All people with type 2 diabetes should be offered access to ongoing DSMES programs.
Providers and health care systems should prioritize the delivery of person-centered care.
Optimizing medication adherence should be specifically considered when selecting glucose-lowering medications.
MNT focused on identifying healthy dietary habits that are feasible and sustainable is recommended in support of reaching metabolic and weight goals.
Physical activity improves glycemic control and should be an essential component of type 2 diabetes management.
Adults with type 2 diabetes should engage in physical activity regularly (>150 min/week of moderate- to vigorous-intensity aerobic activity) and be encouraged to reduce sedentary time and break up sitting time with frequent activity breaks.
Aerobic activity should be supplemented with two to three resistance, flexibility, and/or balance training sessions/week. Balance training sessions are particularly encouraged for older individuals or those with limited mobility/poor physical function.
Metabolic surgery should be considered as a treatment option in adults with type 2 diabetes who are appropriate surgical candidates with a BMI ≥40.0 kg/m2 (BMI ≥37.5 kg/m2 in people of Asian ancestry) or a BMI of 35.0–39.9 kg/m2 (32.5–37.4 kg/m2 in people of Asian ancestry) who do not achieve durable weight loss and improvement in comorbidities (including hyperglycemia) with nonsurgical methods.
In people with established CVD, a GLP-1 RA with proven benefit should be used to reduce MACE, or an SGLT2i with proven benefit should be used to reduce MACE and HF and improve kidney outcomes.
In people with CKD and an eGFR ≥20 ml/min per 1.73 m2 and a UACR >3.0 mg/mmol (>30 mg/g), an SGLT2i with proven benefit should be initiated to reduce MACE and HF and improve kidney outcomes. Indications and eGFR thresholds may vary by region. If such treatment is not tolerated or is contraindicated, a GLP-1 RA with proven cardiovascular outcome benefit could be considered to reduce MACE and should be continued until kidney replacement therapy is indicated.
In people with HF, SGLT2i should be used because they improve HF and kidney outcomes.
In individuals without established CVD but with multiple cardiovascular risk factors (such as age ≥55 years, obesity, hypertension, smoking, dyslipidemia, or albuminuria), a GLP-1 RA with proven benefit could be used to reduce MACE, or an SGLT2i with proven benefit could be used to reduce MACE and HF and improve kidney outcomes.
In people with HF, CKD, established CVD, or multiple risk factors for CVD, the decision to use a GLP-1 RA or SGLT2i with proven benefit should be independent of background use of metformin.
SGLT2i and GLP-1 RA reduce MACE, which is likely to be independent of baseline HbA1c. In people with HF, CKD, established CVD, or multiple risk factors for CVD, the decision to use a GLP-1 RA or an SGLT2i with proven benefit should be independent of baseline HbA1c.
In general, selection of medications to improve cardiovascular and kidney outcomes should not differ for older people.
In younger people with diabetes (<40 years), consider early combination therapy.
In women with reproductive potential, counseling regarding contraception and taking care to avoid exposure to medications that may adversely affect a fetus are important.
In the massively bleeding patient with coagulopathy, our group recommends the administration of an initial bolus of 25 IU.kg-1. This applies for: the acute reversal of vitamin K antagonist therapy; haemostatic resuscitation, particularly in trauma; and the reversal of direct oral anticoagulants when no specific antidote is available.
In patients with a high risk for thromboembolic complications, e.g. cardiac surgery, the administration of an initial half-dose bolus (12.5 IU.kg-1) should be considered.
A second bolus may be indicated if coagulopathy and microvascular bleeding persists and other reasons for bleeding are largely ruled out. Tissue-factor-activated, factor VII-dependent and heparin insensitive point-of-care tests may be used for peri-operative monitoring and guiding of prothrombin complex concentrate therapy.
For the endpoint of rapid INR reduction, the results from our trial are consistent with previously published (mainly observational) data and demonstrate that 4F-PCC is non-inferior and superior to plasma for rapid INR reduction in patients on VKA therapy.
Furthermore, we noted that 4F-PCC could be given more rapidly than plasma, which is in agreement with previously published (retrospectively collected) data.24
For the endpoint of clinical efficacy, we found no other adequately powered trial examining reversal of VKA therapy in patients needing urgent surgical procedures, and this trial therefore offers new insights into their treatment. We noted that 4F-PCC was superior to plasma for haemostatic efficacy.
