What about those really tough cases resistant hypertension?

Right. If BP is still above target even with that three drug combination at maximally tolerated doses, then the addition of spironolactone is suggested. This is based on evidence showing it gives a substantial BP reduction in these cases. Though it's worth noting the long-term cardiovascular outcome data for spironolactone as a fourth agent specifically are still a bit limited, but this aligns pretty well with the 2020 guideline which also flags spironolactone as a strong option for resistant hypertension. Just have to be mindful of monitoring potassium of course, especially with an ACI or ARB on board.

Absolutely. Monitoring is key there. Okay, shifting away from meds for a moment. Yeah. What about lifestyle changes? Still important. Any updates?

Oh, absolutely foundational. Both the 2020 and 2025 guidelines hammer this home. Healthy lifestyle changes are crucial for all adults with hypertension. It includes reducing sodium intake, aiming towards 2,000 milligs a day, and reminding patients, you know, most sodium comes from processed foods,

not just the salt shaker.

Exactly. Also, increasing dietary potassium, fruits, vegetables, weight reduction if needed, aiming for a BMI in the 18.5 to 24.9 range, regular physical activity like 30 to 60 minutes of moderate intensity activity most days of the week, and of course, reducing alcohol consumption.

Let's clarify that. alcohol guidance. It can be confusing sometimes. What do the 2025 guidelines say specifically?

Yeah, it's nuanced. Building on 2020, they note that um while overall reduction is generally good for adults who are already consuming two or more drinks per day, just cutting back to two drinks didn't seem to affect BP much. However, if they were consuming more like three, four to five or six or more drinks per day, then reducing their intake was associated with significant drops in systolic BP. So, the suggested limits remain generally two drinks or less per day for men and one drink or less per day for women.

Okay, that's helpful clarification. Now, what about specific populations? I remember 2020 had detailed sections on pregnancy, children. How does 2025 handle that?

This is a really important distinction to make about the 2025 guidelines. They are specifically focused on adults in primary care. They are not intended for children or pregnant individuals. There are separate specialized guidelines for those groups because their needs are quite different.

Okay, so PDC candidates still need to know about those other guidelines separately.

Yes, absolutely. It's crucial for exam candidates to still be aware of the general principles from the 2020 guidelines and other companion documents for these populations. For instance, remembering that in pregnancy ACE inhibitors and ARBs are generally a no-go due to terodogenic risks and that specific drugs like leettool, mephylopa or long-acting nephetapine are preferred firstline oral agents and knowing which drugs are generally considered okay during breastfeeding like leettool methylopa, nifidapine and a lapal caprill. And for children, you know, the BP thresholds are different based on age, sex, height percentiles. Monotherapy is usually the start often with ACEs, ARBs or long acting CCMs, aiming for BP below the 95th percentile.

Got it. So the 2025 guidelines streamlines for primary care adults, but keep the broader knowledge for exams. What about routine monitoring and lab tests? Any changes there?

Not really major changes to the core tests. Both guidelines recommend routine testing for all hypertensive patients at baseline and during maintenance. This includes things like uran analysis, blood chemistry focusing on potassium, sodium creatinine, also fasting blood glucose or an A1C, a lipid panel, and a standalled 12LE ECG. How often you repeat these depends on the clinical situation, but that baseline set of investigations is still standard.

Okay, standard tests remain.

Finally, let's talk about putting it all into practice, adherence, and implementation strategies. How do the guidelines help us actually achieve these goals in the clinic or pharmacy.

Yeah, this is key, right? Both guidelines stress improving patient adherence. It's a multi-pronged approach. Things like tailoring pill taking to daily habits, simplifying regimens, which is where those SPCs really shine, and providing good patient education. The 2025 guidelines specifically highlight leveraging the WHO's hearts framework for implementation in primary care.

The hearts framework, can you remind us what that involves?

Sure. HARTS is an acronym for healthy lifestyle counseling, evidence-based treatment protocol, calls access to essential medicines and technology, risk based management, team- based care, and systems for monitoring. So, it's about having these practical, accessible tools and algorithms, a systematic approach. This focus is really key to improving BP control on a population level.

That makes a lot of sense. A systematic approach for better outcomes. Well, we've covered a huge amount today from those new diagnostic thresholds and the streamlined treatment targets to the really critical pharmacotherapy updates like upfront combination therapy. and other essential tips for navigating the 2025 Canadian hypertension guidelines. Our hope is that this deep dive has really provided you with clarity, accuracy, and maybe a bit more peace of mind as you prepare for your PBC exams and of course as you step into your vital role as a Canadian pharmacist.

Absolutely. Understanding these nuances, especially the shifts from 2020 to 2025, it's not just about passing an exam. It's truly about optimizing patient care and contributing to better cardiovascular health outcomes right across Canada. This knowledge really empowers you in practice.

Good. agree more. This deep dive was brought to you by the Pharma Board Group based on the CTC reference. Now, just to check your understanding, here's a quick multiple choice question for you to think about. According to the 2025 Hypertension Canada guideline for the diagnosis and treatment of hypertension in adults in primary care, what is the new recommended definition of hypertension in adults when measured with a validated device under optimal conditions? Is it a BP over 190 millime HG, BP or 190 mill CP, BP 180 mm HG? Uh DSBP 120 mm HG.

Think carefully about that key shift, that simplification we discussed today.

We really encourage you to continue exploring these guidelines. Remember, the journey to becoming a well-informed pharmacist, it's an ongoing deep dive. And please take your time absorbing this critical information. Make sure it all sinks in. Until next time, keep learning, keep growing, and keep making a difference.

دیابت
Welcome to the deep dive. Today we're tackling a topic absolutely vital for any aspiring Canadian pharmacist, diabetes malatus. Uh our mission is really to cut through all that information overload.

Yeah, there's a lot out there.

Exactly. We want to distill the core therapeutic choices, medication algorithms, and you know, there's essential practical insights you need for your Canadian pharmacist PBC exams.

Basically, give you clarity, accuracy, and hopefully some peace of mind. Make sure nothing crucial gets missed. for exam day.

And this deep dive, it's brought to you from the Pharma Board Group, and we're basing it all on the therapeutic choices reference material, the CTC.

That's right. And uh just a quick note, we understand many of you might not be native English speakers, so we'll definitely make sure our discussion keeps a clear, comfortable pace, easy to follow.

Perfect. Okay, let's unpack this then. What exactly is diabetes malitis at its heart?

Well, at its core, it's a chronic metabolic issue. The hallmark is high blood sugar, hypoglycemia, either when fasting or after meals.

But it's not just one thing, is it? It's more complex,

right? It's a heterogeneous syndrome. It comes down to either the body not making enough insulin or the body not responding properly to the insulin it does make that's insulin resistance. Or sometimes it's a bit of both.

And there's this term dislycemia. Why is that important for us pharmacists?

Ah, good question. Dislymia refers to abnormal blood glucose levels that maybe don't quite meet the full diagn agnostic criteria for diabetes yet.

Okay.

But the key thing, even these minor elevations, they're linked to an increased risk of cardiovascular problems down the road. So, we can't ignore them.

Which leads us straight into the long-term complications, doesn't it?

It does. Diabetes can really damage blood vessels over time. We talk about microvascular issues, small vessels, think eyes, kidneys, nerves,

retinopathy, nephropathy.

Exactly. And then macrovascular problems, the large vessels. That's where heart disease stroke, peripheral artery disease come in.

Heart disease is the big one.

It's the most common cause of death unfortunately, which is why managing things like blood pressure and cholesterol alongside blood sugar is absolutely critical. It's integrated care.

Got it. So, how do we uh classify diabetes? What are the main types?

Okay, so type 1 diabetes malitis T1DM, that's about 5 to 10% of cases. It's fundamentally an autoimmune disease.

Body attacks itself

precisely. It destroys the insulin producing beta cells in the pancreas. So, you end up with an absolute lack of insulin

and that usually appears when

typically it presents pretty acutely often in children adolesccents or young adults and there's a high risk of diabetic ketoacidosis DKA if it's not treated promptly

you sometimes hear about LADA too

right late autoimmune diabetes of adults it's a slower onset form of autoimmune diabetes that appears in adults still type one essentially

okay then the big one type two

type two diabetes malitis TTDM that's the vast majority maybe 90% of c Here the picture is different. It's primarily insulin resistance where the body cells don't respond well to insulin combined with a relative insulin deficiency the pancreas just can't keep up over time.

