Download A chief of endocrinology department, prof. Vlasenko MV

MINISTRY OF HEALTH PROTECTION OF UKRAINE
Vynnitsa national medical university named after M.I.Pyrogov
«CONFIRM»
on methodical meeting of
endocrinology department
A chief of endocrinology
department, prof. Vlasenko M.V.
_________________
“_31_”_august___ 2012 y
METHODOLOGICAL RECOMMENDATIONS
FOR INDEPENDENT WORK OF STUDENTS
BY PREPARATION FOR PRACTICAL CLASSES
Scientific discipline
Мodule № 3
substantial module №4
Topic
Course
Faculty
Internal medicine
Current practice of internal medicine
Keeping patients in the Endocrinology Clinic
Management the patient with metabolic syndrome
6
Medical № 1
Vynnitsa – 2012
Subject: Keeping a patient with metabolic syndrome.
Actuality. Today one of the most difficult medical and social problems of modern society is the
metabolic syndrome (MS). The interest of scholars and practitioners to this syndrome is caused
primarily wide spread of this disease in the population. According to various authors found that
in industrialized countries among the population over 30 years the prevalence of "syndrome of
Plenty" is 23,7%. This disease is more common in men (24,0% of population) than women
(23,4%), and its frequency increases to 43.5% during the menopausal transition. According to
the NIH in patients with cardiovascular disease prevalence of MS is 84.0%. The complex
hormonal-metabolic disorders developing as a result of obesity and decreased sensitivity of
peripheral tissues to insulin, which are components polimetabolichnoho syndrome, and one of
the leading risk factors for cardiovascular diseases, disorders of carbohydrate and fat metabolism,
pathology of the reproductive system. Given all share the MC potentiates subsequent metabolic
diseases, which are incorporated syndromokompleksu framework, and their combination
accelerates the development and progression of atherosclerotic vascular disease, which according
to WHO estimates, ranks first among the reasons for lower efficiency, early disability and
mortality industrialized countries . At the beginning of the third millennium, together with the
European Society of Cardiology and European Association for the Study of Diabetes (2007)
have developed guidelines of diagnosis and treatment of diabetes mellitus (DM), prediabetu and
cardiovascular diseases and proposed three options for identification of MS: in accordance with
WHO recommendations ( 1998), the third report of the expert group on identification,
assessment and treatment of hypercholesterolemia in adults under the National Education
Program USA, Adult Treatment Panel III (ATP-III, 2001) and the International Diabetes
Federation (IDF, 2005).
Goal training: to teach students modern tactics of patients with metabolic syndrome, in practice,
using modern diagnostic and therapeutic algorithms in patients with MS curation in the hospital
and clinics. Using the principles in the prevention of complications of diabetes type 2, as the
cluster MS.
The student must know:
1. Definition of metabolic syndrome (MS) (insulin resistance syndrome, "New World syndrome,
deadly quartet).
2. Clinical forms of MS (diabetic, dyslipidemichna, hypertension, coronary, hepatic,
postmenopausal, hipotyreozindukovana, cholelithiasis, mixed and other).
3. Etiopthogenic mechanisms of MS.
4. Criteria for laboratory diagnosis of hormonal activity of adipocytes in patients with type 2
diabetes as a component of MS.
5. Physiological effects adypotsytokiniv adipose tissue (leptin, resistin, adyponektyn, visfatyn,
apelin, tumor necrosis factor - α, IL-6, etc.)..
6. Modern methods of diagnosing insulin resistance (index HOMA-IR, Caro et al.).
7. Leptynorezystentnosti diagnostic criteria (degree of obesity, BMI, OT / OS index
leptynorezystentnosti).
8. Interpretations of "hiperleptynemiya", "insulin and leptynorezystentnist.
9. MS criteria (WHO, 2002; ATP III, 2001, the International Diabetes Federation, IDF, 2005).
10. The risk of cardiovascular, neurological complications, prognosis and operability in patients
with MS.
11. Tactic of (test treatment) in patients with type 2 diabetes as a component of MS. Role of
pathology of internal organs in the development of diabetes decompensation.
12. Recommendations by the principles of modern pathogenetic treatment of patients with MS
(diet therapy, dosed physical exercise, tablet or insulin therapy tsurkoznyzhuyuchi mullion
(insulin analogues) and hypolipidemic and antihypertensive drugs).
13. Medical treatment of newly diagnosed type 2 diabetes, a high degree of risk of developing
insulin resistance syndrome.
