Endo - mx Flashcards
Cranial DI management
- DDAVP
- Treatment of underlying cause
- Adequate fluid intake
Nephrogenic DI management
- Adequate fluid intake
- Treatment of underlying cause
- Low sodium diet (<500mg/day)
- Hydrochlorothiazide (thiazide diuretic), indometacin (NSAID)
- genetic/severe DI - intermittent catheterisation to decrease urinary tract backpressure complications
T1DM management
Insulin
Background insulin - basal bolus insulin
- Long acting insulin analogues- Galgrine, detemir, degludec
Insulin with meals- Short acting insulin analogues - Lispro, aspart, glulisine
Aim for glucose level
5-7 mmol/L upon waking
4-7 mmol/L before meals
All patients with diabetes and CVD should be treated with aspirin for secondary prevention
Need to monitor capillary glucose
T2DM management
- Lifestyle changes [1st line]
- Glycaemic control [2nd line i.e. not all patients with T2DM are on metformnin]
Metformin as initial therapy if HbA1c >6.5% // 48mmol/mol
If after lifestyle changes + metformin, blood glucose is still >7.5% // 58mmol/mol add a second drug - Sulphonyluras (preferred)
- GLT-1 agonist
- SGLT-2 inhibitor
Add sulfonylureas (gliclazide, glibenclamide) in young patients, as the get older + develop CVD switch to GLP1 agonists if they have CAD (exenatide, liraglutide) or SGLT 2 inhibitors if they have HF (empagliflozin) as they are more cardioprotective
triple therapy with: Third line metformin, sulfonylurea, DDP4 inhibitor metformin, sulfonylurea, pioglitazone Insulin if HbA1c remains >7.5% on metformin + sulphonylurea
Thiazolidinediones/pioglitazones are used as a 3rd line therapy – enhance actions of endogenous insulin
Should NOT be used in patients with cardiac failure – they cause Na + fluid retention
When is metformin contra-indicated and what can be used instead
- Contra-indicated in conditions that can precipitate lactic acidosis
Mild renal failure
Severe liver failure
Severe heart failure
Alcoholism
Respiratory disease
Metformin decreases the liver uptake of lactate
Metformin is renally excreted so in people with renal failure, it will accumulate in the body
Instead we can use
DDP-4 inibitors/gliptis - sidagliptin, vidagliptin
Glitazones - pioglitazone
Sulphonylureas - Gliclazide, gibenclamide
The main complication of T1DM is hypoglycaemia
Clinically signs + mx
Clinically significant when <3.0 mmol/L
Higher dose of insulin, decreased food intake, increased physical activity
Focal neurological symptoms Fits Confusion Coma Dizziness Pallor Sweating Palpitations Tachycardia Hunger
Fruit juice, IV dextrose, IM glucagon (1mg) (if you can’t obtain IV access)
- If pt conscious – give fruit juice and then long acting carbohydrates
- If pt confused – use a gel
- If pt unconscious – IM glucagon (1mg) / IV dextrose (20% glucose)
HHS/HONK meaning
Complications
Management
HHS/HONK
Hyperosmolar hyperglycaemic state
Hyperglycaemic hyperosmolar non ketotic coma
Cellular dehydration - fluid shift from extravascular to intravascular compartment
Hypovolaemia - osmotic diuresis
Insulin
IVF
Electrolyte replacement (esp K+ replaement)
Prophylactic anticoagulation (patients w HHS/HONK are prone to thromboebolism)
What are pre-proliferative + proliferative diabetic retinopathy
Mx of diabetic retinopathy
Pre-proliferative - cotton wool spots (retinal ischaemia)
Proliferative - growth of abnormal blood vessels
Pan-retinal photocoagulation for cotton wool spots or abnormal vessels
Indications for dialysis as a result of diabetic nephropathy
- eGFR <10ml/min + benefits outweigh risks
- eGFR <6ml/min + no reversible features
- Life-threatening complications
- Hyperkalaemia (>6.5mM)
- High creatinine (>1000μM)
- Hyperuricaemia (>300mM)
- Symptoms or complications of uraemia (e.g. pericarditis)
- Uraemic encephalopathy
- Fluid overload (severe pulmonary oedema)
- Severe acidosis (pH <7.2) refractory to medical management
Diabetic nephropathy management
- Diabetic control
- BP control
- ACEi
- Stop smoking
- Dialysis
- Transplantation
DKA mx
- Immediate resuscitation
- NBM for at least 6h
- IVF - 500 ml isotonic saline (NaCl 0.9%) over 16-30 mins until SBP >100
if fluid is given too quickly there is a risk of cerebral oedema
if Na >155 mmol/l give 0.45% saline - Insulin at a rate of 0.1 unit/kg/hour
- Potassium phosphate*
<3.3 mmol/L - K given before insulin
3.3-5.3 mmol/L - Insulin can be given before K
>5.3 mmol/L - K does not need to be given- IV insulin once K reaches 3.3 mmol/L
Treatment in some patient groups
- Vasopressors e.g. vasopressin, adrenaline if haemodynamically unstable
- Bicarbonate therapy if HCO3 <5 mmol/L or if pH <7
- Phosphate therapy - if respiratory + skeletal muscle weakness (<1mg/dl)
