Diabetes
Let’s 
talk diabetes!
American Diabetes Association (ADA) and the European Society of Cardiology (ESC) released new 2023 guidelines recently and I just had to do a doodle note on it. 
There has been lots of debates regarding whether metformin should still be first-line for all patients with type 2 diabetes.
It still is a great first-line option for most patients due to it’s proven efficacy, safety, and low cost. There are also some speculation that it m-a-y have cardiovascular benefits as well considering many patients in the clinical trials were also on metformin.
However, in patients with ASCVD or high ASCVD risks, heart failure, and chronic kidney disease, the ADA/ESC guidelines recommend starting a SGLT-2 inhibitor or GLP-1 agonists with cardiovascular and renal benefits regardless if they have type 2 diabetes.
It is still important to look at patient specific factors (cost, comorbidities, side effects) when deciding which agent to start first or to add on.
GLP-1 agonists commonly have GI side effects and carry warnings for rare pancreatitis and gallbladder disease. It can cost patients $1000/month. Most of the agents are injectables and supply is not consistent.
SLGT-2 inhibitors are linked to genital yeast infections, and volume depletion. Cost is about $600/month but they do come in oral formulations.
Reference: Diabetes Care. 2023 Jan 1;46 (suppl 1):S140-S157
Let’s talk about HF medications 
Understanding heart failure (HF) medications can be difficult if you don’t understand the underlying pathophysiology of the condition. 
Goals of therapy are to manage structural heart disease, reduce morbidity and mortality, decrease Na+ and water retention, and eliminate or minimize HF symptoms. 
of this series, let’s look over some tips and tricks on remembering the mechanisms of action of the following drugs: ⠀
Not only is knowing the mechanism of action important for exams and NAPLEX (as they are popular test questions), it gives you a baseline to understand/remember the drug indication, side effects, and underlying pathophysiology of the disease state.⠀
. However, with the right approach and some (or a lotta 
) practice, you’ll be able to see more of a pattern.
A strong inhibitor or inducer can lead to 5x the concentration of a drug while a weak inhibitor or inducer will cause less of a change. Higher concentrations lead to adverse side effects. Check out today’s post to help you remember the major inducers and inhibitors of CYP450 enzymes.
For example, tamoxifen is a prodrug. Strong 2D6 inhibitors such as fluoxetine, paroxetine, and bupropion can prevent the conversion of tamoxifen to its active form, therefore, increasing the risk that your patient will experience a reoccurrence of cancer. The same goes for the antiplatelet prodrug clopidogrel.
Check out today’s post to see some examples of some of the major drug interactions.
Inducers can ramp up the metabolism of a medication leading to decrease drug levels while inhibitors block the enzymes that break down the drug leading to higher drug concentrations.
Hypertension is defined as systolic blood pressure ≥140 mmHg or diastolic blood pressure ≥90 mmHg. Chronic hypertension occurs before pregnancy or before 20 weeks gestation and gestational hypertension occurs after 20 weeks
Complications of high blood pressure include increased risks for preeclampsia/eclampsia/stroke for the mother and preterm delivery for the baby
As with most medications in pregnancy, antihypertensives have not been evaluated in robust randomized controlled trials. Check out the post for the preferred anti-hypertensive drugs used in pregnancy. 
Test your knowledge and check your answers on the second slide.
Think of pharmacokinetics (PK) as the drug’s journey into, through, and out of the body. This journey passes through four phases that can be remembered using the mnemonic ADME or “add me”. ⠀
This journey varies depending on patient-specific factors such as renal function, sex, age, and genetics. All of these factors can affect the drug’s half-life, rate of elimination, and distribution and subsequently lead to toxicity or therapeutic failure. Knowledge of pharmacokinetics can assist with adjusting doses correctly especially in drugs that require therapeutic drug monitoring. ⠀
Additionally, drugs go through different processes of metabolism and elimination called first-order and zero-order kinetics. The biggest difference is that zero-order kinetics undergo constant elimination regardless of the plasma concentration while first-order kinetics depends on concentration. A good analogy is relating the concentration of drug to cake: 
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Due to increasing resistance to these antibiotics and their mechanisms, developing new antimicrobials and understanding their mechanisms of action are important. ⠀
Overall, direct oral anticoagulants (DOACs) are now recommended over warfarin in the majority of clinical situations unless there is a compelling reason for them to on warfarin such as valvular atrial fibrillation, severe renal dysfunction, patient costs, or close therapeutic anticoagulation monitoring required.
Key points about INR monitoring:
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