Practice at AMC

5 classes of lipidlowering drugs, and how they impact on lipids

Type of drug Mechanism of action Major side effects Impact on lipids

Statins (rosuvastatin, atorvastatin, simvastatin, lovastatin, pravastatin, fluvastatin) Fibrates (gemfibrozil, fenofibrate, bezafibrate) Ezitimibe

HMG CoA reductase inhibitor

Myositis (<0.1%). Rhabdomyolysis (<0.01%) Increased LFT (2-3%) CYP3A4 inhibition*

LDL 25-60% Atorvastatin and rosuvastatin: TG lowering 15-33% TG 30-50%

PPAR a- agonist

GI Skin rash

Cholesterol absorption inhibitor

LDL 18%

Nicotinic acid

Decreases FFA flux

Flushing PUD Gout Increased LFTs IGT Constipation

HDL 30-35%, TG, LDL 20%

Bile acid sequestrants Colesteryramine

Bile acid absorption inhibitor

LDL 25% TG if already high

How to Start Insulin to 72 yrs male of 100 Kg

Mr Chu is a 72 year-old man with longstanding T2DM, with poor control on maximum metformin, glyburide and pioglitazine. He weighs 100 kg. Weight (kg) x 0.5 = total daily dose of insulin (TDD) = 100x 0.5 = 50 units Half of insulin as rapid acting, half as long acting: Aspart or lispro or glulisine or regular= 8 units tid ac meals Glargine or Detemir = 25 units OR 60% Regular; 40% NPH = 10 units Regular tid ac meals, NPH 20 units qhs, NPH may need to be split into 2 doses) Correction factor = 100/TDD= 100/50 = 2; 1 unit lowers glucose by 2 mmol/L: Premeal glucose 4-8 mmol/L, give 8 units Regular Premeal glucose 8-10 mmol/L, give 9 units Regular Premeal glucose 10-12 mmol/L, give 10 units Regular, Premeal glucose > 12 mmol/L, give 11 units Regular Glyburide and Pioglitazone will be stopped, Metformin will be continued to reduce weight gain on insulin and lower the dose of insulin required.

Diagnosis of Gestational Diabetes

How do you diagnose gestational diabetes? (During pregnancy, no prior diagnosis of diabetes mellitus) Positive screening test: 50 g (non-fasting): 1 hour post glucose > 10.3 mmol/L 2 hr OGTT 75 g (done if 1 hour screening glucose is between 7.8-10.2): at least two glucose readings greater than: Fasting glucose > 5.3 1 hour glucose > 10.6 2 hours glucose > 8.9 What are the A1C and glucose targets for the patient with diabetes in pregnancy? A1C < 6% Fasting glucose 3.8-5.2 mmol/L 1 hr pc glucose 5.5-7.7 mmol/L 2 hr pc glucose 5.0-6.6 mmol/L What is the glucose target during labour? Glucose 4.0-6.7

 Our easy to use blood sugar calculator helps you to get your blood sugar conversion results either in mg/dl used by the American system or in mmol/l used by the British system which is accepted worldwide. Blood sugar conversion is made easy as never before. Please note that 72mg/dl of sugar equals to 4mmol/l of sugar. One mmol/l = 18.18 mg/dL

The fluctuation of blood sugar (red) and the sugar-lowering hormone insulin (blue) in humans during the course of a day with three meals. The effects of a sugar-rich vs a starch-rich meal is highlighted

Giant Cell Arteritis

What are the symptoms of giant cell arteritis (temporal arteritis)?

GCA symptoms are variable and may include any of the following.
i)New onset headache (occurs in two-thirds of patients). ii)Constitutional symptoms iii)Jaw claudication iv)Tongue claudication v)Scalp tenderness vi)Arm claudication vii)Visual disturbance including amaurosis fugax, diplopia or permanent vision loss. viii)Symptoms of polymyalgia rheumatica (including aching of the shoulder or hip girdle).

