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Toronto Notes 2019 Common Presenting Problems
Hypoglycemic Agents (Type 2 DM)
• oral
■ biguanide: metformin (Glucophage®)
■ thiazolidinedione: troglitazone (Rezulin®), rosiglitazone (Avandia®)
■ α-glucosidase inhibitor: acarbose (Precose®)
■ nonsulfonylureas: nateglinide (Starlix®), repaglinide (Gluconorm®)
■ sulfonylureas: glyburide (DiaBeta®), glimepiride (Amaryl®), gliclazide (Diamicron®) ■ DPP-4 inhibitor: sitagliptin (Januvia®)
• injectable
■ GLP-1 analogue: liraglutide (Victoza®)
Other Medications Used in DM
• ACEIorARBinthosewithanyof:
■ clinical macrovascular disease
■ age ≥55
■ age <55 and microvascular complications
• statininthosewithanyof:
■ clinical macrovascular disease
■ age ≥40
■ age <40 and any of the following:
◆ diabetes duration >15 yr and age >30 yr ◆ microvascular complications
◆ other cardiovascular risk factors
• lowdoseASA(81-325mg)
■ for secondary prevention in people with established CVD (NOT to be used routinely for primary
prevention)
Dizziness
• seeOtolaryngology,OT6
Epidemiology
• 70%ofaffectedpatientsseegeneralpractitionersinitially;4%arereferredtospecialists • frequencyisproportionaltoage;commonestcomplaintofambulatorypatientsage>75
Family Medicine FM25
Differential Diagnosis
Vertigo (vestibular)
Objective (external world seems to revolve around individual) or subjective (individual revolves in space)
Dizziness
Psychogenic
Diagnosis of exclusion
Nonvertiginous (nonvestibular) Feeling “light-headed,” “giddy,” “dazed,” “mentally confused,” or “disoriented”
RosiglitazoneRevisited:AnUpdated Meta- Analysis of Risk for Myocardial Infarction and Cardiovascular Mortality
Arch Intern Med 2010;170:1191-1201
Purpose: To evaluate the effectiveness of rosiglitazone on myocardial infarctions (MIs) and mortality.
Methods: Systematic review of RCTs of rosiglitazone, lasting at least 24 weeks in duration, and reporting cardiovascular (CV) adverse events. Main outcomes were MIs, CV-related mortality and all-cause mortality.
Results: Rosiglitazone significantly increased
MI risk (odds ratio (OR) 1.28, 95% CI 1.02-1.63, p=0.04) but not CV mortality (OR 1.03, 0.78-1.36, p=0.86).
Conclusion: Rosiglitazone continues to demonstrate increased risk of MIs, though it is not associated with increased risk of CV or all-cause mortality.
Central (15%)
Brainstem Cerebellar
Etiology
Tumour Stroke Drugs Multiple sclerosis
Peripheral (85%)
Inner ear Vestibular nerve
Etiology
Idiopathic Menière’s BPPV Acoustic neuroma Trauma Drugs Labyrinthitis
Vascular
Etiology
Ocular
Etiology
Decreased visual acuity
Differential Diagnosis of Vertigo
BPPV LabyrinthitisMenière’s Acoustic Neuroma
VBI
Basilar migraine
TIA Orthostatic hypotension Stokes-Adams syndrome Arrhythmia
CHF
Aortic stenosis Vasovagal episodes Metabolic causes
Onset sudden sudden Duration seconds days
Hearing — + Loss
Tinnitus — + Neuro Sx — —
gradual insidious min-hours chronic ++
++ —+
BPPV = benign paroxsymal positional vertigo TIA = transient ischemic attack
VBI = vertebral basilar insufficiency
Figure 11. Differential diagnosis of dizziness
History
• clarifytypeofdizziness:vertigo,pre-syncope,disequilibrium,light-headedness • duration
• exacerbations
■ worse with head movement or eye closure (vestibular)
■ no change with head movement and eye closure (nonvestibular) ■ worse with exercise (cardiac/pulmonary causes)