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

"How it works" series: Linezolid

Linezolid (Zyvox) is one of only two antibiotics currently on the market in the oxazolidinone class (see what the other one is at the bottom of this article).  The unique structure makes cross resistance to other antibiotics like beta-lactams or vancomycin unlikely.  It works by binding to the 50S subunit of ribosomes in bacteria, preventing it from joining its partner 30S subunit.  In stopping the 50S subunit from binding the 30S subunit, the completed complex (70S) is never formed and therefore cannot begin to

Legionnaires' disease - reliability of urine antigen testing

A 58 year old male patient presents to the emergency room with shortness of breath for the last few days.  He also complains of chills, a cough, myalgia, and diarrhea.  His notable findings include WBC = 14 k/uL, Scr = 1.2 mg/dL, BUN = 27 mg/dL, BP = 132/76 mm Hg, RR = 30 breaths/minute, Tmax = 38.5⁰C, and O2sat = 92% on room air.  His chest x-ray reveals a patchy infiltrate suggestive of pneumonia.  Upon further questioning, the patient tells you he lives across the street from an apartment building where several people recently were diagnosed with Legionnaires' disease.  He has no recent exposure to any health care settings, has taken no antibiotics, was not recently incarcerated, is not immunocompromised, and has not recently traveled.  Can we use urine antigen testing to help guide our treatment of this patient's pneumonia?

Warfarin dosing nomogram for initiating therapy

A 60 year old female patient presents to the emergency department with complaints of swelling and pain in her right leg.  She recently had her knee replaced and has healed well since the procedure.  She has a PMH of HTN and CKD (Stage IV).  She has no other complaints at this time.  She is diagnosed with a proximal DVT on lower extremity ultrasound and the decision is made to anticoagulate her with warfarin plus a parenteral anticoagulant.  Her baseline INR is 1.28.  What strategy can we use to initiate her on warfarin to reach a therapeutic INR in a reasonable amount of time without overanticoagulating her?