Updates in Endocrinology 2016 - UCSF Medical · PDF fileUpdates in Endocrinology 2016 ... , htn. Paent complains of fague and just overall decreased energy ... • BMI ≥ 24 kg/m

Updates in

Endocrinology 2016

UCSF Medical Management of HIV/AIDS and Hepatitis

San Francisco December 10th, 2016

Elizabeth J. Murphy, MD, DPhil Professor of Clinical Medicine

University of California, San Francisco Chief, Division of Endocrinology San Francisco General Hospital

NO DISCLOSURES

2

Case47yohispanicMSM,HIV+onHAARTfor15years,htn.Pa?entcomplainsoffa?gueandjustoveralldecreasedenergy.FH:DM2infather,hipfractureinmotherHRB:+EtOH,marijuana,methuse,getsregularexerciseExam:5’9”,185lb,BMI27.3,BP120/80MEDS:Lisinopril10mgdailyWhatwouldwouldyouscreenfor?a)  Diabetes/prediabetesb)  Osteoporosis/bonelossc)  Hypogonadismd)  Nothing

Case47yohispanicMSM,HIV+onHAARTfor15years,htn.Pa?entcomplainsoffa?gueandjustoveralldecreasedenergy.FH:DM2infather,hipfractureinmotherHRB:+EtOH,marijuana,methuse,getsregularexerciseExam:5’9”,185lb,BMI27.3,BP120/80MEDS:Lisinopril10mgdailyWhatwouldwouldyouscreenfor?a)  Diabetes/prediabetesb)  Osteoporosis/bonelossc)  Hypogonadismd)  Nothing

DiabetesScreeningTool(NIH/CDC)

1

1

1

1

1

Prediabetes Risk Based on ADA/AHA Screening Tool

JAMA Intern Med. 2016;176(12):1861-1863.

≥40yearsold >60yearsold

59% 81%

Economic Costs of Diabetes, 2012

American Diabetes Association website. Diabetes Care. 2013;

Total cost of diabetes $245 billion

excess medical expenditures $176 billion

to treat diabetes directly $27 billion

to treat diabetes-related chronic complications attributed to diabetes

$58 billion

excess medical costs $31 billion

reduced national productivity: $69 billion

2007 $174 Billion

Age-Adjusted Prevalence of Diagnosed Diabetes Among U.S. Adults

<4.5% Missing data 4.5%–5.9% 6.0%–7.4% 7.5%–8.9% ≥9.0%

CDC’s Division of Diabetes Translation. National Diabetes Surveillance System available at http://www.cdc.gov/diabetes/statistics

1996


<4.5% Missing data 4.5%–5.9% 6.0%–7.4% 7.5%–8.9% ≥9.0%


1999


<4.5% Missing data 4.5%–5.9% 6.0%–7.4% 7.5%–8.9% ≥9.0%


2002


<4.5% Missing data 4.5%–5.9% 6.0%–7.4% 7.5%–8.9% ≥9.0%


2005


<4.5% Missing data 4.5%–5.9% 6.0%–7.4% 7.5%–8.9% ≥9.0%


2008


<4.5% Missing data 4.5%–5.9% 6.0%–7.4% 7.5%–8.9% ≥9.0%


2010


<4.5% Missing data 4.5%–5.9% 6.0%–7.4% 7.5%–8.9% ≥9.0%


2012 (note new methods)


<4.5% Missing data 4.5%–5.9% 6.0%–7.4% 7.5%–8.9% ≥9.0%


2014

•  Diabetesistheleadingcauseof:– Leadingcauseofblindness– LeadingcauseofESRD– Leadingcauseofnon-trauma?camputa?ons

•  29.1millionAmericans(9.3%)havediabetes•  86millionAmericans(27.5%)haveprediabetes•  25.9%ofAmericans>65havediabetes

DiabetesinAmerica-2012

0

10

20

30

40

50

60

Men Women

Perc

ent

Total Non-Hispanic WhiteNon-Hispanic Black Hispanic

Narayan et al, JAMA, 2003

Estimated lifetime risk of developing diabetes for individuals born in the United States in 2000

1 in every 3 adults in the U.S. will have diabetes by 2050.

What is the only safe way to cure and treat DM2 long-term?

Don’t develop it in the first place.

Pre/DiabetesScreeningWhoisatRisk?