And this one is often found

often it's discovered incidentally during routine checkups in adults but worrying trend. We're seeing it diagnosed more and more in adolescence and even children especially those struggling with obesity.

That is concerning. Are there other types?

Yep. There's gestational diabetes or GDM. That's glucose intolerance. That's first recognized during pregnancy.

Okay.

And then there are other specific causes maybe less common but important to know things like monogenetic syndromes like mody or diabetes resulting from pancreatic diseases certain infections or even some medications.

Ah the medication link that's super relevant for pharmacists. What should we know?

Definitely the CTC reference our source material lists several drugs that can cause dislycemia or worsen existing diabetes. You think things like Obviously,

right?

Some beta blockers, statins, yes, even statins can have a small effect. Second generation anticyotics, certain diuretics like thioides and loops, even things like checkpoint inhibitors in cancer therapy or produce inhibitors used for HIV.

So, quite a few potential culprits. What's the clinical takeaway?

The key message is this. If a patient genuinely needs one of these medications for a clear clinical reason, the fact that it might affect blood sugar should not stop stop you from using it.

Okay. So, you treat the underlying condition.

Exactly. You manage the diabetes or the dislycemia alongside it. You don't withhold necessary therapy just because of the glucose effect. Managing the diabetes remains paramount.

Makes sense. Okay. Diagnosis and screening in Canada. How might a patient present?

It's really varied. Some people are completely asymptomatic. You know, it just pops up on routine blood work,

incidental finding.

Yeah. Others might have really non-specific symptoms, feeling tired, maybe unexplained weight changes. Sometimes the first sign is actually a complication like neuropathy or kidney issues.

Wow. Okay.

Or they could have those classic acute metabolic symptoms, excessive thirst, frequent urination, what we call polyypsia and polyura. And in severe cases, especially with type one, the first presentation could even be DKA.

So what are the actual diagnostic numbers in Canada? The thresholds we need to know for the PBC,

right? The criteria you need one of these random plasma glucose 11.1 millm moles per liter or higher. or fasting plasma glucose FTG that's no food for at least 8 hours 7.0 or higher.

Okay.

Or a 2-hour plasma glucose value of 11.1 or higher after drinking a standard 75 gram glucose strength. It's the oral glucose tolerance test, the OGTT

and HBOC.

Yes, HB1C can also be used specifically in adults. A value of 6.5% or higher as diagnostic. But there are caveats conditions that can affect A1C accuracy like anemas or hemoglobinopathies. You need a viable lab test.

And what if someone's asymptomatic but has one high reading? Is that enough?

No. And this is a critical point for your exam. If the patient has no symptoms, a single abnormal test isn't enough. The diagnosis must be confirmed with a repeat test on a different day.

Using the same test ideally.

Ideally, yes. Use the same test for confirmation if possible. Makes it clear.

Okay. What about screening? Who should we be screening?

For T1DM, routine screening in people with normal glucose levels isn't generally recommended right now. Though there are new developments likeab But that's a different discussion,

right? Focus on T2DM screening.

Yes. For type two, the recommendation is screening every 3 years for individuals aged 40 or older.

Okay. Everyone over 40. Every 3 years

or screening sooner and maybe more often for anyone younger than 40 who has significant risk factors.

And those risk factors, what are the key ones? Think like a quick reference table for the exam.

Okay. Key risk factors for TTVM. Age 40 plus. Obviously, having a first-degree relative parent, Sibly with type two, belonging to a high-risisk population group, indigenous peoples, South Asian, Asian, African, Hispanic heritage.

Got it. What else?

A personal history of pre-diabetes that's impaired fasting glucose or impaired glucose tolerance or a history of gestational diabetes. Already having signs of end organ damage that diabetes can cause like retinopathy or neuropathy.

Vascular risk factors too.

Absolutely. Things like abdominal obesity, high blood pressure, hypertension, abnormal cholesterol levels, dyspademia, and smoking and also associated diseases conditions like polycystic ovary syndrome, PCOS, obstructive sleep apnea, certain psychiatric disorders.

So knowing these helps supply the screening algorithm.

Exactly.

It helps you identify who needs screening and guides the process especially if you get say conflicting results between different tests like FPG and A1C. The algorithm helps decide when maybe an O GTT is needed.

All right, let's shift to management. The non-drug approaches first. These seem foundational.

They absolutely are. Diabetes is for the most part a self-managed condition. What the patient does daytoday is pivotal for long-term success.

So education is key.

Huge self-management education is vital. Patients need to understand the basics. What diabetes is, the role of their diet, exercise, their medications, how to monitor their own blood sugar.

What else falls under that umbrella?

Things like sick day management, what to do when they're ill, recognizing the signs of low blood sugar, hypoglycemia, and crucially, how to treat it. Proper foot care is essential to prevent complications. Understanding heart health, risk factors, awareness of other organs that can be affected like eyes and kidneys

and nutrition

critical. Ideally, counseling should come from a registered dietitian. For many with type two who are overweight, even modest calorie reduction helps. For anyone on intensive insulin therapy, carbohydrate counting is often a really important skill.

What about exercise?

Immen benefits. Improves cardiovascular function. Makes the body more sensitive to insulin. Helps lower blood pressure and lipids. And for type two, it directly improves glycemic control.

What's the recommendation?

The general guideline is at least 150 minutes of moderate to vigorous aerobic activity per week spread over at least 3 days plus resistance training like weights or resistance bands at least twice a week.

Important point for pharmacists regarding insulin users and exercise.

Yes, very important. You need to educate patients using insulin about how exercise can lower their blood glucose sometimes significantly. They need to know how to potentially adjust their insulin doses or their food intake around exercise to prevent hypoglycemia.

Good point. Okay. Monitoring glucose, the feedback loop as you called it,

right? We have two main methods. Capillary blood glucose or CVG, that's the traditional finger prick test,

the one most people know.

Yeah. And then continuous glucose monitoring or CGM, which uses a small sensor usually on the arm or abdomen to measure glucose in the interstatial fluid just under the skin.

Why is monitoring so important?

It's For most patients, especially anyone on insulin, it helps them see the immediate effect of food activity and medication. Crucially, it helps them recognize and manage low blood sugar. Provides that direct feedback for therapy adjustments.

How often should people monitor?

Well, for those on basil bullis insulin regimens, multiple injections a day. The minimum is usually three times a day, often more, like before meals and at bedtime. For non-insulin users, the frequency is much more individualized based on their therapy and goals.

CGM versus CBG. Pros and cons.

CGM gives you a much richer picture. Continuous data, trends, alerts for highs and lows. It can really improve control and reduce hypoglycemia. The downside is cost and access can be issues. CBG is more affordable, accessible, gives you that point in time value. Both have their place.

And HBA1C monitoring still relevant.

Absolutely. It gives you the bigger picture. That average glucose control over the past 2 3 months, typically checked every 3 months. targets aren't being met or therapy is changing and maybe every six months for stable patients who are at target.

Okay. What about monitoring other organ systems? The ongoing checks

crucial for preventing or catching complications early. Annually, patients need their blood pressure checked, a thorough foot examination, including checking sensation with a monofilament. Those at high risk might need referral to a foot care specialist. Yes, annual kidney function screening.

That means checking serum creatinine to estimate GFR and a urine test for albiman to creatinine ratio ACR. to detect early kidney damage,

lipids and eyes,

lipid profile, a diagnosis, and then generally annually or more often if they're on lipid lowering therapy. And a dilated eye examination by an opthalmologist or optometrist is essential for retinopathy screening frequency depends on risk factors and findings

and immunizations often overlooked maybe

shouldn't be. People with diabetes are at higher risk for complications from infections. So annual flu shot, keeping up with CO 19 vaccines, and ensuring they have other Health Canada recommended Vaccines like numaccoal are really important protective measures.

Okay, let's dive into the pharmacologic side. Insulin therapies first. Obviously essential for type one.

Cornerstone for type one. Yes, it could be given by syringe, insulin pen devices or insulin pumps. We have human insulin and insulin analoges. The analogs generally cause less antibody formation and offer more predictable profiles.

For the PBC, understanding the different insulin types and their pharmacocinetics is key, right? Like that table three in the CTC.

Absolutely crucial. You need to know the main classes. Maybe some brand examples and critically their onset, peak and duration. Let's break it down.

Okay. Rapid acting

rapid acting insulin analoges. Think insulin aspart Novore rapid glucosine aided lispro humalogue. And they're even faster versions now like fast acting aspartas.