Although our study was not powered to assess safety, we did not detect any between-treatment differences for the occurrence of thromboembolic events or deaths, a finding in agreement with the existing scientific literature.11, 17, 25, 26 Additionally, although these data guide clinicians on how best to achieve urgent VKA reversal, the scientific literature concerning which patients should be urgently reversed before surgical or invasive interventions continues to evolve; for example, findings from a recent trial showed the safety of pacemaker placement without interruption of anticoagulation.29
Among the key recommendations in this article are the following:
For dosing of VKAs, we recommend the initiation of oral anticoagulation therapy, with doses between 5 mg and 10 mg for the first 1 or 2 days for most individuals, with subsequent dosing based on the international normalized ratio (INR) response (Grade 1B); we suggest against pharmacogenetic-based dosing until randomized data indicate that it is beneficial (Grade 2C); and in elderly and other patient subgroups who are debilitated or malnourished, we recommend a starting dose of ≤ 5 mg (Grade 1C). The article also includes several specific recommendations for the management of patients with nontherapeutic INRs, with INRs above the therapeutic range, and with bleeding whether the INR is therapeutic or elevated.
For the use of vitamin K to reverse a mildly elevated INR, we recommend oral rather than subcutaneous administration (Grade 1A).
For most patients who have a lupus inhibitor, we recommend a therapeutic target INR of 2.5 (range, 2.0 to 3.0) [Grade 1A].
We recommend that physicians who manage oral anticoagulation therapy do so in a systematic and coordinated fashion, incorporating patient education, systematic INR testing, tracking, follow-up, and good patient communication of results and dose adjustments [Grade 1B].
In patients who are suitably selected and trained, patient self-testing or patient self-management of dosing are effective alternative treatment models that result in improved quality of anticoagulation management, with greater time in the therapeutic range and fewer adverse events. Patient self-monitoring or self-management, however, is a choice made by patients and physicians that depends on many factors. We suggest that such therapeutic management be implemented where suitable (Grade 2B).
In patients on VKA therapy presenting with severe hemorrhage, international guidelines recommend, as soon as the diagnosis is confirmed, the administration of PCC (≥20 UI/kg) and vitamin K (≥5 mg) to normalize coagulation (post-reversal INR ≤1.5).
A guideline-concordant administration dose of PCC and vitamin K administrated in the first eight hours was associated with a two-fold decrease in seven-day mortality overall and with a three-fold decrease in the ICH subgroup
The guideline-concordant reversal was performed in 38% of the patients within eight hours after admission
Whereas pre-reversal INR is not absolutely necessary, post-reversal INR is essential to evaluate treatment efficacy
The post-reversal INR target must be performed systematically and immediately after PCC administration
The case: Patient came in for laparoscopic colectomy. She had a history of severe COPD, newly diagnosed adenocarcinoma of colon, anemia (Hb 9), newly diagnosed ANCA vasculitis, h/o mitral stenosis s/p robotic mitral valve replacement, pulmonary HTN, severe TR, systemic HTN, normal EF. Patient had recent exacerbations of CHF with BNP in 1200s. Recent (within the last 3 months) history of coding on induction requiring chest compressions during robotic MVR (50mg propofol). On a steroid taper.
BPs 180-200s/90-110s; PAPs 40-60s/20-40s. 50kg.
Plan: aline, swan, R2, slow induction
Induction: fentanyl 50mcg, propofol 20mg, lidocaine 100mg, etomidate 10mg, roc 50mg. Gtt: epinephrine @ 0.02mcg/kg/min, norepinephrine @ 0.04mcg/kg/min. Milrinone arrived to OR after induction. Able to titrate off epinephrine to Milrinone 0.3mcg/kg/min even with insufflation of abdomen. Did not need to decrease insufflation pressures as hemodynamics were relatively stable.
Extubated safely at the end of the case. Received 100mcg fentanyl, 20mg ketamine, Exparel TAP block, pre-op PO Tylenol 1000mg for pain control. She’s doing well and pleased with her anesthetic management.
80 something year old male came for reverse total shoulder replacement. He had severe COPD as well as an EF 20% with CHF. He had been appropriately optimized. Preoperatively, we performed an anterior approach suprascapular block (10ml, 0.25% bupi) combined with an infraclavicular block (20ml, 0.25% bupi). In retrospect, we could have used 5ml for suprascapular block and 15ml for infraclavicular block.
