Topic Presentation

ASTHMA 1. Background/Introduction a. Introduction: Asthma is a chronic inflammatory disorder of the airways characterized by episodes of airflow obstruction, which leads to symptoms like wheezing, coughing, chest tightness, and shortness of breath. The condition varies in severity and can be triggered by various factors such as allergens, irritants, and respiratory infections. b. Epidemiology: ● Common in both children and adults, with higher prevalence in children. ● The prevalence of asthma varies by region, socioeconomic status, and environmental exposure. ● More common in urban areas due to higher exposure to allergens and pollution. c. Different types/classifications of the disease: ● ● ● ● Intermittent Asthma: Symptoms occur less than twice a week. Mild Persistent Asthma: Symptoms occur more than twice a week, but not daily. Moderate Persistent Asthma: Daily symptoms that can affect daily activities. Severe Persistent Asthma: Symptoms occur throughout the day, severely limiting daily activities. d. Risk Factors: ● ● ● ● ● ● Family history of asthma or allergies Exposure to tobacco smoke, pollution, or allergens Obesity Occupational exposures (e.g., chemicals, dust) Respiratory infections during early childhood History of atopic conditions (e.g., eczema, allergic rhinitis) 2. Pathophysiology/Etiology ● Asthma results from a combination of genetic and environmental factors that lead to airway hyper-responsiveness. Inflammation of the bronchial walls leads to narrowing of the airways, increased mucus production, and airflow obstruction. ● Common triggers include allergens (dust mites, pet dander), pollutants, cold air, exercise, respiratory infections, and stress. 3. Signs and Symptoms a. Pertinent Labs: ● Spirometry: Decreased FEV1/FVC ratio (forced expiratory volume in 1 second/forced vital capacity). ○ Normal is greater than 0.7 ● Peak Expiratory Flow (PEF): Reduced peak flow readings during asthma attacks. ○ 400-700 L/min for adults ○ 150-450 L/min for children ● Allergy testing: Positive for environmental allergens that trigger asthma. ● Eosinophil count: May be elevated in allergic asthma. ○ Normal is <500 cells b. Presenting Symptoms: ● ● ● ● Wheezing Shortness of breath Chest tightness Coughing (especially at night or early morning) c. Assessment/Diagnostic Tools: ● Spirometry: Used to assess lung function and diagnose asthma by measuring how much air you can breathe out in one forced breath. ● Bronchodilator reversibility test: Significant improvement in FEV1 after administration of a bronchodilator indicates asthma. ● Peak Flow Monitoring: Regularly checking peak flow values to monitor asthma control. 4. Treatment a. Approach to therapy i. Pharmacological 1. 1st line/2nd line agents/medication classes ○ 1st line: Inhaled corticosteroids (ICS) i. Budesonide 180-360 mcg BID ii. Fluticasone 88-220 mcg BID ○ 2nd line: Long-acting beta-agonists (LABAs) or LTRA’s in combination w/ ICS i. Salmeterol 50 mcg inhaled BID (LABA) ii. Montelukast 10 mg QD in the evening (LTRA) Rescue medications: Short-acting beta-agonists (SABAs) 1. Albuterol 90 mcg per inhalation 2 puffs Q4-6hrs PRN a. Rationale - ICS reduce airway inflammation, improving long-term control of asthma. - LABAs help to maintain bronchodilation, and LTRAs target leukotrienes involved in the inflammatory pathway. b. Unique aspects of drugs - ICS: Must rinse the mouth after use to avoid oral thrush (fungal infection). Regular monitoring for potential side effects like adrenal suppression and bone density loss is necessary for long-term use. - LABAs: Always combine with ICS due to the risk of asthma-related death. - SABAs: Monitoring for overuse, as it may indicate poor asthma control. 2. Duration of therapy ○ Asthma is a chronic condition, and many patients will need long-term therapy, with medications adjusted based on asthma control and severity. ii. Non-pharmacological ● ● ● ● ● Allergen avoidance (dust mites, pet dander, pollen) Smoking cessation Regular exercise to improve lung function Home environment modifications (e.g., reducing indoor allergens) Use of air purifiers or dehumidifiers where needed 5. Bonus: Name a Clinical Guideline ● Global Initiative for Asthma (GINA) guidelines: A widely used evidence-based guideline for asthma diagnosis, management, and treatment. HTN 1. Background/Introduction a. Introduction: Hypertension (HTN), or high blood pressure, is a chronic medical condition in which the force of the blood against the artery walls is too high. Over time, it can lead to serious health problems, such