Metformin is a multi dimentional drug with least side effect.
Metformin and T2DM.. Clinical evidence effect of metformin in heart failure.. Uses in hypertension.. Nice illustration.. Clinical studies benefits and effect of metformin.. Nice information uploaded. Nice information useful information presentation thanks doctor
Metformin has remained first line drug in management for f DM2T without any doubt and risk Recently the subject became of discussion seeing it's effects in DM with HF As sglt2inhibitor came in market and found to be effective in c/o DM with cardiovascular mortality all cause mortality and cv events This was interesting to see metformin is scoring over all available antidiabetics in all cause mortality in cardiovascular cases and HF. It is cheeper and well tolerated drug Nice information
Informative and educative too thanks
Informative update on metformin application in D2M
METFORMIN IS THE FIRST LINE DRUG IN T2DM & HF , IT SIGNIFICANTLY REDUCES CARDIOVASCULAR MORTALITY AND CV EVENTS IN CAD PATIENTS WITH T2DM. VERY MUCH USEFUL AND INFORMATIVE POST.
Very informative post.. Thanks for sharing..
उपयोगी जानकारी हेतु धन्यवाद देता हूं।
Cases that would interest you
- Login to View the image
You can find here key changes in ADA guidelines. They are published in Diabetes Care once yearly in the month of January. GENERAL CHANGES The field of diabetes care is rapidly changing as new research, technology, and treatments that can improve the health and well-being of people with diabetes continue to emerge. With annual updates since 1989, the ADA has long been a leader in producing guidelines that capture the most current state of the field. To that end, the “Standards of Medical Care in Diabetes” now includes a dedicated section on Diabetes Technology, which contains preexisting material that was previously in other sections that has been consolidated, as well as new recommendations. SECTION 1. IMPROVING CARE AND PROMOTING HEALTH IN POPULATIONS Additional information was included on the financial costs of diabetes to individuals and society. Because telemedicine is a growing field that may increase access to care for patients with diabetes, discussion was added on its use to facilitate remote delivery of health-related services and clinical information. SECTION 2. CLASSIFICATION AND DIAGNOSIS OF DIABETES Based on new data, the criteria for the diagnosis of diabetes was changed to include two abnormal test results from the same sample (i.e., fasting plasma glucose and A1C from same sample). The section was reorganized to improve flow and reduce redundancy. Additional conditions were identified that may affect A1C test accuracy including the postpartum period. SECTION 3. PREVENTION OR DELAY OF TYPE 2 DIABETES This section was moved and is now located before the Lifestyle Management section to better reflect the progression of type 2 diabetes. The nutrition section was updated to highlight the importance of weight loss for those at high risk for developing type 2 diabetes who have overweight or obesity. Because smoking may increase the risk of type 2 diabetes, a section on tobacco use and cessation was added. SECTION 4. COMPREHENSIVE MEDICAL EVALUATION AND ASSESSMENT OF COMORBIDITIES On the basis of a new consensus report on diabetes and language, new text was added to guide health care professionals’ use of language to communicate about diabetes with people with diabetes and professional audiences in an informative, empowering, and educational style. A new figure from the ADA-European Association for the Study of Diabetes (EASD) consensus report about the diabetes care decision cycle was added to emphasize the need for ongoing assessment and shared decision making to achieve the goals of health care and avoid clinical inertia. A new recommendation was added to explicitly call out the importance of the diabetes care team and to list the professionals that make up the team. A recommendation was added to include the 10-year atherosclerotic cardiovascular disease (ASCVD) risk as part of overall risk assessment. The fatty liver disease section was revised to include updated text and a new recommendation regarding when to test for liver disease. SECTION 5. LIFESTYLE MANAGEMENT Evidence continues to suggest that there is NOT an ideal percentage of calories from carbohydrate, protein, and fat for all people with diabetes. Therefore, more discussion was added about the importance of macronutrient distribution based on an individualized assessment of current eating patterns, preferences, and metabolic goals. Additional considerations were added to the eating patterns, macronutrient distribution, and meal planning sections to