Endocrine Flashcards
What is diabetes insipidus and what are the two causes?
- DI is where large amounts of dilute urine are produced, causing extreme thirst.
- Happens when hypothalamus does not make enough ADH (Cranial).
- Or when kidneys do not respond to ADH (Nephrogenic)
- Cranial treated with desmopressin or vasopressin
- Nephrogenic treated with paradoxical effect of TLDs
What is the main side effect of desmopressin?
-Hyponatraemia
Describe syndrome of inappropriate ADH secretion
- Opposite of DI: Too much ADH is produced causing hyponatraemia
- Treated with fluid restriction, demeclocycline or vasopressin antagonist (tolvaptan)
What are the main side effects of mineralocorticoids?
- Water and sodium retention = hypertension
- Hypokalaemia
- Hypocalcaemia
Which steroids have the most glucocorticoid and mineralocorticoid effect?
- Fludrocortisone has most mineral
- Dexamethasone and betamethasone have most gluco
- Hydrocortisone has useful amount of both
Outline the main CCS side effects
- Diabetes and hyperglycaemia
- Osteoporosis
- Muscle wasting
- GI issues
- Psychiatric reactions
- Immunosuppression
- Adrenal suppression (Adrenal gland stops making its own steroids)
- Ophthalmic issues
- Skin thinning
- Growth restriction
- Cushings syndrome
- Increased appetite and weight gain
In what circumstances should CCS be gradually withdrawn?
- More than 3 weeks use
- More than 40mg daily for 1 week
- Repeat evening doses
- Recent repeated courses
- Short course within 1 year of stopping long term therapy
- If adrenal suppression occurs
Describe Addison’s disease
- Low cortisol and aldosterone levels
- Replacement with hydrocortisone and fludrocortisone necessary
- Hydrocortisone given BD: higher in morning and lower in evening
Describe Cushing’s syndrome
- Opposite of Addison’s: Hypercortisol
- Treatment is with ketoconazole or metyrapone (cortisol inhibitor)
Outline DKA and symptoms
- When blood glucose and blood ketones are very high
- Symptoms are: Pear-drop breath, ketonuria, thirst, polyuria, confusion, drowsiness, etc.
- Treated with soluble insulin and fluids
- Potassium given unless anuria
- Established long acting insulins are continued
Outline the rules for driving and blood glucose
- Check BG less than 2 hours before journey and every 2 hours during journey
- If over 5 then safe to drive. If less than 5 then eat carb before driving. If less than 4 then do not drive.
Which insulins are rapid acting?
- Aspart (Novorapid)
- Lispro (Humalog)
- Glulisine (Apidra)
- Take just before or after a meal*
Which insulins are short acting?
- Insulin
- Actrapid, Humulin S, Insuman rapid, HPN, HBN
- Take 30 minutes before food
Which insulins are intermediate acting?
- Isophane insulin
- Insulatard, Humulin I, HBI, HPI, Insuman basal
- Usually given 30-60 minutes before food
Which insulins are long acting?
- Glargine (Lantus)
- Detemir (Levemir)
- Degludec (Tresiba)
- Used once daily, except Levemir which is once or twice daily*
Outline a basal-bolus insulin regimen
-Short/rapid acting insulin before meals (Bolus) and intermediate/long acting once or twice daily (Basal)
Outline a biphasic insulin regimen
- Short/rapid insulin pre-mixed with intermediate/long insulin
- Given once or twice daily before meals
- Not suitable if changing requirements
Outline long/intermediate insulin regimen
- Long/intermediate given once or twice daily
- Used with or without rapid/short acting insulins before meals
- Not routinely used in type 1
What insulin regimens are preferred in Type 1 and 2 diabetes?
- Basal/bolus preferred in type 1
- Isophane and short acting preferred in type 2 as biphasic or basal/bolus.
What are sick day rules for diabetics
- Monitor BG and blood and urine ketones every 3-4 hours, even at night
- If blood ketones >3 or urine >2 then contact GP
Describe metformin
CV benefit: Yes Hypo risk: Low Weight: Decrease RI: Avoid if <30, max dose 2g in 45-49 Warnings: Lactic acidosis, anaesthesia, contrast media
Describe sulphonylureas
CV benefit: No Hypo risk: High Weight: Gain RI: Caution (Increased hypo risk) