advanced clinical final

What is the A1C target in pediatric T2DM?

A1C <7%

Major risk factors for T2DM in youth

Obesity, genetics, Native American/African American/Hispanic/Asian ethnicity, female sex, gestational diabetes exposure, PCOS

Classic symptoms of pediatric T2DM

Polyuria, polydipsia, nocturia, possible DKA

What medications can cause or worsen diabetes?

Glucocorticoids (high dose), atypical antipsychotics (olanzapine, clozapine), propranolol

Non-pharmacologic management of pediatric T2DM

Diet with fruits/vegetables, screen time <2 hrs/day, ≥60 min daily physical activity (<18 yrs)

What did the TODAY trial study?

Durability of glycemic control in youth with T2DM

Key TODAY trial finding

~50% failed metformin monotherapy within 3–4 years

First-line therapy for pediatric T2DM

Metformin or insulin depending on severity

When to start metformin

A1C <8.5%

Metformin MOA

Increases insulin sensitivity and decreases hepatic glucose production

Expected A1C reduction with metformin

~1–1.5%

Common metformin adverse effects

Nausea, diarrhea

Metformin contraindications

Hepatitis, CKD, alcohol use disorder, cirrhosis, cardiopulmonary insufficiency, prior lactic acidosis

When to initiate insulin in pediatric T2DM

A1C ≥8.5% or if ketones/DKA present

GLP-1 agonists used in pediatric T2DM

Liraglutide (approved), semaglutide (off-label)

Benefits of GLP-1 agonists in youth

Weight loss and modest A1C reduction

GLP-1 agonist contraindications

CKD, pancreatitis history, medullary thyroid cancer (personal/family)

SGLT2 inhibitor A1C reduction in youth

~0.2–0.4%

Why SGLT2 inhibitors are popular in adults

CV benefit, ↓ HF, ↓ MI/stroke

Indications for benzodiazepines

Acute seizures, alcohol withdrawal (short term), panic disorder, situational anxiety

Benzodiazepines should be deprescribed when?

Indication unknown or long-term use without benefit

Common benzodiazepine adverse effects

Sedation, cognitive impairment, delirium, falls, MVAs, respiratory depression

NNH for benzodiazepines

6 at 2 weeks

Benzodiazepine withdrawal symptoms

Tremor, anxiety, sweating, hallucinations, psychosis, seizures

Who is at risk of benzo withdrawal?

Patients taking scheduled daily doses

General benzo taper strategy

Convert to one agent, taper slowly

KDIGO definition of AKI

↑ sCr ≥27 µmol/L in 48h OR 1.5× baseline in 7 days OR UO <0.5 mL/kg/hr for 6 hrs

Most common type of AKI

Prerenal (~60%)

Causes of prerenal AKI

Dehydration, hypovolemia, HF, liver failure, drugs

Urea:creatinine ratio in prerenal AKI

>100:1 (curved)

Intrinsic AKI mechanism

Structural kidney damage

Urea:creatinine ratio in intrinsic AKI

Flat (both rise together)

Postrenal AKI causes

BPH, stones, strictures, tumors

Common signs of dehydration

Hypotension, tachycardia, dry mucous membranes, poor skin turgor, dark urine, dizziness, thirst, hypernatremia

Why hold metformin in AKI?

Reduced clearance → accumulation and lactic acidosis risk

When can metformin be restarted after AKI?

CrCl >30, sCr near baseline, eating/drinking normally

Why hold SGLT2 inhibitors in AKI?

Volume depletion worsens AKI

Why hold ACEi/ARBs in AKI?

↓ renal perfusion + hyperkalemia risk

Why hold pregabalin/gabapentin in AKI?

Accumulation → confusion and CNS toxicity

Can ASA 81 mg be continued in AKI?

Yes – not nephrotoxic

When can statins be continued in AKI?

If already dose-adjusted and no rhabdomyolysis

Are PPIs safe in AKI?

Yes

Major AFib risk factors

Age, HTN, HF, CAD, diabetes, obesity, alcohol

When is rhythm control preferred?

Recent diagnosis (<1 yr), high symptoms, recurrent AF, poor rate control

Evidence-based beta blockers for AFib

Bisoprolol, metoprolol, carvedilol

When is digoxin added for AFib?

Inadequate rate control after 2–4 weeks of max BB

Target digoxin trough

0.5–0.9 ng/mL

CHADS-65 components

CHF, HTN, Age ≥65, Diabetes, Stroke/TIA

Safest DOAC for bleeding risk

Apixaban

How does furosemide dose–response change in CKD?

Right shift → higher threshold, ceiling at higher doses

Why does furosemide resistance occur in CKD?

Poor tubular delivery

How does furosemide dose–response change in HF?

Right + downward shift → reduced max effect

Initial IV furosemide dose if diuretic-naïve

20–40 mg IV

Initial IV dose in CKD/AKI/HF

80 mg IV

Max IV furosemide dose in CKD

400 mg/day

Markers of diuretic response

SOB improvement, UOP >150 mL/hr, weight loss ~1 kg/day

Three fluid compartments

Intravascular, intracellular, interstitial

Where does edema occur?

Interstitial space

Why can CHF patients have AKI despite edema?

Low effective intravascular volume

Fluid strategy in AKI + CHF

Net fluid loss (remove more than given)

When to start ACEi/ARB after AKI

Renal function near baseline, K+ normalized

When to start beta blocker in HF

Euvolemic and hemodynamically stable

When to start MRA

eGFR >30 and K+ <5

When to start SGLT2 inhibitor in HF

Euvolemic, renal function at baseline, BP stable