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Endocrinology > Diabetes, DM, DI and SIADH > Flashcards

Diabetes, DM, DI and SIADH Flashcards

1
Q

Glucose levels needed diabetes diagnosis

A

Fasting >7mmol/L
Random >11.1mmol/L
Detected once with symptoms
Or detected on 2 separate occasions

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2
Q

HbA1c diagnosis level

A

> 48mmol/L (6.5%)

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3
Q

Cause of type 1 diabetes

A

Insulin deficiency from autoimmune destruction of insulin-secreting pancreatic beta cells

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4
Q

T1DM patients are prone to

A

Ketoacidosis and weight loss

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5
Q

MZ concordance for T1DM

A

30% therefore some environmental influence

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6
Q

Populations with higher prevalence of T2DM

A

Elderly, men and Asians

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7
Q

Cause of T2DM

A

Decreased insulin secretion with or without insulin resistance

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8
Q

Things which increase risk of t2dm

A

Obesity
Lack of exercise
Calorie
Alcohol excess

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9
Q

MZ concordance of T2DM

A

> 80%

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10
Q

What precedes onset of t2dm

A

Pre-diabetes, new term which refers to previous IGT and IFG

Increased likelihood of developing t2dm

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11
Q

HBa1c needed for pre-diabetes diagnosis

A

6.0-6.4%

or 42-47mmol

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12
Q

Fasting glucose needed for pre-diabetes diagnosis

A

6.1-6.9mmol/l

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13
Q

Other causes of diabetes - drugs

A

Steroids
Anti-HIV drugs
Newer antipsychotics
Thiazides

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14
Q

Other causes of diabetes - medical

A

Pancreatic insufficiency

Cushings, acromegaly, phaeochromocytoma, hyperthyroidism and pregnancy

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15
Q

Increased risk of gestational diabetes

A 
>25 
Family history 
Weight gain
Non-causasian
HIV +ve
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16
Q

Medications in gestational DM

A

Nothing other than insulin or metformin

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17
Q

Antibodies in t1dm

A

Islet cell antibodies

Anti-glutamic acid decarboxylase (GAD) antibodies

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18
Q

Ketonuria in which diabetes

A

T1DM

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19
Q

Metabolic syndrome criteria

A 
Central obesity (BMI>30 or waist circumference)
Plus 2 of;
BP >130/85
Triglycerides >1.7 
HDL 5.6 or DM
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20
Q

Ideal DM diet

A

Low sat fats
Low sugar
High starch and carb
Moderate protein

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21
Q

First medication for T2DM

A

Metformin (biguanide)

500mg bd after food

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22
Q

How does metformin work? And side effects/contraindication

A

Increases insulin sensitivity - helps weight

SE: nausea, diarrhoea, abdominal pain NOT hypoglycaemia

Renal failure - Gfr

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23
Q

When do you need to stop metformin

A

Morning before GA and contrast medium containing iodine

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24
Q

When do you add another drug to metformin and what?

A

16 weeks after starting metformin and Hba1c >53

Add sulfonylurea - eg. gliclazide 40mg/day

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25
Q

How do sulfonylurea work and SE?

A

Increase insulin secretion

SE: hypoglycaemia, weight gain - therefore is BMI >35 or hypoglycaemia an issue - use gliptin

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26
Q

When do you add something to metformin + gliclazide and what

A

If 6 months hba1c >57

Consider
Insulin
Glitazone eg. Pioglitazone - replaces either metformin or sulfonylurea

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27
Q

How does glitazone work?

Side effects and contraindications

A

Increase insulin sensitivity
SE: hypoglycaemia, fractures and fluid retention - LFT increase

Contraindication - past or present CCF, oestoporosis

Need to monitor weight and stop if oedema

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28
Q

Good drug if irregular mealtimes - t2dm

A

Sulfonylurea receptor binders
Eg. Nateglinide or repaglinide

Target post prandial hyperglycaemia

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29
Q

What are exenatide and sitagliptin or vilagliptin

A

Exenatide is a Glucagon-like peptide analogue (incretin)

Sitagliptin and vilagliptin - inhibit dpp-4 which breaks down GLp-1

Decrease appetite therefore good for obesity

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30
Q

Acarbose?