as heart disease, stroke, and kidney failure. b. Epidemiology: ● Prevalence increases with age and is more common in African Americans. ● Hypertension is a major risk factor for cardiovascular disease and mortality. c. Different types/classifications of the disease: ● Primary (essential) hypertension: The most common type, with no identifiable cause. ● Secondary hypertension: Caused by an underlying condition, such as kidney disease, endocrine disorders, or medication use. d. Risk Factors: ● Family history of hypertension ● Age (increased risk with age) ● ● ● ● ● ● ● Obesity High-sodium diet Sedentary lifestyle Excessive alcohol consumption Smoking Stress Chronic conditions like diabetes or kidney disease 2. Pathophysiology/Etiology ● Hypertension is the result of increased vascular resistance due to narrowing of blood vessels, increased cardiac output, or a combination of both. 3. Signs and Symptoms a. Pertinent Labs: ● Serum electrolytes: Potassium levels, especially with diuretic use. ● Serum creatinine: To assess kidney function. ● Fasting glucose and lipid panel: To assess for diabetes and dyslipidemia, which are common comorbidities. ○ Glucose normal 70-100 mg/dL ○ Lipid normal levels ■ Total cholesterol <200 mg/dL ■ HDL >60 mg/dL ■ LDL <100 mg/dL ■ TG <150 mg/dL ● Urinalysis: To check for proteinuria, which can indicate kidney damage. b. Presenting Symptoms: ● Often asymptomatic ("silent killer"). ● In some cases: headaches, dizziness, blurred vision, chest pain, and shortness of breath. c. Assessment/Diagnostic Tools: ● Blood Pressure Measurement: Diagnosed based on consistent BP readings ≥130/80 mmHg over time. ● Ambulatory BP Monitoring (ABPM): Used to confirm diagnosis and detect white coat hypertension or masked hypertension. ● Home BP Monitoring: To assess out-of-office BP levels. ● Screening for target organ damage: Echocardiogram (heart). 4. Treatment a. Approach to therapy i. Pharmacological 1. 1st line/2nd line agents/medication classes ○ 1st line: ■ Thiazide diuretics 1. Hydrochlorothiazide 12.5-25 mg QD 2. Chlorthalidone 12.5-25 mg QD ■ ACE inhibitors (ACE-Is) 1. Lisinopril 10-40 mg QD 2. Enalapril 5-20 mg QD or BID ■ Angiotensin II receptor blockers (ARBs) 1. Losartan 50-100 mg QD 2. Valsartan 80-320 mg QD ■ Calcium channel blockers (CCBs) 1. Amlodipine 5-10 mg QD 2. Diltiazem 120-360 mg QD (also available ER) ○ 2nd line: ■ Beta-blockers 1. Metoprolol 100 mg QD 2. Atenolol 25-50 mg QD ■ Aldosterone antagonists 1. Spironolactone 25-50 mg QD a. Rationale - These classes of medications are proven to reduce cardiovascular morbidity and mortality by lowering blood pressure and preventing organ damage. Selection depends on the patient's comorbidities and risk factors. b. Unique aspects of drugs - ACE-Is/ARBs: Monitor for hyperkalemia and renal function (serum creatinine). ACE-Is can cause a persistent cough. - Thiazides: Can lead to hypokalemia and hyponatremia; monitor electrolytes. - CCBs: Monitor for peripheral edema and dizziness. - Beta-blockers: May cause bradycardia and fatigue; contraindicated in certain patients with asthma or COPD. 2. Duration of therapy ○ Most patients will require lifelong treatment, with adjustments based on blood pressure control, side effects, and comorbid conditions. ii. Non-pharmacological ● Dietary changes: Adoption of the DASH (Dietary Approaches to Stop Hypertension) diet, which emphasizes fruits, vegetables, whole grains, and low-fat dairy products. ● Sodium restriction: Reducing salt intake to <1.5-2 g/day. ● Regular physical activity: At least 150 minutes per week of moderate-intensity exercise. ● Weight loss: Reducing body weight can significantly lower blood pressure in overweight/obese individuals. ● Smoking cessation: Reduces overall cardiovascular risk. ● Limiting alcohol intake: No more than 1 drink/day for women and 2 drinks/day for men. 5. Bonus: Name a Clinical Guideline ● American College of Cardiology/American Heart Association (ACC/AHA) Hypertension Guidelines: Provides recommendations for the diagnosis, treatment, and management of hypertension. Dyslipidemia 1. Background/Introduction a. Introduction: Dyslipidemia is characterized by abnormal levels of lipids (cholesterol, triglycerides) in the blood, increasing the risk of cardiovascular diseases such as atherosclerosis, myocardial infarction, and stroke. b. Epidemiology: ● It is often associated with other conditions, such as obesity, diabetes, and hypertension. ● More common in older adults but can occur in younger individuals with genetic predispositions. c. Different