👇👇👇👇👇👇👇👇👇👇👇👇
مساء الفل....
الدكتور عادل عادةً يحب الطالب يكون فاهم المواضيع الآتية:
- Acne Vulgaris.
- Atopic Dermatitis.
- Seborrheic Dermatitis.
- Lichen Simplex.
- Lichen planus.
- Bullous Diseases.
- Erythroderma.
- Photosensitivity (Generally).
- Porphyria cutanea tarda.
- Urticaria.
- Psoriasis.
- Fixed drug eruption.
- Superficial Bacterial Infections (Folliculitis....)
- Gonorrhea.
- Fungal Infections (T. Pedis, capitis and of the nails).
- Viral Infections ( Warts 🤓, HSV).
- Scabies.
- Alopecia areata.
- SCC, BCC & Melanoma(Classifications & Modalities of treatment).
- Tuberous sclerosis.
- Neurofibromatosis.
ويحب ال
- Commonest Sign in every disease(if present).
- Commonest drugs (Uses & Adverse Effects) used in dermatology.
- Commonest procedures(Wood lamp, KOH...) used in dermatology.
- الفروقات في وصف ال LESIONS.
وإعذرونا على أي Spelling غلط 🙊🙊
مساء الفل....
الدكتور عادل عادةً يحب الطالب يكون فاهم المواضيع الآتية:
- Acne Vulgaris.
- Atopic Dermatitis.
- Seborrheic Dermatitis.
- Lichen Simplex.
- Lichen planus.
- Bullous Diseases.
- Erythroderma.
- Photosensitivity (Generally).
- Porphyria cutanea tarda.
- Urticaria.
- Psoriasis.
- Fixed drug eruption.
- Superficial Bacterial Infections (Folliculitis....)
- Gonorrhea.
- Fungal Infections (T. Pedis, capitis and of the nails).
- Viral Infections ( Warts 🤓, HSV).
- Scabies.
- Alopecia areata.
- SCC, BCC & Melanoma(Classifications & Modalities of treatment).
- Tuberous sclerosis.
- Neurofibromatosis.
ويحب ال
- Commonest Sign in every disease(if present).
- Commonest drugs (Uses & Adverse Effects) used in dermatology.
- Commonest procedures(Wood lamp, KOH...) used in dermatology.
- الفروقات في وصف ال LESIONS.
وإعذرونا على أي Spelling غلط 🙊🙊
Forwarded from Suleiman
Insulin regimens should be tailored individually to each patient. There are a variety of options for patients with T2DM. Treatment of T1DM requires intensive insulin therapy with a multi injection regimen or insulin pump.
Basal insulin regimens [28]
Description: Basal insulin is added to an oral antidiabetic drug regimen.
Indication: T2DM with persistently elevated A1C levels despite adequate treatment with noninsulin antidiabetics
Treatment options
Once-daily injection (recommended starting regimen)
Long-acting insulin (e.g., glargine) OR bedtime NPH insulin
Starting dose: 10 units/day OR 0.1–0.2 units/kg/day
Twice-daily NPH insulin: Consider for patients not meeting their glycemic target with bedtime NPH.
Starting dose: 80% of the previously prescribed bedtime NPH insulin dose, with two-thirds given in the morning and one-third at bedtime
Titration
Adjust according to glycemic monitoring.
Levels above target: Increase insulin dose by 2 units every 3 days until preprandial fasting glucose target is met.
If hypoglycemia due to insulin therapy occurs, reduce insulin dose by 10–20%.
If treatment remains insufficient despite appropriate adjustments , intensify treatment by either adding prandial insulin or considering a mixed regimen.
Not all noninsulin antidiabetics can be combined with insulin. Combination therapy with insulin and sulfonylureas should be avoided because of the risk of hypoglycemia and increased mortality! Once insulin is started, consider tapering and eventual discontinuation of sulfonylureas. Insulin combined with pioglitazone increases the risk of edema, weight gain, and congestive heart failure. Metformin is usually continued.
Addition of prandial insulin [28]
Description
Short-acting insulin or rapid-acting insulin is injected before major meals in patients already on a basal insulin regimen.
Prandial insulin can be added before one meal (the largest meal of the day) or several meals.
Indication: T2DM that is not adequately controlled with basal insulin alone
Starting dose
Basal insulin injections are continued at the previous dose.
4 units of short-acting or rapid-acting insulin before chosen meals
Titration: Adjust according to glycemic monitoring.
Increase prandial insulin dose by 1–2 units twice weekly until preprandial fasting glucose target is met.
If hypoglycemia occurs, reduce the corresponding prandial insulin dose by 10–20%.
