Diabetes And Endocrinology Flashcards
What are the 10 key checks for annual review in diabetes?
Diabetic eye screening-retinopathy
Diabetic foot screening
BMI
Blood pressure
HbA1c
U+E
Lipids
Urine ACR
Smoking cessation advice
Influenza vaccine single pneumococcal
Lifestyle modification advice in diabetes
NERS
Dietician
Weight loss if overweight
Stop smoking
Exercise/activity
Cardio risk: BP, statin
Which diabetic patients should be offered a statin?
T2DM if QRISK>10%
T1DM age >40 or diabetes>10 years, nephropathy, obesity
What should HbA1c targets be?
48 if planning pregnancy (+5mg folic acid)
48 if lifestyle management
48 if lifestyle + metformin
53 if drug treatment associated with hypoglycaemia (such as gliclazide)
53 if risen to 58+ so added 2nd drug
64 mild frailty(de-escalate meds if 58), 69 severe frailty (de-escalate meds if 64)
What are the sick day rules?
If unwell and sugars>13 mmol/L (on insulin pump) or 15 mmol/L, check for ketones in blood:
If ketones>1.5 mmol/L, or confusion or drowsiness, call 999.
Do not stop taking insulin.
Stop ACEi/NSAIDs/diuretics
Stop metformin/SGLT2/gliclazide/GLP-1 if risk dehydration
One glass of fluid per hour.
Seek GP help:
ketones 0.6-1.5 mmol/L.
persistent vomiting.
breath smells like pear drops.
new-onset abdominal pain.
Group 1 drivers DVLA regulations
If insulin/gliclazide inform DVLA + you can drive if:
-You have adequate awareness of the onset of hypoglycaemia.
* You should inform the DVLA if you have more than one severe hypo within
the preceding 12 months. Severe hypoglycaemia is defined as requiring the
assistance of another person.
* You should practice appropriate blood glucose monitoring
Group 2 drivers DVLA regulations
-You have full awareness of hypoglycaemia.
* No episode of severe hypoglycaemia in the preceding 12 months.
* You should use a blood glucose meter with sufficient memory to store 3 months
of continuous readings . You must practice appropriate blood
glucose monitoring before driving + 2hrly
* You can demonstrates an understanding of hypoglycaemia risk.
How do you diagnose diabetes?
Random blood glucose>11.1
fasting blood glucose> 7.0
HbA1c>48
If asymtommatic rpt in 2 weeks to confirm diagnosis
If HbA1c 42-47.9 or FBG 5.5-6.9, diagnose as prediabetes
When should you consider MODY?
Age<30 years.
Age 30-45, not requiring insulin, with:
no metabolic syndrome, or
mild fasting hyperglycaemia (5.5-8 + HbA1c<65 mmol/mol), or
extra-pancreatic features, deafness, neurological abnormalities, urinary tract abnormalities, cardiac hypertrophy, optic atrophy, short stature.
How to reduce GI side effects with metformin
Start at 500mg OD, increasing to 500 mg twice a day after 2 weeks then to 1g BD
taking with or after food.
using MR if ongoing symptoms
Dosing for metformin
eGFR 15 -30 -Avoid metformin
30-60- max 1g daily
60-120-max 2g daily
1st line management T2DM
Metformin 500mg OD- titrate up to 1g BD (if eGFR>60)
4 weeks later add in dapagliflozin if QRISK>10% or CKD or IHD
If metformin is not tolerated or contra-indicated and low cardiovascular risk?
DPP-4 inhibitor- sitagliptin/linagliptin
Pioglitazone
A sulfonylurea.
Give examples of DPP4-i and pros/cons/when to use
Sitagliptin/linagliptin/saxagliptin
weight neutral
low risk hypos
mild effect on hba1c (6-8 drop)
good in frailty
avoid in pancreatitis. Saxagliptin avoid in heart failure
Pioglitazone, pros/cons/when to use
Good in metabolic syndrome, takes 3m to work, reduced lipids
Causes weight gain and incr fracture risk
Contraindicated in heart failure, macular oedema
Give example of sulphonylurea and pros/cons/when to use
Gliclazide
Good in marked osmotic symptoms and steroid induced hyperglycaemia
Incr risk of hypoglycaemia, take with meals
Blood glucose monitoring mornings + before driving
Weight gain so use if BMI<28
Poor durability of effect
Can be used as rescue therapy for 4 weeks if v high HbA1c
If monotherapy is ineffective, what to add?