•  Historyofgesta?onaldiabetes•  Familyhistoryofdiabetes•  Age•  Overweightandobese•  Sedentary•  Highriskethnicgroup•  Impairedglucosemetabolism

Prediabetes

•  Fas?ngglucose100or110-125mg/dl

•  A1C5.7-6.4%

•  2hglucosepost75OGTT140-199mg/dl

LaboratoryScreeningRecommenda?ons•  CDCDiabetesPreven?onProgram

–  Posi?veonhighriskonscreeningtoolsAND•  BMI≥24kg/m2or≥22kg/m2inAsian-AmericansOR•  HistoryofGDM

•  ADA–  Everyoneoverage45– Adultswhoareoverweightorobese(BMI≥25kg/m2or≥23kg/m2inAsian-Americans)

•  USPSTF– Age40-75withBMI≥25kg/m2

USPSTFRecommenda?ons•  NoethnicityappropriateBMIcut-offs•  Doesn’tallowforscreeningof<40•  Resultsinsignificantunder-detec?on•  Sensi?vity45.0%1•  Specificity71.9%1

1O’BrienMJ,LeeJY,CarnethonMR,AckermannRT,VargasMC,etal.(2016)Detec?ngDysglycemiaUsingthe2015UnitedStatesPreven?veServicesTaskForceScreeningCriteria:ACohortAnalysisofCommunityHealthCenterPa?ents.PLoSMed13(7):e1002074.

%DysglycemicPa?entsCapturedbyUSPSTFScreeningGuideline

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

White AfricanAmerican LaSnoO’BrienMJ,LeeJY,CarnethonMR,AckermannRT,VargasMC,etal.(2016)Detec?ngDysglycemiaUsingthe2015UnitedStatesPreven?veServicesTaskForceScreeningCriteria:ACohortAnalysisofCommunityHealthCenterPa?ents.PLoSMed13(7):e1002074.doi:10.1371/journal.pmed.1002074

Conclusions–WhotoScreen?•  USPSTFrecommenda?onsshouldbeaminimumbar

•  Dependsinpartonyourpopula?on,useAsianspecificBMIcut-off

•  Aswithscreeningforgesta?onaldiabetes,perhapseasiesttoscreenwidely

DataforDiabetesPreven?on

•  StudiesofLifestyleInterven?on– USDiabetesPreven?onProgram– DaQingIGTandDiabetesStudy– FinishDiabetesPreven?onStudy

•  Results– Lifestyleinterven?onpreventsdiabetes– Associatedwithweightloss

USDiabetesPreven?onProgram•  Randomizedhighriskpa?entsto

– melormin– extensive,individuallifestyleinterven?on

•  150minutesofmoderate-intensityphysicalac?vityperweek

•  Lifestylegroup– 7%weightlossatoneyear– 4%weightlossat4years

NEJM 346:393, 2002; Lancet 374:1677, 2009.

DiabetesPreven?onProgram

TheFutureofType2DiabetesCare

DPPTransla?onalStudies•  Focusonmorecostefficientdelivery

– Groupeduca?on•  Focusedonweightloss

– Allachieveearlyweightloss– Longtermdurabilityofweightlossnotasclear

Reduc?oninDiabetesbyWeightLossDiabetesPreven-onProgram

NEJM346:393,2002.

DPPTransla?onalStudies•  Focusonmorecostefficientdelivery•  Focusedonweightloss

–  Allachieveearlyweightloss–  Longtermdurabilityofweightlossnotasclear

•  Don’tyethavediabetespreven?ondatafortransla?onalprograms

•  Otherpoten?albenefits–  Lipids–  HTN–  Depression

DiabetesPrevenSonPrograms•  Inperson,groupcoaching

– YMCA(DEPLOY,RAPID…)– WeightWatchersforprediabetes– Manyothers(MontanaDHHS,Kaiser)

•  Digital,humancoaching– OmadaHealth-Prevent®– CanaryHealth-VirtualLifestyleManagementTM

•  Digital,fully-automatedcoaching– TurnaroundHealth-Alive-PDTM

CDCDPPCerSficaSonRequirements•  CDC-approvedcurriculumpromo?ng5-7%weightlossandincreasedphysicalac?vity(DiabetesPreventProgramGroupLifestyleBalanceCurriculumTM)

•  alifestylecoach•  apeersupportgroupofprogrampar?cipants•  Submitannualdataonweightloss,ac?vity,classpar?cipa?on