Mixed insulin regimens [28]
Description
Twice-daily injections of a fixed combination of NPH mixed with either short-acting insulin or rapid-acting insulin; can be self-mixed or premixed
Simple regimens that require minimal patient education and time
Indication: Consider for patients with T2DM who are not meeting glycemic targets with a basal insulin regimen.
Starting dose
Self-mixed insulin
Calculate 80% of the current NPH dose.
Add 4 units of short-acting or rapid-acting insulin per injection.
Premixed insulin: Use the same previous total insulin dose (i.e., the same as for the twice-daily NPH regimen).
Titration
Adjust according to glycemic target.
If treatment results remain inadequate, consider a full basal-bolus regimen.
Mixed insulin regimens are simpler to use and reduce the number of injections required, as both types of insulin are combined into one injection.
Intensive insulin therapy [28][29]
This regimen provides optimal glycemic control as well as more flexibility in the daily diet and exercise plan, and it reduces the risk of complications in patients with good adherence.
Indications
T1DM
T2DM that cannot be sufficiently managed otherwise
Gestational diabetes mellitus
Full basal-bolus regimen: basal regimen with additional short-acting or rapid-acting insulin bolus before every major meal
Insulin pump [30]
Insulin (usually a rapid-acting insulin analog) is subcutaneously infused through a small device attached to the skin.
Basal rates and bolus insulin can be separately tailored to the patient's needs.
Basal insulin regimens [28]
Description: Basal insulin is added to an oral antidiabetic drug regimen.
Indication: T2DM with persistently elevated A1C levels despite adequate treatment with noninsulin antidiabetics
Treatment options
Once-daily injection (recommended starting regimen)
Long-acting insulin (e.g., glargine) OR bedtime NPH insulin
Starting dose: 10 units/day OR 0.1–0.2 units/kg/day
Twice-daily NPH insulin: Consider for patients not meeting their glycemic target with bedtime NPH.
Starting dose: 80% of the previously prescribed bedtime NPH insulin dose, with two-thirds given in the morning and one-third at bedtime
Titration
Adjust according to glycemic monitoring.
Levels above target: Increase insulin dose by 2 units every 3 days until preprandial fasting glucose target is met.
If hypoglycemia due to insulin therapy occurs, reduce insulin dose by 10–20%.
If treatment remains insufficient despite appropriate adjustments , intensify treatment by either adding prandial insulin or considering a mixed regimen.
Not all noninsulin antidiabetics can be combined with insulin. Combination therapy with insulin and sulfonylureas should be avoided because of the risk of hypoglycemia and increased mortality! Once insulin is started, consider tapering and eventual discontinuation of sulfonylureas. Insulin combined with pioglitazone increases the risk of edema, weight gain, and congestive heart failure. Metformin is usually continued.
Addition of prandial insulin [28]
Description
Short-acting insulin or rapid-acting insulin is injected before major meals in patients already on a basal insulin regimen.
Prandial insulin can be added before one meal (the largest meal of the day) or several meals.
Indication: T2DM that is not adequately controlled with basal insulin alone
Starting dose
Basal insulin injections are continued at the previous dose.
4 units of short-acting or rapid-acting insulin before chosen meals
Titration: Adjust according to glycemic monitoring.
Increase prandial insulin dose by 1–2 units twice weekly until preprandial fasting glucose target is met.
If hypoglycemia occurs, reduce the corresponding prandial insulin dose by 10–20%.
Mixed insulin regimens [28]
Description
Twice-daily injections of a fixed combination of NPH mixed with either short-acting insulin or rapid-acting insulin; can be self-mixed or premixed
Simple regimens that require minimal patient education and time
Indication: Consider for patients with T2DM who are not meeting glycemic targets with a basal insulin regimen.
Starting dose
Self-mixed insulin
Calculate 80% of the current NPH dose.
Add 4 units of short-acting or rapid-acting insulin per injection.
Premixed insulin: Use the same previous total insulin dose (i.e., the same as for the twice-daily NPH regimen).
Titration
Adjust according to glycemic target.
If treatment results remain inadequate, consider a full basal-bolus regimen.
Mixed insulin regimens are simpler to use and reduce the number of injections required, as both types of insulin are combined into one injection.
Intensive insulin therapy [28][29]
This regimen provides optimal glycemic control as well as more flexibility in the daily diet and exercise plan, and it reduces the risk of complications in patients with good adherence.
Indications
T1DM
T2DM that cannot be sufficiently managed otherwise
Gestational diabetes mellitus
Full basal-bolus regimen: basal regimen with additional short-acting or rapid-acting insulin bolus before every major meal
Insulin pump [30]
Insulin (usually a rapid-acting insulin analog) is subcutaneously infused through a small device attached to the skin.