A

Alpha glucosidase inhibitor
Stops breakdown of starch to sugar
Often disappointing

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31
Q

Strength of insulin doses

A

100u/ml

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32
Q

Humalog

A

Ultra-fast acting insulin - at start of meal or just after

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33
Q

Novorapid

A

Fasting acting

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34
Q

Novomix

A

Ultrafast component - 30%

And long acting insulin - 70%

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35
Q

Isophane insulin

A

Variable peak at 4-12 hour

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36
Q

Insulin glargine

A

Long acting recombinant human insulin analogue
Before bedtime in t1 or t2
Caution in pregnancy

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37
Q

Insulin detemir

A

Long acting insulin

Good if intense insulin regimes for t2dm

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38
Q

Insulin regimen for t2dm or t1dm with regular lifestyle

A

BD biphasic regimen

Twice daily premixed insulin by pen - eg novo mix

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39
Q

Insulin regimen good for flexibility with t1dm

A

QDS regimen

Before meals ultra fast and bedtime long acting

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40
Q

Good insulin regimen when switching from medication to insulin in t2dm

A

Once daily before bed

Work dose up slowly

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41
Q

Insulin during illness

A

Illness often needs more insulin even if decreased food intake

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42
Q

Gliclazide

A

Sulfonylurea

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43
Q

Pioglitazone

A

Glitazone

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44
Q

..glinide

A

Sulfonylurea receptor binders

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45
Q

Background diabetic retinopathy

A 
Microaneurysms (dots)
Haemorrhages (blots) 
Hard exudates (lipid)

Refer if near macula

46
Q

Pre-proliferative diabetic retinopathy

A

Cotton wool spots (nerve damage)
Haemorrhages
Venous beading

Refer to specialist

47
Q

Proliferative diabetic retinopathy

A

New vessels form - urgent referral

48
Q

Diabetic maculopathy

A

Suspect if decreased acuity

Prompt treatment

49
Q

Cause of diabetic eye problems

A

Capillary endothelial change due to high retinal blood flow from hyperglycaemia

Causes vascular leak and microaneurysms - also occlusion and hypoxia and ischaemia - then new vessel formation

50
Q

Diabetic neuropathy

A

Sensory in glove and stocking distribution - symmetrical
- numbness, tingling and pain

Absent ankle jerks
Neuropathic deformity -eg. Pes cavus

51
Q

Other sign of diabetic foot problems

A

Ischaemia and absent pulses

52
Q

Complication of diabetic foot ulcer and treatment

A

Cellulitis
IV benzylpenicillin and flucloxacillin
With or without metronidazole

53
Q

Treatment of pain in diabetic sensory poly neuropathy

A

Paracetamol
Then tricyclic
Then duloxetine, gabapentin or pregabalin
Then opiates

54
Q

Other neuropathies in diabetics x 3

A

Mono neuritis multiplex
Amyotrophy - painful wasting of muscles
Autonomic neuropathy

55
Q

Hypoglycaemia - glucose level

A
56
Q

Symptoms of hypoglycaemia

A

Autonomic - Sweating anxiety hunger tremor palpitations dizziness

Neuroglycopenic - confusion, drowsiness, visual trouble, seizures and coma

57
Q

Hypoglycaemia + hyperinsulinaemia

A

Insulinoma
Insulin and sulfonylureas
Mutation in insulin receptor gene

58
Q

Hypoglycaemia + undetectable insulin and no excess ketones

A

Non pancreatic neoplasm

Anti-insulin receptor antibodies

59
Q

Hypoglycaemia, low insulin and high ketones

A

Alcohol
Pituitary insufficiency
Addison’s disease

60
Q

Treatment of hypoglycaemia if can swallow

A

Oral sugar 50g glucose followed by long acting starchy snack

61
Q

Treatment of hypoglycaemia if can’t swallow

A

If cannot swallow - IV glucose 50% 25-50ml or glucagon 1mg IM if no IV access

62
Q

What is insulinoma

A

Benign pancreatic islet cell tumour

63
Q

Presentation of insulinoma

A

Fasting hypoglycaemia + whippes triad:

1) symptoms associated with fasting or low glucose
2) recorded hypoglycaemia with symptoms
3) symptoms relieved with glucose

64
Q

Diagnostic test of insulinoma

A

Suppressive test

Give IV insulin and measure c-peptide - normally exogenous suppresses c-peptide production but doesn’t in insulinoma

65
Q

Why does diabetic Ketoacidosis occur

A

Ketoacidosis is alternate metabolic pathway in starvation States (diabetes there is glucose but not insulin therefore has to do this)

