In this episode, we will discuss the most important updates from the American Diabetes Association’s 2023 Standards of Care in Diabetes.

Key Concepts

1. The first-line therapy for type II diabetes is based on whether the primary goal of therapy is cardiorenal benefit (reduced risk of ASCVD, heart failure, or CKD) or glycemic and weight goals.
2. For cardiorenal benefit, GLP1 receptor agonists and SGLT2 inhibitors are heavily emphasized. For glycemic control and weight gain, GLP1 receptor agonists (or GLP1/GIP in the case of tirzepatide) have a very favorable effect on weight loss and glycemic control. While metformin is still mentioned, it is no longer the sole, first-line therapy for type II diabetes.
3. For patients with diabetes and a high risk of ASCVD (20% or higher), high-intensity statins, ezetimibe, and/or PCSK9 inhibitors are recommended to achieve an LDL less than 70 mg/dL. In patients with a history of ASCVD events, these same therapies are used to achieve a recommended LDL goal of less than 55 mg/dL.
4. Among selected patients with diabetes and CKD with albuminuria, finerenone (a new mineralocorticoid receptor antagonist) is recommended to improve renal and cardiovascular outcomes.
5. A variety of different therapies are now recommended for neuropathic pain, including gabapentinoids, SNRIs, TCAs, and several antiseizure medications (lamotrigine, lacosamide, oxcarbazepine, and valproic acid).
6. A wide variety of other new recommendations are discussed in the episode, including NASH/NAFLD, obesity and weight management, special populations, diabetes technology, and health behavior changes.

References

• American Diabetes Association. Standards of Care in Diabetes-2023. Diabetes Care. 2023; 46(1): S1-S292. https://diabetesjournals.org/care/issue/46/Supplement_1

In this episode, we review clinical pearls and common pitfalls of immunosuppression regimens for organ transplantation with a particular focus on tacrolimus and mycophenolate.

Key Concepts

1. Most recipients of an organ transplantation will be on a two or three drug regimen. The most common regimen is tacrolimus and mycophenolate with/without a corticosteroid.
2. Tacrolimus is hepatically eliminated and susceptible to CYP3A4 and PGP drug interactions. Particularly at higher drug concentrations, it is associated with nephrotoxicity and neurotoxicity (among several other adverse effects).
3. Mycophenolate is unstable in the acidic environment of the stomach. The two formulations on the market are CellCept (which uses a prodrug, mycophenolate mofetil, that is converted in the liver to an active compound) and Myfortic (an enteric-coated formulation of mycophenolic acid, which releases after exiting the stomach).
4. The intensity of an immunosuppression regimen is determined by numerous factors, including the type of organ, how long ago the organ was transplanted, if acute rejection has occurred in the past, patient-specific risk factors, and more.

Additional Resources

1. Register to be a donor at Donate Life America (https://donatelife.net) or at the HRSA OrganDonor.gov site (https://www.organdonor.gov)
2. Learn more about stem cell donation and transplant at https://bethematch.org