Corrections 2 Flashcards
What can be used for diagnosis of T2DM in adults?
1) HbA1c
or
2) Plasma glucose
What plasma glucose is diagnostic of T2DM in patients that are symptomatic?
1) Fasting glucose ≥7.0 mmol/l
or
2) Random plasma glucose ≥11.1 mmol/l
What HbA1c is diagnostic of T2DM?
≥48 mmol/mol
in patients without symptoms, the test must be repeated to confirm the diagnosis
What are some conditions where HbA1c may not be used for diagnosis of T2DM?
1) haemoglobinopathies
2) haemolytic anaemia
3) untreated iron deficiency anaemia
4) suspected gestational diabetes
5) children
6) HIV
7) chronic kidney disease
8) people taking medication that may cause hyperglycaemia (for example corticosteroids)
What does the presence of an elevated prolactin level along with 2ary hypothyroidism & hypogonadism indicate?
Pituitary stalk compression –> consistent with a non-functioning pituitary adenoma.
What investigation is required to confirm the diagnosis of acromegaly if a patient is shown to have raised IGF-1 levels?
OGTT with serial GH measurements
(raised blood glucose should stop the body from producing GH)
What effect should the administration of insulin have on c-peptide levels?
Should cause c-peptide levels to fall (will NOT fall in the case of an insulinoma)
What are the 3 features of MEN 1?
1) Parathyroid involvement:
- hyperparathyroidism due to parathyroid hyperplasia
2) Pituitary tumour:
- e.g. prolactinoma
3) Pancreatic tumour:
- e.g. gastrinoma (leading to recurrent peptic ulceration)
- e.g. insulinoma
Most common presentation of MEN 1?
Hypercalcaemia
What gene is involved in MEN 1?
MEN1 gene
What gene is involved in MEN 2?
RET oncogene
mechanism of prochlorperazine?
D2 receptor blocker
What type of medication is prochlorperazine?
1st generation antipsychotic (typical)
What medication can lead to proximal myopathy?
Steroids
What class of medication is chlorpromazine?
Antipsychotic
What gene is medullary thyroid cancer associated with?
RET oncogene
Clinical features of Klinefelter’s (47,XXY)?
1) often taller than average
2) lack of 2ary sexual characteristics
3) small, firm testes
4) infertile
5) gynaecomastia
6) association with autism
Bone profile results in 3ary hyperparathyroidism?
Extremely high PTH vs moderately raised serum calcium
What is the most common type of thyroid cancer?
Papillary carcinoma (excellent prognosis)
Effect of SGLT-2 inhibitors on weight?
Can lead to weight loss
What is fundamental in the prevention of gangrene developing in diabetics?
Education about foot care
at what egfr is metformin contraindicated?
<30
What adrenal autoantibody may be seen in Addison’s?
anti-21 hydroxylase
9am cortisol results in suspected Addison’s:
a) >500
b) <100
c) 100-500
a) Addison’s very unlikely
b) definitely abnormal
c) should prompt an ACTH stimulation test
Mx of a thyrotoxic storm?
Beta blockers + propylthiouracil + hydrocortisone
Role of steroids in a thyroid storm?
Blocks the conversion of T4-T3
After a plasma aldosterone/renin ratio showing high aldosterone levels alongside low renin levels, what is the next investigation in 1ary hyperparathyroidism?
1) High resolution CT abdomen
then
2) Adrenal vein sampling
These are used to differentiate between unilateral and bilateral sources of aldosterone excess
Inheritance of Maturity-Onset Diabetes of the Young (MODY)?
Autosomal dominant
Prolactin levels in a prolactinoma?
Typically >100 ng/ml
Mx of pregnant woman who develop hyperthyroidism in the first trimester?
Propylthiouracil > carbimazole
Which 3 hormones are reduced in stress response?
1) insulin
2) testosterone
3) oestrogen
Which hormones are increased in stress response?
1) catecholamines
2) cortisol
3) glucagon
4) GH
Mx of subacute (De Quervain’s) thyroiditis?
usually self-limiting - most patients do not require treatment
thyroid pain may respond to aspirin or other NSAIDs
What are the 2 most common causes of hypercalcaemia?
1) 1ary hyperparathyroidism
2) malignancy
Levothyroxine in pregnancy?
Women with hypothyroidism may need to increase their thyroid hormone replacement dose by up to 50% as early as 4-6 weeks of pregnancy
What is the main kidney disease seen in diabetes?