14. Algorithm for treatment of type 2 diabetes (Consensus ADA and EASD, 2009) in patients
with MS.
15. Guideline protocols of care for patients with type 2 diabetes in "Endocrinology" (MOH of
Ukraine № 574 from 05.08.2009).
The student should be able to:
1. Conduct survey and physical examination of patients with MS.
2. Measure and assess capillary blood glucose and venous blood lipid spectrum of blood and
blood pressure (BP).
3. Must be able to assess excess body weight according to BMI (classification of degrees of
obesity, WHO, 1997). Identify type (androidnyy, henoidnyy) and degree of obesity in patients
with MS.
4. To be able to test glucose tolerance capillary blood and to assess the value hlikovanoho
hemoglobin fruktozaminu, C - peptide, glycosuria, ketonuria.
5. Principles of physical examination of patients with suspected syndrome of insulin resistance
(weight, height, body mass index (BMI), waist ratio to volume of thighs).
6. Distinguish between different types of diabetes and the notion of violation tolerance to
carbohydrates.
7. Hold interpretation blood lipid spectrum, to know the criteria set dyslipopreteyidemiyi in
patients with MS.
8. Draw up a plan for patients with MS, justify application of the basic methods of analysis, to
determine the indications for their conduct.
9. Based on analysis of laboratory and instrumental examinations, explain and formulate the
diagnosis of type 2 diabetes as a component of MS and its complications.
10. Assign the appropriate treatment of patients with type 2 diabetes, a cluster of MS and its
complications.
11. Demonstrate knowledge of principles of moral and ethical medical expert.
Classes are held in the form of students' work within small teams at the bedside of a patient with
MS. According to the thorough study of the "Internal Medicine" for higher medical institutions
III-IV accreditation levels, the organization of the curriculum should ensure student participation
in the conduct of 3 - 4 patients with type 2 diabetes, as the cluster MS. During the curation sick
student enjoys protocol and fills a patient.
Timing practice (5,5 hrs.):
1. Morning medical conference - 30 min.;
2. Supervision of patients in the department - 2 hours.;
3. Clinical analysis of medical history (seminar) - 1,5 hour.;
4. Independent work (study of literature, articles from the past 2 years, design blog, solving
problems with step 2) - 1.5 hours.
Minutes examination, diagnosis, treatment and prevention
PART OF MANAGEMENT TO ACTION
Welcome Pryvitaytesya and by introducing the patient
Getting Collect passport data of the patient (P, IB, sex, age, residence, place of employment and
profession)
Complaints of the patient at the time of examination Define and refine patient complaints.
In determining complaints of the patient, note the presence of:
- Polydipsia (thirst);
- Polifahiyi (increase appetite);
- Polyuria, nikturiyi (prevalence of night over day diuresis);
- Dry mouth;
- Weight loss or weight gain (amount and time period)
- Itching skin, genitals
- Pain, numbing, cold feet;
- Reduction of view;
- Headaches, dizziness, BP rising (to the nth degree);
- General weakness;
- Reduced capacity and others.
Individual and family history, interviews with agencies and systems
Find out the dynamics of the disease, a poll by organs and systems.
1. Presence of risk factors.
In the survey, note the information on:
- Persons with excessive body weight (BMI ≥ 25 kg/m2);
- Diabetes in family history;
- Sedentary lifestyle;
- Age over 45 years;
- Arterial hypertension (AH);
-Hypercholesterolemia, hypertriglyceridemia;
, Atherosclerosis, gout, chronic liver disease, kidney, cardiovascular system (coronary heart
disease (CHD), heart attacks, strokes in history);
- Periodontal disease and chronic furunculosis;
Slices glycosuria against stressful situations;
- Women who gave birth to a baby weighing more than 4,5 kg, or a history of gestational
diabetes;
Stillbirth, or frequent miscarriages in women;
- Mothers of children with disabilities;
- Polycystic ovarian syndrome;
- Use of hormonal contraceptives;
-Prolonged use of drugs tsukroznyzhuyuchyh
2. Availability symptoms target organs:
- Brain and vision: headache, dizziness, blurred vision, transient ischemic attacks, sensory or
motor failure;
- Heart: palpitations, chest pain, shortness of breath, swelling pastoznist or shins;
- Kidney: thirst, polyuria, nikturiyi, hematuria;
- Peripheral arteries: cold extremities, intermittent claudication.