A DPP-4 inhibitor (sitagliptin)
Pioglitazone.
A sulfonylurea. (gliclazide)
An SGLT-2 inhibitor (if not already on and risk of hypos)
Give examples of SGLT2i and pros/cons/when to use
Dapagliflozin/canagliflozin/empagliflozin
Caution in amputation, PVD,
frequent urogenital infections.
frailty at risk of hypovolaemia, prev DKA, ketogenic diet
Risk of normoglycaemic DKA
Improves cardiovascular + CKD outcomes
If eGFR<45, loses glycaemic beneift but still has CKD/CCF benefit
Stop 48hrs prior to surgery
For triple therapy what combinations are good and which are bad?
Good:
metformin+ dapagliflozin + gliclazide
Metformin + ertugliflozin + sitagliptin
Bad:
Dapagliflozin not with pioglitazone
Instead of triple therapy, consider insulin
If triple therapy ineffective?
Switch one drug for a GLP-1 (need to stop gliptin DPP4)
GLP-1 if:
BMI>35+ medical conditions associated with obesity, or
BMI<35+ insulin therapy would have significant occupational implications, or weight loss would benefit other comorbidities.
Should only be continued if reduction>11 in HbA1c and a weight loss of at least 3% in 6 months.
Give examples of GLP-1 and pros/cons/when to use
Semaglutide (Ozempic) weekly SC, dulaglutide (Trulicity) weekly SC, liraglutide (Victoza) OD SC
Low risk hypo
Cardiovascular protection
Expensive
Interacts w/levothyroxine, slows gastric emptying, can worsen gallstone disease and retinopathy
Oral semaglutide specialist recommended
Not with DPP4-i
Management diabetes + CKD?
Control BP, lipids, sugars
If ACR>3 start ACE-i
Specialist reccomended- dapagliflozin/ consider finerenone
BP management in T2DM
ACEi 1st line or ARB if black/african
Steroid induced hyperglycaemia management
Mostly post-prandial hyperglycaemia
If glucose<15 monitor
If glucose>15 and no diabetic meds, consider starting gliclazide short term
If already on insulin, titrate dose
Symptoms of hypoglycaemia
Hunger, sweating, tremor, anxiety
Dizziness or light-headedness
Sleepiness, confusion
Difficulty speaking, weakness
Usually symptoms when sugar<4
Management hypoglycaemia
If blood glucose (BG)<4 and able to swallow:
170 mL of lucozade
4 glucotabs
3 jelly babies
150 mL juice/pop
Retest BG in 15 mins, bread/2xdigestive biscuit
IM glucagon 1mg if:
unconscious
having a seizure
unable to take anything PO
no change in BG after PO sugar
Risks of poorly controlled GDM (gestational diabetes) + poorly controlled diabetes in pregnancy
Macrosomia
Neonatal hypoglycaemia
Hyperbilirubinaemia
Respiratory distress syndrome
miscarriage.
congenital malformations.
stillbirth and neonatal death
Risk factors for GDM
BMI>30
Previous macrosomic baby>4.5 kg
Previous GDM
1º relative with diabetes
Black, Asian, and other ethnic minority family origin
Management post-natal period GDM
HBA1c at 13 weeks (preferred), or
fasting blood glucose (FBG) at 6 to 13 weeks
If FBG<6, low risk T2DM
If FBG 6-6.9 pre-diabetes
If FBG>7 then has T2DM
All GDM pts will need annual screening HbA1c
Diagnostic criteria GDM and BG aim
FBG>5.6 or OGTT BG>7.8
Target levels are 5.3 fasting, and 7.8 1 hour after meals, or 6.4 2 hours after meals.
Management prediabetes
Smoking cessation
Healthy eating
Increasing physical activity
Weight reduction
Manage cardiovascular risk- eg statins, BP
Consider metformin off label if BMI>35 and deterioration HbA1c despite lifestyle changes
Refer dietician (or low cal diet if England)
Ix for primary amenorrhoea
Check BMI, growth
Pubic/axillary hair, breast development
Bloods: LH, FSH, oestrogen, TSH, prolactin,
testosterone, sex hormone binding globulin (SHBG), if ?androgen excess.