What's the profile?

Very quick onset maybe 51 15 minutes. Peak action around 1.5 hours. Duration is relatively short maybe four or five hours. Great for covering meals offering fibility because you can take them right before eating or even shortly after. Okay. Short acting

that's basically regular human insulin. Humulan R novel Toronto onset is a bit slower 30 60 minutes peaks later around 2 4 hours and lasts maybe 68 hours needs to be taken further ahead of the meal.

Intermediate acting insulin primarily NPH insulin humin and novelin ghee NPH onset 1 2 hours peak around 5 8 hours duration maybe 12 18 hours often used as basil insulin maybe once twice a day but has a more pronounced peak than the long acting analoges

and the long acting analoges these seem important now

very much so these include insulin digludec tresba detimir levir and glargene both u 100 lantis bessagler and the concentrated u300 duch

what's special about them

they provide a much flatter more peakless profile compared to NPH this gives more predictable prolonged basil insulin coverage often lasting 24 hours or even longer like dludec this generally translates to a lower risk of glycemia especially overnight and now there's even a once-weekly basil insulin analog insulin iicodc weekly just coming into play.

Wow, once weekly. Okay, so for type 1 regimens, what's the goal?

The landmark DCCT trial really set the standard. It showed that intensive insulin therapy aiming for nearn normal blood glucose levels significantly reduces the long-term risk of microvascular complications like eye and kidney disease and long-term follow-up showed benefits for cardiovascular events and mortality too.

So intensive is preferred. How is that usually achieved?

The preferred approach for intensive management is typically a multiple dose insulin MDI regimen often called basil bolus. That means using a long acting analog for basil coverage plus rapid acting insulin before each meal for bolus coverage.

You mentioned the honeymoon phase earlier. Can you explain that again? Super relevant for PBC.

Yes. Soon after diagnosis of T1DM, some patients experience this temporary period where if their remaining beta cells actually recover some function, their insulin requirements can decrease. quite dramatically for a while.

So pharmacists need to be aware.

Absolutely. If you're not aware of the honeymoon phase, you might overshoot with insulin doses as the patients own production kicks back in temporarily leading to hypoglycemia.

It requires careful monitoring and dose adjustment in newly diagnosed patients.

How is insulin typically started for T1DM?

A common starting point is about 0.5 units per kilogram of body weight per day. Maybe split 50/50 between basil and bolus, but that's highly ind idualized doses are then titrated every few days based on blood glucose readings

and timing with meals matters.

Yes, regular insulin needs to be taken about 30 minutes before the meal. The rapid acting analoges offer more flexibility, usually 0 to 15 minutes before eating or sometimes up to 20 minutes after starting the meal.

What about insulin pumps?

Insulin pumps or continuous subcutaneous insulin infusion CSI deliver rapid acting insulin continuously for basil needs plus allow the user to program bololises for meals and corrections. They can potentially offer tighter control and less hypoglycemia for some.

Downsides,

they are more expensive, require significant patient training and motivation, including diligent carbohydrate counting and understanding correction factors. It's a bigger commitment.

Okay, let's move to insulin in type 2 diabetes. When does it come into play? It's not usually first line.

Correct. Insulin is typically considered in T2DM when HBA1C targets aren't being met despite optimizing other non-insulin medications or if there's evidence of significant end organ damage, severe symptoms of hypoglycemia or what we call metabolic decompensation also during pregnancy if needed.

Why the delay sometimes you mentioned patients might be hesitant.

Yeah, there are common barriers. Fear of injections, perceived complexity of insulin regimens, concerns about weight gain, and definitely the fear of hypoglycemia. Good counseling is needed to address these.

So, what's the usual approach when starting insulin in T2DM? The step-wise plan like in table four,

it often starts simply The most common initial strategy is adding basil insulin only, usually once daily, typically a long- acting analog like glargine, dete or diglude.

How is the dose determined?

You might start empirically, say 5 or 10 units at bedtime, or use a weight-based approach like 0.1 to 2 units per kilogram. Then the dose is titrated up gradually, usually every few days, based mainly on fasting blood glucose readings, aiming for a target typically below 7 millod.

And other meds like metformin.

Metformin is almost always continued when basil insulin is added unless there's a contraindication. It works well in combination.

What if basil insulin alone isn't enough?

The next step might be a basil plus regimen. You continue the basil insulin and add one injection of rapid acting insulin before the largest meal of the day.

And if that's still not hitting targets,

then you might advance to a full basil bololis regimen similar to T1DM intensive therapy basil insulin plus bololis insulin before all main meals. Multiple daily injections Are there simpler options?

Yes, premixed insulins are available. These combine a rapid or short acting insulin with an intermediate acting one in a fixed ratio. They offer convenience. Usually taken twice daily before breakfast and dinner.

The trade-off,

less flexibility. You can't adjust the meal time and basil components independently, which can make fine-tuning control harder and might increase hypoglycemia risk compared to basil bolus.

Okay, let's talk adverse effects. Hypoglycemia is the big one with insulin.

By far the most common and concerning adverse effect. It can happen for various reasons. Taking too much insulin, skipping or delaying a meal, exercising more than usual without adjusting, drinking alcohol on an empty stomach.

What are the symptoms pharmacists should counsel patients about?

They fall into two categories. Adraic symptoms usually come first. Things like hunger, sweating, shakiness or tremors, anxiety, palpitations, or rapid heartbeat.

And if it gets worse,

then you get neuroglysopenic symptoms as the brain isn't getting enough glucose, confusion, altered behavior, drowsiness, difficulty speaking, weakness, incoordination, seizures, and even loss of consciousness in severe cases.

How is hypoglycemia classified and treated?

The International Hypoglycemia Study Group defines three levels. Level one is a glucose between 3.0 and 3.9 miller or mo alert value treatable by the patient. The rule of 15 is common. Take 15 grams of a fast acting carbohydrate. That could be four glucose tablets, 150 mil, about 23 cup of juice or regular soda or A tablespoon of sugar or honey. Wait 15 minutes. Recheck glucose. If still low, repeat the 15 g.

Okay. Level two.

Level two is glucose below 3.0 miller rolloler. Clinically significant hypoglycemia. Same treatment generally applies 15 grams of fast acting carb. Recheck in 15 minutes. Repeat if needed.

Symptoms especially neuroglycopenic ones are more likely here.

And level three.

Level three is severe hypoglycemia. This is defined by any low glucose level where the person has altered mental or physical status and requires assistance from someone else for treatment.

How is level three treated?

If the person is conscious and able to swallow safely, give 20 grams of oral glucose. If they're unconscious, having a seizure, or unable to swallow safely, they need glucagon.

Glucagon options.

There's injectable glucagon, 1 milligram intramuscularly or subcutaneously. And now there's also a nasal glucagon powder, bi 3 milligrams, spread into one nostril. Much easier for bystanders to administer. Always call emergency services for severe hypoglycemia as well.

What should happen after the glucose level comes up? Once the glucose is back above 4.0 millol and the person feels better, they should eat their usual scheduled meal or snack if it's due soon. If the next meal is more than an hour away, they should have a snack containing about 15 g of carbohydrate plus some protein to prevent the glucose from dropping again.

What about hypoglycemia unawareness? When people don't feel the lows,

that's a dangerous situation. It can develop after repeated episodes of hypoglycemia. The main strategy to regain awareness is actually to relax the glycemic targets for a period, avoiding lows meticulously, and increasing monitoring frequency, perhaps using CGM. This can help the body relearn to recognize the warning signs.

Any other insulin side effects to mention?

Lipo hypertrophy, that's a lump or swelling under the skin from repeated injections in the same spot. It can affect insulin absorption. That's why rotating injection sites is so important. Allergic reactions are rare with modern human insulins and analoges, but can happen.

Okay, great overview of insulin. Let's shift to the non-inssulin agents for type 2 diabetes. How do we start treatment now? Is it always metformin?

Metformin is still generally considered the first line drug of choice for most people with T2DM unless there are contraindications like severe kidney impairment or intolerance. It's effective, safe, doesn't cause hypoglycemia on its own and is inexpensive.

But there's a newer approach too, right? Considering coorbidities early.

Yes, this is a major shift and critical for pharmacists to understand. If a is diagnosed with TTDM and already has established atheroscllerotic cardiovascular disease ASCBD, heart failure, or chronic kidney disease, CKD, guidelines now strongly recommend initiating agents with proven cardinal benefits right from the start, often alongside metformin.

Which agents are those?

