Chiefs’ Inquiry Corner — 8/30/21

 For patients who are found to be pre-diabetic, lifestyle modifications and metformin are generally felt to be appropriate for delaying or preventing the onset of diabetes (though metformin is not FDA approved for this use). The Diabetes Prevention Program Outcomes study examined this question longitudinally over 15 years. They initially randomized patients to intensive lifestyle modification or metformin (vs placebo). They found that diabetes incidence cumulatively over follow-up was lowest in the intensive lifestyle modification group (27% reduction), but metformin also demonstrated an 18% reduction in incidence (all compared to placebo). These findings may impact your decision to tailor recommendations for high risk patients. Of note, the USPSTF recently amended their 2015 guidelines to now recommend diabetes screening in overweight (BMI 25 or greater) and obese patients starting at age 35. This is largely grounded in the increasing prevalence of diabetes and obesity in the United States.

References: Long-term effects of lifestyle intervention or metformin on diabetes development and microvascular complications over 15-year follow-up: the Diabetes Prevention Program Outcomes Study

  Subclinical hyperthyroidism is defined by low or undetectable serum thyroid stimulating hormone (TSH) and normal free thyroxine (T4) and total or free triiodothyronine (T3). The American Thyroid Association (ATA) recommends treating patients with TSH ≤ 0.4 mU/L if they are age ≥ 65 years and patients < 65 years with heart disease, osteoporosis, symptoms of hyperthyroidism, or if they are postmenopausal (not on estrogen or bisphosphonate therapy); the ATA recommends considering treating all individuals with TSH<0.1 mU/L, regardless of presence of symptoms and comorbidities. Subclinical hypothyroidism is defined by elevated TSH and normal free T4. Most patients with subclinical hypothyroidism can be observed clinically. However, the ATA does recommend treating patients with TSH ≥ 10 mU/L. Thyroid hormone replacement therapy for individuals with TSH levels above the upper limit of normal but < 10 mU/L is dependent on the patient, but in general experts agree with treating symptomatic young and middle-aged individuals (under age 65-70 years) and women who are trying to conceive and who have a history of infertility.

References: Subclinical Hypothyroidism: A Review

  It is well-established by the ACG as a Class I, Level A evidence recommendation that Octreotide should be used in patients with suspected acute variceal hemorrhage. However, in patients who have non-variceal UGIB (such as gastric/duodenal ulcers or Mallory Weiss tears) there is limited evidence to support a role for medical therapy beyond the accepted IV PPI. One small randomized-control trial in Iran randomized patients presenting with non-variceal bleeding to standard therapy with pantoprazole (40 mg BID IV intermittent dosing) vs standard therapy + octreotide for 72 hours or until discharge. They found no significant differences in mortality, rates of rebleeding, or transfusion requirements. That being said, expert opinion for critically ill patients still varies with some favoring empiric use in patients with UGIB of unknown source and difficult to control hemorrhage given the relatively favorable safety profile of somatostatin analogues.

References: The Effect of Octreotide in Acute Nonvariceal Upper Gastrointestinal Bleeding: A Randomized, Double-Blind, Placebo-Controlled Trial