better identify candidates for meal plans, specifically for low-carbohydrate eating patterns and people who are pregnant or lactating, who have or are at risk for disordered eating, who have renal disease, and who are taking sodium–glucose cotransporter 2 inhibitors. There is NOT a one-size-fits-all eating pattern for individuals with diabetes, and meal planning should be individualized. A recommendation was modified to encourage people with diabetes to decrease consumption of both sugar sweetened and nonnutritive-sweetened beverages and use other alternatives, with an emphasis on water intake. The sodium consumption recommendation was modified to eliminate the further restriction that was potentially indicated for those with both diabetes and hypertension. Additional discussion was added to the physical activity section to include the benefit of a variety of leisure-time physical activities and flexibility and balance exercises. The discussion about e-cigarettes was expanded to include more on public perception and how their use to aide smoking cessation was not more effective than “usual care.” SECTION 6. GLYCEMIC TARGETS This section now begins with a discussion of A1C tests to highlight the centrality of A1C testing in glycemic management. To emphasize that the risks and benefits of glycemic targets can change as diabetes progresses and patients age, a recommendation was added to reevaluate glycemic targets over time. The section was modified to align with the living Standards updates made in April 2018 regarding the consensus definition of hypoglycemia. SECTION 7. DIABETES TECHNOLOGY This new section includes new recommendations, the self-monitoring of blood glucose section formerly included in Section 6 “Glycemic Targets,” and a discussion of insulin delivery devices, blood glucose meters, continuous glucose monitors (real-time and intermittently scanned, and automated insulin delivery devices. The recommendation to use self-monitoring of blood glucose in people who are not using insulin was changed to acknowledge that routine glucose monitoring is of limited additional clinical benefit in this population. SECTION 8. OBESITY MANAGEMENT FOR THE TREATMENT OF TYPE 2 DIABETES A recommendation was modified to acknowledge the benefits of tracking weight, activity, etc., in the context of achieving and maintaining a healthy weight. A brief section was added on medical devices for weight loss, which are not currently recommended due to limited data in people with diabetes. The recommendations for metabolic surgery were modified to align with recent guidelines, citing the importance of considering comorbidities beyond diabetes when contemplating the appropriateness of metabolic surgery for a given patient. SECTION 9. PHARMACOLOGIC APPROACHES TO GLYCEMIC TREATMENT The section on the pharmacologic treatment of type 2 diabetes was significantly changed to align, as per the living Standards update in October 2018, with the ADA-EASD consensus report on this topic. This includes consideration of key patient factors: (a) important comorbidities such as ASCVD, CKD, and HF, (b) hypoglycemia risk, (c) effects on body weight, (d) side effects, (e) costs, and (f) patient preferences. To align with the ADA-EASD consensus report, the approach to injectable medication therapy was revised. A recommendation that, for most patients who need the greater efficacy of an injectable medication, a GLP-1 agonist should be the first choice, ahead of insulin. A new section was added on insulin injection technique, emphasizing the importance of technique for appropriate insulin dosing and the avoidance of complications (lipodystrophy, etc.). The section on non-insulin pharmacologic treatments for DM1 was abbreviated, as these are not generally recommended. SECTION 10. CARDIOVASCULAR DISEASE AND RISK MANAGEMENT For the first time, this section is endorsed by the American College of Cardiology. Additional text was added to acknowledge heart failure as an important type of cardiovascular disease in people with diabetes for consideration when determining optimal diabetes care. The blood pressure recommendations were modified to emphasize the importance of individualization of targets based on cardiovascular risk. A discussion of the appropriate use of the ASCVD risk calculator was included, and recommendations were modified to include assessment of 10-year ASCVD risk as part of overall risk assessment and in determining optimal treatment approaches. The recommendation and text regarding the use of aspirin in primary prevention was updated with new data. For alignment with the ADA-EASD consensus report, two recommendations were added for the use of