Diabetes and Pituitary Flashcards
Cause of T1DDM?
pancreatic islet beta-cells desstroyed by autoimmmune
ABSOLUTE insulin sinsufficiency -> lipolysis and ketogenesis
Associated with HLADR3/4
Cause of T2DM?
Obesity, HTN, inactivity, and disturbed lipids
Reduced peripheral sensitivty to insulin and reduced insulin production over time
T1DM presentation?
5-15YO
Polyuria and polydipsia (osmotic diuresis)
Weight loss from muscle and fat breakdown
DKA: abdo pain, N&V, tachypnoea (kussmaul), coma
T2DM presentation?
Asymptomatic
RFs present, obesity, Fhx, south asian, black, age,
Fatigue, poludipsia, polyria, infections e.g. fungal, cellulitis
Acanthosis nigricans
Which patients should HbA1c not be used in?
All children/young, high risk of acutely ill, medication that can rise glucose e.g. steroids, antipsychotis, acute pancreatic damage patients
T1DM management?
Basal bolus insulin
Long = glargine subcut OD) Short = lispro/aspart subcut pre meal
T2DM glycaemic Mx?
1) Metformin if HbA1c >48
2) Add another drug (Dpp4i, pioglitazone, SU, SGLT-2i)
3) Add further drug
T2DM lipid Mx?
Atorvastatin 20mg OD if 10year CV>10%
80mg if IHD/CVD/peripheral arter disease
T2DM BP Mx?
1)ACEi or ARB
2) Add CCB or thiazide
3) Add ccb or thiazide
4) if K+>4,5, spironolactone
if less then alpha blocker/beta blocker
Example of each glycaemic medication?
DPP4i = sitagliptin
Pioglitazone
Sulfonylurea = glicazide
SGLT = dapaglifozin
Platelet Mx for T2DM?
Aspiring 75mg for patients with IHD/CVD/perpheral artery disease
what are the micro/macro complications of DM?
Micro = retinopathy, nephropathy, neuropathy
Macro = IHD, Cerebrovascular disease, peripheral artery disease
Causes of hypoglycaemia?
Missed meals, inadequate snacks, unaccustomed exercise, alcohol, some drugs e.g. SU, SGLT2, inappropriate insulin regime
Signs of hypoglycaemia?
Palpitations, tremor, seating, pallor, anxiety, drowsiness, confusion, altered behaviour, coma
Tx for hypoglycaemia?
Conscious = oral glucose and complex carborhydrates
Impaired = PArenteral 1mgglucagon IM
2nd line = IV dextrose (10% glucosie infusion)
DKA triad?
Hyperglyaemia, ketonaemia and metabolic acidosis
Also dehydration
S+S and Ix DKA?
Collapse and confusion, dehyrated, kussmaul breathing, abdo pain, N+V
Ketones >3mmol?l, pH <7.3 (high anion gap metabolic acidosis, plasma glucose >11
Mx of DKA?
Fluids started (normal saline unless K+ <5.5. then potassium chloride)
IV insulin after fluids
Include dextrose
Treat underlying cause
Breakdown of diabetic retinopathy?
Background = blot and dot haemorrhages/hard exudates
Pre-proliferative = background + cotton wool spots
Proliferative = pre-proliferative + new vessels on disk (neovascularization)
maculopathy = Previous + hard exudates near macula
Mx of diabetic retinopathy?
background = improve glycaemic control
Pre and proliferative = pan-retinal photocagulation
Maculopathy = grid of photocoagulation
What is neovascularization associated with?
Retinal detachment and vitreous haemorrhage -> visual loss
Diabetic nephropathy features and Ix?
Albuminuria, reduction of eGFR, associated with retinopathy
1) urinarlysis and eGFR
Biopsy gold standard and show Kimmelstiel-wilson nodules (mesangiel expansion)
Mx for diabetic nephropathy?
Improve glycaemic control and ACEi/ARB
Breakdown of diabetic neuropathy?