We're talking primarily about certain SGLT2 inhibitors and GLP-1 receptor agonist. Their benefits go beyond just lowering glucose.

What if someone presents with really high blood sugar or symptoms of metabolic decompensation?

In those cases, insulin might actually be considered for initial therapy sometimes temporarily to get things under control quickly.

So after metformin and maybe these cardioral agents, how do we choose the next drug if needed?

It's highly individualized.

You need to consider several factors. Does the patient have CV disease, kidney disease, or heart failure? What's their risk of hypoglycemia with different agents? What's the effect on weight? What about side effects, cost, and patient preference?

It's really about tailoring therapy now.

Exactly. The focus has shifted significantly towards not just glucose lowering but also vascular protection using drugs with proven benefits in reducing cardiovascular events, heart failure hospitalizations and kidney disease progression. Major diabetes organizations worldwide emphasize this.

Okay, let's do a quick run through of the key non-inssulin classes maybe hitting the highlights for the PBC like table 9 in CTC. Metformin first

big one class metformin as we said first choice generally main action decreases glucose production by the liver. Also improves peripheral insulin sensitivity a bit. Lowers HBA1C by about 1 to 1.5%. Low risk of hypo weight neutral or slight loss.

Key safety points for metformin.

Important ones. It's generally considered safe and stable heart failure and stable liver disease. Do needs adjustment. If EGFR falls below 45 melamin 1.73 meter inance, it should be stopped if EGFR drops below 30 and temporarily withheld during acute illness, dehydration or before procedure. involving high contrast eye especially if kidney function is already reduced. Lactic acidosis is the rare but serious risk everyone knows about.

Okay. Alphosidase inhibitors

a carbos works locally in the gut delaying the digestion and absorption of carbohydrates. Hottest HBA1C lowering maybe 0.5 to 1%. Main side effects are gastrointestinal flatulence diarrhea. Needs to be taken with the first bite of each main meal.

The crucial tip for hypoglycemia with aos.

Yes. If a patient taking carbos usually in combo with other drugs like insulin or sus. experiences hypoglycemia, they must treat it with pure glucose, dextrose, like glucose tablets. Why? Because a marbose blocks the breakdown of sucrose, table sugar, into glucose. So juice or candy won't work effectively.

Good one. DPP4 inhibitors, the gipins,

dipeptid, peptidase 4 inhibitors. Examples, cited, genevia, saxoptin, uncleiza, linagin, tragenta, alagin, nina. They work by prolonging the action of natural and hormones like GLP-1.

Benefits and risks.

Modest HBA1C reduction. from 0.5 to 1% generally well tolerated low risk of hypoglycemia when used alone weight neutral PEC alert the saver TE53 trial showed an increased risk of hospitalization for heart failure with saxoglyptin oliptin had a similar signal so generally avoided in patients with heart failure citagly and linen appeared neutral in this regard

okay GLP1 receptor agonists a big class now

huge glucagon-like peptide 1 receptor agonists examples lariglutide vtosis dulaglutide trilicity Semaglutide, osimpic rebelsis, lizanotide adixina. They mimic the action of GLP-1.

What do they do?

They stimulate glucose dependent insulin release, suppress glucagon secretion, slow gastric emptying which helps with postmeal glucose and promotes fullness and increase satiety often leading to weight loss.

HBA1C lowering in administration.

Good HBA1C reduction often 1 to 1.5% sometimes more. Most are injectable daily like laglutide or weekly echoloclutide and injectable semiglutide. Semaglutide is also available as a first oral GLP P1 RA ribbolsis.

The major benefit beyond glucose

cardiovascular outcome trials CVOTS have shown that several agents in this class specifically lilutide, injectable simlutide and dulaglutide significantly reduce the risk of major adverse cardiovascular events MAC like heart attack, stroke and CV death in patients with established CVD or high risk. Some also show kidney benefits like slowing eliminate progression. The recent FOW trial shows significant kidney protection with simaglutide.

So in important for that cardioral protection piece. What about tzepide?

Tzepide Munjaro. This is the first dual GIP and GLP-1 receptor agonist. GIP is another increant hormone. It's a weekly subcutaneous injection.

Effects

very potent shows even greater HBA1C lowering than GLP1 RAS alone often around 2% or more. Also leads to very significant weight loss often exceeding that seen with semiglutide. CVOT results are pending but look promising.

Okay. Older classes now insulin and secrets

sophony laurias

sophonyas sus example glycloey diamocrron damocrine gamberide amarol liberide diabeta yug glucon they work by directly stimulating the pancreas to release more insulin regardless of glucose levels

efficacy and downsides

it's effective at lowering hb1c about 1 to 1.5% main downsides are the risk of hypoglycemia because they stimulate insulin release even if glucose is low and weight gain they are generally inexpensive which is an advantage

any differences within the class yes Glyberide carries a higher risk of prolonged and severe hypoglycemia compared to glycoside MR or glyeride especially in older adults or those with kidney impairment. It's generally avoided now MR is often preferred.

Meglitenides like rapeide

repaganide gluconorm also an insulin secret but shorter acting than sus taken just before meals to cover the postmeal glucose rise. Similar hbaw1cloring to sus the main advantage is lower risk of hypoglycemia if a meal is skipped because it's a effect wears off quicker still causes weight gain.

SGLT2 inhibitors another major class now

sodium glucose co-ansporter two inhibitors examples ganagoploin invocana doublephosin forskia and pyofloin jardians they work in the kidneys

how

they block the SGLT2 protein which normally reabsorbs glucose back into the bloodstream from the kidney filtrate by blocking it they cause excess glucose to be excreted in the urine

key effects and benefits

moderate HBA1C lowering 0 521% Importantly, this effect is independent of insulin. They also typically cause modest weight loss due to calorie loss in urine and a small decrease in blood pressure due to mild diuretic effect, low risk of hypoglycemia when used alone.

The really big news with SGLT2s,

the cardioral benefits are profound and a gamecher and pagloin, kagglyphloin and dpiglyphlozosin have all shown significant reductions in mace in patients with T2DM and established CVD. Even more consistently, they show remarkable reductions in hospitalization for heart failure. And this benefit extends even to patients without diabetes.

Heart failure benefit even without diabetes.

Wow. And they also robustly slow the progression of chronic kidney disease, reducing the decline in EGFR and the risk of endstage kidney disease even in patients with already reduced kidney function or albinura. These benefits have led to indications beyond just diabetes.

What are the main side effects or risks?

Increased risk of genital yeast infections due to glucose and urine. Risk of urinary tract infections. But potential for volume depletion or dizziness, especially if used with diuretics. A rare but serious risk is ugly diabetic keto acidosis, DKA, DKA, occurring with only mildly elevated or even normal blood glucose levels. Patients need counseling on sick day management to mitigate this.

Any specific drug concerns?

Early trials with kagglyphlosen showed a signal for increased risk of lower limb amputations and fractures, but later large trials haven't consistently confirmed this. And the overall benefit are thought to outweigh these potential risks for most patients. Still something to be aware of.

Okay, last main class bioidon tzds.

Pyazone Acttose is the main one available now. Rosilazone ofia has restricted use due to the past CV safety concerns. TZDs work by activating PP gamma receptors which improves insulin sensitivity in muscle and fat tissue and reduces liver glucose production.

Efficacy hypo

good HBO lowering similar to metformin or sebc's low risk of hypogly. glycemia when used as monotherapy

but significant side effects.

Yes. Weight gain, fluid retention which can worsen or precipitate heart failure so contraindicated in moderate severe HF. Increased risk of peripheral fractures especially in women.

Macular edema eye swelling is a rare risk. There was also a controversial link between pyblazone and a small increased risk of bladder cancer though data is conflicting.

Any potential niche benefits?

Pyoglyazone has shown some benefits in improving markers of metabolic dysfunction associated steotic liver disease MASLD previously known as NAFLD rosaglitazone CV safety remains a point of concern limiting its use

so choosing between all these kidney function is a big factor right yeah need to know EGFR cut offs

absolutely essential you need a quick reference in your head or readil available for example metformin needs dose reduction below EGFR 45 stop below 30 SGLT2 inhibitors can often be initiated down to an EGFR of 20 or 25 depending on the agent and indication glucose lowering versus heart kidney protection but shouldn't be sort of below that DPP4 inhibitors often need dose adjustment except linen sulfanyluras especially glyberide are risky with poor kidney function knowing these cut offs is vital for safe prescribing and dispensing

and knowing which drugs offer that specific cardiovascular or renal protection based on the patient's profile

yes think about it this way patient has ASCVD prioritize a GLP-1 RA or SGLT2I with proven MCE benefit Patient has heart failure prioritize an SGLD2I patient has CKD with albmenura Prioritize an SGLT2i or maybe a GLP1RA if SGLT2I contraindicated not tolerated. Finer known is another option specifically for CKD and T2DM. Plus, you layer on statins, ACIBs, maybe ASA is indicated for vascular protection. It's multiaceted.

