endo Flashcards
For patients with T2DM, HbA1c should be checked every 3-6 months until stable, then how often
6 monthly
What is the HbA1c target for patients with T2DM receiving management of lifestyle
48mmol/mol
6.5%
n.b. this is the same for those on metformin only
What is the HbA1c target for patients with T2DM receiving management of metformin
48mmol/mol
6.5%
n.b. this is the same for those on lifestyle only
What is the HbA1c target for patients with T2DM receiving management of any drug which may cause hypoglycaemia e.g. sulfonylureas
53mmol/mol
7.0%
What is the HbA1c target for patients with T2DM receiving management of any ONE drug, but now their HbA1c has risen to 58mmol/mol (7.5%)
53 mmol/mol
7.0%
This is the same for T2DM on sulfronyureas
Patients on ONLY metformin for T2DM (target = 48mmol/mol (6.5%), should only have a second diabetic drug added if the HbA1c rises to…
58mmol/mol
7.5%
First line drug in T2DM
Metformin
Second line drug in T2DM
After metformin established and uptitrated
(or if CVD, chronic heart failure, QRISK >10%)
SGLT-2 inhibitor
e.g. empaglifozin, canagliflozin, dapaglifozin
If metformin is contraindicated in T2DM, what medications can be given in a patient WITH risk of CVD, established CVD, or heart failure
SGLT-2 monotherapy
e.g. empaglifozin, canagliflozin, dapaglifozin
If metformin is contraindicated in T2DM, what medications can be given in a patient WITH risk of CVD, established CVD, or heart failure
SGLT-2 monotherapy
If metformin is contraindicated in T2DM, what medications can be given in a patient WITHOUT risk of CVD, established CVD, or heart failure
DPP-4 inhibitor (sitagliptin, linagliptin)
Or pioglitazone
Or sulfonylurea (gliclazide)
SGLT-2 may be used if certain NICE criteria are met.
Examples of DPP-4 inhibitors
GLIPTINS
linagliptin
sitagliptin
Examples of sulfonyureas
Glimepiride
Gliclazide
Glipizide
Tolbutamide
Examples of SGLT-2 inhibitors
empaglifozin
canagliflozin
dapaglifozin
Stepwise T2DM medications
- Metformin
- Add one of: DPP-4 inhibitors, pioglitazone, sulfonyurea, SGLT-inhibitor (if NICE criteria met of CVD/IHD/QRISK >10%)
- Add another from the list above OR start insulin treatment
- If triple therapy is not tolerated/effective then switch one for a GLP-1 mimetic if BMI >35 - specialist referral if on insulin too
If triple therapy for T2DM (metformin + two other drugs or addition of insulin) is not effective or tolerated, consider switching one of the drugs for…:
GLP-1 mimetic
e.g. liraglutide, dulaglutide, semaglutide
If triple therapy for T2DM (metformin + two other drugs or addition of insulin) is not effective or tolerated, consider switching one of the drugs for what class…?
GLP-1 mimetic
e.g. exenatide
Second-line therapy for T2DM if on metformin already, what can you add on
metformin + DPP-4 inhibitor
metformin + pioglitazone
metformin + sulfonylurea
metformin + SGLT-2 inhibitor (if NICE criteria met - CVD/IHD/QRISK >10%)
If metformin is not tolerated e.g. due to GI side effects, what should it be switched to
Metformin modified-release
If triple therapy for T2DM (metformin + two other drugs or addition of insulin) is not effective or tolerated, consider switching one of the drugs for GLP-1 mimetics. These can only be done for patients with:
BMI >35
BMI <35 but insulin havs occupational implications
Reduction of at least 11mmol/mol (1%) in HbA1c and weight loss of >3% in 6 months
When GLP-1 mimetics are added (after triple therapy for T2DM), can this be done in primary care
ONLY add GLP-1 mimetics to INSULIN in SPECIALIST care
When GLP-1 mimetics are added (after triple therapy for T2DM), can this be done in primary care
ONLY add GLP-1 mimetics to INSULIN in SPECIALIST care
NICE recommend starting with human NPH insulin - what type and when
Isophane, intermediate-acting
Bedtime or twice daily according to need
Blood pressure targets in T2DM
SAME as people without T2DM
<80 years: clinic 140/90, home 135/85
>80 years: clinic 150/90, home 145/85
Patients with subclinical hypothyroidism should have what treatment
normal T4/T3
high TSH 5.5-10
