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

Intrapleural tPA and dornase alfa for pleural infection

A 48 year old male is admitted to the hospital after experiencing a fever and malaise for several days.  He states that he has some shortness of breath and chest pain when he coughs.  Imaging of the chest reveals a large loculated effusion and empyema in the right lower lung.  The decision is made to place a chest tube (thoracostomy) and drain the fluid.  The pleural fluid returns with a pH of 7.18, a glucose of 55 mg/dL, and a lactate of 1,150 units/L.  Initial drainage was 200 mL in the first 24 hours, contained pus, and had a putrid odor.  Cultures are pending.  In addition to drainage and appropriate antibiotic therapy, what else can be done to manage this patient?

Management of acute gout - Guideline update

A new guideline from the American College of Physicians for the management of acute and recurrent gout makes a few recommendations based on updated data through March 20161.  Some recommendations and strengths differ from the 2012 recommendations from the American College of Rheumatology.  Here are the main recommendations from the updated guideline:

"How it works" series: Vancomycin

(Click to enlarge)

Vancomycin was the first antibiotic developed of the glycopeptide class.  It is termed "glyco-" because it has two saccharides and "peptide" because it has seven peptides, making a structure larger than almost all other antibiotics.  The main mechanism of action is inhibition of cell wall synthesis.  Under normal conditions in bacteria, as the cell wall is being formed,

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