Basal rates and bolus insulin can be separately tailored to the patient's needs.
👍4❤2👏2
Forwarded from Suleiman
May be beneficial in patients with dawn phenomenon
The goal of intensive insulin therapy is to simulate physiological glucose metabolism (e.g., by keeping fasting blood glucose levels < 100 mg/dL (5.6 mmol/L) and postprandial blood glucose levels < 140 mg/dL (< 7.8 mmol/L).
Patients on a full basal-bolus regimen require intensive education, high motivation, and commitment, as this is the most complex and time-consuming treatment for diabetes and has an increased risk for hypoglycemia.
Full Basal-bolus insulin regimen [2][3][31]
Basal-bolus regimens may vary. Institutional standards should be followed and intensive insulin therapy tailored individually to each patient.
Calculate the total daily dose of insulin (TDD) needed.
If the patient is already on a correction scale: Increase or decrease TDD by 10–20% as needed.
If the patient is aged ≥ 70 years, and/or has GFR < 60 mL/min: 0.2–0.3 units/kg
If none of the above criteria apply, use the blood glucose level:
BG 140–200 mg/dL: 0.4 units/kg
BG > 200 mg/dL: 0.5 units/kg
Divide the TDD of insulin into basal insulin (50%) and nutritional insulin (50%).
Basal insulin: administer as long-acting insulin (e.g., glargine) at bedtime
Prandial insulin: administer as rapid-acting insulin (e.g., lispro) in equally divided doses before meals
Consider adding a correction bolus before each meal estimated with one of the following methods:
Insulin correction factor [31][32]
Divide 1500 (for short-acting insulin) or 1800 (for rapid-acting insulin) by the total daily dose of insulin
The result is the blood glucose level (in mg/dL) that 1 additional unit of insulin is expected to lower for a specific individual.
1–2 units of insulin typically lower the blood glucose level by ∼ 30–50 mg/dL
Insulin-to-carbohydrate ratio (ICR) [31][32]
Divide 500 by the total daily dose of insulin.
The result is the carbohydrates (g) that 1 unit of insulin is expected to lower for a specific patient.
An adult typically requires 1 unit of insulin for 10 g of carbohydrates, although this varies greatly from patient to patient. [33]
Adjust as needed.
In cases of hypoglycemia < 70 mg/dL: Reduce basal insulin by 20% and/or reduce correction bolus.
If fasting glucose is persistently > 140 mg/dL and no episodes of hypoglycemia occur: Increase basal insulin by 20% and/or increase correction bolus.
Decrease or hold nutritional insulin if the patient is NPO.
Principles of insulin adjustment
Preprandial glucose
Mainly affected by the basal insulin dose
Daily capillary early morning measurements and measurements before applying an insulin dose are advised.
Postprandial glucose is mainly affected by meal intake and prandial insulin dose.
Certain conditions require temporary insulin adjustments.
Increased insulin demand
Illness
Stress
Decreased insulin demand
Physical activity
Vomiting and diarrhea: can lead to decreased glucose uptake, increasing the risk of hypoglycemia
Fasting, e.g., for surgery (see “Perioperative management”)
Sliding-scale insulin regimen [3]
Sliding-scale insulin regimens vary and institutional standards should be followed. Sliding-scale regimens alone should not be used for the long-term management of diabetes.
If the patient is eating all or most of each meal: Administer as short-acting insulin (or rapid-acting insulin) before each meal and at bedtime.
If the patient is not eating: Administer as short-acting insulin every 6 hours.
Insulin regimens for glucocorticoid-induced hyperglycemia
Basal-bolus insulin regimen (preferred)
Consider splitting the total daily dose of insulin 30/70 (i.e., 30% long-acting insulin and 70% prandial short-acting insulin).
Patients usually require about 0.4 units/kg/day but in patients receiving dexamethasone, insulin doses as high as 1.0–1.2 units/kg/day may be necessary. [34]
The total required insulin dosage depends on individual patient factors (e.g., prior insulin sensitivity) and the potency of the steroid.
Sliding-scale insulin regimen: may be adequate for short-term management
The goal of intensive insulin therapy is to simulate physiological glucose metabolism (e.g., by keeping fasting blood glucose levels < 100 mg/dL (5.6 mmol/L) and postprandial blood glucose levels < 140 mg/dL (< 7.8 mmol/L).
Patients on a full basal-bolus regimen require intensive education, high motivation, and commitment, as this is the most complex and time-consuming treatment for diabetes and has an increased risk for hypoglycemia.
Full Basal-bolus insulin regimen [2][3][31]
Basal-bolus regimens may vary. Institutional standards should be followed and intensive insulin therapy tailored individually to each patient.