USS pelvis
What should you look for on inspection ?diabetic foot
Ulcers or infection.
nail infection or impingement on adjacent toes.
interdigital infections
Fissured skin, skin atrophy, callus or corn formation, blisters
structural changes-high arch, clawed toes, bunions.
foot swelling.
Features and complications ischaemic foot
Cool, hairless, with diminished or absent pulses
Pale or dependent rubor with atrophic skin
Painful
Ulcers
Intermittent claudication, rest pain, gangrene, and amputation
Signs of diabetic foot attack
Ulceration
Spreading infection
Critical limb ischaemia
Gangrene
Charcot foot:
-Localised swelling, erythema, and increased skin temperature without trauma.
-Rocker‑bottom foot deformity.
-with or without pain
Referral criteria diabetic feet
Admit vascular: critical limb ischaemia
Same day podiatry assessment or, if OOH admit T+O
Active crisis, request urgent (within 24 hours) podiatry assessment or advise patient self-referral to the Podiatry DFEET (Diabetic Foot Early Emergency Triage) Clinic.
Routine podiatry if moderate risk of crisis.
Ix for secondary amennorhoea
Check BMI
Bloods: LH, FSH, oestrogen, TSH, prolactin,
testosterone, sex hormone binding globulin (SHBG), if ?androgen excess.
4 main causes secondary amenorrhoea
PCOS
Premature ovarian insufficiency
Hyperprolactinaemia
Hypothalamic amenorrhoea (eg low BMI)
Definitions of primary vs secondary amenorrhoea
primary amenorrhoea – absence of menarche by age 15 years, or age 13 years if absent secondary sexual characteristics.
secondary amenorrhoea – no menstruation for 3-6 months in a woman with previously normal and regular menses, or 6-12 months in a woman with previous oligomenorrhoea
When to refer primary amenorrhoea
Urgent gynae if lower outlet tract obstruction (imperforate hymen or transverse vaginal septum) is suspected
Routine paeds: If amenorrhoea persists past aged 13 (if secondary sexual characteristics are absent) or past aged 15 years (if secondary sexual characteristics are present) Refer sooner and urgently if any concerning features (growth retardation/thyroid disease/genital malformation/puberty 5 yrs without menarche)
Blood results suggestive of secondary amenorrhoea cause
PCOS- normal FSH, LH, oestrogen, slightly ↑testosterone/prolactin
Premature ovarian insufficiency - ↑FSH, ↑LH, ↓oestrogen, normal testosterone/prolactin
Hyperprolactinaemia- normal/low FSH LH oestrogen testosterone, ↑prolactin
Hypothalamic/pituitary amenorrhoea- normal/low FSH LH, low oestrogen, normal testosterone/prolactin
If very raised testosterone ?adrenal hyperplasia
Define asherman syndrome
acquired condition, scar tissue forms inside the uterus and/or the cervix
Variable scarring inside the uterine cavity, front and back walls of the uterus may adhere to one another
Causes of raised prolactin
Prolactinoma
Medication:
Antipsychotics, Antiemetics, Antidepressants, Opiates
Stress
Pregnancy
Hypothyroidism
Recent breast examination
If no clear cause and >1000 refer urgent endo
Possible causes of premature ovarian insufficiency
Age<40 for premature, refer routine gynae (unless endocrine disorder)
Turner’s syndrome
Fragile X syndrome
Empty sella syndrome
Ovarian or pelvic surgery, chemotherapy, or radiotherapy
Autoimmune disorders
Causes of hypercalcaemia
Primary hyperparathyroidism
Malignancy – myeloma, (breast ca, lung ca, kidney ca)
Medications (lithium, thiazide diuretics, vitamin D toxicity)
Sarcoidosis
Thyrotoxicosis
Cortisol deficiency
Milk-alkali syndrome
Symptoms of hypercalcaemia
Nausea Vomiting
Constipation
Abdominal pain
Thirst
Polyuria
Confusion
Ix for hypercalcaemia
Bloods: U+E, LFT, Bone profile, PTH, vitamin D
If age>60, myeloma screen
(PTH should be low if calcium raised)
If the above is normal consider:
FBC, ESR, chest X‑ray, X‑ray of spine or painful sites (sarcoidosis, malignancy)
Radionuclide bone scan
Serum electrophoresis + paraprotein + immunoglobulins
Thyrotoxicosis – TFT
Cortisol deficiency – 9am cortisol + ACTH
Referral criteria for hypercalcaemia
Admit if:
calcium>3.5
calcium> 3 + n+v
calcium>3 + dehydration
Routine endocrinology if:
primary hyperparathyroidism, medication/surgery.
