When to intubate in GCS?

GCS ≤ 8 requires intubation for airway protection. The patient cannot protect their own airway at this level of consciousness. Motor score is the most prognostically important component.

What is the best initial fluid for sepsis resuscitation?

Lactated Ringer's (LR) is the preferred resuscitation fluid. The SMART trial (2018) showed balanced crystalloids reduced death, new renal failure, and persistent renal dysfunction compared to normal saline.

When to start vasopressors in septic shock?

Start norepinephrine (first-line vasopressor) if MAP remains < 65 mmHg after initial 30 mL/kg crystalloid resuscitation, or earlier if patient is profoundly hypotensive. Do not delay pressors to complete full fluid resuscitation.

Why can serum uric acid be normal during acute gout?

During acute inflammation, IL-6 increases renal urate excretion and redistributes urate from plasma to tissues. Up to 40% of acute gout flares have normal serum uric acid. Joint aspiration with polarized microscopy is needed for definitive diagnosis.

How do you distinguish lupus flare from infection in SLE?

Key clues: CRP is low/normal in flare but elevated in infection. Complement (C3/C4) drops in flare but is normal/elevated in infection. Procalcitonin is elevated in bacterial infection but normal in flare. Anti-dsDNA rises in flare, stable in infection.

What is the difference between DKA and HHS?

DKA features acidosis (pH 600), hyperosmolality (> 320), and minimal ketosis -typically in Type 2 DM. DKA requires insulin drip; HHS requires aggressive fluid resuscitation first.

When to give tPA in acute ischemic stroke?

IV alteplase (tPA) can be given within 4.5 hours of last known well time in eligible patients. CT head must rule out hemorrhage first. For large vessel occlusion, mechanical thrombectomy can be performed up to 24 hours with favorable imaging.

What antibiotics for community-acquired pneumonia?

Inpatient non-ICU: ceftriaxone + azithromycin. ICU: ceftriaxone + azithromycin (add vancomycin if MRSA risk). Outpatient healthy: amoxicillin. Outpatient with comorbidities: augmentin + azithromycin or respiratory fluoroquinolone. Duration: 5 days if clinically stable for 48 hours.

How to interpret iron studies?

Iron deficiency: low ferritin (< 30), high TIBC, low iron, low transferrin saturation (< 20%). Anemia of chronic disease: normal/high ferritin (acute phase reactant), low TIBC, low iron. A ferritin of 50-100 in an inflamed patient may still represent iron deficiency.

What is the correction rate for hyponatremia?

Correct sodium no more than 8 mEq/L in 24 hours to avoid osmotic demyelination syndrome (ODS). For symptomatic severe hyponatremia with seizures, give 3% hypertonic saline 100-150 mL bolus over 10-20 minutes. If overcorrected, use D5W + DDAVP rescue protocol.

When to start antibiotics in meningitis?

Within 30-60 minutes. Do NOT delay antibiotics for LP or CT. Draw blood cultures, start empiric antibiotics (vancomycin + ceftriaxone ± ampicillin if > 50 or immunocompromised), then perform LP when possible. Dexamethasone should be given before or with the first antibiotic dose.

DOACs vs warfarin in antiphospholipid syndrome?

DOACs are contraindicated in APS. The TRAPS trial (2018) showed rivaroxaban was inferior to warfarin with more thrombotic events in triple-positive APS patients. Warfarin with INR target 2-3 is the standard for APS, indefinitely.

How to manage scleroderma renal crisis?

ACE inhibitors (captopril) are life-saving -start immediately and titrate aggressively. Do NOT hold for rising creatinine. Steroids > 15 mg prednisone per day precipitate scleroderma renal crisis. ARBs are NOT a substitute -evidence is only for ACEi.

What are the 4 pillars of heart failure treatment?

Guideline-directed medical therapy (GDMT) for HFrEF: (1) ARNI or ACEi/ARB, (2) beta-blocker (carvedilol, metoprolol succinate, or bisoprolol), (3) MRA (spironolactone or eplerenone), (4) SGLT2 inhibitor (dapagliflozin or empagliflozin). All four should be initiated and titrated to target doses.

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Obesity Management & GLP-1 Agents

Obesity is a chronic disease, not a lifestyle choice. BMI ≥ 30 (or ≥ 27 with comorbidities) qualifies for pharmacotherapy. GLP-1 agonists and tirzepatide have transformed the field -15–25% weight loss is now achievable.

