Internal medicine essentials - أساسيات أمراض الباطنة

1.7.26
Consider adding metformin to insulin therapy for adults with type 1 diabetes if:

they have a BMI of 25 kg/m2 or above (23 kg/m2 or above for people from South Asian and related family backgrounds) and

they want to improve their blood glucose control while minimising their effective insulin dose.

Recommendations | Type 1 diabetes in adults: diagnosis and management | Guidance | NICE This guideline covers care and treatment for adults (aged 18 and over) with type 1 diabetes. It includes advice on diagnosis, education and support, blood glucose management, cardiovascular risk, and identifying and managing long-term complications

NOGG 2021

NICE Algorithm for heart valve referral

https://www.nice.org.uk/guidance/ng208

🧠 Anticoagulation in Stroke Patients with Other Comorbidities

(Quick, ward-friendly summary for clinical practice)

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1️⃣ Disabling ischaemic stroke + atrial fibrillation

Start aspirin 300 mg daily for the first 14 days

Delay anticoagulation until after this initial period
🔹 Rationale: reduce early haemorrhagic transformation risk

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2️⃣ Prosthetic heart valve + disabling cerebral infarction

Withhold anticoagulation for 1 week if haemorrhagic transformation risk is high

Substitute aspirin 300 mg daily during this period
🔹 Then reassess and restart anticoagulation when safe

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3️⃣ Ischaemic stroke + symptomatic DVT or PE

Anticoagulation is preferred over aspirin, unless contraindicated
🔹 Treat the VTE adequately—stroke alone is not a reason to avoid anticoagulation

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4️⃣ Haemorrhagic stroke + symptomatic DVT or PE

Aim to prevent further pulmonary emboli using:

Anticoagulation, or

IVC (caval) filter, if bleeding risk is prohibitive
🔹 Choice depends on bleeding risk vs thrombotic risk balance

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📝 Key Clinical Pearls

Aspirin is often a temporary bridge, not definitive therapy

VTE treatment takes priority even in stroke patients

Decisions must be individualised, especially after haemorrhagic stroke

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📚 Reference
Adapted from National Institute for Health and Care Excellence (NICE) guideline NG128 – Stroke and transient ischaemic attack in over 16s
👉 Recommendations 1.4.17–1.4.20
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Recommendations | Stroke and transient ischaemic attack in over 16s: diagnosis and initial management | Guidance | NICE This guideline covers interventions in the acute stage of a stroke or transient ischaemic attack (TIA). It offers the best clinical advice on the diagnosis and acute management of stroke and TIA in the 48 hours after onset of symptoms

NICE GUIDELINES:

🔍 Diabetic Foot Infection: Colonization or True Infection?

Brain-storming questions to engage your audience:

🦶 Is every diabetic foot wound an infection that needs antibiotics?

❓ What is the minimum clinical evidence required to diagnose diabetic foot infection?

📏 Why does the 2-cm erythema rule matter in classifying severity?

🔥 Which finding upgrades a case from mild to moderate infection?

💊 Why Rivaroxaban Must Be Taken With Food (Key Teaching Point)

Bottom line:
👉 Rivaroxaban 15 mg & 20 mg must be taken with food to ensure full absorption and effective anticoagulation.

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🔬 Pharmacokinetic Rationale

With food, AUC ↑ ~39% and Cmax ↑ ~76% → ~100% bioavailability at 15–20 mg doses.

In fasting state, 20 mg bioavailability drops to ~66%, risking subtherapeutic anticoagulation.

Mechanism: rivaroxaban is lipophilic with low aqueous solubility; food prolongs gastric residence time and enhances dissolution.

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💊 Dose-Specific Rule

15 mg & 20 mg (AF stroke prevention, VTE treatment): MUST be taken with meals.

2.5 mg & 10 mg: Food-independent absorption → can be taken with or without food.

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⚠️ Clinical Implications

Taking 15–20 mg without food → ↓ drug exposure → ↑ thromboembolic risk.

The food effect is meal-type independent (fat, calories, carbs all acceptable).

No specific dietary restrictions (unlike warfarin) — only the timing with meals matters.

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📝 Practical Teaching Pearl

> “If it’s 15 or 20 mg, think plate first, pill second.”

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📚 References

1. Bratsos S. Pharmacokinetic Properties of Rivaroxaban in Healthy Human Subjects. Cureus. 2019.

2. Ageno W et al. ACCP Antithrombotic Therapy Guidelines (9th ed). Chest. 2012.

3. Cheung K, Leung WK. GI bleeding & NOACs. World J Gastroenterol. 2017.

4. Turpie AG et al. Consensus guidance on rivaroxaban use. Thromb Haemost. 2012.

5. Sanmartín-Fernández M et al. Safety of NOACs—focus on rivaroxaban. Clin Appl Thromb Hemost. 2017.

💡💡ENLS approach to a patient with coma

💡💡💡A Quick Guide to Chest Imaging Patterns (CXR/CT)

📕Pocket medicine