Okay. Special populations, pregnancy and breastfeeding. What are the key concerns?

Diabetes in pregnancy, whether it's pre-existing type 1 or two or gestational diabetes GDM increases risk for both the mother like preeclampsia C-section and the baby like large birth weight, birth defects, if glucose is high early on, neonatal hypoglycemia.

So, pre-preg planning is vital. What should pharmacists advise?

Crucial. Ideally, women with pre-existing diabetes should plan their pregnancies. Key steps: Start highdose folic acid well before conception. Get a thorough eye exam. Aim for the best possible glycemic control before getting pregnant. Generally, an HBA1C of 7% or less, ideally 6.5% or less if achievable safely. Consider CGM for tighter control

medication adjustments before before pregnancy

absolutely critical stop any potentially territogenic medications that means ACE inhibitors arbs statins most non-inssulin anti-hypoglycemic agents

which diabetes meds are okay

insulin is a preferred agent during pregnancy metformin and glyoride can be continued if already used pre-reg and control is good but insulin is often needed eventually other agents should generally be switched to insulin before conception if possible

and during pregnancy how is GDM managed

screening for GDM usually happens between 24 28 weeks gestation using an O GTT. If diagnosed, lifestyle changes, diet and exercise are first line. If blood glucose targets aren't met with lifestyle alone, medication is needed.

Which meds are used for GDM?

Insulin is the preferred medication. Rapid acting analoges aspart and regular insulin are used for meal coverage. Long- acting analoges like betimir and glargene U are considered safe for basil needs. Metformin and glyberide are sometimes used off label, but insulin remains the standard of care due to more data. Glycemic targets are tighter in pregnancy, right? Like table six.

Yes. Very strict. For example, fasting or premeal glucose targets are typically less than 5.3 millol. 1 hour postmeal less than 7.8 or 2hour postmeal less than 6.7. Requires frequent self monitoring. SMBG. Lowdos ASA is also recommended for many pregnant individuals with diabetes to reduce preeacclampsia risk.

What about breastfeeding?

Breastfeeding is strongly encouraged for its benefits to both mother and baby. Insulin is safe during breastfeeding. as it's broken down in the infant's gut.

Glucose control postpartum

can be tricky.

Insulin requirements often drop dramatically right after delivery due to hormonal changes and the energy demands of lactation. Frequent monitoring is needed. For those with GEM, it usually resolves after delivery, but they have a high lifelong risk of developing T2DM. A 75 DOG GTT is recommended 6 weeks to 6 months postpartum to check for ongoing diabetes or pre-diabetes. Metformin or glyberide can potentially be used during breastfeeding if needed. But data is limited.

Okay, let's touch on prevention and remission of type 2 pre-diabetes.

Pre-diabetes includes impaired fasting glucose, IFG, fasting glucose between 6.1 and 6.9, and impaired glucose tolerance, IGT, 2-hour O GTT glucose between 7.8 and 11.0. These individuals, along with those having metabolic syndrome, cluster of risk factors like central obesity, high triglycerides, low HDL, high BP, high FPG, are at very high risk of developing T2DM and cardiovascular disease.

Can T2DM be prevented? Yes, significantly. Lifestyle interventions are incredibly effective. Large studies like the diabetes prevention program, DPP, show that intensive lifestyle programs focusing on diet, weight loss, aiming for 57% and supervised exercise, 150 msweek, reduce the risk of progressing from pre-diabetes to T2DM by 58%.

What about medications for prevention?

Several medications have shown some ability to reduce the incidence of T2DM in high-risisk individuals in trials. Metformin is the most studied and sometimes recommended especially for younger more obese individuals with pre-diabetes a carbose tzds or liist elisata weight loss drug lialutide and tzepite have also shown preventive effects but lifestyle remains the cornerstone

can type 2 diabetes go into remission

yes it's possible especially relatively early in the disease course remission is generally defined as achieving an hbaw1c below the diagnostic threshold usually 6.0% or 6.5% depending on definition and staying off all glucose lowering medic for at least 3 months.

How is remission achieved?

The single biggest factor is significant and sustained weight loss. Losing more than 10 15 kg, especially through intensive dietary changes or beriatric surgery, offers the greatest chance.

What about medications during remission attempts?

You typically look at stopping medications associated with weight gain like SUS, TZDs, insulin if possible. Importantly, medications with proven cardioral benefits SGLT2i, GP1 array might be continued even If A1C is in the remission range for their protective effects, if the patient has underlying CVD or CKD,

who has the best chance of remission?

Factors associated with higher likelihood include shorter duration of diabetes diagnosed 6 years ago, not requiring insulin before the attempt, having lower baseline HBA1C, and being highly motivated for significant weight loss.

Okay, last big topic. Diabetic ketoacidosis, DKA, emergency. What is it?

DKA is a life-threatening complication resulting from severe insulin deficiency. It's most common in T1DM but can occur in T2DM under stress. It's characterized by the triad of hypoglycemia, high blood sugar, ketosis, ketone buildup, and metabolic acidosis, acidic blood.

What else is going on physiologically?

Profound volume depletion due to osmotic diuresis, glucose pulling water into urine, significant electrolyte imbalances, potassium is a key one. Serum potassium might be normal or even high initially, but the total body potassium is severely depleted. Sodium levels might look artificially low due to hyper glycemia pseudohhyponetriia consciousness can be depressed

that triggers DKA.

Common triggers in known T1DM include missing insulin doses, non-adherence, illness or infection which increases insulin needs, surgery, trauma, heart attack. It can also be the initial presentation of undiagnosed T1DM. And remember, SGLT2 inhibitors can trigger DKA, sometimes ugly DKA.

Management principles thinking like table 7 and CTC, the critical steps

absolutely critical to manage systematically.

One, fluids a Aggressive IV fluid resuscitation is first priority to correct dehydration and improve tissue profusion. Usually start with isotonic saline.9% ACL maybe 1 2 L quickly then adjust based on hydration status. Two potassium monitor potassium very closely. If initial K plus is high 5.5 don't give K plus initially if K plus is normal or low 3.3 5.5 add potassium to the IV fluids early on to prevent levels dropping further once insulin starts working. Crucially if initial K plus is low 3.3 Do not start insulin until potassium is corrected to 3.3 because insulin will drive potassium into cells and can cause life-threatening arrhythmias. Three, insulin. Once potassium is confirmed 3.3 millmal, start a continuous IV infusion of regular insulin, usually at 0.1 unit scour. This helps stop ketone production, corrects acidosis, and lowers glucose.

What happens when the glucose level starts to fall with IV insulin?

When blood glucose reaches around 14 mil, you need to add dextrose to the IV fluids. For example, switch to D5W with half normal saline. This prevents hypoglycemia while allowing you to continue the IV insulin infusion. The insulin is needed to resolve the ketosis and acidosis, not just lower the glucose. Never stop IV insulin until the annion gap is closed, indicating acidosis is resolved, ketones are clearing, and the patient is stable and able to eat.

Overlapping 5V and subcutaneous insulin.

Yes, essential. Before stopping the IV insulin drip, you must give a dose of subcutaneous basil insulin and maybe bolus if eating and allow at least 1 to 2 hours of overlap to prevent rebound hypoglycemia in ketosis.

Bicarbonate use

generally not recommended unless the acidosis is extremely severe at PH 6.9 or 7.0 or causing hemodynamic instability or severely depressed consciousness. It has potential risks.

Key lab tests

bedside beta hydroxybutyrate the main ketone is very useful if available.

Initial labs glucose electrolytes including potassium, ura, creatinine, venus or arterial blood gas or pH of bicarbonate CBC. Repeat glucose and electrolytes frequently often hourly initially

and any other supportive care.

Keep the patient warm. Consider an NG tube if vomiting persistently. Urinary catheter if unable to void. Treat any underlying precipitating cause like infection.

Important pitfalls in DKA management to watch out for.