types/classifications of the disease: ● Primary (genetic) dyslipidemia: Familial hypercholesterolemia (FH) is an inherited condition causing high levels of low-density lipoprotein (LDL). ● Secondary dyslipidemia: Caused by other conditions such as diabetes, hypothyroidism, or lifestyle factors (diet, lack of exercise). d. Risk Factors: ● ● ● ● ● ● ● ● Family history of dyslipidemia or cardiovascular disease Obesity Sedentary lifestyle Poor diet, especially high in saturated and trans fats Diabetes Smoking Alcohol consumption Chronic kidney disease (CKD) 2. Pathophysiology/Etiology ● Dyslipidemia is often due to a combination of genetic and environmental factors. It results in increased levels of LDL ("bad cholesterol") and/or decreased levels of high-density lipoprotein (HDL, "good cholesterol"). Excess LDL cholesterol can deposit in artery walls, leading to plaque formation and narrowing of blood vessels (atherosclerosis). 3. Signs and Symptoms a. Pertinent Labs: ● Lipid Panel: Measures total cholesterol, LDL, HDL, and triglycerides. ○ Total cholesterol <200 mg/dL ○ HDL >60 mg/dL ○ LDL <100 mg/dL ○ TG <150 mg/dL ● Liver Function Tests (LFTs): May be monitored when using lipid-lowering medications (e.g., statins). b. Presenting Symptoms: ● Often asymptomatic until complications arise (e.g., heart attack, stroke). ● In severe cases (e.g., familial hypercholesterolemia), patients may have physical signs like xanthomas (cholesterol deposits in the skin) or corneal arcus (cholesterol deposits in the eye). c. Assessment/Diagnostic Tools: ● Fasting lipid panel: Used to assess lipid levels and determine cardiovascular risk. ● Cardiovascular risk calculators: Tools like the ASCVD (Atherosclerotic Cardiovascular Disease) Risk Calculator help guide treatment decisions based on the patient’s 10-year risk of cardiovascular events. 4. Treatment a. Approach to therapy i. Pharmacological 1. 1st line/2nd line agents/medication classes ○ 1st line: ■ Statins 1. Atorvastatin 10-80 mg QD 2. Rosuvastatin 10-40 mg QD ○ 2nd line: ■ Ezetimibe: Inhibits cholesterol absorption in the small intestine. 1. Ezetimibe 10 mg QD ■ Fibrates 1. Fenofibrate 48-145 mg QD 2. Gemfibrozil 600 mg BID 30 min before meals a. Rationale - Statins are the mainstay of therapy because they significantly reduce LDL cholesterol and lower the risk of cardiovascular events. Ezetimibe is used in patients with statin intolerance or those not reaching target levels with statins alone. b. Unique aspects of drugs - Statins: Monitor for myopathy, muscle pain, and increased liver enzymes. Counseling points include taking the medication in the evening (for short-acting statins). - Ezetimibe: Well tolerated, but may cause gastrointestinal discomfort. - Fibrates: Can cause muscle pain when used with statins and may increase the risk of gallstones. 2. Duration of therapy ○ Long-term or lifelong treatment is often necessary, depending on the patient’s risk factors and lipid levels. Medications are usually continued indefinitely to maintain target lipid levels and reduce cardiovascular risk. ii. Non-pharmacological ● Dietary changes: Following a heart-healthy diet (e.g., Mediterranean diet) with an emphasis on whole grains, vegetables, fruits, and lean proteins. Reducing intake of saturated fats and trans fats. ● Exercise: Engaging in regular physical activity, at least 150 minutes of moderate-intensity exercise per week, can improve lipid levels. ● Weight loss: Reducing excess body weight, particularly in patients with obesity or metabolic syndrome. ● Smoking cessation: Important to reduce cardiovascular risk. ● Alcohol moderation: Limiting alcohol intake to reduce triglycerides and other cardiovascular risks. 5. Bonus: Name a Clinical Guideline ● 2018 AHA/ACC Multisociety Guideline on the Management of Blood Cholesterol: Provides recommendations for the treatment of dyslipidemia, including the use of statins and other lipid-lowering therapies based on individual cardiovascular risk. Type 2 Diabetes 1. Background/Introduction a. Introduction: Type 2 diabetes (T2DM) is a chronic metabolic disorder characterized by insulin resistance and a progressive decline in insulin production, leading to hyperglycemia. It is the most common form of diabetes, often associated with obesity and a sedentary lifestyle. b. Epidemiology: ● T2DM accounts for about 90-95% of all diabetes cases worldwide. ● There is an increasing prevalence due to rising rates of obesity and aging populations. ● More common in adults, but it is increasingly diagnosed in younger individuals due to