418.3 🩺 內科專科考前版

418.3.0.1 📌 一頁重點

22E + 2025 trial updates:
- Eu-DKA from SGLT2 — recognized + protocol (hold pre-op + ill day)
- Anti-VEGF revolution for DME + PDR; faricimab (Vabysmo) Ang2/VEGF dual (FDA 2022)
- Finerenone (FIDELIO 2020, FIGARO 2021) — DM + CKD with albuminuria
- Semaglutide for CKD (FLOW 2024 NEJM) — semaglutide reduces CKD progression
- CONFIDENCE trial 2025: tirzepatide + finerenone CKD (combined cardiorenal benefit)
- Tirzepatide + HFpEF + obesity (SUMMIT 2024 NEJM)
- Acute HbA1c drop + retinopathy worsening caveat (esp. with intensive therapy + GLP-1 + pump)
- Resmetirom (THRβ agonist) approved 2024 for NASH (Ch 419)
Taiwan: 健保 finerenone 條件給付; SGLT2 + GLP-1 for CKD/CV; 健保 anti-VEGF 條件; DAROC + 國健署篩檢計畫

418.3.0.2 🌟 Pearls (20)

418.3.0.2.1 Acute

Eu-DKA from SGLT2: glucose can be < 200 — measure ketones + AG + pH if symptoms
DKA in pregnancy: can occur at lower glucose (placental shunting); treat aggressively
DKA cerebral edema in kids: gradual fluid replacement; mannitol if signs
Cinacalcet, hypoCa during DKA Tx: K shift can cause arrhythmia
Insulin pump DKA: change set + ketone test if 高 glucose; new pump revolution AID-resistance to DKA

418.3.0.2.2 Retinopathy

Faricimab (Vabysmo): Ang2 + VEGF dual; longer dosing intervals
Brolucizumab: small (single chain VEGF inhibitor); rare uveitis risk
Aflibercept HD (8 mg): longer duration than 2 mg
Pregnancy DR worsening: 視力 surveillance each trimester
DR + intensive therapy: 6-12 mo transient worsen; benefit long-term

418.3.0.2.3 Nephropathy

Finerenone vs spironolactone: less hyperK, less gynecomastia (selective)
GLP-1 + SGLT2 + finerenone triple cardiorenal: emerging in trials
CONFIDENCE trial: tirzepatide + finerenone CKD progression (results 2025)
FLOW trial: semaglutide 1 mg in CKD (24% RR ↓ CKD progression)
Renal ULAR cutoff: > 200-300 (high), > 300 macroalbuminuria
Patiromer / SPS for hyperK to allow ACE-i/ARB use

418.3.0.2.4 Neuropathy

Painful diabetic neuropathy combination: SNRI + gabapentinoid 比 mono effective
Gastroparesis treatment: dietary (small meal, low fat, low fiber), prokinetic (metoclopramide, erythromycin), pyloric injection, GES (gastric electrical stim), G-pylorus injection of botox
Hypoglycemia unawareness: avoid glucose < 70 for 2-3 wk → restoration

418.3.0.2.5 Foot

Charcot foot: immobilize × 8-12 wk + total contact cast; offloading vital; multidisciplinary

418.3.0.3 📍 Taiwan + 健保

418.3.0.3.1 Acute

健保 NS, 0.45% NS, KCl, NaHCO3, K phos
健保 IV insulin, regular insulin
健保 ICU monitoring

418.3.0.3.2 Retinopathy

國健署 DR 篩檢計畫 (限制)
健保 anti-VEGF (條件):
- Aflibercept (Eylea), ranibizumab (Lucentis)
- Bevacizumab (off-label)
- Faricimab (Vabysmo) 健保條件 expanding
健保 PRP, vitrectomy, focal laser

418.3.0.3.3 Nephropathy

健保 ACE-i / ARB 充分
健保 SGLT2 (CKD 條件: eGFR > 20 + albuminuria)
健保 GLP-1 RA for CV/CKD (條件)
健保 finerenone (Kerendia) 條件給付 (DM + CKD + albuminuria)
健保 patiromer 條件 (hyperK)
健保 HD/PD/transplant for ESRD

418.3.0.3.4 Neuropathy

健保 pregabalin, gabapentin
健保 duloxetine, venlafaxine
健保 amitriptyline
健保 tapentadol (條件)
健保 capsaicin, lidocaine patch

418.3.0.3.5 Foot

健保 multidisciplinary 糖尿病足 clinic
健保 wound care + offloading
健保 vascular surgery (revascularization)
健保 diabetic shoes 條件

418.3.0.3.6 CV

健保 statin, aspirin
健保 ACE-i / ARB / β-blocker / MRA / SGLT2 for HF
健保 GLP-1 RA for CV (條件)
健保 ICD / CRT 條件

418.3.0.3.7 學會 + 指引

DAROC 2024 (臺灣糖尿病學會)
ADA 2026 Standards
KDIGO 2024 Diabetes in CKD
ADA + KDIGO consensus
CTAOH for thyroid (相關)

418.3.0.4 🎓 內專必懂 (20)

DKA vs HHS + diagnostic criteria
DKA 5 支柱治療 + AG resolution
eu-DKA from SGLT2 + ill day rules
Cerebral edema in pediatric DKA + management
Pregnancy DKA at lower glucose + protocol
Lactic acidosis from metformin (rare; eGFR > 30 safe)
Retinopathy stages (NPDR/PDR/DME)
Anti-VEGF + faricimab (22E new)
Pregnancy + DR worsening
DKD progression markers (UACR + eGFR)
DKD treatment cascade: ACE-i → SGLT2 → GLP-1 → finerenone
Finerenone (FIDELIO, FIGARO) + hyperK prevention
FLOW trial semaglutide in CKD (22E)
CONFIDENCE trial tirzepatide + finerenone (22E)
DSPN diagnosis + screening (10g monofilament)
Painful neuropathy treatment (pregabalin/duloxetine/TCA/tapentadol)
Autonomic neuropathy (cardiac, GI, GU, hypoglycemia unawareness)
Foot ulcer multidisciplinary management
Charcot foot + offloading
Macrovascular CV: SGLT2 + GLP-1 + tirzepatide HFpEF (SUMMIT)