Several key ones. Cerebral edema is a rare but devastating risk especially in children. Requires careful fluid management and monitoring. Initial temperature might be low even with infection. Initial white blood cell count can be high just from stress. Pseudohypon MIA needs to be recognized. High initial potassium masks severe total body depletion. Dehydration can mask signs of infection. Abdominal pain is common in DKA but should resolve as treatment progresses. And importantly, switching to subcutaneous insulin too early or discharging before the patient is fully stable leads to high rates of recurrence.

Excellent summary to DKA. Okay, let's pull it all together. Glycemic targets, they're individualized, right? Like table five,

highly individualized. Yes. The general HBA1C target for most adults with diabetes is 7 0% or less.

Oh, 7.0%.

Can we aim lower sometimes? Yes. For some patients with T2DM, especially if they are younger, have a shorter duration of diabetes, no significant CBD, and are at low risk of hypoglycemia, aiming for an HBA1C of 6.5% or less. 6.5% might be considered to further reduce the risk of microvascular complications like CD and retinopathy.

And sometimes higher targets are needed

definitely for patients who are functionally dependent, frail older adults, have limited life expectancy, extensive morbidities or a history of recurrent severe hypoglycemia or hypoglycemia unawareness. A less stringent target maybe between 7.1% and 8.5% is often more appropriate to prioritize safety and quality of life.

What about the fingerprint glucose targets that correspond to the A1C?

For most people aiming for A1C is 7.0%.

The corresponding targets are generally fasting or premeal glucose 4.0 to 7.0 mill and 2hour postmeal glucose 5.0 to 10.0 milll. If aiming for A1C 6.5% The postneal target might be tightened to 5.0 8.0 mill.

And time in range TR with CGM. What's the goal there?

T is becoming increasingly important. It's the percentage of time spent within the target glucose range. Usually 3.9 10.0 mil. For most people with T1DM or T2DM, the general target is 70% IR with 4% time below range 3.9 and minimal time above range 10.0.

Is TRI linked to A1C?

Yes, there's a good correlation. Roughly speaking, a 10% change in TR corresponds to about a.5% change in HBO C. TI gives more granular insight into daily fluctuations than A1C alone.

Okay, final framework the ABCDA of diabetes care. A good way to remember the comprehensive approach.

It's a great amount for holistic management. Let's run through it. A A1C achieve individualized glycemic targets using A1C, CBG, CGMTir. BP optimized blood pressure control, usually a 30 380 mill or HG for most. C cholesterol managed lipids, LDLC targets based on CV risk, usually with statins.

Okay. ABCD drugs use medications for cardiovascular and/or cardioral protection as indicated SGLT2i, GLP1, RA, ACIB, statin, ASA, ferin, e exercise, encourage regular physical activity goals plus healthy eating patterns and the S's there are three

yeah the three S's screening regularly screen for complications cardiac risk feet kidneys eyes and ensure recommended immunizations are up to date as smoking sessation is absolutely crucial smanagement stress, sleep, other barriers, support self-management skills, address psychosocial factors like stress and sleep, and identify address any other barriers to care through personalized goal setting and mental health support if needed.

That's a really comprehensive checklist. Okay, let's step back and think critically for a second. Based on everything we've discussed about managing blood glucose, especially with insulin, here's something for you, our listener, to consider. Why might a patient newly diagnosed with type 1 diabetes who initially needs say.5 units of insulin in per kilo suddenly find their insulin requirement drops significantly in the months after diagnosis. What's that phenomenon called?

That's an excellent clinical scenario to ponder. And the answer relates directly to something we touched on earlier. It's called the honeymoon phase or remission period. It happens because some of the patients own insulin producing beta cells which weren't completely destroyed at diagnosis temporarily recover some function.

So their own body starts making some insulin again.

Exactly. For a limited time. This residual function significantly imp improves glucose control and reduces the need for external insulin. Recognizing this is critical for pharmacists and the healthcare team to avoid causing hypoglycemia by continuing the initial higher insulin doses. You have to adjust downward during this phase.

Fantastic insight. Really highlights a practical nuance. Okay, time to test your knowledge with a multiple choice question based on our deep dive today. Which of the following medications is associated with an increased risk of hospitalization for heart failure and should generally be avoided in patients with a history of heart failure.

A metformin.

Yay.

Empagen. C. Saxagliptin. D. Liraglutide

Okay. Thinking back to our discussion on the different classes, the correct answer is C. Saxagliptin.

Why saxagliptin?

Well, metformin is generally safe and stable HF and impaglazin and SGLT2i and laglutide, a GLP1 RA actually have cardiovascular benefits, including reducing HF risk for SGLT2s. The DPP4 inhibitor saxoglyptin specifically showed that increased risk of hospitalization for heart failure in its major cardiovascular outcome trial, SART TMI 53. It really underscores why knowing the specific trial data for individual drugs within a class matters, especially when managing patients with coorbidities like heart failure.

Great explanation.

We have certainly covered a massive amount of information today from the basics of diabetes diagnosis monitoring all the way through insulins, non-inssulin agents, special situations like pregnancy, emergencies like DKA and those targets and comprehensive care strategies.

We really hope this deep dive gives you our PBC candidates the key insights distilled from the therapeutic choices reference that clarity and accuracy you need for exam success.

Absolutely. We strongly encourage you to go back through your own study notes, review the relevant CTC chapters, and really integrate this information. Use it in your practice questions and preparation.

Apply these concepts, think about patient cases, and we sincerely wish you the very best of luck on your PEVC exams. You've got this.

Thank you so much for joining. us on this deep dive into diabetes malitis. Until next time, keep learning, keep growing.

چاقی
Welcome everyone to the deep dive. Today we're really getting into something vital in healthcare. Um the pharmacological side of obesity treatment. It's you know constantly evolving. And whether you're practicing or maybe studying for the PBC exams, this is need to know stuff. We want clarity, accuracy, and well practical insights.

Exactly. Our goal here is basically to unpack the key info from the reference materials on these obesity drugs. We're looking at indications, mechanisms, and those really critical practical points for patient care. And just, you know, this deep dive is brought to you by Pharma Board Group, and it's based on CTC reference material.

Yep. And to get us there, we'll be looking closely at uh comparative drug charts, you know, lining up the different options, and we'll also break down the body mass index or BMI classifications in detail. The aim is a summary that's concise, easy to follow, making sure you catch all the really crucial bits without getting lost. Ready to jump in?

Okay, so first things first, we absolutely have to start with the foundation. Body mass index. Why is BMI? Well, why is It's so fundamental almost the mandatory starting point for managing obesity. Well, BMI is uh essentially our baseline. It's a key tool we use for classifying health risk. The calculation itself is weight in kilograms divided by height in meters squared. So, BMI equals weight kilog over height m^ squ. It just gives us a standard way to look at weight relative to height and importantly helps categorize the health risks involved. And if you look at the guidelines like from the WHO consultation on obesity or health Canada, the adult BMI classifications are quite Clear underweight is defined as less than 18.5 kilogram or meters. That actually carries an increased health risk. Normal weight falls between 18.5 and 24.9 kilogram fine bre which is generally seen as the lowest risk category. Then you hit overweight that's 25 to 29.9 kilmters of the near the risk starts increasing again there.

Right. So those numbers aren't just numbers they quickly translate into real health implications for a patient.

Precisely. And then we get into the obesity classes. Class one is a BMI of 30 to 34.9. calorie meture that's high risk. Class 2 goes from 35 to 39.9 kilometer per minute runs indicating a very high risk. And obesity class 3 is anything 40 kilometer or above. That's considered extremely high risk for associated health problems. It's worth noting these are generally for adults not usually applied if someone is pregnant or lactating.

Okay, that detailed breakdown of BMI is so critical especially when we think about the next step which is you know potentially starting medication. It feels like this isn't just assessing health, it's a direct trigger. for guiding those treatment choices, right?

Absolutely. Knowing these specific thresholds is essential. They directly tell us if a patient might be a candidate for pharmacological treatment, usually alongside um lifestyle changes, of course.

So, with BMI established as our starting point, let's shift focus now to the actual drugs, the pharmacological toolkit. The sources lay out a pretty interesting mix from newer agents to some more established ones. For pharmacists listening, this is well, this is where it gets really practical. Comparing these options is key for counseling. Let's maybe start with the class that's getting a lot of attention lately. The GLP-1 agonists. How about tzepide?

