EndokrinologiLäs om Hälsosamma levnadsvanor sid xx Diabetes mellitus Hälsosamma levnadsvanorVid diabetesbehandling är stöd för hälsosamma levnadsvanor avgörande och ska ske i kombination med läkemedelsbehandling. Tänk särskilt på rökning, balanserad kost, övervikt/fetma, regelbunden fysisk aktivitet samt alkoholvanor.Alkohol kan bidra till symtom, sjukdom eller dålig behandlingseffekt. Var uppmärksam, erbjud stöd och behandling vid riskbruk av alkohol.Multifaktoriell behandlingHjärt-kärlsjukdom är vanligt vid diabetes. Förutom glukoskontroll är det viktigt att uppnå god blodtryckskontroll (målblodtryck, se sid xx), dock med försiktighet vid neuropati/ortostatism och hos äldre. ACE-hämmare eller ARB är förstahandsval vid diabetes mellitus med mikroalbuminuri. Statinbehandling är indicerad för majoriteten (HYPERLINK "intern:Endokrinologi_DM_Multifakt_Beh_Prev_hk_Riskskattning"målvärden, se sid xx).Mål för HbA1cGod glukoskontroll är viktigt för att förebygga diabeteskomplikationer. Ett generellt målvärde är HbA1c ≤52 mmol/mol men bör anpassas individuellt. Vid diagnos och åren närmast därefter kan målet sättas lägre, 42–48 mmol/mol. Beakta risk för hypoglykemi. Hos äldre multisjuka, där målet är symtomfrihet snarare än förebyggande av diabeteskomplikationer, kan högre värden accepteras. Målvärde för HbA1c rekommenderas inte till sköra patienter med kort förväntad överlevnad men HbA1c <70 mmol/mol eftersträvas.Hjärta och kärl sid xxDiabetes hos vuxna; viss.nu Att förebygga aterosklerotisk hjärt-kärlsjukdom med läkemedel; lakemedelsverket.se Diabetes mellitus typ 2Många diabetesläkemedel ska sättas ut i samband med dehydrering och risk för försämrad njurfunktion. Se Vätskebrist och läkemedel; janusinfo.se.BasbehandlingMetformin i kombination med hälsosamma levnadsvanor är basbehandling hos alla patienter, se Hälsosamma levnadsvanor sid xx.METFORMINmetforminMetformin …, MitforgenBeakta försiktighetsprinciper och kontraindikationer, t.ex. vid nedsatt njurfunktion. Ska sättas ut tillfälligt vid risk för vätskebrist (oavsett eGFR). Ska sättas ut i samband med kontraströntgen om eGFR <45 ml/min. Patientinformation finns för utskrift på janusinfo.se.Aterosklerotisk hjärt-kärlsjukdom, hjärtsvikt eller kronisk njursjukdomHos patienter med aterosklerotisk hjärt-kärlsjukdom (ischemisk hjärt-kärlsjukdom, ischemisk stroke/TIA, perifer artärsjukdom), hjärtsvikt eller kronisk njursjukdom (eGFR <60 ml/min och/eller albuminuri) omfattar basbehandlingen även SGLT2-hämmare med bevisad hjärt- eller njurskyddande effekt.SGLT2-HÄMMAREdapagliflozinForxiga* 10 mgempagliflozinJardiance* 10 mg*Begränsad subvention; tlv.seDen blodsockersänkande effekten av SGLT2-hämmare avtar med minskande njurfunktion och är låg vid eGFR <45 ml/min. Kardiovaskulär- och njurskyddande effekt finns däremot även vid lägre eGFR. Kan nyinsättas ned till eGFR 20 ml/min. Se under Njursjukdomar sid xx.Observera risk för ketoacidos även vid normala blodsockervärden. Sätt ut vid vätskebrist och överväg behandlingsuppehåll vid akut sjukdom och fasta. Patientinformation finns för utskrift på janusinfo.se. Metformin och SGLT2-hämmare kan i dessa patientgrupper sättas in samtidigt eller i omgångar. SGLT2-hämmare ska inte användas hos patienter med diabetes mellitus typ 1.Individualiserad tilläggsbehandlingIndividualiserad tilläggsbehandling ges med hänsyn till samsjuklighet om läkemedel enligt basbehandling inte ger tillräcklig effekt eller inte är lämplig. Kardiovaskulär riskskattning rekommenderas som stöd i behandlingsstrategin, se Hög kardiovaskulär risk sid xxDe flesta