Endo Flashcards
1
Q
What is the management plan for Acromegaly?
A
- 1st Line - trans-phenoidal hypophysectomy
- + Neoadjuvant Radiotherapy to shrink pituitary
- Medicaition if surgery contraindicated
- 2nd Line - Subcutaneous somatostatin anologue = octreotide
- Dopamine agonist for hyperprolactinaemia (cabergoline, bromocriptine)
- 3rd Line - GH agonist e.g. Peguisomant
2
Q
What is the management plan for Addisonian Crisis?
A
- Rapid IV rehydration + 50ml 50% dextrose
- IV 200mg bolus hydrocortisone followed by 100mg/6hr until normalised BP
- Treat cause of crisis e.g. ABx for infection
- Monitor regularly
3
Q
What is the management plan for Chronic Adrenal Insufficiency?
A
Note - aim of treatment is to replace relevant hormones lost
- Glucocorticoids - Hydrocortisone (3/day)
- Increase dose during illness/stress
- If hypothyroid always give hydrocortisone before thyroxine
- Mineralocorticoids - Fludrocortisone
- Advice - wear steroid warning card and medic alert bracelet
4
Q
What is the management plan for Cushing’s Syndrome?
A
- If iatrogenic cause discontinue steroids gradually w/ low-dose or steroid sparing to avoid addisonian crisis
- Surgical - 1st Line = transphenoidal adenoma resection if ACTH dependent
- If ACTH independent or ectopic - surgical removal of tumour and treatment of mets
- Carcinoma usually requires adrenolectomy
- If ACTH independent or ectopic - surgical removal of tumour and treatment of mets
- Medical therapy = 2nd Line or if surgery contraindicated
- Metyrapone or ketoconazole to reduce cortisol synthesis
- Ketoconazole causes severe liver damage
- Monitor LFTs and treat osteoporisis
- Also hydrocortisone and fludrocortisone required post-op
- Metyrapone or ketoconazole to reduce cortisol synthesis
- 3rd Line = Radiotherapy (often done alongside surgery)
- 4th Line = Bilateral Adrenolectomy
5
Q
What is the management plan for Diabetes insipidus - cranial and nephrogenic?
A
- Cranial - identify cause w/ CT/MRI head
- 1st Line = oral desmopression
- IV/Oral fluids if dehydrated
- Can use chlorpropamide/ carbamezapine to potentiate limited vasopressin
- 1st Line = oral desmopression
- Nephrogenic
- 1st Line = maintanence of adequate fluid intake and treat the cause if possible
- Consider hydrochlothiazide - Inhibits NaCl in DCT which increases compensatory Na+ absorption in PCT
6
Q
What is the management plan for T1DM?
A
- Monitor - regular capillary glucose tests + Hba1c every 3/6 months
- Screen and manage complications e.g. RFTs and fundoscopy
- Glycaemic control - education and advice e.g. increase dose when stress/ill and control lifestyle factors
- 1st Line = Basal-Bolus Regime
- LA insulin - once/twice daily e.g. insulin glargine
- SA insulin - pre meals e.g. insulin lispro/aspart/glusiline
- Consider pramlitide - amylin analogue alongside
- Note if gastroparesis
- 2nd Line = Fixed dose insulin - subcut twice daily
- 1st Line = Basal-Bolus Regime
7
Q
What is the management plan for diabetic induced hypoglycaemia?
A
- If reduced consciousness = 50% 50ml IV glucose or 1mg IM glucagon
- If conscious = 50g oral glucose + starch snack
8
Q
What is the management plan for DKA?
A
Diagnosis = pH < 7.3, hyperglycaemia and ketonaemia
- 1st Line = IV Fluids
- If SBP >90 = 0.9% saline transfusion
- If SBP <90 = 500ml bolus
- Supportive care and ICU admission
- Consider K+ therapy if <5.3mmol/L
- IV insulin neutral (only once K+ reaches 3.3mmol/L if below 3.3)
- If severe volume depletion use vasopressors
- if pH <7 = Sodium Bicarbonate therapy
- Very dangerous so be careful
Treat precipitating cause if possible e.g. infection
9
Q
What is the management plan for T2DM?