If <65 years, high TSH 5.5-10 on 2 separate occasions 3 months apart AND symptoms - consider 6 month trial of levothyroxine
If >80 years - watch and wait
Asymptomatic - watch and wait, repeat in 6 months
T1DM HbA1c should be monitored how often
Every 3-6 months
What is the T2DM HbA1c target
48mmol/mol (6.5%)
- same as T2DM
Blood glucose targets for T1DM:
(a) on waking
(b) before meals at other times of day
(a) on waking: 5-7
(b) before meals at other times of day: 4-7
When do NICE recommend adding metformin in T1DM
If BMI >25
for mealtime insulin replacement for adults with type 1 diabetes, what insulin should be offered
rapid-acting insulin ANALOGUES
injected before meals
(NOT rapid-acting soluble human or animal insulins)
what insulin should T2DM patients be started on
NPH insulin [aka isophane insulin] (injected once or twice daily according to need) should be offered
Kallman’s syndrome
What is high/low/normal for androgens
LH and FSH = low/normal
Testosterone = low
Klinefelter’s syndrome
What is high/low/normal for androgens
LH and FSH = high
Testosterone = low
Diabetes sick day rules
T1DM
How much fluid should be drank in one day
Encourage fluid intake at least 3 litres/day
Diabetes sick day rules
T1DM
How many times should blood sugars be checked, and insulin taken
Continue normal insulin regime but ensure checking blood sugars regularly (every 1-2 hours including night)
SGLT-2 inhibitors (dapagliflozin) has risks of which kind of infections
UTIs
Genital (candida)
Impaired fasting glucose (IFG)
Glucose levels and HbA1c levels
Glucose: 6.1-6.9 mmol/l
HbA1c: 42-47 mmol/mol (6-6.4%)
hyperthyroidism can lead to what bone disorder
osteoporosis
due to increased bone turnover from excess thyroid hormones
Type 2 diabetes
Glucose (fasting + 2 hours) and HbA1c levels
Fasting: 7.0 mmol/l
2 hours: >11.1 mmol/l
HbA1c: 48mmol/l (6.5%)
Patients with subclinical hypothyroidism should have what treatment if bloods show:
normal T4/T3
high TSH >10
levothyroxine if TSH >10 on 2 separate occasions 3 months apart
Normal/above average height
Delayed puberty
Hypogonadism
Anosmia
Low/normal LH/FSH
Low testosterone
what is the defect
Kallman’s syndrome
Klinefelter’s syndrome
what karyotype
47XXY
Patients with subclinical hypothyroidism (normal T4/T3, high TSH) should have what test
Thyroid peroxidase antibodies
Can indicate patients who can progress to hypothyroidism
Impaired glucose tolerance
Glucose levels at 2 hours
2 hours: 7.8-11.1 mmol/l
Diabetes sick day rules
T1DM
If struggling to eat, how can you maintain carb intake
Sugary drinks
When choosing between liraglutide (GLP-1 mimetic) vs orlistat (pancreatic lipase inhibitor) for obesity, which is preferential for patients with T2DM too?
Liraglutide (GLP-1 memetic)
n.b. BMI at least >35 and/or prediabetic hyperglycaemia (HbA1c 42-47) is criteria
Kallman’s syndrome - delayed puberty secondary to hypogonadotropic hypogonadism. What is its inheritance
X-linked recessive
Lack of smell (anosmia)
Delayed puberty
Inappropriately low/normal FSH and LH
Normal or above-average height
what is the condition
Kallman’s syndrome
Management of Kallman’s syndrome
What two things can be supplemented
- Testosterone
- Gonadotrophins - can result in sperm production if fertility is desired later on
Are patients with impaired glucose tolerance or impaired fasting glycaemia more likely to develop diabetes?
impaired glucose tolerance
What is the mechanism of action of SGLT-2 inhibitors (empagliflozin)
increasing urinary excretion of glucose
mechanism of action of sulphonylureas e.g. gliclazide.
Increase insulin release from pancreas
DPP4-inhibitors (GLIPTINS) e.g. sitagliptin, linagliptin, mechanism of action
reduce breakdown of incretins, decreases glucagon secretion from pancreas
Diabetic ketoacidosis criteria
Glucose >11
ketones >3
bicarb <15
pH is …?
pH <7.3
DKA is caused by uncontrolled…
LIPOLYSIS
leads to excess free fatty acids that convert to ketone bodies
3 most common precipitating factors of DKA
Infection
Missed insulin doses
Myocardial infarction
deep hyperventilation in DKA is called
Kaussmaul respiration
Diabetic ketoacidosis criteria
pH 7.3
Glucose >11
ketones >3
bicarb is …?
