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Endo Flashcards

1
Q

How often is HbA1c checked?

A

Every 3-6 months until stable

Then 6 monthly

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2
Q

What are the target HbA1cs?

A

Lifestyle: <48mmol
Lifestyle + metformin: <48mmol
Otherwise: <53mmol

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3
Q

What is the metformin pathway of T2DM management?

A
  1. Metformin
  2. Metformin + gliptin/sulfonylurea/pioglitazone/SGLT2 inhibitor
  3. 3 of the above OR insulin
  4. Metformin + sulphonylurea + GLP-1 mimetic
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4
Q

What is the HbA1c threshold for adding another hypoglycaemic agent?

A

58mmol

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5
Q

What is the level of HbA1c dependent on?

A

Red blood cell lifespan

Average blood glucose concentration

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6
Q

Which conditions mean HbA1c is lower than expected?

A

Sickle cell
G6PD deficiency
Hereditary sphreocytosis

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7
Q

Which conditions mean HbA1c is higher than expected?

A

Vit B12/folic acid def
IDA
Splenectomy

(increased RBC lifespan)

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8
Q

How do you calculate the average plasma glucose from HbA1c?

A

2x HbA1c - 4.5

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9
Q

What is T2DM is a symptomatic patient?

A

Fasting glucose >7mmol

Random or post OGTT >11.1

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10
Q

What is T2DM in an asymptomatic patient?

A

FG>7 or random/post OGTT>11.1

On 2 separate occasions

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11
Q

What is impaired fasting glucose?

A

Fasting glucose 6.1-7mmol

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12
Q

What is impaired glucose tolerance?

A

Fasting glucose <7mmol AND

OGTT 2 hour value 7.8-11.1mmol

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13
Q

What can be added in T1DM patients with BMI over 25?

A

Metformin

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14
Q

Which is the first hormone secreted in response to hypoglycaemia?

A

Glucagon

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15
Q

What are the characteristics of MODY?

A

Patients younger than 25 years
Autosomal dominant
Lack of ketosis
Good response to sulfonylurea

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16
Q

What is the most common type of MODY?

A

MODY 3 - defect in HNF-1 alpha gene

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17
Q

What is MODY 3 associated with?

A

Increased risk of HCC

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18
Q

What is the pathophysiology of DKA?

A

Uncontrolled lipolysis which results in an excess of free fatty acids which are converted to ketone bodies

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19
Q

What is the diagnostic criteria of DKA?

A

Glucose >11mmol or known DM
pH<7.3
Bicarb<15
Ketones>3 or urine ketones +++

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20
Q

What is the management of DKA?

A

Fluid resuscitation +/- K
IV insulin 0.1IU/kg/hr
Once BM<15 - start 5% dextrose

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21
Q

What should happen with a patient’s normal insulins when in DKA?

A

Continue long acting insulin

Omit short acting insulin

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22
Q

When should a patient be switched to normal insulins post DKA?

A

Eating and drinking

After first meal

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23
Q

Name 5 complications of DKA.

A 
Hypokalaemia
Cerebral oedema
Arrhythmias
ARDS
AKI
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24
Q

What is the pathophysiology of HHS?

A

Hyperglycaemia –> osmotic diuresis
Volume depletion –> raised serum osmolality –> hyperviscosity
electrolyte disturbances

