First Line Treatment (NAPLEX REVIEW)
Diabetes - ANS T1D: insulin
T2D: metformin
ASCVD or CKD risk: SGLT2 (-) or GLP-1 agonist
HF risk: SGLT2 (-)
wt loss: SGLT2 (-), GLP-1 agonist
cost: SU, TZDs
hypoglycemia risk: avoid insulin and SU together
DKA and HHS - ANS 1. fluids: NaCl first, then switch to D5W1/2NS when BG < 200
2. regular insulin (0.1u/kg)
3. prevent hypokalemia (monitor potassium)
4. treat acidosis (pH < 6.5) with sodium bicarb
Hypothyroidism - ANS 1st line: levothyroxine (1.6mcg/kg--using IBW)
alternatives: liothyronine, armour thyroid
if low salt intake: consume food with iodine (dairy, seafood, meat, bread) or take multivitamin
with iodine
Hyperthyroidism - ANS 1st line: meds (PTU--preferred in in 1st trimester if pregnant,
methimazole--preferred in 2nd and 3rd trimester if pregnant), radioactive iodine (destroy parts of
the gland--take with potassium iodine to prevent cancer) or surgery
beta-blockers for symptom control
Thyroid Storm (decompensated hyperthyroidism) - ANS 1st line: PTU
alternatives: inorganic iodine therapy (SSKI drops), beta blockers (propranolol), steroids
(dexamethasone), APAP or other supportive therapy to help cool down temp
Rheumatoid arthritis (RA) - ANS non drug: PT, rest, exercise, diet/weight control, surgery (joint
replacement)
drug: 1. DMARDs--traditional/non-biologic or biologics (TNF inhibitor or non-TNF inhibitor), 2.
steroids (used to bridge till DMARD takes effect), 3. NSAIDs
options: MTX (1st line) +/- steroid or 2 DMARDS (biologic + non-biologic or 2 non biologic)
Lupus - ANS non drug: rest, exercise, sun protection, quit smoking
drug:
mild-NSAIDS + PPI (reduce GI risk)
mod-sev (1 or more immunosuppressants): steroids, hydroxychloroquine, cyclophosphamide,
azathioprine, mycophenolate, cyclosporine, anifrolumab (saphnelo), belimumab (benlysta)
,multiple sclerosis - ANS 1.steroids--exacerbations (IV methylprednisolone 3-7 days)
2. disease modifying therapies (1st line)
3. supportive therapy: (anticholinergics--incontinence, laxatives--constipation,
loperamide--diarrhea, skeletal muscle relaxants or analgesics--muscle spasms and pain,
propranolol--tremors, SNRI--neuropathic pain, modafinil--fatigue, stimulants--ADHD,
scopolamine or meclizine--dizziness, donepezil--cognitive function, PDE-5 (-)---ED)
Raynauds - ANS calcium channel blocker (nifedipine)
alternatives: iloprost, topical NTG, PDE-5 (-)
celiac disease - ANS avoid gluten (avoid starch products--corn, potato, tapioca, wheat, etc.)
myasthenia gravis - ANS 1st line: cholinesterase inhibitors (pyridostigmine)--stop ACh
breakdown to reduce muscle weakness
alternatives/add ons: steroids, azathioprine, IVIG (severe), efgartigimod (vyvgart)
sjogren's syndrome - ANS dry eyes: artificial tears (OTC: systane, refresh, RX: restasis,
lifitegrast (xiidra))
dry mouth: (OTC: sugar free chewing gum/lozenge, antimicrobial mouthwash, salivary
substitutes, RX: oral muscarinic agonists--pilocarpine, cevimeline)
psoriasis - ANS non drug: oatmeal bath, UV light exposure--reduces scaling and inflammation,
photochemotherapy/laser light therapy
drug (1st line): topical meds (steroids, vitamin D analog (calcipotriene), anthralin, retinoids,
salicylic acid, coal tar, moisturizers
2nd line: topical calcineurin (-): protopic, elidel
severe: MTX, cyclosporine, hydroxyurea, entarecept, humira, infliximab, etc.)
pulmonary arterial hypertension - ANS -treat underlying causes (toxin, drug or disease
associated)
-CTEPH (chronic thromboembolism pulmonary HTN): warfarin
-non drug: sodium restriction, avoid NSAIDs, vaccinations (flu, pneumonia), avoid high altitudes
(causes hypoxia--trigger), oxygen
-drug (responders): calcium channel blockers (nifedipine, diltiazem, amlodipine)
-drug (non-responders/responders that failed CCB therapy)
pulmonary fibrosis - ANS chronic oxygen supplementation, pirfenidone (esbriet), nintedanib
(ofev)---both drugs slow rate of lung function decline
Asthma - ANS ICS or ICS/LABA (formoterol)
COPD - ANS Bronchodilators
Class A: SABA or SAMA PRN, LABA or LAMA
Class B: LAMA or LABA
, Class C: LAMA
Class D: LAMA, LAMA/LABA, or ICS/LABA (eos > 300)
Exacerbation: SABA + oral steroid
Tobacco cessation - ANS non drug: counseling
drug: NRT (patch, gum, lozenge, inhaler, spray), bupropion, varenicline
Hyperlipidemia - ANS Statins
add on: ezetimibe or pcsk9 (-)
Hypertension - ANS ACE/ARB, thiazides, DHP calcium channel blockers
others: beta blockers, clonidine, guanfacine, hydralazine, methyldopa, alpha blockers
stable ischemic heart disease (chest pain/angina) - ANS antiplatelets: aspirin, clopidogrel, both
(stent only)
antianginals: nitrates, beta blockers, CCBs
acute coronary syndromes - ANS PCI (revascularization procedure--preferred for STEMI)
if not possible with 120 min, give fibrinolytic within 30 min of hospital arrival
1st line drugs: morphine sulfate, oxygen, nitrate, aspirin (MONA)
next: anticoags, clopidogrel, beta blockers, ACE inhibitors
Heart Failure - ANS 1st: ACE/ARB/ARNI + beta blocker + loop diuretic
add on: spironolactone, then SGLT2, hydralazine, ivandrabine
last line: digoxin, vericiguat
Arrhythmias - ANS Rate: Class 2 or 4 (beta blockers and non-DHP CCBs)
Rhythm: cardioversion-Class 1 or 3 (Na and K blockers) + anticoagulant for stroke prophylaxis
(3 weeks before, 4 weeks after)
Ischemic Stroke (acute) - ANS remove clot w/ stent or dissolve clot with IV fibrinolytics
(alteplase), aspirin and/or clopidogrel or ticagrelor within 24-48 hrs and continued for 21-90 days
administer alteplase:
-30 min of STEMI
-3 hours of symptom onset
-60 min of hospital arrival
Ischemic Stroke (chronic prophylaxis) - ANS noncardioembolic: antiplatelet monotherapy
(aspirin or clopidogrel)
cardioembolic: oral anticoagulant (DOACS or warfarin)
hemorrhagic stroke - ANS if on anticoagulant: use reversal agent
treat seizures
lower ICP: mannitol or hypertonic sol'n
