Muzammal Hospital

05/10/2025

Management of Type 2 DM

05/10/2025

📌 Caveats and Cautions When Prescribing Diabetes Medications in PALTC

Metformin
🚫 Avoid if:
Decompensated HF
eGFR < 30
Hepatic disease
Risk of dehydration
Diarrhea → consider ER formulation or alternative

GLP1-RA
🚫 Avoid if:
Anorexia
Chronic constipation
Gastroparesis / motility issues
Unexplained GI symptoms
Weight loss
✅ Preferred if ASCVD or HF present

SGLT2 inhibitor
🚫 Avoid if:
Acute kidney injury
Bedbound status
Dehydration
Dialysis
Fractures
Frequent UTI / ge***al yeast infection
Unable to drink fluids independently
Urinary incontinence
Weight loss
⚠️ Stop 5 days before elective procedure
✅ Preferred if CKD or HF present

DPP-4 inhibitor
🚫 Avoid if:
Severe anorexia
Unexplained GI symptoms
Concurrent use with
GLP1-RA

Basal insulin
🚫 Avoid if:
High hypoglycemia risk
Injectable treatment not feasible (e.g., some ALFs)
Assisted living facilities
Inconsistent BG monitoring
Lack of caregiver support
⚠️ Stop sulfonylureas, SSI

Prandial insulin
🚫 Avoid if:
Erratic meal intake
Hypoglycemia risk
Injectable treatment not feasible in care setting
Inconsistent BG monitoring
Lack of caregiver support
Tube feeding
⚠️ Stop sulfonylureas, SSI

Sulfonylureas
🚫 Avoid if:
Concurrent insulin use
Dementia
Hypoglycemia risk

TZDs
🚫 Avoid if:
Bladder cancer
HF / edema
Osteoporosis---

https://t.me/msaidelgamalclinicalpearls

05/10/2025

‏📊 الجدول الإكلينيكي لعلاج ارتفاع الضغط في الحمل: الخيارات الدوائية والجرعات (مزمن + طارئ)
https://t.me/msaidelgamalclinicalpearls

05/10/2025

🧵 Diagnostic Algorithm for Anemia
🩸 Confirm anemia → CBC, indices, reticulocytes,
smear if needed

Classify by MCV (micro 100 fL)
Add history & meds.
Merck Manuals+1

🧮 Microcytic (MCV 100) → first rule out reticulocytosis (hemolysis/bleeding), alcohol, liver disease, hypothyroidism, drugs (hydroxyurea, MTX, AZT, phenytoin).

🧩 Megaloblastic macrocytosis → check B12 & folate.
• Low B12 → confirm with ↑MethylMslonic
Acid ± ↑homocysteine
• Folate deficiency → ↑homocysteine with normal MMA.

🧬 If dysplasia/cytopenias (esp. macrocytosis)
or unexplained anemia → consider Mylodysplastic syndrome;
proceed to marrow exam with cytogenetics/ molecular test panel NGS as indicated.

🔁 Special pearls
• Always interpret ferritin with inflammation
(can be normal/high in IDA).
• Retic correction/absolute retic helps gauge marrow response.
🧭 One-page flow (clinically aligned with the figure):
MCV↓ → iron studies → IDA vs ACD; if not → sideroblastic/thalassemia.
MCV↔ → retic ↑ (hemolysis/bleed) vs retic ↓ (renal/endocrine/marrow).
MCV↑ → B12/folate ± MMA/hcy; exclude liver/thyroid, alcohol/drugs; think MDS if cytopenias. ARUP Consult
✅ When in doubt → combine clinical context + targeted labs; escalate to marrow exam if persistent/unexplained. Merck Manuals

Credits: Handbook of Hematologic Malignancies, 2025

https://t.me/msaidelgamalclinicalpearls

05/10/2025

Gastrointestinal Bleed

04/10/2025

Amitriptyline
هو Tricyclic Antidepressant (TCA)، استخدامه في أمراض الجهاز الهضمي كـ neuromodulator في الحالات اللي فيها
visceral hypersensitivity أو
functional pain disorders.
📌 Indications of Amitriptyline in GI Diseases

1️⃣ Functional GI Disorders
Irritable Bowel Syndrome (IBS)
Especially IBS with predominant pain/diarrhea.
Improves abdominal pain, stool frequency, and quality of life.

Functional dyspepsia
Used at low doses for epigastric pain,
early satiety, and fullness.

2️⃣ Esophageal Disorders
Non-cardiac chest pain (functional chest pain of esophageal origin).
May help in esophageal hypersensitivity.

3️⃣ Gastroduodenal Disorders
Refractory functional dyspepsia (Rome IV).
Adjunct in chronic nausea/vomiting syndromes.

4️⃣ Other Indications
Chronic idiopathic abdominal pain
(without structural cause).

Centrally mediated abdominal pain syndrome (CAPS).

Adjunct in cyclic vomiting syndrome (sometimes used in pediatric/adult cases).

💊 Notes on Use

Low dose (10–25 mg at night;
can titrate up to 50 mg).

Effect is neuromodulation of gut-brain axis
(not antidepressant dose).

Helps improve sleep, reduce anxiety, modulate visceral pain.

Side effects: constipation, dry mouth, drowsiness (can sometimes help IBS-D).
✅ الخلاصة:
Amitriptyline in GIT mainly for functional & pain-predominant disorders
(IBS, functional dyspepsia, non-cardiac chest pain, CAPS, cyclic vomiting).

03/10/2025