When examining the physical examination of the patient rate:
1. Body weight (kg)
2. Sight waist (cm)
3 Body mass index (BMI) kg/m2
When examining the patient, note the presence of:
No evidence of damage target organs:
- Peripheral arteries (absence or asymmetry weakening pulse, cold extremities, coronary, skin
lesions);
- Heart (apex location and characteristics of shock, cardiac rhythm, rales in the lungs, peripheral
edema), measuring heart rate, pulse and SC (the definition of pulse pressure) in the horizontal
(lying down) and upright (sitting) position of the patient's body;
- Brain (noises in the neck arteries, motor and sensory disorders);
- Retina (data fundoskopiyi, if possible).
Test Plan complete blood count;
urinalysis;
Median ioduria;
The level of blood glucose (glycemic profile) and urine (hlyukozurychnyy profile);
Daily protein loss in urine;
Ketonemiya, ketonuria;
NbA1c level, C-peptide, imunoreaktyvnyy insulin (IRI), leptin, and other adyponektyn
adypokiniv, cortisol, thyroid stimulating hormone (TSH), testosterone;
Biochemical blood analysis: lipid spectrum - Total cholesterol (ZHS), triglycerides (TG), free
fatty acid (VZHK), low density lipoprotein cholesterol (LDL cholesterol), cholesterol, very low
density lipoproteins (VLDL cholesterol), HDL cholesterol ( HDL cholesterol) ratio aterohennosti
(SC), liver function tests - Total bilirubin, direct and indirect bilirubin, total protein, protein
fractions: albumins, globulins, AST, ALT, tymolova test, renal function - creatinine, urea,
glomerular filtration rate (GFR ) electrolyte composition of blood;
Koagulogramma (indicators of homeostasis).
Laboratory and instrumental investigations Evaluate level:
- Fasting glucose and glycemic profile;
-Lipid spectrum of blood: ZHS, HDL cholesterol, LDL cholesterol, VLDL cholesterol,
triglycerides and blood serum VZHK;
- Urea and creatinine in serum;
- Indicators of homeostasis (activator inhibitor plazmynohenu 1, fibrinogen, factor VII, factor
Villibranda);
- Liver function tests: total bilirubin, direct and indirect bilirubin, total protein, protein fractions:
albumins, globulins, AST, ALT, tymolova test;
- Renal function - creatinine, urea, uric acid, glomerular filtration rate (GFR), the daily loss of
protein in urine and microalbuminuria;
- Level NbA1c, C-peptide, leptin, adyponektynu, serum resistin, IRI, cortisol, TSH, testosterone;
-Calculate and estimate the rate of insulin resistance HOMA-IR or Caro (see Section 1, markers
of insulin resistance ");
- Leptynorezystentnosti of coefficient (the ratio of serum leptin levels in TG content);
- Determine the level of thyroid stimulating hormone (TSH) and the content of testosterone in
women over the age of 50 years;
-Abdominal ultrasound (D-steatohepatozu signs);
- ECG
- RVH lower extremities;
-Ultrasound imaging of carotid arteries.
Formulation of Basic disease diagnosis:
Diabetes Type 2, moderate (mild or severe) in the phase subcompensated (compensation,
decompensation or without ketosis ketosis). Metabolic syndrome (see Chapter 2 "The criteria of
metabolic syndrome").
Underlying disease:
Diabetic microangiopathy:
- Retinopathy (indicate the stage at the left eye (OS) on the right eye (OD) condition after
lazerofotokoahulyatsiyi or surgical treatment (if any) of the year ....
- Nephropathy (specify stage)
- Diabetic neuropathy (form of)
- Angiopathy of lower extremities
Diabetic macroangiopathy:
- IBS (point form).
- Heart failure (specify degree by NYHA).
- Cerebrovascular disease (specify which).
- Peripheral angiopathy (specify the type and stage).
Non-alcoholic fatty liver disease (steatohepatoz, steatohennyy steatohepatitis or cirrhosis)
Diseases:
Obesity (degree)
Hypertension (specify degree)
Dyslipidemia (if any)
Other associated diseases.
Make a plan of medical treatment algorithm for patients with MS, which should include
nefarmakolohichnu and pharmacological correction of metabolic disorders including pathogenic
mechanisms of disease development.