Ketoacidosis produces acetone as by product (fruity breath) and ketones

66
Q

Typical picture of diabetic Ketoacidosis

A

Gradual drowsiness
Vomiting
Dehydration

67
Q

Typical patient with Ketoacidosis

A

T1dm

Rarely t2dm

68
Q

Triggers of diabetic Ketoacidosis

A 
Infections
MI
Surgery
Pancreatitis
Chemo
Non compliance
69
Q

3 things needed for Ketoacidosis diagnosis

A

Acidaemia - blood ph below 7.3
Glucose >13.9
Serum bicarb below 18

70
Q

Severe DKA

A

If one of more of the following features is present then consider transfer to HDU or ICU for monitoring

Blood ketones >6 (urine ketones don’t always equate with Ketoacidosis)
Venous bicarbonate below 10
Ph below 7

71
Q

Symptoms of hyperglycaemia

A 
Polyuria 
Polydipsia
Unexplained weight loss
Visual blurring 
Genital thrush 
Lethargy
72
Q

First Management of Ketoacidosis if SBP low

A

Give 500ml bolus saline

If no response give a second bolus and get ICU advice

73
Q

management of diabetic Ketoacidosis - when fluid stable

A

Insulin - actrapid 50u with 50ml saline - infuse constantly - only give stat if there is a delay in starting infusion

Continue long acting insulin

74
Q

Aim for managing diabetic ketoacidosis

A

Fall in blood ketones of 0.5mmol/L/hour

Or rise in venous bicarb of 3mmol/L/hour

Fall in glucose of 3mmol/L/hour

If this isn’t achieved then increase to 1u of insulin

75
Q

Other diabetic ketoacidosis management

A

NG tube if vomiting or drowsy
Catheter if not urinating
Start all patients on LMWH

76
Q

What do you need to avoid when treating diabetic ketoacidosis

A

Hypoglycaemia

When glucose is below 14 start giving glucose

77
Q

When do you continue fixed rate insulin until?

A

Ketones 7.3

Venous bicarb >18

78
Q

Fluid replacement in DKA

A 
Typical fluid deficit is 100ml/kg 
For an average 70kg man = 7litres
Give 1L in 1st hour
1L over 2hours 
1L over 2 hours
1L over 4 hours 
1L over 4 hours 
1L over 6 hours
79
Q

K+ in DKA

A

Plasma k+ falls as k+ enters cells with insulin
Don’t add K+ to first bag
Monitor UO and start adding k+ when >30ml an hour

80
Q

Presentation of hypoglycaemic coma

A

Rapid onset
Preceded by odd behaviour - aggression
Sweating, tachycardia and seizures

81
Q

Management of hypoglycaemic coma

A

20-30g glucose IV - 200-300ml of 10% dextrose rather than 50% glucose because harms veins

Then when conscious give sugary drinks and meal

82
Q

What is HONK, who gets it, presentation and treatment?

A

Hyperglycaemic hyperosmolar non-ketotic coma

T2dm

1 week hx of marked dehydration and glucose >35 - no acidosis as no switch to ketone metabolism

Osmolality >340

Risk of occlusive events

Rehydrate slowly with 0.9% saline over 48hours - deficits slightly larger than in DKA

K+ replacement and only insulin if blood glucose not falling by 5/hour

83
Q

Egs of sulphonylureas

A

Glipizide
Gliclazide
Gliquidone
Glimepiride

84
Q

Mechanism of action of sulfonylureas

A

Bind to k+ channel on beta s

85
Q

What is diabetes insipidus?

A

Inadequate secretion of vasopression (ADH) or renal insensitivity to ADH causing lack of water resorption in the collecting duct and therefore a hypotonic polyuria

86
Q

What are the two types of DI

A

Cranial/central - failure of production of ADH by the posterior pituitary
Nephrogenic - insensitivity of kidneys (failure of aquaporin activation)

87
Q

Causes of central DI

A 
Similar to causes of other pituitary problems
Trauma
Vascular (Sheehans)
Tumour
Infiltrative - sarcoid
Infection - meningitis
88
Q

Causes of nephrogenic DI

A 
Idiopathic 
Drugs (lithium)
Post-obstructive nephropathy 
Pyelonephritis 
Pregnancy 
Osmotic diuresis (diabetes mellitus)
89
Q

Symptoms of DI

A

Polyuria
Polydipsia
Nocturia (enuresis in children)
Dehydration if fluid intake is not greater than fluid output