Good place to start. Tepatitide, which is zeppbound. It's uh interesting because it acts on two receptors. It's a glucose- dependent insulinotropic polyeptide or GIP receptor agonist ND a glucagon-like peptide 1 GLP-1 receptor agonist. Basically, it mimics two gut hormones that signal fullness to the brain, slow stomach emptying, and help regulate blood sugar. All that works together to reduce appetite, lower calorie intake, and ultimately promote weight loss.

That's a clear way to put it.

So for Canada, what are the official indications and what dose are we looking at typically?

Okay, so in Canada, the indication is for adults with a BMI of 30 kgometers or more or it can be a BMI of 27 kilgram or more if they also have at least one weight related health issue like say hypertension, type 2 diabetes or dysipidemia. The maintenance dose is usually between 5 and 15 milligrams given as a subcutaneous injection once a week. Now thinking about side effects at adverse reactions with tears appetite. The common ones are things like nausea, vomiting, diarrhea, constipation, dyspsia, uh abdominal pain. There also more serious though less frequent risks to be aware of. Gallbladder issues, pancreatitis, and a potential risk of medularary thyroid carcinoma. And a really practical tip for pharmacists, if the patient's also taking other diabetes meds, you might need to adjust those doses to lower the risk of hypoglycemia.

That makes perfect sense given how it works on blood sugar, too. Okay, next up, laglutide, which is marketed as saxenda is its mechanism and indication pretty similar.

Lyricutide is also a GLP-1 receptor agonist like one part of two epatide. So yeah, the mechanism involves satiety signals and slowing gastric emptying and the Canadian indication is identical. BMI of 30 or more or 27 or more with a weight related coorbidity. The main difference here is dosing. Lerglutide is 3 milligram given subcutaneously but it's once daily.

Okay, daily injection for laglutide versus weekly for twoepide. That's a pretty big difference for patients when thinking about stick to the treatment plan. We talked about the common GI side effects for tears. Does laggutide follow that same pattern mostly or are there any specific differences in its side effect profile we should highlight?

Yes, you're right. Those common GI side effects you mentioned for epetide. They're very much a class effect for GLP1 agonist including lolutide. Patients often experience nausea sometimes vomiting or constipation particularly when starting or increasing the dose. It's linked to that slowed stomach emptying which helps with weight loss. But largide's profile also specifically mentions increased heart rate as a potential adverse reaction. And importantly, suicidal ideiation has been noted with liclutide. It's less common, but a very serious concern to monitor. Much to appetite, adjusting other diabetes meds might be needed to avoid low blood sugar and a key point for laglutide. There's a clear guideline to stop treatment if the patient hasn't lost at least 5% of their starting weight after 12 weeks on the full 3 milligram dose. Then there's simaglutide. The brand name is Wiggoi. Another GLP-1 receptor agonist. Its Canadian indication lines up perfectly with the others. BMI 30 or more or 27 or more. with a coorbidity for semiglutide the maintenance dose range is 1.7 to 2.4 milligrams injected subcutaneously once a week

all right so semiglutide is also weekly like tzepatide and it sounds like these GLP1s generally share a similar list of potential side effects anything unique practically for semaglutide any specific tips

that's generally correct the adverse reactions for semiglutide look very similar to laglutide you know nausea vomiting diarrhea constipation disyspsia abdominal pain also the increased heart rate gallbladder issues, pancreatitis, medularary thyroid carcinoma risk and suicidal ideiation. Again, watch for hypoglycemia if the patient is on other diabetes drugs. For semiglutide, the practical point is maybe a bit softer than lagglutides cut off. It suggests considering discontinuation if there isn't clinically significant BMI improvement after 12 weeks on the maintenance dose.

Okay, so we've covered these injectable GLP1s. They work by mimicking gut hormones. They share many side effects, but what about patients who maybe aren't candidates for injections or perhaps have different reasons driving their weight. That brings us to options like Nal Trexone combined with bupropion.

That's a totally different approach and it's an oral tablet.

Right? Nrexone plus bupropion which is sold as contra is definitely different. It combines an opioid antagonist Nrexone with an inhibitor of dopamine and norapenophrne reuptake bupropion. So the nrexone part might help curb cravings while bipropene works more on the brain's reward pathways and appetite control centers. Sort of a two-pronged attack. on hunger and cravings. The indication criteria though are the same. BMI 30 or more or 27 or more with a coorbidity and the usual maintenance dose for contra is two tablets taken by mouth twice a day. That dual mechanism is interesting given how different it is. What should pharmacists really be watching for with contra especially around interactions or how patients should take it?

Okay. Common side effects include nausea, constipation, headache, dizziness, trouble sleeping, dry mouth, sometimes increased heart rate and again and suicidal ideation is listed. But crucially, there are some very important practical points. First, patients must avoid taking it with high-fat meals. This can significantly boost how much drug gets into their system, which isn't good. Patients might not realize this. Second, and this is critical, it absolutely must be avoided in patients who are currently taking opioid medications. The null trexone component can trigger opioid withdrawal, which can be severe. Pharmacists also need to screen carefully for other potential drug interactions, as there are quite a few. And similar to laglutide, there's a recommendation to discontinue contra if the patient hasn't lost at least 5% of their initial body weight after 12 weeks on the full dose.

Wow. Yeah, that opioid interaction is a major red flag for pharmacists. Okay, let's switch gears again. How about orvat brand name Zenicle? Its classification sounds completely different from everything else we've discussed.

It is very different. Orlistat is classified as an inhibitor of gastrointestinal liposes. Its whole mechanism is about blocking the enzymes in your gut that break down dietary fat thereby preventing some of that fat from being absorbed.

The official indication in Canada is again familiar.

BMI of 30 or more or 27 or more with a weight related coorbidity. The maintenance dose is 120 milligrams taken by mouth three times a day.

Okay, so another oral option, but this one works directly in the gut on fat absorption. What are the typical side effects like and what are the really key counseling points to help patients manage them?

Unsurprisingly, its side effects are almost entirely gastrointestinal directly related to that fat blocking action. Patients often report things like um fecal incontinence, oily spotting or discharge, diarrhea, gas, and abdominal discomfort. So, patient counseling here is absolutely vital to help manage these effects and improve adherence. Orlist needs to be taken during or up to 1 hour after a meal that contains fat. If a meal has no fat, the dose can be skipped. Pharmacists also need to advise patients that or can interfere with the absorption of certain medications and especially fat soluble vitamins. A, D, E, and K. Because of this, a daily multivitamin supplement is recommended. And crucially, it should be taken at least two hours before or two hours after the oralistat dose or perhaps at bedtime just to ensure the vitamins get absorbed properly. You can imagine if a patient is experiencing those oily side effects, talking about managing dietary fat intake and timing that multivitamin correctly can make a huge difference. And finally, there's semeort type 4 or MC4 receptor agonist. What's really striking about set melanotide is its indication in Canada. It's incredibly specific unlike the general BMI criteria we saw for the other drugs.

Yeah, that's a huge difference from the others. Set melanotide is for very specific rare genetic conditions causing obesity.

How would a pharmacist even, you know, come across a patient needing set melanotide given how rare these genetic conditions are and what are the key details for it?

That's a good point. Set melanotide is indicated specifically for bard beetle syndrome, BBS or for obesity. D to confirm deficiency in BOMC, PCSK1 or LAPR genes. These are genetic disorders that cause severe obesity starting very early in life. So while it's rare, a pharmacist might encounter a patient on this therapy in a specialized hospital clinic setting or perhaps as part of a multi-disiplinary team managing these complex cases. The dose is 1 to 3 milligram injected subcutaneously once daily. Adverse reactions can include injection site reactions, skin hyperpigmentation, nausea, headache, diarrhea, abdominal pain, uh spontaneous erections in males, and again Suicidal ideation is listed. And for the practical tips, the discontinuation criteria actually differ depending on the specific genetic condition. For POMC, PCSK1 or LPR deficiency, it's stopped if weight loss is less than 5% after 12 to 16 weeks. For BBS, they allow a longer trial, stopping if less than 5% weight loss after 6 to 12 months.

That's really covered the spectrum. Quite a comprehensive overview of these important medications. So for pharmacists listening, several key things jump out. I think we've seen those distinct indications especially set melanotide which is very different from the general BMI cutoffs and points towards more personalized medicine. We've looked at the different side effect profiles from oristat's very specific GI issues managed by counseling to the shared effects and more serious warnings for the GLP-1s and contra like heart rate or mood changes and just as vital we've hit on those crucial counseling points the how to take it and what to watch for that really matter dayto-day in practice

absolutely and connecting this back you know the pharmacical ical management of obesity. It's complex. It's evolving fast. It demands really precise knowledge not just of indications and how the drugs work, but also contraindications, side effects, monitoring needs, and of course, how to talk to patients effectively. Nailing down these details is just fundamental for safe, effective care, for navigating treatment choices, and naturally for success in exams like the BBC.