Treatment of patients with MS includes five major tasks:
1. Fighting obesity (insulin resistance) - the normalization of body weight:
- Changed way of life;
- Correction principles diet;
- Increasing physical activity;
2. Correction of carbohydrate metabolism:
1 + hypoglycemic mullion;
3. Correction of dyslipidemia:
1 + hypolipidemic drugs;
4. Normalization of blood pressure:
1 + antihypertensive drugs
5. Dezahrehatsiyna therapy (aspirin).
Drug therapy
Give advice on lifestyle modifications:
2. the presence of obesity or overweight fighting hypodynamia, normalization of carbohydrate
metabolism and the principles of diet (see Chapter 3 "Principles of diet in patients with
metabolic syndrome");
3. limit the use of easily digestible carbohydrates;
4. reduce alcohol consumption;
5. regularly perform dynamic exercise (see Chapter 4, "Physical activity of patients with
metabolic syndrome");
6. limit the use of salt to 3 g / day in arterial hypertension;
7. limit consumption of saturated fats and cholesterol;
8. give up smoking;
9. included in the diet of foods rich in dietary fibers and marine fish.
Drug therapy
Methods of drug therapy at the present stage for the treatment of overweight and obesity used
captopril three preparations:
• Orlistat - pancreatic lipase inhibitor. Take on 120 mg in a capsule before, during or after the
main meal three times a day not more than 2 rokiv.zy reduces absorption of fat meal by 25 -30%.
The drug is effective in uncomplicated obesity, dyslipidemia, diabetes, hypertension;
• Sybutramin - serotonin reuptake inhibitor. Designed for 10 or 15 mg once in the morning
regardless of the meal, lasting no more than 1 year, has a central mechanism of action, inhibits
the reuptake of serotonin and norepinephrine in the synapses of central nervous system, which
increases the feeling of satiation and increasing thermogenesis. The drug is contraindicated in
people with hypertension, ischemic heart disease, heart failure, arrhythmia, a history of stroke;
• Rimonabant - endokanabioyidnyh receptor antagonist. The drug blocks kanabioyid-1 receptors
hunger center, located in the hypothalamus. Endokanabioyidni receptors are components of the
center of fun, responsible for feeding behavior, as well as of pleasure from alcohol and drugs,
smoking. Among the side effects of gastrointestinal disorders, mood swings. Since 2008, stopped
production of the vehicle, in connection with the development of serious psycho-neurological
side effects.
The principles of hypoglycemic therapy:
1. Based on the evaluation of carbohydrate metabolism of the patient, who had not received
treatment, decide on the need to start drug therapy (due to lack of effect of nefarmakolohichnyh
treatment of patients with obesity and mild type 2 diabetes);
2. Identify which specific drugs should be patient, based on its previous experience of treatment,
presence of complications and concomitant diseases, indications and contraindications for
specific purpose
drugs and their cost;
3. When choosing a drug count under their evidence of controlled data. Preparations bihuanidiv
group (metformin) is recommended as first-class drug in patients with MS.
In patients with signs of IP in choosing hypoglycemic therapy recommended
hlyukometabolichnu also consider the situation. Drugs of choice remain bihuanidy, hlitazony,
alpha glucosidase inhibitors (see Section 5 "Oral tsukroznyzhuyuchi drugs").
Correction of dyslipidemia:
The decision to use lipid lowering drugs based on the results as lipidohramy, establishing the
nature of dyslipidemia (see "Classification dislipoidemia). After compliance with the diet at least
3-6 months, and the definition of the total risk of atherosclerosis patients with manifest
dyslipidemia, which is not susceptible of correction through diet, prescribed hypolipidemic
drugs: statins or fibrates. Choice of lipid lowering drugs conducted under lipidohramy
parameters, indications, contraindications, and level of evidence base (see Chapter 6 "Drug
therapy of dyslipidemia in patients with MS)
Antihypertensive therapy:
Determination of SA levels required for the application of antihypertensive therapy based on an
understanding of the fact that the factors underlying the development of MS have high antibodies
to values that are considered harmful and contribute to the development of cardiovascular
complications. Thus, patients with hypertension and MS should receive treatment according to
recommendations 2007 European Society of AH / European Society of Cardiology (ESH / ESC)
for diagnosis and treatment of hypertension, according to which priorities are measures of
lifestyle modifications, and in constantly elevated levels of systolic AT (140 mmHg) or BP (90
mmHg) should be used antihypertensive drugs. In the presence of microalbuminuria or other
violations of prognostically important target organs (left ventricular hypertrophy (LVH),
atherosclerotic lesions of carotid arteries, increasing the stiffness of the arteries) should be used
antihypertensive therapy (target level AT <140/90 mmHg) in addition to intensive lifestyle
changes.