•  Enroll>50%ofpa?entsbasedonlabtests

HowtoFindaProgram

hqps://www.cdc.gov/diabetes/preven?on/index.html

OnDigitalDPP

hqps://www.omadahealth.com/

WhotoRefer•  CDCDPP:prediabetesandBMI≥24or≥22forAsianAmericansor

historyofGDM•  ADA:Prediabetes

–  “Follow-upcounselingandmaintenanceprogramsshouldbeofferedforlong-termsuccessinpreven-ngdiabetesandsuchprogramsshouldbecoveredbythird-partypayers”

–  EvidencelevelB•  USPSTF:Prediabetes

–  “intensivebehavioralcounselinginterven-onstopromoteahealthfuldietandphysicalac-vity”

–  EvidencelevelB–  Similarrecommenda?onforCVDriskfactorsandoverweight/obese

Coverage•  30+privateplanscover•  MontanaMedicaid•  CDC/MedicaidPilotProjects

– Maryland– Oregon

•  StateEmployeecoverage

StateEmployeeHealthCoverage

Coverage•  30+privateplanscover•  MontanaMedicaid•  CDC/MedicaidPilotProjects

– Maryland– Oregon

•  StateEmployeecoverage•  March2016,CMSannouncedplanstocover

– PilotprogramwithYMCAsaved$2650perpersonenrolled

MedicareDiabetesPrevenSonProgram(MDPP)•  January1,2018•  MedicarePartBenrollees•  BMIofatleast25kg/m2(or23kg/m2Asian)ANDoneof– FPG110-125mg/dL– OGTTof140-199mg/dL– HbA1cbetween5.7%and6.4%.

MedicareDiabetesPrevenSonProgram(MDPP)•  January1,2018•  MedicarePartBenrollees•  BMIofatleast25kg/m2(or23kg/m2Asian)ANDoneof– FPG110-125mg/dL– OGTTof140-199mg/dL– HbA1cbetween5.7%and6.4%.

OtherMethodsofDiabetesPrevenSon

•  Melormin– Mosteffec?veinage<60withBMI>35orgesta?onaldiabetes

– Costsavingover10years– 18%reduc?onindiabetesover15years– Lifestyleinterven?onismoreeffec?ve

•  Othermedica?ons?•  Bariatricsurgery

44

Case47yohispanicMSM,HIV+onHAARTfor15years,htn.Pa?entcomplainsoffa?gueandjustoveralldecreasedenergy.FH:DM2infather,hipfractureinmotherHRB:+EtOH,marijuana,regularexerciseExam:5’9”,185lb,BMI27.3,BP120/80MEDS:Lisinopril10mgdailyWhatwouldwouldyouscreenfor?a)  Diabetes/prediabetesb)  Osteoporosis/bonelossc)  Hypogonadismd)  Nothing

Case47yohispanicMSM,HIV+onHAARTfor15years,htn.Pa?entcomplainsoffa?gueandjustoveralldecreasedenergy.FH:DM2infather,hipfractureinmotherHRB:+EtOH,marijuana,methuse,getsregularexerciseExam:5’9”,185lb,BMI27.3,BP120/80

HehasaDXAT-scorespineof-2.3,femoralneckof-2.2.

Whatwouldyoudo? a)  Encouragemodifica?onofriskfactorsandop?mize

vitaminDandcalciumintakeb)  a+bisphosphonatec)  Don’thaveenoughinforma?ond)  a+testosteronee)  a+denosamab(Prolia)



Whatwouldyoudo? a)  Encouragemodifica?onofriskfactorsandop?mize

vitaminDandcalciumintakeb)  a+bisphosphonatec)  Don’thaveenoughinformaSond)  a+testosteronee)  a+denosamab(Prolia)

BMD•  Proxy for fracture •  Best fracture data is in older folks •  Doesn’t always correlate with bone strength

BMDandFracturebyAge

Huietal.JClinInvest1988;81:1804-9

BMD

•  Z-score–  ComparedtoBMDofsameage

–  Usedforkids,premenopausalwomen,men<50

•  T-score –  United States - compared to

a sex and ethnicity concordant 30 year old

–  WHO – compared to 30 yowf –  Used for post-menopausal

women and men > 50 y

•  Proxy for fracture •  Best fracture data is in older folks •  Doesn’t always correlate with bone strength

WHODefiniSonsLowBMD

Status T-score Osteopenia between −1.0 and −2.5 Osteoporosis ≤−2.5 Severe osteoporosis ≤−2.5 + fragility fracture

Status Z-score Low BMD ≤ - 2.0

BMDinHIV

•  Decreased•  HIVposi?vepa?entshaveincreasedriskfactorsforlowBMD

•  IntrinsictoHIV?•  Doesthattranslateintoincreasedfractures?

Triant,Brown,Hang,Grinspoon;TheJournalofClinicalEndocrinology&Metabolism2008,93,3499-3504.

FracturePrevalenceinHIVInfectedPaSents

Female Male

ARTMakesitWorse

•  DecreaseinBMDof2-6%infirsttwoyearsoftreatment

•  Stabilizesover?me•  BoostedPIseemworse•  Tenofivirisworse

Tenofivir•  Tenofivirdisoproxilfumarte(TDF)

–  DecreasesBMDinhipandspine–  Increasedfractures–  Likelymediatedbychangesinrenalphosphatehandling(canhavefrankFanconiSyndrome)

ChangeinBMDTAFv.TDF

Saxetal,TheLancet(2015)385:2606–2615.

L-Spine Hip

---------E/C/F/TAF----------E/C/F/TDF

Tenofivir•  Tenofivirdisoproxilfumarte(TDF)

–  DecreasesBMDinhipandspine–  Increasedfractures–  Likelymediatedbychangesinrenalphosphatehandling(canhavefrankFanconiSyndrome)

•  Tenofiviralafenamidefumarate(TAF)–  SlightlybeqerBMD–  Slightlybeqerkidneys–  Slightlyworselipids– Muchworsewallet

BMDprePrEP•  InSanFranciscoPrEPstudy

–  9.5%withlowBMD(ZScore<-2)atbaseline

•  DecreasedriskoflowBMD– MVI,calcium,orVitaminDuse(OR0.26)

•  IncreasedriskoflowBMD–  Amphetamineuse(OR5.86)–  Inhalantuse(OR4.57)

Liuetal,PLoSOne,2011,6:e23688.

BMDlosswithPrEP

Mulliganetal,ClinicalInfec?ousDiseases,2015,61:572-580



AgertreaSngmodifiableriskfactorswhatwouldyoudo?

ModifiableOsteoporosisRF•  Diet

–  VitaminDdeficiency–  Inadequatecalciumintake

•  PhysicalInac?vity•  Smoking,Alcohol,otherrecrea?onaldruguse•  Lowweight

VitaminD•  Decreasedlevelswithefavirenz•  Endocrinesocietysaysscreenhighriskfolks•  EuropeanAIDSClinicalSocietysaysscreenHIV+at

diagnsois•  Brownetal,20151–Checkinpa?entshistoryof

lowBMDand/orfracture.Considercheckingif–  Darkskin–  Dietarydeficiency–  Avoidanceofsunexposure–  Obese–  CKD–  Rxwithefavirenz–  Malabsopr?on

CHECK EVERYONE!

TreatmentGoal>30forhighrisk>20isokayforpreven?on

1Brownetal,Recommenda?onsforEvalua?onandManagementofBoneDiseaseinHIV,2015,ClinicalInfec-onsDiseases,60:1242.



AgertreaSngmodifiableriskfactorswhatwouldyoudo?

a)  Treatwithabisphonateb)  CalculateaFRAXtodecideabouttreatmentc)  GoreadaboutFRAXd)  Treatwithtestosterone

FRAX

WhentoTreatPost-MenopausalWomen,Men>50•  T-score<-2.5%(osteoporosis)•  T-scorebetween-1and2.5AND

•  ≥20%riskofmajorosteoporosisfracturefromFRAX•  ≥3%riskofhipfracturefromFRAX

•  HistoryofhiporvertebralfracturePre-MenopausalWomen,Men<50•  Safetyandefficacydatamuchlessclear•  Canconsidertreatmentforseverediseasebutaggressivelycontrolsecondarycausesfirst

EvaluateforTreatableSecondaryCauses

•  SwitchtononPIornonTDFbasedtherapy

•  ThingstoCheck–  25OHVitaminD–  TSH(hyperthyroid)–  AMTestosteroneormenstrualhistory

–  Calcium,Albumin,Phos,Crea?nine(hyperpara)

–  Frac?onalexcre?onofphosphate

•  Thingstoconsiderbasedonclinicalsezng–  Cushing’ssyndrome–  Mul?plemyeloma

FRAX

Case52yohispanicMSM,HIV+onHAARTfor15years,htn.Pa?entcomplainsoffa?gueandjustoveralldecreasedenergy.FH:DM2infather,hipfractureinmotherHRB:+EtOH,marijuana,methuse,getsregularexerciseExam:5’9”,185lb,BMI27.3,BP120/80HehasaDXAT-scorespineof-2.3,femoralneckof-2.2.FRAX10yrriskofhipfractureof4.9%.AgeragerevaluaSngforandtreaSngmodifiableriskfactorsandsecondarycauseswhatwouldyoutreatwith?

a)  abisphonateb)  terapera?de(rPTH/forteo)c)  testosteroned)  denosamab(Prolia)

OsteoporosisTreatmentOpSons

•  BoneResporpSon–  Bisphosphonates

•  IncreaseBMDinHIV•  NoFracturedata•  Osteonecrosis(increasedrisk?)

–  Estrogens•  OCP/HRT•  Raloxifene(SERM)

–  Denosumab(RANKLmonoclonalAb)

•  Don’tuseinHIV

•  BoneFormaSon–  Teraperi?de(rPTH;Forteo)–  Testosterone–  Abalopara-de(rPTHrp)–  Romosozumab(Scleros-nmonoclonalAb)

BoneHealthinHIV

•  EVERYONE–  Focusonmodifiableriskfactors–  Adequatecalcium/D/weightbearingexercise

•  <40?•  Men40-49andpremenopausalwomen≥40

–  CancalculateFRAXwithoutBMD–  DXAifsignificantrisk

•  Men≥50andpost-menopausalwomen–  DXA

Case

38yom,HIV+,(VLUD)bodybuildernotedtohavesevereerythrocytosis(19.8/60).Whatshouldbeyournexttest?a)  Bonemarrowbiopsyb)  Ferri?nc)  Testosteroned)  TSHandFreeT4

Case

38yom,HIV+,(VLUD)bodybuildernotedtohavesevereerythrocytosis(19.8/60).Whatshouldbeyournexttest?a)  Bonemarrowbxb)  Ferri?nc)  Testosteroned)  TSHandFreeT4

12!

TSHandT4normalbuthighT3

60

46.3

Hct

60

46.3

Hct

Abuse….isassociatedwithserioussafetyrisksaffec?ngtheheart,brain,liver,mentalhealth,andendocrinesystem.Reportedseriousadverseoutcomesincludeheartaqack,heartfailure,stroke,depression,hos?lity,aggression,livertoxicity,andmaleinfer?lity.Individualsabusinghighdosesoftestosteronehavealsoreportedwithdrawalsymptoms,suchasdepression,fa?gue,irritability,lossofappe?te,decreasedlibido,andinsomnia.

BACKGROUND:Prescrip?ontestosteroneproductsareFDA-approvedashormonereplacementtherapyformenwhohavelowtestosteroneduetocertainmedicalcondi?ons.Examplesofthesecondi?onsincludefailureofthetes?clestoproducetestosteronebecauseofgene?cproblems,ordamagetothetes?clesfromchemotherapyorinfec?on.

ImportantTestosteronePrinciples

1.  Testosteroneassaysarenotverygood.

77

TestosteroneAssays•  Knowthetypeandqualityofassayyouareusing•  Mostassaysoftotaltestosteronewillallowforthediagnosisof

classichypogonadism–  Obtainonamorningsample–  Considerrepea?ngatleastonce–  Normalrangeshouldbecloseto300-1000(basedonyoungmen)

•  Mostassaysarenotverypreciseorreproducibleinthe200-300range

•  LCMSMSisthebestassayoftotaltestosteronebutisexpensive•  FreeTestosteroneisbestmeasuredasacalculatedvaluewith

highqualitytestosteroneandSHBGassaysthoughcalcula?onshavenotbeenspecificallydeterminedforHIV

•  HIVcanincreaseSHBGandfalselyelevatetotaltestosterone(considerfreetestosterone)

TotalTestosteroneAssays

DirectassaybyRIA,ELISA,CLIA

Easy,inexpensive,fast,automated.

Canoveres?mateT,notstandardized,notgreat<300

GCMSMSorLCMSMS Accuratewhenproperlyvalidated.

Expensive,hasnotbeenwellstandardized,slow

RIAa{erextrac?on/chromatography

Goodreferencesranges. Difficult,laborintensive,slow,expensive.

FreeTestosteroneAssays

DirectRIA Easy,inexpensive Doesn’tworkwell.Don’teveruse.

EquilibriumDialysis(physicalsepara?on)

Accurate,sensi?ve,reproducible

Expensive,technicallydifficult

FreeAndrogenIndex(TT/SHBG)

Easy DependentonaccuracyofTT/SHBGassay

CalculatedFreeT(severalmethods)

Easy DependentonaccuracyofTT/SHBGassayandcalcula?ons

BioT(precip?a?on) Easy Lotsofinaccuracies.

TotalTestosterone8:30am,singlesample,samereferencelab

ImportantTestosteronePrinciples

1.  Testosteroneassaysarenotverygood.2.  Testosteronelevelsdecline1-2%peryearas

menage3.  Trea?ngtheunderlyingchroniccondi?on

typicallycorrectsthelowtestosterone4.  Directtoconsumeradver?singandmarke?ng

tophysicianshassignificantlyincreasedtheuseoftestosterone

5.  DataonCVrisksaremixed.82

TrendsinAndrogenPrescribingintheUS2001-2011

83

0

0.5

1

1.5

2

2.5

3

3.5

2000 2002 2004 2006 2008 2010 2012

Year%M

en>40Given

And

rogenRe

placem

entT

herapy

Baillargeonetal,JAMAInternalMedicine(2013)173:1465.

Over2billioninAnnualSales

What’sNew?TheTestosteroneTrials

•  7doubleblinded,place-controlledmul?centertrials

•  Sexualfunc?on,Physicalfunc?on,Vitalitytrials•  AverageTestosterone<275ng/dl•  Excluded:

–  Highriskoractuallyhavingprostatecancer–  HighCVrisk(MI/CVAwithin3months,unstableangina,classIII/IVCHF,SBP>160,DBP>100,severedepression

Snyderetal.,EffectsofTestosteroneTreatmentinOlderMen,NEJM,Feb2016,374:611,

•  Oneyearoftestosteronetreatmentinprimarilynon-hispanic,whitemen>65

•  Testosteroneconcentra?onsincreasedfrom250toapproximately500withtreatment

Results•  Increasesinsexualac?vity,desireanderec?lefunc?on

•  Effectonerec?ledysfunc?onwaslessthantypicallyseenwithphosphodiesteraseinhibitors

•  Nobenefitwasseenwithwalkingabilityorvitalityprimaryoutcomes

•  Largeplaceboeffect•  Notdesignedtoassesssafety

Snyderetal.,EffectsofTestosteroneTreatmentinOlderMen,NEJM,Feb2016,374:611,

Conclusions•  Neverstarttestosteronetherapyinsomeonewho

hasnothadalowtestosteronelevel.•  Forpa?entsstartedforreasonsotherthanaclear

pituitaryortes?cularproblem(e.g.andropause)discusspoten?alrisks.

•  Forpa?entsalreadyonandrogens,monitorforsafetyanddecreaseasable,againdiscussingrisks.

•  Somepa?entsmightfeelbeqerontestosterone,wejustdon’tknowtherisk/benefitdataatall.

•  RememberlessonslearnedfromHRTinwomenandGHtherapy.

Case47yohispanicMSM,HIV+onHAARTfor15years,htn.Pa?entcomplainsoffa?gueandjustoveralldecreasedenergy.FH:DM2infather,hipfractureinmotherHRB:+EtOH,marijuana,regularexerciseExam:5’9”,185lb,BMI27.3,BP120/80MEDS:Lisinopril10mgdaily1)Considerdiabetesriskandmodifyingthatrisk.2)Improvemodifiableosteoporosisriskfactors.3)Avoidcheckingtestosteroneintheabsenceofandrogenspecificsymptoms.

UsefulWebSites•  2pageguideforinclinicprediabetesscreeningandac?onworkflow– hqp://www.cdc.gov/diabetes/preven?on/pdf/point-of-care-prediabetes-iden?fica?on-algorithm_tag508.pdf

•  DiabetesScreeningTool– hqps://doihaveprediabetes.org/pdf/Prediabetes_PrintableRiskTest(English).pdf

•  CDCDiabetesPreven?oninforma?on– hqps://www.cdc.gov/diabetes/preven?on/index.html

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Updates in Endocrinology 2016 - UCSF Medical · PDF fileUpdates in Endocrinology 2016 ... , htn. Paent complains of fague and just overall decreased energy ... • BMI ≥ 24 kg/m