Osteoporosis
Features of hyperkalaemia
arrhythmias/palpitations/syncope
n+v
paraesthesia
ascending muscle weakness legs->trunk->arms.
muscle pain
Medication causes of hyperkalaemia
Spironolactone
ACEi/ARB
Propranolol
Digoxin toxicity
NSAIDs
Trimethoprim
Tacrolimus, ciclosporin
Heparins
LoSalt
Alfalfa, dandelion, nettle
Non medication causes of hyperkalaemia
False reading, haemolysis of sample
AKI/CKD
Aldosterone deficiency
Rhabdomyolysis, burns, tumour lysis syndrome, crush injuries
Massive haemolysis
Acidosis, low insulin levels, or medications (shift from cells)
Massive blood transfusion
Referral criteria hyperkalaemia
999 if acutely unwell
Admit if:
potassium>6.5
symptomatic hyperkalaemia
AKI
ECG changes (do ECG if K>6)
K rising rapidly.
Chronic hyperkalaemia routine ref cardio/renal for consideration of potassium binders.
Symptoms hypokalaemia
hypotension, brady/tachycardia, arrhythmia
Weakness, fasciculations, tetany
Lethargy, paraesthesia, mental status change
Constipation
Medication causes of hypokalaemia
Diuretics (furosemide, thiazides)
Salbutamol, theophylline
Insulin
Steroids
Non medication causes hypokalaemia
D+V
Anorexia, bulimia, alcoholism
Excessive sweating, DKA, polydipsia.
Liquorice
Intestinal fistula, hypothermia, burns Hyperaldosteronism, Cushing’s, Conn’s syndrome, refeeding syndrome, diabetes insipidus
Ix hypokalaemia
Blood sugar if diabetic
Mg if GI losses
ECG if K<3
ECG changes with hyperkalaemia
Peaked T waves
PR prolongation
P wave loss
QRS widening
Sine wave
Ventricular arrhythmias, asystole
Referral criteria for hypokalemia
Admit if:
K<2.5
ECG changes.
low magnesium (IV replacement)
significant symptoms
K<3 and decreasing
Routine endo:
?hyperaldosteronism or Conn’s
Nephrology advice if ↑urine potassium excretion, normal BP, no vomiting/diuretics
Underlying conditions causing low magnesium levels
Malabsorption, malnutrition, Crohn’s, coeliac, refeeding syndrome, pancreatitis and cirrhosis
T2DM, DKA
Renal disorders
Hyperthyroidism, hypoparathyroidism, hyperaldosteronism
Medications that can cause low magnesium
PPI
Loop and thiazide diuretics
Insulin
Digoxin
Cisplatin
Gentamicin
Ciclosporin, tacrolimus
Features of low magnesium levels
Arrhythmia
Tremor
Confusion
Tetany
Seizure
Coma
Referral criteria low magnesium
Admit if:
arrhythmia, tetany or seizure.
magnesium<0.7
hypokalaemia + low magnesium.
When should steroid sick day rules be used and what are they?
At risk if>5 mg prednisolone daily for >3 weeks
Double usual dose for 2 to 3 days, then back to normal maintenance dose if minor illness
If vomiting/unable to absorb meds- admit
Long term steroids monitoring + prophylaxis
Monitor BP, HbA1c, weight
Consider PPI
Yearly optometry for cataract/intraocular pressure
Calci-D
Alendronate if age>65 dependent on FRAX if age<70
Avoid live vaccinesI
Baseline Ix after low impact fracture/concerns over bone health
FBC, Bone profile, U+E, LFT, GGT, TFT
Vitamin D, PTH, paraprotein/electrophoresis/immunoglobulins
Anti-TTG
Management of osteoporosis
As per FRAX score/DXA
Weight bearing exercise
Stop smoking/alcohol
Avoid being underweight
Calci-D
Alendronic acid 70mg once weekly or ibandronic acid 150 mg once a month (specialist recommended)
HRT if age<60 (but benefit lost once stopped)
Causes of low testosterone in men
Pituitary and hypothalamic diseases.