preparatgrupperna kan kombineras, men det är olämpligt att kombinera GLP-1-analog och DPP4-hämmare eftersom båda är inkretinläkemedel. Insulinfrisättare och insulin är inte heller lämpliga att kombinera på grund av ökad hypoglykemirisk. Vid val av läkemedel bör särskilda överväganden göras vid tillstånden nedan. Oavsett samsjuklighet behöver många patienter förr eller senare insulinbehandling för acceptabel glukoskontroll. Då är det vanligen lämpligt att börja med medellångverkande humaninsulin till natten.Aterosklerotisk hjärt-kärlsjukdom Hos patienter med aterosklerotisk hjärt-kärlsjukdom (ischemisk hjärt-kärlsjukdom, ischemisk stroke/TIA, perifer artärsjukdom) omfattar basbehandlingen metformin och SGLT2-hämmare. Vid behov av ytterligare glukossänkande behandling prioriteras i första hand subkutant administrerade GLP-1-analoger med bevisad hjärtskyddande effekt enligt nedan. I första handGLP-1-ANALOGERdulaglutidTrulicity* injektion 1 gång per veckaliraglutidVictoza* injektion 1 gång per dagsemaglutidOzempic* injektion 1 gång per vecka*Begränsad subvention; tlv.seBehandlingen ska utvärderas. I andra handVid otillräcklig effekt på HbA1c bör annan glukossänkande behandling läggas till.HjärtsviktHos patienter med hjärtsvikt omfattar basbehandlingen metformin och SGLT2-hämmare. Vid otillräcklig effekt på HbA1c bör annan glukossänkande behandling läggas till.Kronisk njursjukdomHos patienter med kronisk njursjukdom (eGFR <60 ml/min och/eller albuminuri) omfattar basbehandlingen metformin och SGLT2-hämmare. Vid behov av ytterligare glukossänkande behandling prioriteras i första hand subkutant administrerade GLP1-analoger med bevisad njurskyddande effekt enligt nedan. Nedsatt njurfunktionVid eGFR <45 ml/min behöver vissa diabetesläkemedel dosjusteras.Vid eGFR <30 ml/min är metformin kontraindicerat.Vid eGFR <15 ml/min eller dialysbehandling kan insulin eller DPP4-hämmare användas.I första handGLP-1-ANALOGERdulaglutidTrulicity* injektion 1 gång per veckaliraglutidVictoza* injektion 1 gång per dagsemaglutidOzempic* injektion 1 gång per vecka*Begränsad subvention; tlv.seBehandlingen ska utvärderas. I andra handVid otillräcklig effekt på HbA1c bör annan glukossänkande behandling tilläggas under beaktan av njurfunktionen.DPP4-HÄMMAREKan användas för glukossänkning vid nedsatt njurfunktion men har inte en njurskyddande effekt.I första handsitagliptinSitagliptin …*, Januvia*, Xelevia*Sitagliptin behöver dosjusteras vid eGFR <45 ml/min.I andra handNär njurfunktionsbaserad dosjustering är ett problemlinagliptinTrajenta*Linagliptin kan användas utan dosjustering oavsett njurfunktion. *Begränsad subvention; tlv.seINSULINFRISÄTTARErepaglinidRepaglinid …, NovonormKan användas för glukossänkning vid nedsatt njurfunktion men har inte en njurskyddande effekt.Insuliner Kan användas för glukossänkning vid nedsatt njurfunktion men har inte en njurskyddande effekt.Läs mer sid xxHög kardiovaskulär risk Definitionerna på hög kardiovaskulär risk vid diabetes varierar men de flesta innehåller ålder ≥55 år tillsammans med ≥2 av följande riskfaktorer: obesitas, hypertoni, rökning, dyslipidemi eller albuminuri. Riskskattningsverktyget SCORE2-Diabetes används för patienter utan aterosklerossjukdom. Se Hjärta och kärl sid xx. Vid hög kardiovaskulär risk, där HbA1c-mål ej nås med enbart basbehandling, prioriteras i första och andra hand tilläggsbehandling med hjärtskyddande effekt enligt nedan.I första handSGLT2-HÄMMAREdapagliflozinForxiga* 10 mgempagliflozinJardiance* 10 mg*Begränsad subvention; tlv.seDen blodsockersänkande effekten av SGLT2-hämmare