(probably should refer directly to amir sams lectures)
A
Step wise approach to glycaemic control
- At diagnosis = Lifestyle changes e.g BP/lipid/glucose management
- e.g. weight loss, exercise, smoking + alcohol cessation
- Serum glucose >16.6 mmol/L or HbA1c >86 or symptomatic
- 1st Line = basal/bolus regime + CVS/lifestyle management
- consider metformin in absence of N+V
- 1st Line = basal/bolus regime + CVS/lifestyle management
- Serum glucose <16.6 mmol/L or HbA1c <86mmol
- 1st Line = Metformin + CVS/Lifestyle management
- 2nd Line = Add on - case specific (refer to Amir)
- Sulphonylurea e.g. gliclazide
- if metformin not tolerated 1st Line
- SGLT2 inhibitors e.g. empaglifozin
- GLP-1 agonist e.g. liraglutide
- good CVS/ kidney/ mortality effects
- DPP4 inhibitor e.g. stagliptin
- Sulphonylurea e.g. gliclazide
- 3rd Line = If 2nd Line fails but sustain metformin
- a-glucosidase inhitor e.g. acarbose
- Thiazolideinedione e.g. pioglitazone
- Not in HF or at risk of HF
- 4th Line = consider bariatric surgery
- Regular screening for microvascular complications
- Hyperosmolar Hyperglycaemic state = same as DKA
10
Q
What is the management plan for Dyslipidaemia?
A
- Lifestyle advice - BMI target of 20-25 + increase exercise
- Diet w/ <10% calories from saturated fat
- HIgh fibre, fruit and veg, Omega 3 Fatty acids
- Treatment varies between familial and secondary hyperlipidaemia
- Medication
- 1st Line = statins e.g. simvastatin/ atorvostatin
- 2nd Line = fibrates e.g. bezafibrate
- Or cholesteral absorption inhibitors e.g. ezetimibe
- note - hypertriglycerolideamia responds best to fibrates
- Statins are expensive and limited to given priority to:
- Known CKD -> T2DM -> 10 yr risk of CKD >20%
11
Q
What is the management plan for Primary hyperparathyroidism?
A
- If no surgical intervention + asymptomatic - Monitor + Vit D supplements
- If surgical indication/symptomatic - parathyroidectomy + Vit D supplements
- consider bisphosphanates if osteoporosis presents
12
Q
What is the management plan for secondary Hyperparathyroidism?
A
- Treat the cause
- Low Vit D - 1st Line Increase UV exposure –> Vit D + Calcium supplementation
- Malabsorption - treat disease + Vit D + Calcium supplementation
- CKD - stage 3/4 = decrease dietary phosphate + ergocalciferol
- If stage 5 = parathyroidectomy
13
Q
What is the management plan for Hypopituitarism?
A
Usually from the perspective of hormone replacement (unless pituitary apoplexy - IV hydrocortisone to stop CVS collapse)
- ACTH = oral corticosteroids (consider IV instress/illness)
- TSH = Levothyroxine
- GnRH - If fertility desired = gonadotrophins
- If fertility not desore = oestrogen + progesterone in women and testosterone in men
- GH = Recombinant human GH e.g. somatotrophin
- ADH/vasopressin = Desmopressin
Remember to always treat cause
14
Q
What is the management plan for Hypothyroidsm?
A
- Chronic Primary - 1st Line = levothyroxine
- gradually increase to 25mg/kg to normalise TSH
- note - >60 yrs require low dose levothyroxine
- rule out addisons disease as levothyroxine can precipate addisonian crisis
- Secondary - Levothyroxine but adjust to T4 not TSH
- If pituitary adenoma - can perform transphenoidal hypophysectomy
- Myxoedema Coma - O2, Rewarm, Rehydrate, IV hydrocortison
- IV T3 (Liothyronine) - faster onset than T4
15
Q
What is the management plan for Osteomalacia?
A
- Vit D deficiency - 1st Line = Oral D3 (Colecalciferol) + Calcium carbonate
- If taking anti-convulsants, glucocorticoids dose is increased
- If Hepatic Disease - Oral Vit D2 (Ergocalciferol)
- Inherited disorder, phosphate wasting or oncogenic osteomalacia
- 1st Line = calcitriol + sodium phosphate + calcium carbonate
- monitor - serum calcium, phosphate, ALP, PTH, Vit D
- Treat underlying cause