And that leads to a really interesting thought for everyone listening to maybe ponder how might future research, especially around personalized medicine and genetics like we see with semlanitiz specific targets. How might that further refine how we approach obesity treatment? And as these therapies become even more targeted, what's the expanding role for pharmacists in helping patients navigate these sophisticated options? Something to think about. Okay, before we wrap up, let's test your recall from this deep dive with a quick multiple choice question. Which of the following medications used for obesity treatment should be avoided in patients currently taking opioid medications? Is it A or the Stat Zenicle? B. Seaglutide WGOI C Nrexone plus bopropion contra or D tepatide zbound. Take a moment. The correct answer is C. Nrexone plus propion controp because the nrexone component. Well, thank you so much for joining us on this deep dive into the pharmacological treatments for obesity. We really hope this gave you some valuable insights and helped clarify some critical information for your practice or your PBC prep. Keep exploring, keep learning, and keep putting this knowledge to work. We'll catch you on the next deep dive.

بیماری های تیرویید
Welcome to the deep dive, your shortcut to being wellinformed.

Today we're plunging into uh really a vital topic for Canadian pharmacists.

Absolutely.

Whether you're a PBC candidate prepping hard for exams, or you're already in practice and want to keep sharp.

Imagine, you know, a patient walks in tomorrow, vague symptoms, maybe fatigue, maybe weight changes.

Yeah. It could be anything.

Could it be their thyroid?

Yeah.

That's what we're tackling. Our mission is to arm you with the essential knowledge the therapeutic choices, the real practical tips, right?

So you can confidently handle these cases. We want clarity, accuracy, practical insights, drawing straight from the key Canadian reference, therapeutic choices.

Yeah.

The CTC,

a cornerstone really.

Exactly. A guide you probably use daily. And this deep down is brought to you from the Pharma Board Group, tailor made for pharmacists like you.

And you know, one thing that always strikes me about thyroid disease is just how common it is, especially in women. They're much more affected.

And the symptoms Well, frankly, they can be notoriously non-specific. They often mimic other things,

right? The great mimicker.

Precisely. So, that makes a high index of suspicion and, you know, timely screening really critical. We need to catch patients early. Yeah.

So, today we're covering the whole spectrum. Hypothyroidism, thyrotoxyosis, and thyroid nodules.

The big three.

Yeah. And through it all, the core goals are pretty consistent. Get the patient to a stable uoid state, manage their symptoms effectively,

of course. Identify any problematic nodules and critically ensure proper management during pregnancy. That's a big one.

Definitely. So, let's kick things off with hypothyroidism. You mentioned it's the most common scenario here in North America.

It is.

It's a clinical syndrome, right? Yeah. Usually from iodine deficiency, though that's pretty rare for us.

Very rare in Canada. Yeah.

Or much more often it's autoimmune like Hashimoto's thyroiditis.

Now, that's the main driver here.

And for diagnosis, we really lean on TSH, thyroid stimulating hormone.

We do. It's a very very sensitive indicator for primary hypothyroidism.

So an elevated TSH basically flags that the thyroid gland itself isn't beeping up.

Exactly. But and this is important, TSH might actually be low or even normal if the issue is higher up.

Ah like pituitary or hypothalamic problems.

Precisely. And beyond that straightforward hypothyroidism, we also see subclinical hypothyroidism.

Right. Where the TSH is elevated but the actual thyroid hormone levels FT4 and FT3, they're still normal.

Correct. And for these folks, treatment isn't always automatic, but you should consider it

when what are the triggers?

Well, definitely if their TSH is consistently over 10 ml or if they have an abnormal lipid profile or if they're clearly having symptoms of hypothyroidism despite the normal hormone levels and critically if they're planning a pregnancy.

That pregnancy planning point seems key.

So, if we're assessing a patient, what signs, what symptoms should we really be looking out for,

right? Hey, thinking about the bigger clinical picture, a really thorough history is just crucial.

Makes sense.

You're hunting for those classic though often subtle clues. Persistent fatigue, maybe trouble with memory, constipation, feeling cold all the time, changes in skin or hair,

things people might dismiss.

Absolutely. Then on physical exam, you might see things like coarser facial features, dry skin, dry hair, maybe hypertension, a slow heart rate, braticardia, or even that delayed relaxation. in reflexes.

Interesting.

And we always have to be aware of the most severe form, mixedma coma. That's a true medical emergency.

Life-threatening.

Yes. Characterized by low blood pressure, coma, low body temperature, needs immediate action.

Okay. And for lab tests,

usually TSH alone is enough for screening primary hypothyroidism. Simple start.

But if it's abnormal,

then you add the free T4 and free T3 to get the full story.

What about antibodies like anti-TPO?

We generally only test for those if the result is actually going to change how we manage the patient,

like in specific situations.

Yeah. For instance, there's some debate in cases of recurrent spontaneous abortion, but honestly, that usually requires specialist consultation.

Got it.

And here's a really practical tip for your patients. Something pharmacists can directly advise on. Biotin supplements.

Ah, yes. You mentioned interference

big time. They can significantly mess with thyroid assays. So, always tell patients to stop taking biotin at least 48 hours before their thyroid tests. Good advice. Biotin's in everything these days, it seems. Okay, so moving to causes and importantly treatment. Hashimoto's is the big one here.

Yep. Most common in North America,

but also things like surgery, radioactive iodine therapy, even certain drugs,

right? Amuterone, lithium, sulfanyluras, some of the newer amunotherapies, they can all potentially cause hypothyroidism.

So when we have that diagnosis, where do we begin with treatment? What's the go-to?

Levothyroxin. Mhm.

LT4. That alone is uh definitely the treatment of choice for replacement.

Simple goal. Normalize the TSH.

That's the primary goal. For adults, the average starting dose is often around 1.6 micrograms per kilogram per day.

And adjustments

usually check and adjust every 6 weeks if needed. But uh you need to be a bit quicker during pregnancy. More like every four weeks then.

Okay. Any special populations to be careful with?

Absolutely. Older patients or anyone with known coronary artery disease, you must start low. Sometimes as low as 12.5 micrograms a day.

Wow. Really low.

Yeah. And titrate up slowly, maybe every 4 weeks. And it's crucial for pharmacists to counsel that high doses leading to a suppressed TSH might increase fracture risk, especially in older folks.

That's a really important safety point. Now, you said LT4 is the choice, but we do hear about T3ine sometimes or combinations. Patients ask.

They do ask. Yeah, it comes up. The thing with T3 liotronine is it's very short acting,

so not ideal for steady levels. Exactly. It leads to these peaks and troughs in T3 levels which isn't great. It can potentially increase risks like atrial fibrillation. So generally not ideal for soul replacement.

Is there any use for it?

It has a specific niche mainly for short-term use in thyroid cancer patients before they get radioactive iodine therapy when they need to withdraw from LT4.

Okay. And combining LT4 and T3, does that help with lingering symptoms?

That's the million-dollar question, isn't it? Recent studies, um, they really show little or no consist an extra benefit for most patients.

And there are still concerns about potential T3 side effects. However,

yes,

for a very small group of patients, the ones who still feel unwell on LT4, even with a normal TSH, a low dose of T3, say 5 to 12.5 micrograms daily, can be considered,

but cautiously,

very cautiously. And if you add T3, you might need to slightly lower the LT4 dose

and definitely recheck TSH in 6 to 8 weeks. It's really about managing expectations and sticking with the evidence for the majority.

That provides great clarity. Thanks. Now, let's shift gears to where management gets well really interesting, maybe more complex. Pregnancy

definitely a key area.

Untreated hypothyroidism here carries big risks, right? Infertility, miscarriage,

significant risks, which is why preconception TSH checks and getting levels normal before pregnancy is so important.

Makes sense.

And there's a nuance. In the first trimester, you might actually see TSH levels naturally dip a bit lower. It's due to the high levels of beta hCG. which has some TSH like activity.

So if a patient's TSH in the first trimester isn't lower or isn't suppressed, that could be a flag for new hypothyroidism.

And if it stays high, say over four,

then treatment with levothyroxine is absolutely needed.