avtar med minskande njurfunktion och är låg vid eGFR <45 ml/min. Kardiovaskulär- och njurskyddande effekt finns däremot även vid lägre eGFR. Kan nyinsättas ned till eGFR 20 ml/min. Se under Njursjukdomar sid xx.Observera risk för ketoacidos även vid normala blodsockervärden. Sätt ut vid vätskebrist och överväg behandlingsuppehåll vid akut sjukdom och fasta. Patientinformation finns för utskrift på janusinfo.se. SGLT2-hämmare ska inte användas hos patienter med diabetes mellitus typ 1.I andra handGLP-1-ANALOGERdulaglutidTrulicity* injektion 1 gång per veckaliraglutidVictoza* injektion 1 gång per dagsemaglutidOzempic* injektion 1 gång per vecka*Begränsad subvention; www.tlv.seBehandlingen ska utvärderas. Vid otillräcklig effekt på HbA1c bör annan glukossänkande behandling tilläggas.ObesitasVid obesitas (BMI ≥30) där HbA1c-mål ej nås med enbart basbehandling, prioriteras i första hand tilläggsbehandling med subkutant administrerade GLP1-analoger. I andra hand prioriteras SGLT2-hämmare.I första handGLP-1-ANALOGERdulaglutidTrulicity* injektion 1 gång per veckaliraglutidVictoza* injektion 1 gång per dagsemaglutidOzempic* injektion 1 gång per vecka*Begränsad subvention; tlv.seI andra handSGLT2-HÄMMAREdapagliflozinForxiga* 10 mgempagliflozinJardiance* 10 mg*Begränsad subvention; tlv.seDen blodsockersänkande effekten av SGLT2-hämmare avtar med minskande njurfunktion och är låg vid eGFR <45 ml/min. Kardiovaskulär- och njurskyddande effekt finns däremot även vid lägre eGFR. Kan nyinsättas ned till eGFR 20 ml/min. Se under Njursjukdomar sid xx.Observera risk för ketoacidos även vid normala blodsockervärden. Sätt ut vid vätskebrist och överväg behandlingsuppehåll vid akut sjukdom och fasta. Patientinformation finns för utskrift på janusinfo.se. SGLT2-hämmare ska inte användas hos patienter med diabetes mellitus typ 1.Mest sjuka äldreSe även avsnittet om diabetes i Klok läkemedelsbehandling för de mest sjuka äldre; janusinfo.se.DPP4-HÄMMAREKan användas för glukossänkning vid nedsatt njurfunktion, men har inte en njurskyddande effekt. Till patienter där hypoglykemier bör undvikas I första handsitagliptinSitagliptin …*, Januvia*, Xelevia*Sitagliptin behöver dosjusteras vid eGFR <45 ml/min.I andra handNär njurfunktionsbaserad dosjustering är ett problemlinagliptinTrajenta*Linagliptin kan användas utan dosjustering oavsett njurfunktion. *Begränsad subvention; tlv.seInsulinerI första handMEDELLÅNGVERKANDE HUMANINSULINinsulin humantHumulin NPHinsulin humantInsulatardI andra handLÅNGVERKANDE INSULINANALOGKan övervägas vid återkommande hypoglykemier trots justering av NPH insulin.insulin glarginAbasaglar* 100 E/mlinsulin glarginToujeo* 300 E/ml*Begränsad subvention; tlv.seLångverkande insulinanalog vid svårbehandlad diabetes mellitus typ 2; janusinfo.seÖvriga (ingen samsjuklighet enligt ovan)Individanpassad behandling. Samtliga ovanstående läkemedelsgrupper samt insulinfrisättare och insuliner kan övervägas. För insulinfrisättare och insuliner, se nedan. INSULINFRISÄTTAREglimepiridGlimepirid …repaglinidRepaglinid …, NovonormInsulinerOavsett samsjuklighet behöver många patienter förr eller senare insulinbehandling för att uppnå acceptabel glukoskontroll.I första handMEDELLÅNGVERKANDE HUMANINSULINinsulin humantHumulin NPHinsulin humantInsulatardI andra handLÅNGVERKANDE INSULINANALOGKan övervägas vid återkommande hypoglykemier trots justering av NPH insulin.insulin glarginAbasaglar* 100 E/mlinsulin glarginToujeo* 300 E/ml*Begränsad subvention; tlv.seLångverkande insulinanalog vid svårbehandlad diabetes mellitus typ 2; janusinfo.seMIXINSULINERinsulin