tablets and 7 Iron tablets First discuss with the female about its benefits including non contraceptive benefits like improvement in menorrhagia, dysmenorrhea, anemia, pre-menstrual syndrome, acne, hirsutism.  Also talk about possible risks like Hypertension, Venous Thromoboembolic conditions, MI - Confirm the female is not pregnant - Obtain Blood Pressure - Review Past Medical History for Contraindications- Uncontrolled HTN, History of VTE, advanced DM, Migraine with aura, Known ASCVD, Cirrhosis - Obtain smoking history ( Not given in smokers more than 35 years of age ) Initiation Plan:  - Quick start: Take 1st Pill as soon as prescription filled, need backup contraception for 7 days - 1st day start: Take 1st Pill on 1st day of period, backup contraception not needed - Sunday start: Take 1st Pill on Su...

a. Kocher Method- Traction, External Rotation, Adduction, Internal Rotation b. Hippocrates method c. Stimpson's method- 4-6 kg weight suspended from wrist. In most cases, this gradual traction overcomes muscle spasm and reduction achieved in 20-25 minutes. d. Milch Method- Does not usually require anesthesia or sedation. Patient supine, steady downward traction applied at elbow; combined with slow, gradual external rotation and abduction of limb (image source: Netter's concise orthopedics Anatomy)  e. Traction- Counter Traction Method