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Q1095. A 65-year-old man is admitted with an extensive anterior STEMI and undergoes successful primary PCI. On the third day, he suddenly develops severe breathlessness, hypotension and pulmonary oedema. His blood pressure is 82/54 mmHg, and a new harsh pansystolic murmur with a palpable thrill is heard along the lower left sternal border. Echocardiography identifies a new ventricular septal defect with left-to-right flow.
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لو الـ Patients من البداية مايتحملش
Metformin is not tolerated or contraindicated (CI)
Initial monotherapy
اختار واحد:
Gliptin.
Sulfonylurea.
Pioglitazone.
Dual therapy
إذا HbA1c أكبر من (7.5%):
Gliptin + Pioglitazone.
Gliptin + Sulfonylurea.
Pioglitazone + Sulfonylurea.
Insulin
If HbA1c remains greater than 58 mmol/mol (7.5%)
نتنقلوا للـ Insulin.
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#Metformin
First-line treatment.
1. Rule out renal failure (RF) before starting Metformin.
2. Reassess HbA1c after 3 months.
If HbA1c is greater than 58 mmol/mol (7.5%), add a second drug.
#Dual_therapy
اختار واحد من الاثنين اهما
Metformin + Gliptin.
Metformin + Sulfonylurea.
Metformin + Pioglitazone.
Metformin + SGLT-2 inhibitor.
Reassess HbA1c after 3 months.
If HbA1c remains greater than 58 mmol/mol (7.5%), proceed to Triple therapy.
#Triple_therapy
اختار واحد من الثلاثة اهما
Metformin + Gliptin + Sulfonylurea.
Metformin + Pioglitazone + Sulfonylurea.Metformin + Sulfonylurea + SGLT-2 inhibitor.
Metformin + Pioglitazone + SGLT-2 inhibitor.
If HbA1c remains above 7.5% despite triple therapy → Insulin therapy.
لو كانت Triple therapy:
Not effective.
Not tolerated.
Contraindicated.
AND BMI greater than 35.
نستخدموا:
Metformin + Sulfonylurea + GLP-1 mimetic.