💊 Anti-Obesity Medications

Drug	Mechanism	Weight Loss	Key Notes
Semaglutide 2.4 mg (Wegovy) PREFERRED	GLP-1 receptor agonist → ↑ satiety, ↓ appetite, delayed gastric emptying	~15% body weight STEP 1, 2021	Weekly SC injection. Titrate slowly over 16 weeks (nausea management). Also reduces MACE by 20% SELECT, 2023 -CV benefit independent of diabetes. Contraindicated: personal/family history of medullary thyroid carcinoma, MEN2.
Tirzepatide (Zepbound) MOST EFFECTIVE	Dual GIP + GLP-1 receptor agonist	~20–25% body weight SURMOUNT-1, 2022	Weekly SC injection. Most potent weight loss agent available. Also FDA-approved for T2DM (as Mounjaro). Same GI side effects and contraindications as semaglutide.
Liraglutide 3.0 mg (Saxenda)	GLP-1 RA	~5–8%	Daily SC injection. Less effective than semaglutide but first GLP-1 approved for obesity. Being replaced by weekly options.
Phentermine-topiramate ER (Qsymia)	Sympathomimetic + anticonvulsant (appetite suppression)	~8–10%	Oral daily. Avoid in uncontrolled HTN, glaucoma, hyperthyroidism. Topiramate: teratogenic (REMS program), cognitive effects, metabolic acidosis, kidney stones.
Naltrexone-bupropion (Contrave)	Opioid antagonist + dopamine/NE reuptake inhibitor	~5–6%	Oral. Good for patients with food cravings/binge eating. Avoid in seizure disorders, opioid use, uncontrolled HTN. Bupropion helps with smoking cessation too.
Orlistat (Xenical/Alli)	Lipase inhibitor (blocks fat absorption)	~3–5%	GI side effects (oily stools, flatulence, fecal urgency) limit tolerability. OTC version (Alli 60 mg). Least effective.

Bariatric Surgery

Indications: BMI ≥ 40, or BMI ≥ 35 with obesity-related comorbidity (DM, HTN, OSA, NAFLD). ADA 2026: consider for BMI ≥ 30 with uncontrolled T2DM.
Roux-en-Y gastric bypass: ~30% excess weight loss. DM remission in 60–80%. Malabsorptive → lifelong vitamin supplementation (B12, iron, calcium, folate, vitamin D).
Sleeve gastrectomy: most commonly performed. ~25% excess weight loss. Fewer nutritional deficiencies than RYGB. GERD may worsen.
Most effective long-term treatment for obesity and T2DM -superior to all medications for sustained weight loss and diabetes remission.

📋 On Rounds

Pimp Questions

Why do SGLT2 inhibitors cause weight loss while sulfonylureas cause weight gain?

SGLT2 inhibitors (empagliflozin, dapagliflozin) block sodium-glucose co-transporter 2 in the proximal tubule → glycosuria (urinating out ~70g glucose/day = ~280 kcal/day). This caloric loss drives ~2–3 kg weight loss. Additionally, osmotic diuresis causes initial fluid loss. Sulfonylureas (glipizide, glimepiride) stimulate pancreatic β-cells to release insulin regardless of glucose level → hyperinsulinemia →

A patient asks: 'Will I regain the weight if I stop semaglutide?' What's the evidence?

Unfortunately, yes -most patients regain ~2/3 of lost weight within 1 year of stopping GLP-1 agonists. The STEP 1 extension trial showed that after stopping semaglutide 2.4 mg, participants regained most of the weight they had lost. This is because GLP-1 agonists work by suppressing appetite centrally and slowing gastric emptying -when the drug is removed, appetite returns to baseline.

What are the criteria for bariatric surgery referral?

BMI ≥ 40 (regardless of comorbidities) OR BMI ≥ 35 with ≥ 1 obesity-related comorbidity (T2DM, HTN, OSA, NAFLD/NASH, GERD, OA, dyslipidemia). Some guidelines now support BMI ≥ 30 with uncontrolled T2DM. Types: Roux-en-Y gastric bypass (gold standard, ~30% excess weight loss), sleeve gastrectomy (most common currently, ~25% EWL), adjustable gastric band (declining use).

What are the side effects of GLP-1 agonists that every prescriber should counsel about?

