Heart Failure with Preserved Ejection Fraction - Managing Comorbidities

Heart failure (HF) is a complex condition characterized by signs of volume overload or symptoms such as dyspnea, exercise intolerance, and fatigue. Being a syndrome, HF is not explained by one unifying pathophysiologic cause.  Rather, various mechanisms lead to the deficit between the amount of blood delivered and the amount of blood that needs to be delivered through the body to maintain homeostasis.  HF is defined as the previously mentioned signs or symptoms being caused by structural or functional cardiac abnormalities plus either 1) elevated natriuretic peptides (e.g., BNP) or 2) objective evidence of

Diabetes discharge checklist

A 55 year old business executive is being discharged from the hospital after a brief admission for cellulitis.  His only PMH is HTN and obesity.  During his stay, his casual serum glucoses were found to be in the high 200s mg/dL and a hemoglobin A1C resulted at 11.6%.  What should be done at the inpatient to outpatient transition to address his diabetes?

Essentials from the 2016 American Diabetes Association guidelines

The 2016 American Diabetes Association diabetes guidelines is a lengthy document outlining many aspects of diabetes care including evaluation, diagnosis, prevention, management of glycemia, and management of nonglycemic issues.  Here are some of the more common elements that come up in the internal medicine setting regarding glycemic control.

Empagliflozin (Jardiance) new indication - reduces mortality in type 2 diabetes mellitus

A middle-aged patient with diabetes mellitus type 2, CAD, HTN, and obesity is in clinic for a followup appointment 1 year after his diagnosis with diabetes.  His medications include lisinopril, atorvastatin, aspirin, and metformin (started 1 year ago and titrated to maximum tolerated dose).  Today in clinic, his BP = 148/88 mm Hg, HR = 78 bpm, and HbA1c = 7.6%.  In addition to metformin, are there any other antihyperglycemic medications that we can use to reduce his risk of cardiovascular events?

For many years, metformin was the only antihyperglycemic medication proven to reduce mortality in patients with diabetes mellitus type 2 (as per the UKPDS trial).  Other classes of medications such as the sulfonylureas, thiazolidinediones, and DPP-4 inhibitors have only been shown to reduce HbA1c and/or microvascular events.  This month, the FDA approved

Metformin in kidney dysfunction - restriction revised

Metformin is the preferred initial pharmacologic therapy in every patient with type 2 diabetes mellitus who does not have a contraindication or intolerance.  It is recommended as monotherapy after diagnosis, continued when adding other medications (including insulin regimens), and should even be considered to prevent diabetes in certain patients (see who at the bottom).  

Old labeling

From approval, the restriction on metformin related to kidney function was as follows

Risk of hyperglycemia from glucocorticoids

A 65 year old patient with COPD sees his primary care provider for worsening shortness of breath over the past week.  His current medications include tiotropium and albuterol.  He has no other significant past medical history but has a family history of diabetes.  His current labs include a fasting plasma glucose of 96 mg/dL, HbA1c of 6.1%, Scr = 0.8 mg/dL.  His primary care provider determines that the patient is having a COPD exacerbation and is opting to initiate a 5 day course of prednisone 40 mg orally daily (click here for more on a 5 days course versus longer steroid courses for COPD exacerbations).  What are some of the risk factors, the time-course, and the mechanism for developing hyperglycemia in a situation like this?

Update on niacin - Results from the HPS2-THRIVE study

In a previous blog post, niacin for dyslipidemia, we discussed the concerns regarding niacin's lack of improvement of clinically meaningful endpoints in addition to some of its adverse effects and how to deal with them.  Recently, final results of the HPS2-THRIVE study have been published.  Here are a few highlights of the results of this study.

Tips for prescribing insulin therapy and diabetes supplies

There are many different insulin preparations and supplies available in order to create individualized regimens for patients.  Here are some tips and a checklist to help avoid getting future calls from pharmacies.