A markedly elevated ESR is usually seen, although giant cell arteritis is occasionally seen in patients with a normal ESR. Frequency of PMR and GCA increase with age and the conditions are essentially not seen in individuals under 50 years of age.

Red Flags in Back Pain

In a patient complaining of back pain, what are the "red flags" on history that suggest a need for urgent surgical intervention? What historical features suggest an underlying medical cause for the pain (such as a tumor, infection or an inflammatory problem)? Surgical emergencies in patients presenting with back pain include the cauda equina syndrome (usually due to a tumor or massive disc herniation) and aortic aneurysmal dissection or rupture. Historical features that should raise suspicion of these conditions include: * Numbness (particularly "saddle anesthesia") * Focal weakness * Progressive neurological compromise in the lower extremities * Bladder or bowel incontinence * Complaints suggestive of heart failure or ischemia (aortic aneurysm) An underlying medical cause for back pain is suggested by the following features: *Fever *Weight loss *Known history of malignancy *Recent infection *Immunosuppression *IVDU *Night pain Inflammatory back pain is more likely to occur in patients with IBD, psoriasis or uveitis. The following 5 questions are particularly useful in assessing patients for inflammatory back pain. The presence of four of these five features provide a sensitivity of 0.95 and a specificity of 0.85 for spondylitis: *Presence of morning stiffness *Improvement of pain with exercise *Onset before age 40 *Insidious onset *Duration of symptoms longer than three months Do not forget to consider visceral causes of back pain, such as pancreatitis, pyelonephritis, renal colic or a penetrating duodenal ulcer.

Metric Units: BMI = Weight (kg) / (Height (m) x Height (m)) English Units: BMI = Weight (lb) / (Height (in) x Height (in)) x 703

 BMI (Body Mass Index) is a measurement of body fat based on height and weight that applies to both men and women between the ages of 18 and 65 years. BMI can be used to indicate if you are overweight, obese, underweight or normal. A healthy BMI score is between 20 and 25. A score below 20 indicates that you may be underweight; a value above 25 indicates that you may be overweight. You can calculate your BMI by using our BMI Calculator below, or by using the BMI Formula. Please remember, however, that this is only one of many possible ways to assess your weight. If you have any concerns about your weight, please discuss them with your physician, who is in a position, unlike this BMI calculator, to address your specific individual situation.

 Your waist to hip ratio is an important tool that helps you determine your overall health risk. People with more weight around their waist are at greater risk of lifestyle related diseases such as heart disease and diabetes than those with weight around their hips. It is a simple and useful measure of fat distribution. Use a measuring tape to check the waist and hip measurements. - Measure your hip circumference at its widest part. - Measure your Waist Circumference at the belly button or just above it. The Waist to Hip Ratio Calculator indicates your probable health risks. People with more weight around the waist, face more health risks than people who carry more weight around their hips.

BMI Classification
18.5 or less 18.5 to 24.99 25 to 29.99 30 to 34.99 35 to 39.99 40 or greater Under Weight Normal Weight Over Weight Obesity Class 1 Obesity Class 2 Morbid Obesity

 What is maximum heart rate? The maximum heart rate is the highest heart rate achieved during maximal exercise. One simple method to calculate your predicted maximum heart rate, uses this formula: 220 - your age = predicted maximum heart rate Example: a 40-year-old's predicted maximum heart rate is 180 beats/minute. There are other formula's that take into account, the variations in maximal heart rate with age and gender. If you are interested in learning more about these more accurate but slightly more complicated formula's, please see these resources:

 What is maximum heart rate? The maximum heart rate is the highest your pulse rate can get. To calculate your predicted maximum heart rate, use this formula: 220 - Your Age = Predicted Maximum Heart Rate Example: a 40-year-old's predicted maximum heart rate is 180. Your actual maximum heart rate can be determined by a graded exercise test. Please note that some medicines and medical conditions might affect your maximum heart rate. If you are taking medicines or have a medical condition (such as heart disease, high blood pressure, or diabetes), always ask your doctor if your maximum heart rate/target heart rate will be affected. If so, your heart rate ranges for exercise should be prescribed by your doctor or an exercise specialist.