<15
Diabetic ketoacidosis criteria
bicarb <15
pH <7.3
Glucose >11
What are ketones?
ketones >3
Diabetic ketoacidosis criteria
bicarb <15
pH <7.3
Ketones >3 (or urine ++)
what is glucose?
Glucose >11
In DKA, fluids, insulin and K+ are given.
Insulin IV infusion should be started at what rate?
0.1unit/kg/hour
In DKA, fluids, insulin and K+ are given.
Insulin IV infusion is started at 0.1unit/kg/hour. When should dextrose be given?
When blood glucose reaches <14, 10% dextrose at 125mls/hr should be given along with 0.9% NaCl
Potassium infusions should not be given faster than…
20mmol/hour
What insulins should be stopped/continued during a patient’s DKA
Continue long-acting insulin
Stop short-acting insulin
Three criteria that define DKA resolution
pH >7.3
Ketones <0.6
Bicarb >15
When can patient’s with DKA be switched from IV to subcut insulin
When patient is eating and drinking
Addison’s disease (high ACTH, low cortisol, low aldosterone) leads to what electrolyte disturbance
Hyponatraemia
Hyperkalaemia
Aldosterone effects on Na/K levels
Retains (increases) Na+
Excretes K+
Hyperpigmentation is associated with one of the following - which one:
Primary’s hypoadrenalism - Addisons
Secondary adrenal insufficiency
Addison’s (primary hypoadrenalism)
Due to pituitary increased ACTH which breaks down into MSH and melatonin precursors
people with change in levothyroxine dose should recheck TFTs after how long
8-12 weeks
women who have hypothyroidism and then become pregnant should have levothyroxine dose changed by how much
increased by at least 25-50mcg of levothyroxine
levothyroxine can worse heart disease by which 2 side effects
worsens angina
atrial fibrillation
levothyroxine interacts with which 2 medications
iron and calcium carbonate
reduces the absorption of levothyroxine; give at least 4 hours apart
In type 1 diabetics, how many times should you aim to monitor blood glucose
at least 4 times a day
including before each meal and before bed
What HbA1c indicates pre-diabetes
42-47 mmol/mol (6-6.4%)
For a child with a palpable abdominal mass or unexplained enlarged abdominal organ, should they be referred urgently or routinely
48hr urgent review
For specialist assessment for neuroblastoma and Wilm’s tumour
Neuroblastoma is one of the top 5 causes of cancer in children. What tissue does the tumour arise from
Arises from neural crest tissue of adrenal medulla and sympathetic nervous system
Investigations for neuroblastoma may show raised levels of what
VMA
HVA
Persistent vomiting and bloating in a poorly controlled diabetic can be due to what condition …?
gastroparesis
(in gastrointestinal autonomic neuropathy)
Gastroparesis in diabetic patients can be treated with which 2 drugs
Metoclopramide
Domperidone
Diabetics can get gastrointestinal autonomic neuropathy. What are the 3 main symptoms they get in this
- Gastroparesis
- chronic diarrhoea - at night
- GORD - reduced sphincter pressure
which diabetic medication is contraindicated in heart failure
pioglitazone
Causes of raised prolactin - the 6 p’s
- pregnancy
- prolactinoma
- physiological [stress, exercise, sleep]
- PCOS
- primary hypothyroidism [acromegaly]
- Phenothiazines, metocloPramide, domPeridone
+ haloperidol
Patients on insulin may now hold a HGV licence if they meet strict DVLA criteria relating to..
hypoglycaemia
The body’s response to hypoglycaemia
- Insulin secretion decreases
- Glucagon secretion increases
- GH and cortisol are released
Insulin increase has what effect on growth hormone and cortisol
INVERSE RELATIONSHIP
Insulin increase = GH and cortisol decrease
Hypoglycaemia management in the community
Oral glucose 10-20g in liquid, gel or tablet
Or Glucogel
Hypoglycaemia management in hospital:
are they alert?