418.3.0.5 ⚙️ DKA Detailed Protocol (內專)

Step 1 — Diagnosis:
- Glucose > 250 (eu-DKA: < 200; SGLT2 / pregnancy / starvation)
- pH < 7.30, HCO3 < 18, AG > 10
- Ketones + (urine + serum β-OHB > 3 mmol/L)
- 排 starvation ketosis, lactic acidosis (separate)

Step 2 — Fluid:
- NS 1 L over 1 h (slower if HF; faster if shock)
- Then: NS or 0.45% NS 250-500 mL/hr based on corrected Na
- Corrected Na = measured Na + 1.6 × (glucose - 100)/100
- Goal: maintain euvolemia + slow correction

Step 3 — Insulin:
- Regular insulin 0.1 U/kg IV bolus + 0.1 U/kg/hr infusion
- OR: skip bolus, just 0.14 U/kg/hr (similar outcome)
- K必先 > 3.3 (hold insulin if K < 3.3, give K 20-40 mEq/hr first)
- Glucose decline target 50-75 mg/dL/hr
- When glucose < 200: switch to D5/0.45% NS + ↓ insulin to 0.05 U/kg/hr
- Do not stop until AG ≤ 12

Step 4 — Potassium:
- K > 5.3: hold; recheck q2h
- K 3.3-5.3: 20-30 mEq KCl in each L
- K < 3.3: hold insulin + give K 20-40 mEq/hr until > 3.3

Step 5 — Bicarbonate:
- pH > 7.0: not needed
- pH < 6.9: NaHCO3 100 mEq + K 20-30 mEq in 400 mL water over 2 h
- pH 6.9-7.0: controversial; not routine

Step 6 — Phosphate:
- Routinely not needed
- < 1.0 + cardiac/respiratory dysfunction: KPhos in fluid

Step 7 — Resolution:
- Glucose < 200 + 2 of: pH > 7.30, HCO3 > 18, AG ≤ 12
- Transition to SC insulin (basal-bolus)
- IV insulin overlap 1-2 h with SC

Step 8 — Education:
- Sick day rules
- Glucose + ketone monitoring
- Insulin pump troubleshooting
- Trigger identification
- Family teaching

418.3.0.6 ⚙️ Eu-DKA from SGLT2 (內專)

Mechanism:
- SGLT2 → ↑ glucagon, ↓ insulin, ↑ ketogenesis
- Glucose normal-low because urinary excretion
- High-risk: surgery, illness, fasting, low-carb diet, alcohol

Recognition:
- Glucose can be 100-250 (low for DKA)
- AG metabolic acidosis
- Ketones+

Prevention:
- Hold SGLT2 3 d before elective surgery
- Hold during major illness, low-carb diet, prolonged fasting
- Patient education

Treatment:
- Same as DKA but:
  - Glucose may need maintenance with D5/D10 from start (not later)
  - Insulin still standard
  - Restart SGLT2 after recovery (sometimes change strategy)

418.3.0.7 ⚙️ DKD Treatment Algorithm (內專)

Step 1 — All DM patients:
- HbA1c < 7% (individualized)
- BP < 130/80
- Smoking cessation

Step 2 — Albuminuria detected (UACR > 30) OR eGFR < 60:
- ACE-i or ARB (max tolerated)
- Even if normotensive
- Monitor K + Cr

Step 3 — Add SGLT2 (eGFR > 20):
- Empagliflozin 10 mg or dapagliflozin 10 mg
- CV + renal benefit
- DAPA-CKD, EMPA-KIDNEY, CREDENCE

Step 4 — Add GLP-1 RA (FLOW 2024):
- Semaglutide 1 mg/wk
- Renal + CV benefit
- Especially if obese / cardiometabolic

Step 5 — Add finerenone (FIDELIO, FIGARO):
- 10-20 mg/d
- DM + CKD + albuminuria + on max ACE-i/ARB
- Monitor K (vs spironolactone less hyperK)

Step 6 — Combinations:
- ACE-i + SGLT2 + GLP-1 + finerenone all-cardiorenal
- CONFIDENCE trial (2025): tirzepatide + finerenone

Step 7 — Symptomatic / progressive:
- Nephrology referral
- Anemia (ESA, iron)
- Phosphate management
- Vitamin D
- HD/PD/transplant prep at eGFR 20-30

418.3.0.8 ⚙️ Painful DPN Treatment

1st line (any of):
- Pregabalin 75-150 mg BID (max 300 BID)
- Gabapentin 300-1200 mg TID
- Duloxetine 60 mg/d
- Amitriptyline 25-100 mg HS (老人 caution; QT, anticholinergic)

2nd line:
- Combination 1st + 2nd line agent
- Tapentadol 50-100 mg q6h
- Capsaicin 8% patch (Qutenza)
- Lidocaine 5% patch

3rd line:
- Spinal cord stimulation
- Dorsal root ganglion stimulation

Avoid:
- Long-term opioid (not tapentadol)
- NSAIDs alone (not effective)

Education:
- Foot care to prevent ulcer
- Mental health (depression common)
- Sleep hygiene (pain at night)

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