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25
What is the diagnostic criteria of HHS?
Hypovolaemia Hyperglycaemia >30mmol without ketonaemia or acidosis Raised serum osmolality >320mosmol/kg
26
What is the treatment of HHS?
IV 0.9% saline | Fixed rate insulin 0.05IU/kg/hr
27
What are the features of thyroid MALT lymphoma?
Painless goitre | Non-functional thyroid tumour
28
90% Hashimoto's thyroiditis patients have which antibody?
anti-TPO
29
How does subacute De Quervain's thyroiditis present?
Occurs following a viral infection | Typically presents with hyperthyroidism, painful goitre, raised ESR
30
How is De Quervain's thyroiditis diagnosed?
Thyroid scintigraphy - globally reduced uptake of iodine-131
31
What is the treatment of De Quervain's thyroiditis?
Self limiting | NSAIDs for pain
32
What are the biochemical abnormalities in non thyroidal illness?
Low TSH, low thyroxine, low T3
33
What is the most common type of thyroid cancer?
Papillary
34
What cell does medullary thyroid cancer originate from?
C cells (parafollicular) which produce calcitonin
35
Which syndrome is medullary thyroid cancer associated with?
MEN 2a and 2b
36
What is the treatment of papillary and follicular thyroid cancer?
Total thyroidectomy Followed by radio-iodine I-131 Yearly thyroglobulin levels
37
Which antibodies are diagnostic of Graves' disease?
TSH receptor stimulating antibodies (present in 90%)
38
What percentage of Graves' patients have eye problems?
30%
39
What are other signs of Graves' disease?
Pretibial myxoedema Thyroid acropachy, which is a triad of: digital clubbing, soft tissue swelling of hands and feet, periosteal new bone formation
40
What percentage of Graves' patients have positive anti-TPO and anti-thyroglobulin antibodies?
Anti-TPO: 75% | Anti-thyroglobulin: 30%
41
What is the cause of subclinical hyperthyroidism?
Excessive thyroxine | Multinodular goitre
42
What are risk factors for thyroid eye disease?
Smoking | Radio-iodine
43
What is the treatment of thyroid eye disease?
Steroids Topical lubricants Radiotherapy
44
What is the treatment of myxoedemic coma?
Hydrocortisone and levothyroxine | Treated as presumed adrenal insufficiency until ruled out
45
What are the features of MEN type 1?
Pancreatic endocrine tumours Pituitary tumours Primary hyperparathyroidism
46
What are the features of MEN type 2a?
Primary hyperparathyroidism Phaeochromocytoma Medullary thyroid cancer RET oncogene
47
What are the features of MEN type 2b?
``` Marfinoid body habitus Neuromas Phaeochromocytoma Medullary thyroid cancer RET oncogene ```
48
What is the most common cause of primary hyperaldosteronism?
Bilateral idiopathic adrenal hyperplasia
49
What are the other causes of primary hyperaldosteronism?
``` Adrenal adenoma (Conn's) Adrenal carcinoma ```
50
What are the features of primary hyperaldosteronism?
Hypokalaemia Hypertension High aldosterone, low renin
51
How is bilateral adrenal hyperplasia differentiated from Conn's syndrome?
CT abdomen | Adrenal vein sampling
52
What is the treatment of bilateral adrenocortical hyperplasia?
Spironalactone
53
What are the features of hypocalcaemia?
Tetany Perioral paraesthesia Chronic: depression, cataracts
54
What are Trousseau's and Chvostek's sign in hypocalcaemia?
Trousseau's: carpal spasm if brachial artery is occluded | Chvostek's: tapping over parotid causes facial muscles to twitch
55
What is seen on ECG in hypocalcaemia?
Prolonged QT
56
When is calcium chloride used in hypocalcaemia?
Haemodynamically unstable or liver failure Gluconate must be hepatically metabolized before the calcium becomes available
57
What is the cause of secondary hyperaldosteronism?
High levels of renin e.g. in nephrotic syndrome, heart failure, liver failure
58
How can you differentiate the hypertension and hypokalaemia in Cushing's syndrome, bilateral renal artery stenosis, and Liddle syndrome?
Cushing's: high aldosterone, low renin Bilateral renal artery stenosis: high aldosterone, high renin Liddle syndrome: low aldosterone, low renin
59