(a) yes
(b) no
(a) If alert - then quick acting carbohydrate e.g. oral glucose 10-20mg or glucogel
(b) If unconscious or unable to swallow - SC or IM glucagon or IV 20% glucose solution through large vein
what is the most common cause of thyrotoxicosis in the UK
Graves’ disease
exenatide can be useful in obese diabetes, what is the NICE BMI criteria for its use
Patient on metformin + sulfonylurea and:
- BMI >35 or
- BMI <35 and insulin cannot be used
Patients diagnosed with prediabetes need follow up when …
every 12 months for HbA1c
How often should Insulin-dependent diabetics must check their blood glucose while driving
Every 2 hours
Patients with diabetes cannot drive if they have had a hypoglycemic episode that required the assistance of another person in the past what timeframe
In the past year
Diabetic foot disease occurs secondary to which two main factors
- neuropathy - 10g monofilament to test sensation
- peripheral arterial disease - macro and microvascular ischaemia - palpate pulses
All patients with diabetes should be screened for diabetic foot disease at least…
annually
Diabetics who are moderate/high foot risk (micro/macro vascular issues or neuropathy) should have what management
Referral to local diabetic foot centre
Anti-thyroid peroxidase antibodies are seen in which conditions
Graves’ disease (75%)
Hashimoto’s disease (90%)
What medication should be used in new cases of Graves’ disease to help control symptoms (to block adrenergic effects) while patient is awaiting endocrinologist review
Propranolol
If patient’s symptoms from hyperthyroidism (Graves’ disease) are not controlled well in primary care with propranolol, what should be considered
Carbimazole
but usually is initiated by endocrinologist
Major complication of carbimazole therapy is…
agranulocytosis
Radioiodine treatment for hyperthyroidism (Graves’ disease) patients is often used in what 2 groups of patients
- Patients who relapse after anti-thyroid drug treatment e.g. carbimazole
- Patients who are resistant to primary anti-thyroid drug treatment
Contraindications to radioiodine treatment with Graves’ disease
Pregnancy (avoid 4-6 months after treatment)
Age <16 years
Relative contraindication - thyroid eye disease
How do Sulfonylureas affect weight
Weight gain
Addison’s disease has what hormone profile
High ACTH
Low cortisol
Low aldosterone
Primary hypoadrenalism
PTH level in primary hyperparathyroidism is
Inappropriately normal
Or high
(with low phosphate)
4 causes of primary hyperparathyroidism
85% solitary adenoma
10% hyperplasia
4% multiple adenoma
1% carcinoma
X-ray findings:
pepperpot skull
osteitis fibrosa cystica
Primary hyperparathyroidism
Management for primary hyperparathyroidism
- Curative = total parathyroidectomy
- If not suitable for surgery, treat with cinacalcet (this mimics action of calcium on tissues)
Long term steroids should not be withdrawn abruptly as this may lead to
Addisonian crisis
Gradual withdrawal of systemic steroids is needed if patients has one of 3 criteria:
- Over 40mg prednisolone OD for >1 week
- Over 3 weeks treatment
- Recent repeated courses
primary hyperaldosteronism is also called
Conn’s syndrome
Conn’s syndrome (primary high aldosterone) - how does this present with electrolytes and on a blood gas
High/normal sodium
Low potassium
Metabolic alkalosis
HYPERTENSION
First-line screening test for Conn’s syndrome (primary hyperaldosteronism)
Renin-aldosterone ratio
(shows high aldosterone, low renin due to negative feedback)
What is the most common cause of primary hyperaldosteronism (Conn’s syndrome)
Bilateral idiopathic adrenal hyperplasia
Renin-aldosterone ratio in Conn’s syndrome shows…
HIGH ALDOSTERONE
LOW RENIN
What 2 methods can be used to differientiate between unilateral adenoma and bilateral adrenal hyperplasia causing aldosterone excess (i.e. Conn’s syndrome)
CT abdomen
Adrenal venous sampling
What is the management for adrenal unilateral adenoma (causing Conn’s syndrome through primary hyperaldosteronism)
Surgery
What is the management for bilateral adrenal hyperplasia (causing Conn’s syndrome through primary hyperaldosteronism)
Aldosterone antagonist
e.g. spironolactone
Before diagnosing T2DM, asymptomatic patients with an abnormal HbA1c or fasting glucose must be confirmed with
A second abnormal reading
Patients with Addison’s should be given what for adrenal crises
Hydrocortisone injection kit (intramuscular)
Addison’s disease need both glucocorticoid and mineralocorticoid replacement therapy. They therefore take a combination of which 2 meds:
- Hydrocrtisone (GC) - doubles in illness
- Fludrocortisone (MC) - stays same in illness
Which T2DM medications is associated with an increased risk of severe pancreatitis and renal impairment?