medications that have proven cardiovascular benefit in people with ASCVD, with and without heart failure. SECTION 11. MICROVASCULAR COMPLICATIONS AND FOOT CARE To align with the ADA-EASD consensus report, a recommendation was added for people with type 2 diabetes and chronic kidney disease to consider agents with proven benefit with regard to renal outcomes. The recommendation on the use of telemedicine in retinal screening was modified to acknowledge the utility of this approach, so long as appropriate referrals are made for a comprehensive eye examination. Gabapentin was added to the list of agents to be considered for the treatment of neuropathic pain in people with diabetes based on data on efficacy and the potential for cost savings. The gastroparesis section includes a discussion of a few additional treatment modalities. The recommendation for patients with diabetes to have their feet inspected at every visit was modified to only include those at high risk for ulceration. Annual examinations remain recommended for everyone. SECTION 12. OLDER ADULTS A new section and recommendation on lifestyle management was added to address the unique nutritional and physical activity needs and considerations for older adults. Within the pharmacologic therapy discussion, de-intensification of insulin regimes was introduced to help simplify insulin regimen to match individual’s self-management abilities. SECTION 13. CHILDREN AND ADOLESCENTS Introductory language was added to the beginning of this section reminding the reader that the epidemiology, pathophysiology, developmental considerations, and response to therapy in pediatric-onset diabetes are different from adult diabetes, and that there are also differences in recommended care for children and adolescents with type 1 as opposed to type 2 diabetes. A recommendation was added to emphasize the need for disordered eating screening in youth with type 1 diabetes beginning at 10–12 years of age. Based on new evidence, a recommendation was added discouraging e-cigarette use in youth. The discussion of type 2 diabetes in children and adolescents was significantly expanded, with new recommendations in a number of areas, including screening and diagnosis, lifestyle management, pharmacologic management, and transition of care to adult providers. New sections and/or recommendations for type 2 diabetes in children and adolescents were added for glycemic targets, metabolic surgery, nephropathy, neuropathy, retinopathy, nonalcoholic fatty liver disease, obstructive sleep apnea, polycystic ovary syndrome, cardiovascular disease, dyslipidemia, cardiac function testing, and psychosocial factors. SECTION 14. MANAGEMENT OF DIABETES IN PREGNANCY Women with preexisting diabetes are now recommended to have their care managed in a multidisciplinary clinic to improve diabetes and pregnancy outcomes. Greater emphasis has been placed on the use of insulin as the preferred medication for treating hyperglycemia in gestational diabetes mellitus as it does not cross the placenta to a measurable extent and how metformin and glyburide should not be used as first-line agents as both cross the placenta to the fetus. SECTION 15. DIABETES CARE IN THE HOSPITAL Because of their ability to improve hospital readmission rates and cost of care, a new recommendation was added calling for providers to consider consulting with a specialized diabetes or glucose management team where possible when caring for hospitalized patients with diabetes. SECTION 16. DIABETES ADVOCACY The “Insulin Access and Affordability Working Group: Conclusions and Recommendations” ADA statement was added to this section. Published in 2018, this statement compiled public information and convened a series of meetings with stakeholders throughout the insulin supply chain to learn how each entity affects the cost of insulin for the consumer, an important topic for the ADA and people living with diabetes.Dr. Peerzada Ovais Ahmad6 Likes10 Answers
- Login to View the image
65 year old male. Non-alcoholic. morbidly obese and history of diabetes mellitus type 2. Enlargement of abdomen. what HISTOLOGICAL specimen is this and what disease?Faiz Sheikh0 Like15 Answers
- Login to View the image