- NG tube if low GCS
- Thromboprophylaxis (low dose heparin)
*in DKA we have hyperkalaemia (high extracellular K+) but low total body K+
therefore give insulin to push k+ back into cells
give K+ to replenish loss of K+ through diuresis
• Transfer to SC insulin once capillary ketones <0.5mM + pH >7.3 + venous bicarbonate >18 mmol/L
o Don’t stop the infusion until 1-2h after the SC insulin has restarted
https://forums.studentdoctor.net/threads/dka-and-k.710715/
Primary hyperparathyroidism mx
Acute hypercalcaemia
- IVF
- Bisphosphonates (if calcium remains high and if caus eof hypercalcaemia are bony mets)
1st line
- Total Parathyroidectomy
2nd line (if unsuitable for surgery)
- Cinacalcet
(Calcinomimetics) increases the receptor’s sensitivity to calcium to enhance negative feedback and decrease PTH + calcium
- Vitamin D supplementation
Secondary hyperparathyroidism mx
Osteomalacia
Osteomalacia due to CKD
secondary hyperparathyroidism = osteomalacia
Acute hypocalcaemia - IV calcium infusion (calcium gluconate)
Osteomalacia
- Calcium
- Vitamin D supplements (ergocalciferol, colecalciferol)
Osteomalacia due to CKD
- Treat CKD
- Calcium
- Vitamin D (Calcitriol analogues (e.g. alfacalidol))
- Phosphate binders (e.g. sevelamer, lanthanum, calcium acetate) - (if phosphate is high - CKD)
- Calcinomimetics e.g. cinaclcet increases the receptor’s sensitivity to calcium to enhance negative feedback and decrease PTH + calcium
- Phosphate (if phosphate is low - Vitamin D deficiency)
- Parathyroidectomy considered in severe cases refractory to medical treatment
Treatment – for acute hypocalcaemia
Treatment – for acute hypocalcaemia
• IV calcium infusion (calcium gluconate)
Acute hypercalcaemia mx
Acute hypercalcaemia
• IVF (saline)
• Bisphosphonates (if calcium remains high, good for cancer mets, Zolendronate)
• Avoid factors that can exacerbate hypercalcaemia including thiazide diuretics
Karim said don’t give bisphosphonates in patients who don’t have cancer
you would give bisphosphonates if PTH is suppressed in the setting of hypercalcaemia as that would suggest cancer
Cerebral oedema is a complication of DKA
How do you treat it?
Mannitol infusion
Mechanical ventilation
To decrease the raised ICP
Hypothyroidism mx
- Levothyroine (T4)
25-200μg daily
Initial dose in healthy pt - 50μg
Initial dose in elderly/pt w IHD - 25μg + gradually increase [to avoid worsening angina or precipitating an MI]
Titration in small increments every 6 weeks to therapeutic dose + monitor for ischaemic symptoms
Monitor TFTs after 6 weeks and adjust dose accordingly - Monitor by serum TSH and serum T4
Before starting thyroid replacement therapy, rule out + treat adrenal insufficiency (e.g. as a result of secondary hypothyroidism where there is a problem with the pituitary). Giving thyroxine to someone with a concomitant glucocorticoid deficiency can precipitate an Addisonian crisis.
Hyperthyroidism mx
Antithyroid drugs (ATD)
- Propylthiouracil + Carbimazole (inhibit TPO + hormone synthesis) (carbimazole needs 120 days to take effect)
- Potassium iodide
- B blockers (symptomatic relief until ATD start to work)
Graves
- ATD
o 1st line
o Rashes are common (CBZ)
o Agranulocytosis is rare but patients should be warned to report infectious symptoms immediately (CBZ)
o Can use the “block + replace” approach - large amounts of carbimazole to switch off thyroid function + thyroxine
- Radioiodine
o 1st or 2nd line
o Increasingly used for the treatment of thyrotoxicosis at all ages particularly where medical therapy or compliance is a problem, in patients with cardiac disease + in patients who relapse after thyroidectomy
o Commonly used for adenomas or toxic multinodular goitre
o Must avoid pregnancy for 4 months + close contact with pregnant women/young children for 2 weeks
o Hypothyroidism may develop at any stage after the treatment
o Contraindications: pregnancy + breastfeeding - Subtotal thyroidectomy
o 3rd line
o Reserved only for those with large or obstructive goitre + those who can’t take ATD due to allergy or agranulocytosis
o Recommended in young patients with large goitres to remove neck swelling
o More commonly performed for adenoma or toxic multinodular goitre than for Grave’s
o Iodine + CBZ 10-14 days before surgery - control + decrease vascularity of thyroid gland
o Complications: hypoparathyroidism, recurrent laryngeal nerve damage, bleeding into the neck causing laryngeal oedema - B-blockers for symptomatic relief
o rapid relief of thyrotoxic symptoms, controls supraventricular arrhythmias 1y to thyrotoxicosis
Relapse after medical treatment
- Radioiodine
- Surgery
Toxic adenoma/toxic multinodular goitre
- Radiodine
- Surgery