Most common (GI -dose-dependent, typically improve with slow titration): nausea (30-40%), vomiting, diarrhea, constipation, abdominal pain. Counsel: start low and titrate slowly, eat smaller meals, avoid fatty/fried foods. Serious but rare: (1) Pancreatitis: FDA warning, though causal link is debated. Stop if severe abdominal pain + elevated lipase

Clinical Examples

📋 Case 1, GLP-1 RA for Obesity with Comorbidities

Patient: 44M, BMI 38, prediabetes (A1c 6.3), OSA on CPAP, knee OA limiting exercise. Failed 6-month structured diet program (lost 3 kg, regained). Motivated for pharmacotherapy.

Key findings: Pharmacotherapy indicated: BMI ≥ 30 (or ≥ 27 with comorbidities) after failing lifestyle modification. GLP-1 RAs have the most robust evidence for weight loss + cardiometabolic benefit among anti-obesity medications.

Management:

Semaglutide 2.4 mg SQ weekly (Wegovy), titrate from 0.25 mg over 16 weeks to minimize GI side effects STEP 1, 2021
Continue lifestyle modification (medication + lifestyle > either alone)
Counsel on GI side effects: nausea (most common, improves with slow titration), eat smaller meals, avoid fatty foods
Monitor: A1c (may normalize → prevent T2DM), BP, lipids, OSA symptoms (may be able to reduce CPAP pressure)
If weight loss ≥ 5% at 3 months: continue. If < 5%: reassess adherence, consider alternative or combination

Teaching point: Anti-obesity medications are NOT a shortcut, they correct the neurohormonal dysregulation that drives weight regain. Just as we don't shame patients for needing metformin for diabetes, we shouldn't shame them for needing semaglutide for obesity. Weight regain after stopping is expected, not failure.

📋 Case 2, Bariatric Surgery Evaluation

Patient: 52F, BMI 46, T2DM (A1c 9.4 on insulin + metformin), HTN on 3 drugs, OSA, NASH with fibrosis. Failed semaglutide (intolerable GI effects). Interested in surgical options.

Key findings: Bariatric surgery indicated: BMI ≥ 40 (or ≥ 35 with obesity-related comorbidities). This patient has multiple comorbidities likely to improve or resolve with surgery. T2DM remission rates: 60-80% after Roux-en-Y.

Management:

Multidisciplinary bariatric evaluation: surgeon, dietitian, psychologist, medical clearance
Roux-en-Y gastric bypass (RYGB): 25-35% total body weight loss, highest T2DM remission rate, durable results STAMPEDE, 2017
Alternative: sleeve gastrectomy (20-25% weight loss, lower complication rate, simpler technically)
Pre-op requirements: OSA screening, cardiac clearance, nutritional labs (B12, iron, folate, vitamin D), psych evaluation
Lifelong supplementation post-RYGB: B12, iron, calcium + vitamin D, multivitamin (malabsorptive anatomy)

Teaching point: Bariatric surgery is the most effective treatment for severe obesity, it produces durable weight loss AND remission of T2DM, HTN, and OSA in a large proportion of patients. RYGB is superior to sleeve for T2DM remission but has higher long-term complication rates.

📋 Case 3, Tirzepatide for Obesity + T2DM

Patient: 58F, BMI 36, T2DM (A1c 8.1 on metformin), no ASCVD. Insurance covers tirzepatide for diabetes. Wants weight loss and glucose control simultaneously.

Key findings: Tirzepatide (dual GIP/GLP-1 agonist) achieves greater weight loss than semaglutide in head-to-head trials. At highest dose, mean weight loss ~20-25%, approaching surgical levels.

Management:

Tirzepatide 2.5 mg SQ weekly → titrate q4 weeks to max 15 mg (slow titration essential for GI tolerance) SURMOUNT-1, 2022
Continue metformin (complementary mechanism, renal protection)
May be able to reduce or stop insulin as A1c improves
Monitor for pancreatitis (rare but reported), gallstones (rapid weight loss increases risk)
Discuss: weight regain occurs if medication is stopped, likely lifelong therapy needed for weight maintenance

Teaching point: Tirzepatide represents a paradigm shift, 20%+ weight loss was previously only achievable with surgery. The dual GIP/GLP-1 mechanism provides more weight loss than GLP-1 alone. Long-term data on cardiovascular outcomes is pending (SURPASS-CVOT ongoing).

📣 Sample Presentation

One-Liner

"Mr. Rodriguez is a 42-year-old with BMI 38, prediabetes (A1c 6.2), OSA on CPAP, and knee osteoarthritis. He has tried diet and exercise programs without sustained weight loss. Interested in pharmacotherapy."

