A practical and evidence-based approach to management of inpatient diabetes in non-critically ill patients and special clinical populations

AbstractInpatient diabetes is a common medical problem encountered in up to 25–30% of hospitalized patients. Several prospective trials showed benefits of structured insulin therapy in managing inpatient hyperglycemia albeit in the expense of high hypoglycemia risk. These approaches, however, remain underutilized in hospital practice. In this review, we discuss clinical applications and limitations of current therapeutic strategies. Considerations for glycemic strategies in special clinical populations are also discussed. We suggest that given the complexity of inpatient glycemic control factors, the “one size fits all” approach should be modified to safe and less complex patient-centered evidence-based treatment strategies without compromising the treatment efficacy

Methimazole-Induced Goitrogenesis in an Adult Patient With the Syndrome of Resistance to Thyroid Hormone

Patients with the syndrome of resistance to thyroid hormone (RTH) have clinical (tachycardia and anxiety) and biochemical (elevated thyroid hormones level) features of hyperthyroidism. Based on previous reports in pediatric patients with the RTH, antithyroid treatment in these patients is not indicated. Clinical and biochemical sequel of antithyroid therapy in an adult patient with RTH was not previously reported. A 63-year-old African American female with history of RTH was treated with a therapy consisting of methimazole 15 mg daily and atenolol. Methimazole treatment resulted in reduction in thyroid hormone level while the patient’s TSH increased with a peak of 24.88 mIU/L. Having achieved biochemical euthyroidism, the patient developed thyroid gland enlargement associated with progressive symptoms of dysphagia and dyspnea. Examination demonstrated globally enlarged firm thyroid gland with areas of nodularity in both lobes. A computed tomography of the neck showed enlarged thyroid gland with extension around bilateral sternocleidomastoid muscles and compression onto the trachea. Methimazole therapy was discontinued and patient was treated just on atenolol. Over 12 months following discontinuation of methimazole, the patient experienced marked clinical and radiographic improvement of the goiter size associated with TSH reduction to 1.26 mIU/L and modest free thyroxine increase as expected in RTH. It seems appealing to treat patients with the RTH with antithyroid medications. However, in these patients decrease in thyroid hormone levels will stimulate TSH production, which can, in turn, predispose to goiter formation. Our report supports prior observations in children with RTH that treatment with methimazole is not indicated in adult patients with RTH

Acute Kidney Injury Associated with Linagliptin

Linagliptin is a dipeptidyl peptidase-IV (DPP-IV) inhibitor that is approved for the treatment of type 2 diabetes mellitus. About 5% of linagliptin is eliminated by the kidneys and no dose adjustment is recommended in kidney impairment. We report a first case of linagliptin-associated acute kidney injury (AKI) in a patient with preexisting chronic kidney disease (CKD). We hypothesize that AKI was due to renal hypoperfusion from linagliptin-induced natriuresis and intravascular volume contraction in the setting of concomitant lisinopril use, which is known to impair autoregulation and potentiate hypotension-induced AKI. It may be prudent to exert caution and closely monitor kidney function when initiating linagliptin in combination with ACE-inhibitors in CKD patients

Case Report Acute Kidney Injury Associated with Linagliptin

Linagliptin is a dipeptidyl peptidase-IV (DPP-IV) inhibitor that is approved for the treatment of type 2 diabetes mellitus. About 5% of linagliptin is eliminated by the kidneys and no dose adjustment is recommended in kidney impairment. We report a first case of linagliptin-associated acute kidney injury (AKI) in a patient with preexisting chronic kidney disease (CKD). We hypothesize that AKI was due to renal hypoperfusion from linagliptin-induced natriuresis and intravascular volume contraction in the setting of concomitant lisinopril use, which is known to impair autoregulation and potentiate hypotension-induced AKI. It may be prudent to exert caution and closely monitor kidney function when initiating linagliptin in combination with ACE-inhibitors in CKD patients

Follicular Thyroid Carcinoma Presenting With Endobronchial Metastases

Endobronchial metastasis is a rare manifestation of differentiated thyroid cancer. A 79-year-old male was admitted to the hospital with shortness of breath, chest pain, anemia, and weight loss. Computed tomography of chest revealed multiple lung nodules. Bronchoscopy showed an endobronchial lesion in the right upper lobe. The biopsy of the lesion demonstrated neoplastic cells stained positive for thyroglobulin, thyroid transcription factor-1, and cytokeratin-7, consistent with metastatic follicular thyroid cancer. Physical examination revealed a firm fixed thyroid nodule, which was confirmed by thyroid ultrasound. He subsequently underwent total thyroidectomy and neck exploration. Thyroid gland pathology revealed a nodule with features of high-grade follicular thyroid carcinoma. Metastatic thyroid cancer should be considered in workup of pulmonary nodules. We recommend an examination of thyroid gland in patients who present with pulmonary nodules associated with signs and symptoms of malignancy