In November 2022, I opted to try a continuous glucose monitor (CGM) to track my blood sugar readings. Granted, I am not diabetic, however my father and my aunt are diabetics and I had gestational diabetes during my 2nd pregnancy. I’m a bit of a data nerd and like to see how my body responds to the things I eat. So, I signed up for a program through Zoe and started following the app and logging my food. After I completed the 14 days, I then stumbled upon Glucose Goddess and want to try another 14 days with the CGM. Here’s the data from the first trial.
I felt that my blood glucose was actually pretty well maintained. My average reading was 94 and I fluctuated from 72-138. That’s pretty much carrying on with my regular lifestyle: protein shake for breakfast, whole food plant based meal for lunch, and regular dinner and a snack before bed. After reading the Glucose Revolution book, I find that I have an even better understanding of what I can do to improve my stability and consistency of my glucose curve. 2nd trial coming soon!
April 2023
I opted to try the CGM again for a two week period. Similar results with the diet/nutrition and knowledge that I had from before. Biggest issue is will power.
Breakfast: ACV water when wake up. Vedge protein shake
Lunch: PBM or balance of veggies to protein w ACV
Snack: Vedge protein shake
Dinner: ACV, balance of veggies and protein
Kept wine/bevies to 1-2 on weekend only. My body just doesn’t like it and I sleep like crap. If I am to have alcohol, it’s better at lunch for me so it doesn’t mess up my sleep.
After listening to the Huberman Lab podcast (and you should too! He’s got nuggets of info on health!), I decided to schedule a Dexa Scan as well as VO2 max test. I want to have a baseline of where I am at my age. This year has been a huge year of change. I’ve committed to my health (yes I’m currently 7 months in with a strength program called Rise; I started 1-2x/wk rowing; MMA 1x/wk). I’m changing jobs. I have cut back or cut out unnecessary or harmful things to my life. I’m participating in a glucose monitoring study. I wish I had done these metrics every decade of my life starting at 10.
The more I dig into the world of health and wellness, the more there is to learn. Hormones, gut health, nutrition, supplements, macros/micros, exercise (role for mobility, flexibility, cardio, strength, functional, etc). I wish they taught this stuff in medical school. This is the real foundation of health and wellness.
What does an angiotensin receptor blocker (ARB) do?
Angiotensin II receptor blockers (ARBs) represent a newer class of effective and well tolerated antihypertensive agents 1. Several clinical studies have indicated the beneficial effects of ARBs in hypertensive patients such as reduction of left ventricular hypertrophy, decrease in ventricular arrhythmias, and improved diastolic function 1. Inhibitors of the renin-angiotensin system (RAS), either angiotensin converting enzyme (ACE) inhibitors or ARBs, mediate vasodilation and consequently decrease blood-pressure by different mechanisms 1. ARBs specifically inhibit angiotensin II from binding to its receptor, the Angiotensin-1 (AT 1) receptor on vascular smooth muscle cells. This blockade results in increased angiotensin II and normal bradykinin plasma levels. ARBs were developed to overcome several deficiencies of ACE inhibitors, which, by comparison, lead to decreased angiotensin II, but increased bradykinin levels. Hence, the key advantage of ARBs over ACE inhibitors is their lack of adverse effects related to bradykinin potentiation. ARBs have been shown to reduce morbidity and mortality associated with hypertension, and therefore, it is not surprising that an increasing number of patients scheduled for surgery are chronically treated with ARBs 2. However, RAS blockade increases the risk of severe hypotension during and after anesthetic induction. ACE-inhibitors are well known for inducing severe circulatory side effects during anesthesia, which led to the general recommendation to withhold the drug on the day of surgery 3.
Chronic AT 1 blockade also reduces the vasoconstrictor response to α 1 receptors activated by norepinephrine, which explains why ARB-induced hypotension can be so resistant to phenylephrine, ephedrine and norepinephrine 2, 8 Clinical studies have shown significant vasoconstrictor effects of vasopressin and increased cardiac filling during echocardiographic measurements 2.