What is target heart rate? You gain the most benefits and lessen the risks when you exercise in your target heart rate zone. Usually this is when your exercise heart rate (pulse) is 60 to 80 percent of your maximum heart rate. In some cases, your health care provider may decrease your target heart rate zone to begin with 50 percent. It is not recommended to exercise above 85 percent of your maximum heart rate. Intensity at that level increases both cardiovascular and orthopedic risk with minimal, additional health-related benefit from the exercise. Always check with your health care provider before starting an exercise program. Your health care provider can help you find a program and target heart rate zone that matches your needs, goals and physical condition. When beginning an exercise program, you may need to gradually build up to a level that is within your target heart rate zone, especially if you have not exercised regularly before. If the exercise feels too hard, slow down. You will reduce your risk of injury and enjoy the exercise more if you don't try to over-do it! To find out if your are exercising in your target zone (between 60 and 80 percent of your maximum heart rate), stop exercising and check your 10-second pulse. If your pulse is below your target zone, increase your rate of exercise. If your pulse is above your target zone, decrease your rate of exercise.

Target heart rate

You gain the most benefits and lessen the risks when you exercise in your target heart rate zone. Usually this is when your exercise heart rate (pulse) is 60 percent to 80 percent of your maximum heart rate. In some cases, your health care provider might decrease your target heart rate zone to begin with 50 percent. Do not exercise above 85 percent of your maximum heart rate. This increases both cardiovascular and orthopaedic risk and does not add any extra benefit. When beginning an exercise program, you might need to gradually build up to a level that is within your target heart rate zone, especially if you have not exercised regularly before. If the exercise feels too hard, slow down. You will reduce your risk of injury and enjoy the exercise more if you don't try to over-do it. To find out if you are exercising in your target zone (between 60 percent and 80 percent of your maximum heart rate), stop exercising and check your 10-second pulse. If your pulse is below your target zone (see the chart below), increase your rate of exercise. If your pulse is above your target zone, decrease your rate of exercise.

Age
20 25 30 35 40 45 50 55 60 65 70

Age Target Heart Rate (HR) Zone (60 - 85%) Target Heart Rate (HR) Zone (60 - 85%) Predicted Maximum HR 20 120 170
120 170 117 166 114 162 111 157 108 153 105 149 102 145 99 140 96 136 93 132 90 123 25 30 35 40 45 50 55 60 65 70 117 166 114 162 111 157 108 153 105 149 102 145 99 140 96 136 93 132 90 123 200 195 190 185 180 175 170 165 160 155 150

What is your target zone? Target Heart Rate Zones by Age * Predicted Maximum HR
200 195 190 185 180 175 170 165 160 155 150

Your Actual Values Your Actual Values (Actual values are determined from a graded (Actual values are determined from a graded exercise test) exercise test)
Target HR: Target HR: Max. HR: Max. HR:

 What is your target zone? Target Heart Rate Zones by Age * AgeTarget Heart Rate (HR) Zone (60 - 85%)Predicted Maximum HR20120 17020025117 16619530114 16219035111 15718540108 15318045105 14917550102 1451705599 1401656096 1361606593 1321557090 123150Your Actual Values (Actual values are determined from a graded exercise test) Target HR:Max. HR:

Age

Target Heart Rate (HR) Zone (6085%) 120-170 117-166

Predicted Maximum Heart Rate 200 195

20 25

30
35 40 45 50 55

114-162
111-157 108-153 105-149 102-145 99-140

190
185 180 175 170 165

60
65 70

96-136
93-132 90-128

160
155 150

Your actual values

Target HR

Max. HR