Caused by blockage of vasa nervorum
Perpheral neuropathy = loss of sensation (feet) and may not sense injury. Monofilament exam and loss of anklejerk/vibration/fractures (charcots joint)
Mononeuropathy = sudden motor loss usually e.g. wrist drp, foot drop, 3rd nerve palsy (down and out)
Autonomic neuropathy = dysphagia, delayed gastric empyting, bladder dysfunction, postural hypotension and cardiac autonomic supply
Mx of diabetic neuropathy?
Glycaemic control, if painful then neuropathic pain agent e.g. duloxetine, pregabalin or gabapentin
Causes of cranial DI?
pituitary tumour/surgery, TBI, infection e.g. meningitis, sarcoidosis, SAH
Causes of nephrogenic DI?
Lithium therapy, electrolyte imbalance e.g. Increase ca, decreased K, idiopahic, ureteric obstruction ,
Inherited AVPV2 gene
DI presentation?
polyuria and nocturia, polydipsia, dehydration so tachycardia, reduced tissue turgor, dry mucous membranes
Cause e.g. bitemporal hemianopia
IX for DI?
General = U&Es, Na but increased urea, glucose to exclude DM
Water deprivation test with desmopressin is diagnostic
Mx for DI?
1) treat the cause
2) Crnial = intranasal desmopressin (less water)
3) nephrogenic = thiazide diurteic or NSAIDs (these inhibit prostaglandin and prostaglandin inhibits AHD)
Causes of SIADH?
CNS = SAH, stroke, tumour, TBI Pulmonary = pneumonia, bronchietasis Malignancy = Small cell lung cancer Drugs = carbamazepine, SSRI Idiopathic
Features of SIADH?
expansion of ECF volume, decreased plasma osmolality and hyponatraemia, concentrated urine and increased Na excretion
Mx for SIADH?
Treat the cause
Immediate fluid resus for hyponatraemia
oral demeclocyline or IV vaptans
Features of volume statuses with hyponatraemia?
Hypovolaemic = tachy, reduced skin turgor, dry, low bp, postural hypotension and urine sodium low
Euvolaemic = normal or cause
Hypervolaemia = peripheral oedema, bibasal crackles and raised JVP
Causes of each volume status with hyponatraemia?
Hypo = vomiting/diarrhoea + diuretics
Eu = Hypothrypid (TFTs) Adrenal insufficiency (short synacthen)or SIADH (decreased plasma and increased urine osmolality
hyper = heart failure, cirrhosis of nephrotic syndrome
Mx for volume statues>
Hypo = volume replacement with 0.9% saline
Other two si fluid restriction and treat underlying cause
What do rapid Na+ changes cause?
if seizing/reduced GCS + hyponatraemic = give hypertonic 3% saline
Usually slow changes to prevent central pontine myelinlysis = quadriplegia, pseudobulbar palsy, seizures, coma and death
Causes of hypernatraemia?
GI losses and sweat loss, rena losses such as osmotic diuresis (HHS) or DKI
Sodium Overload in Cushings, primary aldosteronism, iatrogenic
Mx of hypernatraemia?
Correct water deficit - 5% dectrose
Correct ECF volume - 0.9% saline
Measure Na every 4-6 hours
Examples of pituitary adenomas?
Acromegaly (GH secreting)
Prolactinoma
Cusings
Causes of hyperprolactinaemia?
Pregnancy and breast feeding
Prolactinoma or other pituitary adenoma (stalk compression), oprimary hypothyroidism
High prolactin suppresses GnRH pulsatility
S+S of hyperprolactinaemia?
Men = libido loss, erectile dysfunction, infertility, rare galactorrhoea
Women = galactorrhoea, secondary amenorrhoea/oligomenorrhoea, libido loss, infertilyi
Mass effect = heachache/visual field deficit
Ix for hyperprolactinaemia>
Pregancy test
TFTs
Basal serum prolactin (if >60000mU/L) = prolactinma
MRI
Prolactinoma Mx.
Dopamine agonists e.g. oral bromocriptine and cabergoline
what is a hyperosmolar hyperglycaemic state (HHS)
hyperglycaemia but no ketonaemia so same presentation as DKA bar abdo pain as no ketonaemia