Calculate the total daily dose of insulin (TDD) needed.
If the patient is already on a correction scale: Increase or decrease TDD by 10–20% as needed.
If the patient is aged ≥ 70 years, and/or has GFR < 60 mL/min: 0.2–0.3 units/kg
If none of the above criteria apply, use the blood glucose level:
BG 140–200 mg/dL: 0.4 units/kg
BG > 200 mg/dL: 0.5 units/kg
Divide the TDD of insulin into basal insulin (50%) and nutritional insulin (50%).
Basal insulin: administer as long-acting insulin (e.g., glargine) at bedtime
Prandial insulin: administer as rapid-acting insulin (e.g., lispro) in equally divided doses before meals
Consider adding a correction bolus before each meal estimated with one of the following methods:
Insulin correction factor [31][32]
Divide 1500 (for short-acting insulin) or 1800 (for rapid-acting insulin) by the total daily dose of insulin
The result is the blood glucose level (in mg/dL) that 1 additional unit of insulin is expected to lower for a specific individual.
1–2 units of insulin typically lower the blood glucose level by ∼ 30–50 mg/dL
Insulin-to-carbohydrate ratio (ICR) [31][32]
Divide 500 by the total daily dose of insulin.
The result is the carbohydrates (g) that 1 unit of insulin is expected to lower for a specific patient.
An adult typically requires 1 unit of insulin for 10 g of carbohydrates, although this varies greatly from patient to patient. [33]
Adjust as needed.
In cases of hypoglycemia < 70 mg/dL: Reduce basal insulin by 20% and/or reduce correction bolus.
If fasting glucose is persistently > 140 mg/dL and no episodes of hypoglycemia occur: Increase basal insulin by 20% and/or increase correction bolus.
Decrease or hold nutritional insulin if the patient is NPO.
Principles of insulin adjustment
Preprandial glucose
Mainly affected by the basal insulin dose
Daily capillary early morning measurements and measurements before applying an insulin dose are advised.
Postprandial glucose is mainly affected by meal intake and prandial insulin dose.
Certain conditions require temporary insulin adjustments.
Increased insulin demand
Illness
Stress
Decreased insulin demand
Physical activity
Vomiting and diarrhea: can lead to decreased glucose uptake, increasing the risk of hypoglycemia
Fasting, e.g., for surgery (see “Perioperative management”)
Sliding-scale insulin regimen [3]
Sliding-scale insulin regimens vary and institutional standards should be followed. Sliding-scale regimens alone should not be used for the long-term management of diabetes.
If the patient is eating all or most of each meal: Administer as short-acting insulin (or rapid-acting insulin) before each meal and at bedtime.
If the patient is not eating: Administer as short-acting insulin every 6 hours.
Insulin regimens for glucocorticoid-induced hyperglycemia
Basal-bolus insulin regimen (preferred)
Consider splitting the total daily dose of insulin 30/70 (i.e., 30% long-acting insulin and 70% prandial short-acting insulin).
Patients usually require about 0.4 units/kg/day but in patients receiving dexamethasone, insulin doses as high as 1.0–1.2 units/kg/day may be necessary. [34]
The total required insulin dosage depends on individual patient factors (e.g., prior insulin sensitivity) and the potency of the steroid.
Sliding-scale insulin regimen: may be adequate for short-term management
❤2👏2
Forwarded from Suleiman
Weight-based NPH insulin regimen [35]
Convert glucocorticoid to equivalent prednisone dose (see “Glucocorticoids”).
Calculate daily NPH dose based on prednisone dose equivalent and patient weight.
Administer glucocorticoid with NPH as a single dose in the morning.
Prednisone dose equivalent (mg/day)NPH (units/kg/day)100.1200.2300.3≥ 400.4
NPH doses should be administered in addition to usual basal insulin in patients who are already receiving insulin.
Consider using glargine or detemir in patients receiving dexamethasone. Dexamethasone has a longer hyperglycemic effect than prednisone and most other commonly used systemic glucocorticoids.
Convert glucocorticoid to equivalent prednisone dose (see “Glucocorticoids”).
Calculate daily NPH dose based on prednisone dose equivalent and patient weight.
Administer glucocorticoid with NPH as a single dose in the morning.
Prednisone dose equivalent (mg/day)NPH (units/kg/day)100.1200.2300.3≥ 400.4
NPH doses should be administered in addition to usual basal insulin in patients who are already receiving insulin.
Consider using glargine or detemir in patients receiving dexamethasone. Dexamethasone has a longer hyperglycemic effect than prednisone and most other commonly used systemic glucocorticoids.
❤1