GLP-1 agonists
e.g. exenatide
what should be used to assess for diabetic neuropathy in the feet
10g monofilament
orlistat mechanism of action
inhibits gastric and pancreatic lipase to reduce digestion of fat
which diabetic medication can cause jaundice
sulfonylureas
treatment of prolactinoma
FIRST LINE = dopamine agonists
e.g. cabergoline, bromocriptine
(even if significant neuro complications)
these stop prolactin release from pituitary gland
what type of medication are cabergoline, bromocriptine
dopamine agonists
stop prolactin release from pituitary gland
what anti-thyroid drug treatment in hyperthyroidism (i.e. Graves) can be used in pregnancy in the first trimester
propylthiouracil
then can be switched back to carbimazole at start of 2nd trimester
best diagnostic test for hypothyroidism
MRI pituitary gland
Which T2DM medication would increase insulin sensitivity?
pioglitazone
it acts to reduce peripheral insulin resistance
HbA1c is not as useful for patients with a possible or suspected diagnosis of T1DM as it may not accurately reflect a recent rapid rise in serum glucose. What are four useful indicators?
- Urine dip - for glucose + ketones
- Fasting/random glucose - venous - DIAGNOSTIC
- C-peptide levels - low
- Diabetes antibodies
What 4 antibodies can be seen in diabetes (usually T1DM)
- Antibodies to glutamic acid decarboxylase (anti-GAD)
- Anti-islet cell Abs (ICA)
- Insulin autoantibodies (IAA)
- Insulinoma-associated 2 auto Abs (IA-2A)
which medications used in management of prostate cancer can cause gynaecomastia
GnRH agonists
e.g. goserelin
which medication should be considered as an adjunct for weight loss in obese class II (BMI >35) patients who are prediabetic
LIRAGLUTIDE
pioglitazone is associated with which bone issues
osteoporosis and fractures
what blood test in U+Es is associated with metabolic syndrome
raised uric acid
Hypoglycaemia: A child with a body-weight <=25kg should be administered
IM 500mcg glucagon
Patients over the age of 60 with new onset diabetes and weight loss should be referred for
urgent CT abdomen
to exclude pancreatic cancer
Over-replacement with thyroxine increases the risk for what bone disorder
osteoporosis
maturity onset diabetes of the young inheritance pattern
autosomal dominant
For diagnosis of metabolic syndrome, at least 3 of the following should be identified:
- Increased waist circumference
- High TGs
- Reduced HDL
- High BP
- High fasting plasma glucose
Main pathophysiological factor of metabolic syndrome
Insulin resistance
Liraglutide (GLP-1) requires HbA1c reduction and weight loss of how much after 6 months
HbA1c reduction of 11mmol/mol (1%) and weight loss of >3%
Orlistat requires how much weight loss
5% in 3 months
what is the best test to diagnose Addison’s disease
Short synACTHen test
during ramadan, what metformin doses should be split
1/3 of normal metformin dose before sunrise
2/3 after sunset
inability to close the eye in exopthalmos can lead to what risk
exposure keratopathy
Target cholesterol for type 2 diabetics (NICE)
40% reduction in non-HDL cholesterol
paget’s disease - what happens in terms of osteoblasts and osteoclasts
Increased osteoblast activity
Decreased osteoclast
Increased and uncontrolled bone turnover
Older male with bone pain
Raised ALP
Normal calcium and phosphate
What is the diagnosis
Pagets disease!
X-ray showing osteolysis, sclerotic lesions
Skull x-ray = thickened vault, osteoporosis circumscripta
What is the diagnosis?
Paget’s disease
Raised ALP only
Management for Paget’s disease
- Bisphosphonate (oral risderonate or IV zoledronate)
- Calcitonin - used less now
What are the 4 indications for treatment of Paget’s disease
- bone pain
- skull or long bone deformity
- fracture
- periarticular Paget’s
Five complications of Paget’s disease
- Deafness - cranial nerve entrapment
- Bone sarcoma
- Fractures
- Skull thickening
- High output cardiac failure
priapism is persistent erection defined lasting longer than how long
4 hours
investigations for priapism
- cavernosal blood gas analysis - differentiates between ischaemic vs non-ischaemic
- doppler or duplex USS
- FBC, toxicology screen to find cause
Management of ischaemic priapism
(n.b. non-ishaemic priapism is suitable for observation)
Medical emergency
1st line = aspiration of blood rom cavernosa, while injecting saline flush to clear viscous blood that has blood
Or inject vasoconstrictive agent e.g. phenylephrine
Surgery can be considered if above fail
Chronic fatigue syndrome has a diagnosis after what timeframe
3 months
Denosumab is a treatment for osteoporosis
what is its category and mechanism of action
Human monoclonal antibody
Prevents development of osteoclasts by inhibiting RANKL
the 6 A’s of ankylosing spondylitis
Apical fibrosis
Anterior uveitis
Aortic regurgitation
Achilles tendonitis
AV node block
Amyloidosis
Plain XR of sacroiliac joints in ankylosing spondylitis may be normal, but later changes, what 5 things may be seen?