What is the threshold for chronic over acute hyponatraemia?
48 hours
60
What are the causes of hypovolaemic hyponatraemia?
Dehydration Diuretic stage of renal failure Diuretics Addisonian crisis
61
What is the cause of euvolaemic hyponatraemia?
SIADH
62
What is the cause of hypervolaemic hyponatraemia?
Heart failure Liver failure Nephrotic syndrome
63
What is the treatment of chronic hyponatraemia?
Hypovolaemic: isotonic saline Euvolaemic: fluid restrict 500-1000ml/day, consider demeclocycline/vaptans Hypervolaemic: fluid restrict 500-1000ml/day, consider loop diuretics/vaptans
64
What happens if sodium falls after administration of isotonic saline in hyponatraemia?
Suggests SIADH
65
What is the treatment of acute hyponatraemia with severe symptoms?
3% NaCl
66
What is a complication of treating hyponatraemia?
Osmotic demyelination syndrome/cerebral pontine myelinolysis
67
How do vaptans work in hyponatraemia?
Act on V1 and V2 receptors causing vasoconstriction and selective water diuresis
68
What are the irreversible symptoms of cerebral pontine demyelinosis?
``` Dyarthria Dysphagia Quadraparesis Seizures Coma ```
69
How does demeclocycline work in SIADH?
Inhibits G-protein coupled receptor signalling downstream of ADH binding to the renal vasopressin V2 receptors Thus inducing nephrogenic diabetes insipidus
70
What is the management of SIADH?
Mild: fluid restrict Mod/sev: IV 3% hypertonic saline Resistant: demeclocycline
71
What metabolic abnormality is seen in Cushing's syndrome?
Hypokalaemic metabolic alkalosis
72
How is Cushing's syndrome diagnosed?
Overnight dexamethasone suppression test - morning cortisol not suppressed High 24 urinary free cortisol
73
In Cushing's syndrome, how is a non ACTH-dependent cause diagnosed?
Suppressed ACTH in 9am and midnight plasma ACTH and cortisol levels
74
What are the results of CRH stimulation in pituitary and adrenal/ectopic sources of Cushing's syndrome?
Pituitary: cortisol rises | Adrenal/ectopic: no change in cortisol
75
How is ACTH pituitary adenoma diagnosed?
High dose dexamethasone test | Cortisol and ACTH suppressed
76
Why is eplenerone less likely to cause gynaecomastia than spironalactone?
Eplenerone does not inhibit free testosterone binding to androgen receptors on breast tissue
77
Why does prednisolone cause neutrophilia?
Demargination of neutrophils via the endovascular lining Delayed migration of neutrophils into tissue Releases of immature neutrophils from bone marrow
78
What are 5 causes of hypoadrenalism?
``` TB Metastases Waterhouse-Friderichsen syndrome HIV Anti-phospholipid syndrome ```
79
What are the features of Addison's?
``` N+V, weakness, weight loss Hyperpigmentation Vitiligo Low Na and High K Loss of pubic hair and libido secondary to androgen deficiency Hypotension and hypoglycaemia ```
80
How is Cushing's disease differentiated from pseudo-Cushing's?
Insulin stress test In normal pituitary function, GH and cortisol should rise
81
What is the pathophysiology of PCOS?
Hyperinsulinaema | High levels of LH
82
How does empty sella syndrome present?
Symptoms of hypopituitarism
83
Hypokalaemia and normotension are seen in which syndromes?
Gitelman's | Bartter's
84
What are 6 causes of raised prolactin?
``` Pregnancy Prolactinoma Physiological PCOS Primary hypothyroidism Phenothiazines, metoclopramide, domperidone ```
85
What are the causes of hypertriglyceridaemia?
``` DM Obesity Alcohol CKD Thiazides, BB, unopposed oestrogen Liver disease ```
86
What are the causes of hypercholesterolaemia?
Nephrotic syndrome Cholestasis Hypothyroidism
87
What is the inheritance of androgen insensitivity syndrome?
X-linked recessive
88
What is the pathophysiology of androgen insensitivity syndrome?
End-organ resistance to testosterone Genotypically male children have a female phenotype
89
What are the features of androgen insensitivity syndrome?
Primary amenorrhoea Undescended testes Breast development may occur as a result of conversion of testosterone to oestradiol
90
How is phaeochromocytoma diagnosed?
24h urinary metanephrinesW
91