lifestyle factors. c. Different types/classifications of the disease: ● Type 1 diabetes: Autoimmune destruction of beta cells, leading to an absolute insulin deficiency. ● Type 2 diabetes: Characterized by insulin resistance and relative insulin deficiency. ● Gestational diabetes: Hyperglycemia diagnosed during pregnancy. d. Risk Factors: ● ● ● ● ● ● Family history of diabetes Obesity Sedentary lifestyle Unhealthy diet (high in processed foods and sugars) Age >45 years Ethnicity: Higher prevalence in African Americans, Hispanics, Native Americans, and Asian Americans ● Hypertension and dyslipidemia ● History of gestational diabetes or polycystic ovary syndrome (PCOS) 2. Pathophysiology/Etiology ● T2DM is caused by a combination of insulin resistance (where the body’s cells do not respond well to insulin) and a progressive decline in pancreatic beta-cell function, leading to insufficient insulin production. This results in elevated blood glucose levels. Obesity, genetic factors, and a sedentary lifestyle contribute to the development of insulin resistance. 3. Signs and Symptoms a. Pertinent Labs: ● ● ● ● Fasting Plasma Glucose (FPG): ≥126 mg/dL Oral Glucose Tolerance Test (OGTT): 2-hour plasma glucose ≥200 mg/dL Hemoglobin A1c (HbA1c): ≥6.5% Random plasma glucose: ≥200 mg/dL in a patient with symptoms of hyperglycemia. b. Presenting Symptoms: ● ● ● ● ● ● ● Polyuria (frequent urination) Polydipsia (excessive thirst) Polyphagia (increased hunger) Fatigue Blurred vision Slow-healing wounds or frequent infections In advanced cases: weight loss, numbness or tingling in the hands or feet (neuropathy) c. Assessment/Diagnostic Tools: ● Diagnosis is based on elevated blood glucose levels (FPG, OGTT, or HbA1c) and the presence of symptoms. ● Routine monitoring of blood glucose and HbA1c is essential for assessing glycemic control. ● Additional tests may include lipid panels, kidney function tests (e.g., serum creatinine, urine albumin), and blood pressure assessment for cardiovascular risk management. 4. Treatment a. Approach to therapy i. Pharmacological 1. 1st line/2nd line agents/medication classes ○ 1st line: ■ Metformin 500 mg BID 1. decreases hepatic glucose production and improves insulin sensitivity. ○ 2nd line: ■ SGLT-2 inhibitors 1. Empagliflozin 10-25 mg QD 2. Dapagliflozin 5-10 mg QD a. Reduce glucose reabsorption in the kidneys, leading to glucose excretion. ■ GLP-1 receptor agonists 1. Semaglutide 0.25 mg Once weekly for 4 weeks then 0.5-1mg once weekly 2. Liraglutide 0.6 mg QD for 1 week then 1.2 mg QD a. Both interventions enhance insulin secretion, suppress glucagon, and slow gastric emptying. ■ DPP-4 inhibitors 1. Sitagliptin 100 mg QD ■ Sulfonylureas 1. Glimepiride 1-4 mg QD w/ first meal 2. Glyburide 2.5-5 mg QD or BID a. Rationale - Metformin is the first-line agent due to its efficacy, low cost, and safety profile. SGLT-2 inhibitors and GLP-1 receptor agonists are preferred second-line agents, especially in patients with cardiovascular or kidney disease, due to their additional benefits. Insulin is used when oral medications are insufficient to control blood glucose. b. Unique aspects of drugs - Metformin: Monitor for gastrointestinal side effects and rare risk of lactic acidosis. Avoid in patients with severe renal impairment. - SGLT-2 inhibitors: Risk of genital infections and dehydration; may reduce cardiovascular and kidney complications. - GLP-1 receptor agonists: Can cause nausea and vomiting; weight loss is a beneficial side effect. - Sulfonylureas: Risk of hypoglycemia and weight gain. 2. Duration of therapy ○ T2DM is a chronic condition that typically requires lifelong therapy. Treatment should be individualized based on the patient's response, side effects, and disease progression. ii. Non-pharmacological ● Dietary changes: Emphasize a balanced diet rich in vegetables, whole grains, lean proteins, and healthy fats. Reduce intake of processed foods, sugars, and refined carbohydrates. ● Exercise: At least 150 minutes of moderate-intensity exercise per week to improve insulin sensitivity. ● Weight management: Achieving and maintaining a healthy weight is crucial for improving insulin sensitivity and glycemic control. ● Smoking cessation: Reduces cardiovascular risk. ● Regular monitoring: Patients should monitor their blood glucose levels and keep track of their HbA1c every 3-6 months. 5. Bonus: Name a Clinical Guideline ● American Diabetes Association (ADA) Standards of Medical Care in Diabetes: Provides comprehensive guidelines for the diagnosis, management, and treatment of T2DM.