endo Flashcards
DPP-4 inhibitors (gliptans) MoA
reduce peripheral breakdown of incretins (such as GLP-1)
metformin moa
increases peripheral insulin sensitivity and reduces hepatic gluconeogenesis
sulfonylureas moa
increase pancreatic insulin secretion
hence can lead to hypoglycaemia
GLP mimetics, e.g. exenatide, moa
increase pancreatic insulin secretion
suppress glucagon release
slow gastric emptying and promote satiety
best diabetic med for overweight patients
DPP-4 inhibitors (they do not cause weight gain, e.g. Sitagliptin) SGLT-2 inhibitors (-flozins) GLP1 analogues (only in BMI>35)
important glucocorticoid side effects
osteoporosis and osteonecrosis impaired glucose regulation neutrophilia immunosuppression psychosis avascular necrosis
Graves’ autoantibodies
TSH receptor stimulating antibodies (90%)
anti-TPO (75%)
features of Graves’ but not other causes of hyperthyroidism
eye signs - exophthalmos and ophthalmoplegia
pretibial myxoedema
digital clubbing
hyperthyroidism with painful goitre
most likely subacute (De Quervain’s) thyroiditis
HHS vs DKA
HHS does not cause hyperketonaemia and metabolic acidosis but can have much higher glucose
HHS more common in old and fat T2DM
DKA more common in young, skinny T1DM
mx of thyroid storm
beta blocker - propranolol
propylthiouracil
hydrocortisone
LADA vs MODY
LADA - no fhx, 30-50 years
MODY - <25 years, no ketones
Addison’s crisis mx
only IV hydrocortisone
OGTT cut offs
fasting ≥ 7.0 mmol/L
random or after glucose tolerance test ≥ 11.1 mmol/L
blood glucose targets T1DM
how often to measure
on waking - 5-7
before meals (except breakfast) - 4-7
measure 4 times per day
HbA1c target in T2DM
48 mmol/mol if lifestyle (+/- metformin) mx
53 mmol/mol if taking any drug that causes hypoglycaemia
at 58 mmol/mol consider adding a second agent
impaired fasting glucose
blood glucose 6.1-7.0
Kallman’s bloods
low-normal FSH and LH
low testosterone
hypothyroidism TFTs
high TSH
low T4
hyperthyroidism TFTs
low TSH
high T4
drug causes of gynaecomastia
spironolactone GnRH agonists (goserelin)
what conditions is Pioglitazone CI in
HF
bladder cancer
most common cause of Cushing’s syndrome
ACTH dependent causes - Cushing’s disease (pituitary tumour secreting ACTH producing adrenal hyperplasia)
how to interpret dexamethasone suppression testing
lack of cortisol suppression by low dose dexamethasone - excess glucocorticoid
high dose testing used to localise the problem
if both ACTH and cortisol are suppressed by high dose - pituitary cause
if only cortisol is suppressed by high dose - adrenal cause
if neither are suppressed - ectopic ACTH secretion
features of Addison’s
vague symptoms of lethargy, weakness, anorexia
hyperpigmentation, vitiligo
hypoglycaemia
hyponatraemia and hyperkalaemia
what should be done with steroid replacement for Addison’s patients with illness, e.g. gastroenteritis
double hydrocortisone
same fludrocortisone
most common cause of primary hyperaldosteronism
bilateral idiopathic adrenal hyperplasia
mx of myxoedemic coma
thyroxine
hydrocortisone
ix for acromegaly
- serum IGF-1 (insulin growth factor-1)
2. OGTT
most common cause of primary hyperparathyroidism
solitary adenoma
bloods in primary hyperparathyroidism
high PTH (can be inappropriately normal)
high Ca
low phosphate
bloods in secondary hyperparathyroidism
high PTH
low/normal Ca
high phosphate
low vitamin D
bloods in tertiary hyperparathyroidism
extremely high PTH normal/high Ca low/normal phosphate low/normal vitamin D high ALP
which thyroid cancer produces calcitonin
medullary
commonest thyroid cancer
papillary (65%)
follicular (20%)
mx of DKA
0.9% NaCl
IV 0.1 unit/kg/hr insulin infusion, once blood glucose <15 mmol/l start 5% dextrose
correct electrolyte disturbances
cont long acting insulins, stop short acting
cause of hyperthyroidism then hypothyroidism
De Quervain’s thyroiditis
results of water deprivation test in cranial DI
low urine osmolality after fluid deprivation
high urine osmolality after desmopressin
results of water deprivation test in nephrogenic DI
low urine osmolality after both fluid deprivation and desmopressin
electrolyte abnormality seen in Cushing’s
hypokalaemic metabolic alkalosis
adverse effects of thryoxine therapy
hyperthyroidism due to over treatment
reduced bone mineral density
AF
worsening of angina
which type of hyperparathyroidism in CKD
most likely tertiary
causes of lower than expected HbA1c
anything that causes higher turnover of red cells, e.g. spherocytosis, sickle cell, G6PD deficiency
causes of higher than expected HbA1c
anything that causes red cells to be held onto for longer, e.g. iron deficiency anaemia, splenectomy, vitamin B12/folate deficiency
HbA1c that indicates prediabetes
42-47 mmol/mol
ix for Addison’s
short synacthen (ACTH) test
Klinefelter vs Kallmanns
both cause infertility
Klinefelter’s - above average height, small testes, gynaecomastia
Kallman’s - anosmia, no gyanecomastia
mx of primary hyperaldosteronism
Spironolactone if bilateral adrenal hyperplasia
Surgery if adrenal adenoma
features of MEN1
3 Ps
parathyroid - hyperparathyroidism
pancreas - insulinoma, gastrinoma (leading to peptic ulceration)
pituitary - prolactinoma
insulin infusion rate in DKA
0.1 unit/kg/hr
how to differentiate between causes of Cushing’s
dexamethasone suppression test
adrenal cause - cortisol is not suppressed by high-dose dexamethasone
pituitary cause - cortisol is suppressed by high dose dexamethasone
mx of acromegaly
- trans-sphenoidal surgery
- if surgery not appropriate or unsuccessful - somatostatin analogue (Octreotide), GH receptor antagonist (Pegvisomant), dopamine agonist (Bromocriptine)
what should be done to metformin dosing during intercurrent D&V
suspend during illness as it increases risk of lactic acidosis
orlistat moa
pancreatic lipase inhibitor
mx of hypoglycaemia in drowsy patient
IV 20% glucose is first line
if drowsy there may be risk of aspiration with gluco-gel
best diabetic med for patients w CKD
Sitagliptin (DPP-4 inhibitor)
mx of prediabetes
refer to Diabetes Prevention Programme
low TSH and low T4
suggests secondary hypothyroidism which needs and MRI pituitary to confirm dx
which medications may reduce absorption of levothyroxine
iron/calcium carbonate
results of water deprivation test in psychogenic/primary polydipsia
high urine osmolality after fluid deprivation and after desmopressin
complication of papillary thyroid cancer
spread to cervical lymph nodes
mx of hypoglycaemia if person is alert and able to swallow
glucose tablets
CI to testosterone therapy
PSA >4
hx of or active prostate/breast cancer
haematocrit >0.55
drug cause of hyperthyroidism
amiodarone
adverse effects of glitazones
ELBOW Edema fluid retention Liver dysfunction Bladder cancer Osteoporosis - fractures Weight gain
mx of prolactinoma
dopamine agonists (e.g. Cabergoline or Bromocriptine) surgery is only performed for those who cannot tolerate/fail to respond to medical therapy