B M I n O B E S I T Y BMI is commonly used to diagnose overweight and obesity, often in conjunction with measurement of waist circumference. Leading guidelines, such as those produced by the American Association for Clinical Endocrinology (AACE),the UK National Institute for Health and Care Excellence (NICE), and the European Association for the Study of Obesity (EASO),consider a BMI of 30 kg/m2 to be the threshold for obesity, and describe 3 classes of obesity, rising in severity from low-risk/class 1 (between 30.0 and 34.9 kg/m2), through moderate-risk/class 2 (between 35.0 and 39.9 kg/m2), to high-risk/class 3 (≥40.0 kg/m2). Lower BMI thresholds may be recommended for black African, African-Caribbean, and Asian (particularly South Asian) populations in order to trigger action to reduce the risk for comorbid conditions. For example, in the NICE guidelines, a BMI of 23.0 kg/m2 in these groups indicates increased risk for type 2 diabetes mellitus (T2DM), and 27.5 kg/m2 indicates a high risk. Obesity is a global epidemic and its prevalence more than doubled between 1980 and 2014. In 2014, more than 1.9 billion adults (≥18 years), which is 39% of all adults, had overweight. More than 600 million had obesity, representing 13% of all adults. The fundamental cause of obesity and overweight is an imbalance between calories consumed and expended. Changes in dietary and physical-activity patterns worldwide have led to the increase in obesity and overweight.Obesity is a serious chronic condition that is associated with multiple comorbidities and decreased life expectancy.An increase in BMI increases a person's risk for cardiovascular disease (CVD), and obesity is an independent risk factor for CVD.It also increases the risk for T2DM; fatty liver disease; musculoskeletal disorders, in particular osteoarthritis; and some cancers, including breast, colon, kidney, and pancreatic cancer.Higher BMIs are also associated with cognitive/mood disorders, obstructive sleep apnea, gallstones, and gastroesophageal reflux. Classes 2 and 3 obesity are associated with significantly higher all-cause mortality than class 1 obesity and normal weight.Other factors, such as waist circumference, also contribute to the increased risk for obesity-related disease. As well as fat accumulation, fat distribution is related to obesity-related mortality and morbidity. Central obesity, also known as the apple shape, confers a higher risk than general obesity for several chronic diseases.In recent years, there has been a broadening of focus from BMI alone, so that the management of obesity-related comorbidities is also a priority Physical-activity counseling is an integral part of obesity management, but would not be effective on its own. EASO guidelines recommend that pharmacological therapy is considered in patients who are overweight or who have class 1 obesity if they also have comorbidities. Treatment guidelines recommend that the first stage in managing patients with obesity is to assess their views of their weight and the diagnosis, as well as the possible reasons for weight gain. Failure to engage patients and to convince them of the benefits of lifestyle interventions aimed at weight loss is likely to result in the lifestyle interventions being less effective. Therefore, this is an important first step. Eating patterns and physical-activity levels should be explored, as well any beliefs about diet, exercise, and weight gain that may be unhelpful to the patient. The physician should find out if the patient has already tried to lose weight and how successful these efforts were. They should assess the patient's confidence and willingness to engage in a weight-loss program. The health and other risks of obesity should be explained, as well as the benefits of weight loss and increasing physical-activity levels. The physician should be aware that a patient's feelings about obesity and other health problems, such as surprise or denial, may reduce their willingness or ability to change. For this reason, it may help to stress that obesity is a clinical condition with specific implications for health, rather than something that focuses on how a patient looks. It has reported a divergence in the perception of obesity between people with obesity and the clinicians treating them. For example, 65% of people with obesity consider obesity to be primarily a lifestyle disease and 44% think it is possible to have obesity and be healthy, compared with 88% and 4%, respectively, for clinicians. Barriers can be motivational, such as lack of willpower, emotional/personal, such as eating habits, or practical/systemic, such as medication costs or lack of support services. A comprehensive lifestyle intervention is a fundamental part of the management of obesity. This consists of lifestyle/behavioral training, a dietary calorie-reduction plan, and increased physical activity.When developing a weight-loss plan for a patient, the main requirement is that total energy intake is less than total energy expenditure.This will help address the imbalance of energy regulation that characterizes obesity. Obesity develops when the body's weight and energy