Glomerulosclerosis
To confirm a diagnosis of T2D, when is the HbA1c repeated?
Repeated after 1 month to confirm the diagnosis (unless there are symptoms or signs of complications).
Mechanism of pioglitazone?
Increases insulin sensitivity and decreases liver production of glucose
What are the notable side effects of Pioglitazone?
- weight gain
- HF
- increased risk of bladder cancer
- increased risk of bone fractures
How are GLP-1 mimetics given?
SC injection
Which GLP-1 mimetic can be used for weight loss in non-diabetic obese patients?
Liraglutide
What is the principal feature of diabetic nephropathy?
Proteinuria
What ACR defines proteinuria?
≥30 mg/mmol
What 2 medications are used in the mx of obesity?
1) Orlistat (pancreatic lipase inhibitor)
2) Liraglutide (GLP-1 mimetic)
2 adverse effects of orlistat?
- faecal urgency/incontinence
- flatulence
Criteria for use of orlistat in obesity?
1) BMI ≥28 or more with associated risk factors
2) BMI ≥30
3) continued weight loss e.g. 5% at 3 months
Criteria for use of liraglutide in obesity?
BMI ≥35
1st line surgical intervention in patients with BMI 30-39?
laparoscopic-adjustable gastric banding (LAGB)
What can you give if metformin is contraindicated:
a) if risk of CVD/HF
b) if no risk of CVD/HF
a) SGLT-2 inhibitor
b) DPP-4 inhibitor or Pioglitazone or Sulfonylurea (SGLT-2 may be used if certain NICE criteria met)
Define impaired fasting glucose
6.1-6.9
When should you consider the addition of metformin to T1D management?
Patients with T1D and BMI >25
In type 1 diabetics, what are the blood glucose targets:
a) on waking
b) before meals at other times of the day
a) 5-7
b) 4-7
At what eGFR is metformin contraindicated?
<30
How often should patients with diabetes be screened for diabetic foot disease?
Annually
What is involved in diabetic foot disease screening?
1) Ischaemia –> palpation of dorsalis pedis and posterior tibial pulse
2) Neuropathy –> 10g monofilament
Cause of growth retardation in Cushing’s in children?
Cortisol mediated suppression of GH
What is an ACTH independent cause of Cushing’s?
Adrenal adenoma
Metabolic disturbance seen in Cushing’s?
Hypokalaemic metabolic alkalosis
What cells produce PTH?
Chief cells of the parathyroid glands
What is the most common cause of 1ary hyperparathyroidism?
Solitary parathyroid adenoma
Inheritance of familial hypocalciuric hypercalcaemia (FHH)?
Autosomal dominant
What test can be used to differentiate between hyperparathyroidism & FHH?
24h urinary calcium:
1) FHH results in a hypocalciuria
2) 1ary hyperparathyroidism results in high or normal urinary calcium
If surgery is not possible, what are some mx options for symptomatic hypercalcaemia in 1ary hyperparathyroidism?
1) calcitonin (secreted by thyroid gland)
2) cinacalcet
3) bisphosphonates
What are some procedure specific complications that can arise following a parathyroidectomy? (2)
1) damage to recurrent laryngeal nerves
2) post-op hypocalcaemia (removal of too much)
What is the most common cause of hypoparathyroidism?
Damage or removal of the parathyroid glands during neck surgery, especially thyroidectomy.
What genetic disorder can result in hypoparathyroidism?
DiGeorge syndrome
1st line investigation in phaeochromocytoma?
Urinary metanephrines (24h collection)
Mx of phaeochromocytoma?
Surgery is the definitive management. The patient must first however be stabilised with medical management:
a) alpha-blocker (e.g. phenoxybenzamine), given before a
b) beta-blocker (e.g. propranolol)
What class of medication is cinacalcet?
A calcimimetic
Role of calcimimetics?
These drugs mimic the action of calcium on tissue by allosteric activation of the calcium-sensing receptors
1st line mx of prolactinomas, even if there are significant neurological complications?
Dopamine agonists (e.g. cabergoline)
Mx of hHypoglycaemia with impaired GCS?
Give IV glucose if there is access
What is the single best blood test to assess response to levothyroxine?
TSH
When is a gradual withdrawal of systemic corticosteroids indicate?
a) received more than 40mg prednisolone daily for more than one week
b) received more than 3 weeks of treatment
c) recently received repeated courses