Key Points to Cover on Rounds

BMI 38 with obesity-related comorbidities (prediabetes, OSA, OA). Prior weight loss attempts: commercial programs, lost 10 lbs but regained. Pharmacotherapy options discussed: (1) semaglutide 2.4 mg SQ weekly (most effective, ~15% weight loss [STEP 1, 2021]), (2) tirzepatide (dual GIP/GLP-1, ~20% weight loss [SURMOUNT-1, 2022]). Starting semaglutide 0.25 mg weekly, uptitrate monthly to 2.4 mg. Counseling: medication is one component alongside lifestyle (goal: 150 min/week moderate exercise, dietary changes). Insurance coverage checked. Bariatric surgery discussed as alternative (BMI ≥35 + comorbidities = eligible). Plan: monthly follow-up for dose titration, weight, and A1c monitoring.

🧪 Workup

See the Overview and Management tabs for topic-specific diagnostic evaluation.

💊 Medications

Medications

Anti-obesity medication details (GLP-1 agonists, semaglutide, liraglutide; dual GIP/GLP-1, tirzepatide; phentermine/topiramate; naltrexone/bupropion; orlistat) with evidence-based dosing, weight-loss percentages, and trial citations (STEP 1, SURMOUNT-1, SELECT, SCALE) are in the Management tab.

⚡ Summary

Summary

Pharmacotherapy

Semaglutide 2.4 mg SQ weekly (~15% weight loss [STEP 1, 2021]). Tirzepatide (~20% [SURMOUNT-1, 2022]). Titrate slowly to reduce GI side effects.

Bariatric Surgery

BMI ≥ 40 or ≥ 35 + comorbidity. Sleeve gastrectomy most common. RYGB gold standard. T2DM remission 60-80%. 50-70% excess weight loss.

Lifestyle

Foundation: 150 min/week moderate exercise + caloric deficit + behavioral counseling. Alone = ~5% weight loss. Needed alongside all pharmacotherapy.

Comorbidity Screening

OSA (STOP-BANG), NAFLD (LFTs, US), T2DM (A1c), dyslipidemia, HTN, GERD, OA, depression. Treat all identified comorbidities.

Post-Bariatric

Lifelong vitamin monitoring (B12, iron, calcium, D, folate). Protein ≥ 60g/day. No NSAIDs (marginal ulcer). Psychiatric support.

Not "Willpower"

Obesity is a chronic disease with genetic, hormonal, and environmental drivers. Frame treatment like any chronic disease -no blame, evidence-based management.

🔍 Overview

Overview -Obesity Management & GLP-1 Agents

See the tabs above for the complete clinical reference: Workup, Management, Medications, Monitoring, Rounds, Summary, and One Pager.

⚡ Management

Management -Obesity Management & GLP-1 Agents

See the Management section above for the full treatment algorithm with evidence-based recommendations and trial citations.

📄 One Pager

Endocrine / Primary Care · One Pager

Obesity

BMI ≥ 30 = obesity. GLP-1 RAs are transformative (~15-20% weight loss). Bariatric surgery for BMI ≥ 40 or ≥ 35 + comorbidity. Lifestyle is foundation but insufficient alone for severe obesity.

🧪 Classification

BMI 25-29.9 = overweight. 30-34.9 = class I obesity. 35-39.9 = class II. ≥ 40 = class III. Screen for comorbidities: OSA, NAFLD, T2DM, HTN, dyslipidemia.

🚨 Pharmacotherapy

Semaglutide 2.4 mg SQ weekly (~15% weight loss [STEP 1, 2021]). Tirzepatide (dual GIP/GLP-1, ~20% [SURMOUNT-1, 2022]). Titrate slowly to minimize GI side effects. Lifestyle (150 min/week exercise + dietary changes) is always the foundation.

💊 Bariatric Surgery

BMI ≥ 40 or ≥ 35 + comorbidity. Sleeve gastrectomy (most common). RYGB (gold standard). T2DM remission 60-80%. 50-70% excess weight loss. Lifelong vitamin monitoring required.

💊 Key Drugs

Semaglutide0.25 → 2.4 mg SQ weekly

Tirzepatide2.5 → 15 mg SQ weekly

Phentermine-topiramate3.75/23 → 15/92 mg daily

Lifestyle150 min/week exercise + caloric deficit