- Sacroilitis - subcondral erosions, sclerosis
- Squaring of lumbar vertebrae
- Bamboo spine
- Syndesmophytes
- Apical fibrosis on CXR
If the xray is negative for sacroiliac involvement but suspicion for ankylosing spondylitis is still high, what is the next step?
MRI
- early inflammation may show oedema
what BMI warrants referral for bariatric surgery
over BMI 40
3 categories of bariatric surgery and the subtypes
- Restrictive operations
- laparoscopic-adjustable gastric banding (LAGB)
- sleeve gastrectomy
- intragastric balloon - Malabsorptive operations
- biliopancreatic diversion with duodenal switch - usually if BMI >60 - Mixed (restrictive + malabsorptive) operations
- Roux-en-Y gastric bypass
Taller than average
Lack of secondary sexual characteristics
Small bilateral testes
Chr XXY
Infertility
High FSH, low testosterone
what is the condition
Klinefelter’s syndrome
Acromegaly is abnormality of what hormone
Increased growth hormone
What is the commonest cause of acromegaly
Pituitary adenoma
results in increased GH
what is subclinical hypothyroidism defined as
normal T3/T4
high TSH
no obvious symptoms
What HbA1c levels indicate pre-diabetes/high risk
42-47mmol/mol
(6.0-6.4%)
black patient with T2DM and hypertension
what is first line anti-hypertensive
Angiotensin receptor blocker (ARB)
in pregnancy what changes of thyroid occur (for hyper and hypothyroidism)
Hyper/thyrotoxicosis:
- Increases thyroxine-binding globulin which increases total thyroxine (not free)
- Also activation of TSH receptor by hCG can occur
Hypothyroid:
- Increased doses of levothyroxine are needed
what is the most common cause of thyrotoxicosis in the pregnancy
Grave’s disease
- it is also the commonest for the UK!
Maternal thyroid levels should be kept to what in terms of the reference ranges to avoid foetal hypothyroidism
Upper third of normal free thyroxine levels
Diabetes sick day rules
T2DM
What should be done about medication?
If taking oral hypoglycaemics
STOP some of these
Risk of hypoglycaemia
Diabetes sick day rules
T1DM and T2DM
What should be done about insulin?
Continue insulin!
Do not stop otherwise risk of DKA
Diabetes sick day rules
T2DM
What should be done about medication if taking metformin?
Stop metformin
Risk of dehydration and lactic acidosis
Diabetes sick day rules
T2DM
What should be done about medication if taking SGLT-2 inhibitors?
Check for ketones
Stop if acutely unwell or at risk of dehydration due to risk of DKA
Diabetes sick day rules
T2DM
What should be done about medication if taking GLP-1 receptor agonists?
Stop treatment if risk of dehydration
To reduce risk of AKI
what diabetic medication should be avoided in pregnancy and breastfeeding?
sulfonylureas
remember only metformin + insulin are given in pregnancy!
dopamine effect on prolactin
dopamine inhibits prolactin
NICE advises that you risk stratify patients in terms of diabetic foot into:
(a) low risk
(b) moderate risk
(c) high risk
what are the criteria of each?
(a) low risk - only callus
(b) moderate risk - deformity, neuropathy or non-critical limb ischaemia
(c) high risk - previous ulcer, amputation, RRT, non-critical limb ischaemia with any of the above issues
what medication class reduce hypoglycaemic awareness
b-blockers
thiazolidinediones e.g. pioglitazone, mechanism of action
reduce peripheral insulin resistance
adverse effects and contraindications of thiazolidinediones e.g. pioglitazone
weight gain
liver impairment
fluid retention - contraindicated in heart failure
bladder cancer
what makes HbA1c result unreliable
anaemia (haemolytic + IDA)
haemoglobinopathies
HIV
What is the mechanism of 5 a-reductase deficiency syndrome?
inability to convert testosterone to 5 alpha-DHT
Hypothyroidism
Painless goitre
Anti-TPO antibodies
what is the diagnosis
Hashimoto’s thyroiditis disease