The aim of treatment is necessary to put prevention of damage target organs or rehresuvannya.
First choice of antihypertensive drugs in patients with MS are:
10. angiotensin converting enzyme (ACE): captopril (25-100 mg / day), enalapril (5-40 mg /
day), lisinopril (10-40 mg / day);
11. II angiotensin receptor blocker (ARBs): losartan (50-100 mg / day), irbesartan (150-300 mg /
day) kandesartan (8-32 mg / day), olmesartan (20-40 mg / day) because in many large
multicenter studies have proven quite convincingly their metabolically neutral and
orhanoprotektyvna action;
12. calcium antagonists: verapamil (120-480 mg / day), Diltiazem (120-540 mg / day) felodypin
(2,5-20 mg / day) lerkanydypin (10-40 mg / day);
13. the need for possible use of low doses of thiazide diuretics, but should be preferred
Indapamide: indopamid-retard (1,5 mg / day) or spironolactone (25-50 mg / day) that are
essentially metabolically neutral properties;
Beta-blockers with high selectivity, which can block the β1-adrenoreceptors: metoprolol (50-200
mg / day), bisoprolol (2,5-10 mg / day), carvedilol (12,5-50 mg / day), labetalol (
I.
II.
I.
II.
II.
Sensitizing
These controlled trials: the level of evidence 1. Shown with type 2 diabetes with the prevalence
of insulin resistance (obesity) and fasting hyperglycemia with the ineffectiveness of diet and
physical activity. Contraindicated in type 1 diabetes, ketoacidosis, pregnancy and lactation,
chronic heart, liver, renal insufficiency, anemia, alcoholism, old age.
Mechanism of action: reducing insulin resistance of muscle and adipose tissue, reduced liver
glucose production. Shown with type 2 diabetes with the prevalence of insulin resistance with
the ineffectiveness of diet and physical activity. Contraindicated in type 1 diabetes, ketoacidosis,
pregnancy and lactation, liver disease (increase of ALT> 2.5 times) severe heart, renal
insufficiency.
Shown with type 2 diabetes with the prevalence of hyperglycemia with the ineffectiveness of
diet and physical activity. Contraindicated in type 1 diabetes, ketoacidosis, pregnancy and
lactation, diseases of the gastrointestinal tract.
Modern hypoglycemic drugs
Inkretyn-modulators:
Agonists HPP - 1
These controlled trials: the level of evidence 2. Contraindicated in type 1 diabetes, ketoacidosis,
pregnancy and lactation, diseases of the gastrointestinal tract, chronic pancreatitis.
1.
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1. Art.
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Independent work
1. The study of literature
14. Endocrinology. Edited. Sci. PM Bodnar. New book. - Vinnytsya. - 2010s. - 464p.
15. Ed. Prof. PN Bodnar. New book. - Vinnitsa, 2007s. - 236s.
16.
17.
18. Order MZ of Ukraine from 08.05.2009 № 574 "On approval of protocols of care in"
Endocrinology ".
2. Preparation of abstract classes on the topic from the article:
19. Endocrinology. Ed. MD Tronko (Kyiv)
The problems of endocrine disorders. Ed. YI Karachentsev (Kharkiv)
21. International Journal of Endocrinology. Ed. VI
22. Problems of Endocrinology and Endocrine Surgery Ed. OS Larin (Kyiv)
Journals therapeutic profile.
3. Solution tests and situational problems Step 2.
4. Writing reports of clinical analysis of patients.
Protocol analysis of clinical patient
Name _____________________________________________ patient
_____________________________________________________________________________
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Profession _______________________________ Age ______________
Complaints patient ___________________________________________
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Results of physical examination of the patient: _________________
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Previous diagnosis: _______________________________________
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Which diseases should conduct a differential diagnosis:
1. ______________________________________________________
2. ______________________________________________________
3. ______________________________________________________
4. ______________________________________________________
5. ______________________________________________________
Test Plan: _________________________________________
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Results of laboratory and instrumental examinations:
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Justification of clinical diagnosis: _________________________
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Clinical diagnosis: ________________________________________
The main diseases: ___________________________________
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Complications: ____________________________________________
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Diseases: ____________________________________
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Prediction: ________________________________________________
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Able to work: __________________________________________
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Treatment: _______________________________________________
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Drug therapy: __________________________________
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Marks on learning practical skills
Number p / p and manipulation skills Signature
student / manager
1. Practical skills
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