What are the causes of primary hyperparathyroidism?
80% solitary adenoma 15% hyperplasia 4% multiple adenoma 1% carcinoma
92
Why does peptic ulceration and hypertension occur in primary hyperparathyroidism?
Hypercalcaemia Ca stimulates gastrin release Ca causes vasoconstriction
93
What are the biochemical results seen in primary hyperparathyroidism?
High Ca High-normal PTH Low PO4
94
When is surgery indicated in primary hyperparathyroidism?
Symptomatic Calcium>2.85 End organ disease
95
What are the causes of secondary hyperparathyroidism?
CKD - lack of vit D hydroxylation by kidneys | Vit D deficiency
96
What are the biochemical abnormalities seen in secondary hyperparathyroidism?
Low-normal Ca High PTH High PO4 Low Vit D
97
What is the treatment of secondary hyperparathyroidism?
Phosphate binders | Calcium/vit D supplementation
98
What are the manifestations of renal bone disease?
Osteitis fibrosa cystica Osteomalacia Osteoporosis
99
What are the biochemical abnormalities seen in tertiary hyperparathyroidism?
``` High-normal Ca High PTH Low-normal PO4 Low-normal Vit D High ALP ```
100
What is the treatment of tertiary hyperparathyroidism?
Parathyroidectomy
101
How is benign familial hypocalciuric hypercalcaemia diagnosed?
Urine calcium: creatinine clearance ratio <0.01
102
Where is growth hormone secreted?
Somatotroph cells of anterior pituitary
103
What stimulates and inhibits secretion of growth hormone?
Stimulated: GnRH pulses from hypothalamus, sleep, exercise Inhibits: glucose, somatostatin
104
How is acromegaly diagnosed?
Serum IGF-1 with serial GH measurements OGTT confirms diagnosis if IGF-1 raised
105
What is the management of acromegaly?
Trans-sphenoidal surgery Somatostatin analogue octreotide or SC pegvisomant (GH receptor antagonist)
106
What are 4 complications of acromegaly?
HTN Diabetes Cardiomyopathy Colorectal Ca
107
What are the features of insulinoma?
Hypoglycaemia | Weight gain
108
How is insulinoma diagnosed?
High insulin Raised proinsulin:insulin ratio High C peptide 72 hour fast
109
When is metformin contraindicated?
eGFR<45
110
What are the side effects of metformin?
Diarrhoea | Lactic acidosis
111
Which class of hypoglycaemics are used for patients with an erratic lifestyle?
Meglitinides
112
How do sulfonylureas lower blood glucose?
Bind to beta cell receptors (Close K channel --> depolarises cell --> opens VG Ca channels --> increases intracellular Ca) Leads to insulin secretion Also stimulates glycolytic pathway
113
What are the side effects of sulfonyureas?
``` Weight gain Severe hypos Teratogenic SIADH Bone marrow suppression ```
114
How do meglitinides such as repaglinide work?
Increase pancreatic insulin secretion by blocking K channel of beta cells
115
Which diabetes drug is an agonist to the PPAR-gamma receptor (controls adipocyte differentiation and function) therefore reduces peripheral insulin resistance?
Pioglitazone
116
What are the side effects of pioglitazone?
``` Weight gain Increased fracture risk Fluid retention liver impairment Bladder Ca ```
117
What is the mechanism of action of DPP-4 inhibitors such as sitagliptin?
Increases insulin, lowers glucagon Reduce the peripheral breakdown of incretins such as GLP-1
118
Which DPP-4 inhibitor is linked with ischaemic heart disease?
Saxagliptin
119
What is GLP-1?
A hormone released by small intestine in response to PO glucose load
120
How do GLP-1 mimetics work?
Activate GLP-1 receptor to increase insulin, lower glucagon, slow gastric emptying
121
What is a favourable feature of GLP-1 mimetics and SGLT-2 inhibitors?
Prevent weight gain/lose weight
122
What are the side effects of GLP-1 mimetics such as exenatide?
GI disturbance | Acute pancreatitis
123
How do SGLT-2 inhibitors work?
Reduce glucose reabsorption in PCT by reversibly inhibiting sodium-glucose co-transporter 2
124
What are the side effects of canagliflozin?
Genital thrush --> Fournier's gangrene Increased risk of euglycaemic ketoacidosis Increased risk of lower limb amputation

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