Opiates
testicular pathology (trauma, radiation, infection).
Klinefelter syndrome.
Obesity, OSA, T2DM
Anabolic steroid abuse
Referral criteria low testosterone
Routine endo if 2 morning testosterone levels are low (<8) or borderline low (8-12),
USC urology if abnormal PSA in testosterone therapy/abnormal DRE
What is Graves?
Autoimmune hyperthyroidism
Women>Men
Most common cause of hyperthyroidism
Diffuse goitre
Thyroid eye disease
Thyroid antibodies +ve in 90%
What is thyroiditis
Subacute (de Quervain) thyroiditis:
Tender diffuse goitre, transient hyperthyroidism then hypothyroidism then normal
?viral
Doesn’t respond to carbimazole.
Postpartum thyroiditis (painless).
Medications (amiodarone, lithium)
external radiation
Symptoms hyperthyroidism
Palpitations, tachycardia
Sweating
Tremor
Weight loss despite increased appetite
Symptoms of heart failure
Symptoms of goitre
Ix for hyperthyroidism
TFT
TSH receptor antibodies
FBC, LFT, U+E
CRP, ESR if thyroiditis is suspected.
ECG if arrhythmia.
Management hyperthyroidism
Admit if psychosis, fast AF, CCF
Urgent endo + same day ophthalmology if drop in visual acuity, or altered colour perception
Routine endo ref for everyone else for advice re carbimazole 20-40mg OD (risk agranulocytosis)
Start propranolol 20-40mg BD
Stop smoking
Contraception
Management mild thyroid eye disease
Lubricating tear drops
Elevation of head of bed
Cold packs to eyes
Wearing dark glasses
NSAIDs
Selenium – OTC 200mcg OD
Causes of hypothyroidism
Auto-immune hypothyroidism (Hashimoto’s) – most common cause in iodine-sufficient areas of the world.
Post radioiodine, thyroidectomy, or external radiation therapy.
Medications (lithium or amiodarone)
Sub-acute thyroiditis or postpartum thyroiditis
Central cause (very rare)
Symptoms hypothyroidism
Tiredness
Sensitivity to cold
Weight gain
Constipation
Depression
Muscle aches and weakness
Dry and scaly skin, brittle hair and nails
Loss of libido
Irregular or heavy periods
When should you suspect central cause of hypothyroidism?
Low or normal TSH with low FT4
Pituitary symptoms:
menstrual cycle.
cortisol deficiency.
hypogonadism.
visual fields.
Management subclinical hypothyroidism
TSH>10: treat if symptommatic, or rpt 3-6 months and treat if still raised
TSH 4-10: rpt 3-6 months with TPO Ab, if positive + TSH still raised treat for 6m, if not treating monitor annually
Management thyroid lump
Thyroid lump if moves on swallowing, central lower neck
USC endo if TSH raised or normal
Routine endo if TSH is low
USC if hypothyroid patient with goitre that persists once the patient is euthyroid.
Management vitamin D deficiency
Loading:
Stexerol (colecalciferol) 25,000 unit tablets, take 2 once a week for 6 weeks.
Or- InVita D3 (colecalciferol) oral solution 25,000 units/mL, take 2 mL once a week for six weeks.
Check serum calcium 4 weeks after loading complete
Symptoms of Addison’s crisis and Addison’s disease
Crisis: hypotension, hypovolaemic shock, delirium, reduced consciousness, acute abdominal pain, vomiting, headache, low-grade fever, and muscle weakness.
Fatigue
Hyperpigmentation
Weight loss, cravings for salt.
Ix for Addison’s
9am cortisol
U+E: Na low K high
Glucose
Cortisol<100- admit
100-500- refer for Synacthen test.
Features of Conn’s
Hyperaldosteronism
Low K, raised BP
Treatment resistant hypertension
Features of carcinoid syndrome
When neuroendocrine tumours produce serotonin, usually when spread to liver
diarrhoea, tummy pain and loss of appetite
flushing of the skin, particularly the face
fast heart rate
breathlessness and wheezing