90
Q

What are the two types of DI

A

Cranial/central - failure of production of ADH by the posterior pituitary
Nephrogenic - insensitivity of kidneys (failure of aquaporin activation)

91
Q

Causes of central DI

A 
Similar to causes of other pituitary problems
Trauma
Vascular (Sheehans)
Tumour
Infiltrative - sarcoid
Infection - meningitis
92
Q

Interpretation of results of diagnostic test for DI

A

Give desmopressin which is ADH analogue
Urine osmolality should increase over the test (>600mosmol/kg)
If lack of ADH activity then urine will not become concentrated and osmolality will remain below 400mosm/kg
If cranial cause for DI then desmopressin will cause >50% increase in urine osmolality
If renal DI cause then desmopressin administration will cause urine osmolality to rise less than 45%

93
Q

Treatment of central DI

A 
Given desmopressin (Vasopressin analogue) 10ug/day intranasally
In mild disease chlorpropamide or carbamazepine can be used to increase effects of residual vasopressin
94
Q

DI Investigations

A

Raised plasma osmolality
Low urine osmolality
Ca may be high (hypercalcaemia can cause nephrogenic DI)
U&E

95
Q

Diagnostic test for DI

A

Water deprivation test - 8h (monitor weight and if WL >3%then stop)
Measure plasma and urine osmolality every hour
Desmopressin given after 8h and measure urine osmolality again

96
Q

Interpretation of results of diagnostic test for DI

A

Urine osmolality should increase over the test (>600mosmol/kg)
If lack of ADH activity then urine will not become concentrated and osmolality will remain below 400mosm/kg
If cranial cause for DI then desmopressin will cause >50% increase in urine osmolality
If renal DI cause then desmopressin administration will cause urine osmolality to rise less than 45%

97
Q

Treatment of central DI

A 
Given desmopressin (Vasopressin analogue) 10ug/day intranasally
In mild disease chlorpropamide or carbamazepine can be used to increase effects of residual vasopressin
98
Q

Treatment of renal DI

A

Treat the cause
Sodium and/or protein restriction may help
Thiazide diuretics

99
Q

What is SIADH

A

Syndrome of inappropriate ADH secretion - continual ADH secretion despite absence of normal stimuli for secretion (high serum osmolality or low blood volume) - as it functions to retain water in the body

100
Q

Causes of SIADH

A 
Multiple brain, lung and tumour causes
Also drugs (vincristine, opiates, carbamazepine, chlorpropramide)
101
Q

What does SIADH cause

A

Hyponatraemia due to dilutional affects of water retention

SIADH is the cause for more than 50% of severe hyponatraemias caused in hospital

102
Q

Symptoms of SIADH

A

Symptoms of hyponatraemia - headache, n+v, muscle cramp/weakness, irritability, confusion, drowsiness, convulsions and coma
Along with symptoms of the underlying cause

103
Q

Signs of SIADH

A

Signs of hyponatraemia - decreased reflexes

Along with signs of underlying cause

104
Q

SIADH diagnosis

A

Decreased plasma osmolality and sodium
Increased urinary osmolality >100mosm and sodium >20mmol
In the absence of hypovolaemia/hypotension, oedema, renal failure, adrenal insufficiency and hypothyroidism

105
Q

Management of SIADH

A

Identify underlying cause
Water restriction
If ineffective then give demeclocycline (decrease responsiveness of collecting duct to ADH)
Vasopression receptor antagonists eg. tolvaptan may help

106
Q

Management of severe SIADH

A

IV slow hypertonic 3% saline + furosemide
Change in Na must not be >10mmol in first 24hrs and 18mmol in 48hrs
Rapid correction can cause central pontine myelinolysis

107
Q

target hba1c in D1m

A

Below 7%

Check every 3-6months

108
Q

Causes of secondary diabetes

A 
Pancreatic disease (Chronic pancreatitis, HH, pancreatic cancer, surgical removal of pancreas)
Endocrine (Cushing's, acromegaly, phaeochromocytoma, glucagonoma) 
Drugs (steroids, atypical antipsychotics, protease inhibitors)
109
Q

Side effects of pioglitazone? X6

A 
Weight gain
Liver impairment - monitor LFT's
Fluid retention therefore CI in heart failure
Fracture risk
Bladder cancer
110
Q

BP target in T2DM

A

less than 130/80 if end organ damage

less than 140/80 if no end organ damage

Endocrinology (8 decks)

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