aspartNovomix 30insulin lisproHumalog Mix 25, Humalog Mix 50DIREKTVERKANDE INSULINANALOGERI första handinsulin aspartInsulin aspart Sanofiinsulin lisproInsulin lispro SanofiI andra handT.ex. vid behov av minnespennainsulin aspartNovorapidSpecialiserad vårdDiabetes mellitus typ 1DIREKTVERKANDE INSULINANALOGERI första handinsulin aspartInsulin aspart Sanofiinsulin lisproInsulin lispro SanofiI andra handNär annat direktverkande insulin har prövats och inte bedömts ändamålsenligtinsulin aspartFiaspI andra handT.ex. vid behov av minnespennainsulin aspartNovorapidLÅNGVERKANDE INSULINANALOGinsulin glarginAbasaglar* 100 E/mlinsulin glarginToujeo* 300 E/ml*Begränsad subvention; tlv.seSvår hypoglykemi/insulinkomaglukagonGlucagon Novo NordiskHypoglykemi vid behandling med glimepirid och andra sulfonylureapreparat kan bli allvarlig och långvarig. Tillståndet ska föranleda inläggning. TyreoideasjukdomarFör diagnostik och behandling av tyreoideasjukdomar, se viss.nu.TYREOIDEAHORMONlevotyroxinLevaxinSpecialiserad vårdTYREOSTATIKAKan orsaka neutropeni och allvarlig leverskada. Vid feber/infektion, kontrollera neutrofila granulocyter akut. Följ leverenzymer regelbundet, särskilt vid behandling med propyltiouracil.tiamazolTiamazol ..., ThacapzolVid intolerans mot tiamazolpropyltiouracilPropyltiouracil (licens)D-vitaminbristD-vitaminbrist definieras som S-25-OH-vitamin D <25 nmol/l. Riskfaktorer är bristande solexponering, täckande klädsel, mörk hud, hög ålder, malabsorption och lågt intag av D-vitamin via kosten.D-vitaminbrist; viss.nu D-VITAMINkolekalciferolKolekalciferol …, Divifarm, DivisunVid samtidigt lågt kalciumintagkalciumkarbonat +kolekalciferolKalcium/Kolekalciferol …, D-Calsor, Kalcipos-D forte, Recikalc-D Forte tablettkalciumkarbonat +kolekalciferolBencium, Calcichew-D3 Citron, Kalcipos-D forte, Kalcium/Kolekalciferol Citron, Recikalc-D Forte tuggtablettSpecialiserad vårdBrist på binjurebarkshormonDe tidiga symtomen är diffusa – trötthet, aptitlöshet, koncentrationssvårigheter, hypotoni och ospecifika smärtor. Binjurebarkssvikt är en ovanlig men viktig differentialdiagnos vid cirkulationssvikt. Snabb diagnostik och behandling är livräddande. Binjurebarkssvikt kan också uppträda efter kortisonbehandling.GLUKOKORTIKOIDhydrokortisonHydrokortison …, Kortifarm tablett hydrokortisonHydrokortison …*, Solu-Cortef* inj*Ingår inte i läkemedelsförmånen. Fri prissättning gör att priset kan variera på olika apotek.MINERALKORTIKOIDfludrokortisonFlorinefHyperprolaktinemiUtredning på endokrinologisk och/eller gynekologisk specialistklinik. För kvinnor, se även Gynekologi och obstetrik sid xx.DOPAMINAGONISTERbromokriptinParlodel, PravidelkabergolinCabergoline …, Dostinex Manlig hypogonadismUndvik rutinmässig testosteronkontroll; janusinfo.se Testosteronbrist hos män; viss.nu TESTOSTERONtestosteronTestogel geltestosteronTostrex geltestosteronTestosteron …, Nebido injiVBORw0KGgoAAAANSUhEUgAAAvMAAAHwCAIAAACkG3ezAAAACXBIWXMAAAsSAAALEgHS3X78AAAg AElEQVR42uydfVxUx9n3Z3snUSDEyoskYtCWgGhiiILW3doiVrCGNUaXGolviBaW+KiI4qfuamOq rLkDGtTHBKhGTDQQ65oSd5uIJqAxkOoSpSSCElohYmJdsAlZ0LTPzfPH1cx9enb3sCxvu/D7fvjw OTtnzrxcZ87MdWauuY6so6ODAQAAAAAMCH4AEQAAAAAAmg0AAAAAADQbAAAAAABoNgAAAAAA0GwA AAAAAM0GAAAAAACaDQAAAAAANBsAAAAAAGg2AAAAAAA9pdkYjUaZTCaTyXowpnshqpfoJx0bjUa0 s+43gz4TpsRNHKjN2MH2DAAA7q3ZaLVamQCFQqHVao1GY1tbW790uJS7W8u6sbExPz8/Pj7eLZJl jLW1tRUVFfGWoNVqz5w5g2emD+D6hCsrFr3X8AAAoDvc42C8ioqKiooKxphcLn/ttdfCwsIYY3Fx cX3z2SmlUskYMxgM7iVckXCqq6tTUlJ6PJdeSpaGroSEBP5Tp9PpdDqDwRAXFzc4n5Y+a/BuUcHe 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