regulatory mechanisms do not work properly, leading to an elevated body fat "set point," ie, the amount of fat the body wants to retain. The energy intake behavior of an individual is determined by whether he or she is at, above, or below the set point. Diets with a daily deficit of 600 kcal, leading to a 5% to 10% reduction in current body weight over 6 months, are considered to be realistic and have proven health benefits.Lower-calorie diets with an intake of 800 to 1600 kcal/day can be considered, but they are less nutritionally complete. Very low-calorie diets (<800 kcal/day) should not be routinely used to manage obesity. Evidence from systematic reviews suggests that, although initial weight loss is more rapid with very low-calorie diets, weight change after 1 year is not very different from comprehensive approaches. Physical activity is part of a comprehensive lifestyle intervention. Although it may have only modest effects on weight loss, it will bring other benefits, such as a reduction in the risk for T2DM and CVD.Physical activity also helps to preserve fat-free mass during weight loss and promote weight maintenance. People who have had obesity but have lost weight may need to do 60 to 90 minutes of activity per day to avoid regaining weight. Weight loss is difficult to achieve for most patients with obesity because a desire to restrict caloric intake is counteracted by biological responses to weight loss. The reduction in energy expenditure and increase in appetite that occur after weight loss are associated with changes in several hormones. Some of the hormonal changes result in altered physiology that leads to weight gain, whereas other changes lead to improvements in hormonal systems as the patient gets closer to a healthy weight. Weight-loss medications aim to reinforce the patient's efforts to change eating behaviors and produce an energy deficit.Most promote weight loss through their effects on appetite -- increasing satiety and decreasing hunger. It is possible that satiety signaling and inhibitory control are weaker in people who are prone to obesity. Many treatment guidelines recommend that weight-loss medication is considered for patients with a BMI ≥30 kg/m2 or a BMI ≥27 kg/m2 if they also have 1 or more comorbidities and a history of failure to lose weight.The inclusion of comorbidities in the criteria reinforces the benefits of weight loss for people with obesity-related disease. ORLISTAT Unlike most weight-loss medications, orlistat is a reversible gastric and pancreatic lipase inhibitor that blocks absorption of 30% of ingested fat from a 30% fat diet when taken at the recommended dosage (120 mg 3 times per day). It is approved for use in adults and adolescents, is considered one of the safest drugs in its category, and is available in most countries around the world. However, it has well-documented GI adverse events, such as fecal leakage, which limit its popularity. NALTREXONE/BUPROPION This is a sustained-release combination of an opioid receptor antagonist (naltrexone) and a noradrenaline reuptake inhibitor (bupropion). Naltrexone has a minimal weight-loss effect on its own,but it acts synergistically with bupropion to stimulate central melanocortin pathways and antagonize inhibitory feedback loops that limit weight reduction. This leads to improved energy expenditure and a reduction in appetite.The maximum total daily dose is 32 mg naltrexone/360 mg bupropion.Naltrexone/bupropion is associated with increased BP, so it should be avoided in patients whose hypertension is not controlled, and BP should be monitored in the initial phase of therapy. The most common adverse events are nausea, headache, vomiting, anxiety, and insomnia. The risk for GI events can be minimized by gradual titration. Other anti obesity drug is Liraglutide but this and Naltrexone are not available n approved in India by FDA .Only Bupropion is available but at present is used in smoking cessation n in depression.Dr. Girish Dahake12 Likes21 Answers
- Login to View the image
50 yrs old a/k/c of T2DM 15 yr, on OHA, hypertensive for the past 2 yrs on treatment, presents with breathlessness on exertion, abdominal distention, Early satiety 10 days H/O PND 1 episode 15 days back no c/o orthopnea no c/o decreased output O/E facial puffiness+ b/l pitting pedal edema+ lt basal crepts+ investigation urine albumin ++ PPBS 256mg urea 38mg% creatinine 1.91mg% opinion regarding further managementDr. Suresh Mariappan2 Likes17 Answers
- Login to View the image
I saw these while doing a foot exam on my 50 year old diabetic patient today. He says they are tender but not itchy. What am I looking at here?Dr. Mahima Chaudhary3 Likes15 Answers