Vasopressin or its synthetic analogues can restore the sympathetic response and may be useful pressors in cases of refractory hypotension during anaphylaxis 9 and septic shock 10 as well as in patients on RAS inhibitors, although norepinephrine has been reported to have a more favorable effect on splanchnic perfusion and oxygen delivery 11.
When conventional therapies such as: decreasing the anesthetic agent, volume expansion, phenylephrine, ephedrine, norepinephrine, and epinephrine are not effective, exogenous vasopressin may improve hypotension. To date, at least 5 clinical trials have demonstrated that patients on chronic ACEI/ARB undergoing general anesthesia, respond to exogenous vasopressin derivatives with an increase in blood pressure and fewer hypotensive episodes.6,7 Typically, a 0.5-1 unit bolus of AVP is administered to achieve a rise in mean arterial pressure.4 The subsequent recommended infusion dose is 0.03U/min for AVP and 1-2 mcg/kg/h for terlipressin. Caution should be used as V1 agonists have been associated with the following deleterious effects: reduction in cardiac output and systemic oxygen delivery, decreased platelet count, increased serum aminotransferases and bilirubin, hyponatremia, increased pulmonary vascular resistance, decrease in renal blood flow, increase in renal oxygen consumption, and splanchnic vasoconstriction.
Studies involving cardiac surgical patients suggest that MB treatment for patients with VS may reduce morbidity and mortality.5 It has also been suggested that the early use (preoperative use in patients at risk for VS) of MB in patients undergoing coronary artery bypass grafting may reduce the incidence of VS.5,9A bolus dose of 1-2mg/kg over 10-20 minutes followed by an infusion of 0.25mg/kg/hr for 48-72 hours is typically utilized in clinical practice and trials (with a maximum dose of 7 mg/kg).10 Side effects include cardiac arrhythmias (transient), coronary vasoconstriction, increased pulmonary vascular resistance, decreased cardiac output, and decreased renal and mesenteric blood flow.1 Both pulse and cerebral oximeter readings may not be reliable during MB administration due to wavelength interference.11,12 The use of MB is absolutely contraindicated in patients with severe renal impairment because it is primarily eliminated by the kidney.13 It may also cause methemoglobinemia and hemolysis.13 At high doses, neurotoxicity may occur secondary to the generation of oxygen free radicals. Neurologic dysfunction may be more severe in patients receiving serotoninergic agents such as: tramadol, ethanol, antidepressants, dopamine agonists and linezolid. Recommended doses for VS ranging from 1-3 mg/kg do not typically cause neurologic dysfunction.14 However, recent reports suggest that MB in doses even ≤ 1mg/kg in patients taking serotonin reuptake inhibitors (SSRIs) may lead to serotonin toxicity due to its monoamine oxidase (MAO) inhibitor property.15
Over the years, our hospital has been using Amicar… until there was a drug shortage. With that drug shortage came a different drug called tranexamic acid. We’ve been using it for awhile and I can’t seem to tell a difference in coagulation between the two drugs. Let’s break down each one and also discuss cost-effectiveness.
Tranexamic acid acts by reversibly blocking the lysine binding sites of plasminogen, thus preventing plasmin activation and, as a result, the lysis of polymerised fibrin.12 Tranexamic acid is frequently utilised to enhance haemostasis, particularly when fibrinolysis contributes to bleeding. In clinical practice, tranexamic acid has been used to treat menorrhagia, trauma-associated bleeding and to prevent perioperative bleeding associated with orthopaedic and cardiac surgery.13–16 Importantly, the use of tranexamic acid is not without adverse effects. Tranexamic acid has been associated with seizures,17 18 as well as concerns of possible increased thromboembolic events, including stroke which to date have not been demonstrated in randomised controlled trials.
Fibrinolysis is the mechanism of clot breakdown and involves a cascade of interactions between zymogens and enzymes that act in concert with clot formation to maintain blood flow.25 During extracorporeal circulation, such as cardiopulmonary bypass used in cardiac surgery, multiplex changes in haemostasis arise that include accelerated thrombin generation, platelet dysfunction and enhanced fibrinolysis.26 Tranexamic acid inhibits fibrinolysis, a putative mechanism of bleeding after cardiopulmonary bypass, by forming a reversible complex with plasminogen.
In summary, we found no evidence that tranexamic acid increases the risk of death and thrombotic complications after coronary-artery surgery. Tranexamic acid was associated with a lower risk of bleeding complications than placebo but also with a higher risk of postoperative seizures.
The study used a high-dose regimen, in which either 50 mg/kg or 100 mg/kg of TXA was delivered for each patient. There is a possibility that lower dose of TXA can be equally effective while causing less adverse effects. In fact, TXA plasma concentrations required to suppress fibrinolysis and plasmin-induced platelet activation are merely 10 and 16 μg/ml, respectively [7, 8]. This relatively low plasma concentration can be reached in cardiac surgery when 10 mg/kg of TXA is administered as a bolus then followed by continuous infusion of 1 mg kg/h and 1 mg/kg in CPB [9]. But another potential mechanism of TXA action might be the increase in thrombin formation, which requires concentrations more than 126 μg/ml to be effective [10, 11]. 30 mg/kg of TXA administered as a bolus followed by 16 mg/kg/h and 2 mg/kg in CPB prime solution was able to maintain the plasma concentration above 114 μg/ml [9].
Using their model-based meta-analysis, the authors conclude that low-dose tranexamic acid (total dose of 20 mg/kg of actual body weight) provides the best balance between reduction in postoperative blood loss and red blood cell transfusion and the risk of clinical seizure. The use of higher doses would only marginally improve the clinical effect at the cost of an increased risk of seizure.
Low-risk group received a single 50 mg/kg TXA bolus after induction of anesthesia. The high-risk group received Blood Conservation Using Anti-fibrinolytics Trial (BART) TXA regimen, consisting of 30 mg/kg bolus infused over 15 minutes after induction, followed by 16 mg/kg/h infusion until chest closure with a 2 mg/kg load within the pump prime.
Risk of seizure is dose-dependent, with the greatest risk at higher doses of tranexamic acid. We conclude that, in general, patients with a high risk of bleeding should receive high-dose tranexamic acid, while those at low risk of bleeding should receive low-dose tranexamic acid with consideration given to potential dose-related seizure risk. We recommend the regimens of high-dose (30 mg kg−1 bolus + 16 mg kg−1 h−1 + 2 mg kg−1 priming) and low-dose (10 mg kg−1 bolus + 1 mg kg−1 h−1 + 1 mg kg−1 priming) tranexamic acid, as these are well established in terms of safety profile and have the strongest evidence for efficacy.
The exposure value with the low-dose tranexamic acid regimen proposed by Horrow et al. (10 mg/kg followed by 1 mg/kg/h over 12 h) was close to the 80% effective concentration for postoperative blood loss and above the 80% effective concentration for erythrocyte transfusion. Compared to this regimen, a fivefold increase in total dose (100 mg/kg) achieved only a 58 ml (95% credible interval,54 to 65 ml) increment in the reduction of postoperative blood loss, up to 48 h postsurgery, with a decrease in erythrocyte transfusion rate from 46% to 44%.
Concentrations close to 80% effective concentration can be achieved at the end of surgery with a low-dose regimen administered either as a preoperative bolus plus infusion (10mg/kg followed by 1mg/kg/h) or as a single preoperative loading dose of 20mg/kg (fig. 6). Postoperative administration of tranexamic acid appears unnecessary because tranexamic acid concentrations will decrease but nevertheless remain sufficient (greater than or equal to EC50) up to the end of the drug’s contribution to blood loss reduction (8 h after the start of surgery).
The type of surgery and the duration of CPB both affected the risk of seizure. Open-chamber surgery resulted in a 5.5-fold increase in the risk of seizure compared to closed-chamber procedures (95% credible interval, 3.2 to 10). Each additional hour of CPB doubled the risk of seizure (2.0;95% credible interval, 1.2 to 3.2).
Ortho/Spine
OB
Trauma
Currently at our hospital (June 2022):
TXA DOSING AND ADMINISTRATION OVERVIEW
How supplied from Pharmacy
TXA 1000mg/10mL vials Will not provide premade bags like with Amicar; Amicar is a more complex mixture than TXA Will take feedback on this after go-live and reassess
There are a number of dosing strategies in the literature. What I recommend for maximal safety and efficacy is taken from Zuffery, et al. Anesthesiology 2021 meta-analysis and is practiced at Scripps Mercy.
~ 20 mg/kg total dose recommended in this meta-analysis.
Two dosing strategies they report that were as effective as high-dose but with lower seizure risk than high dose: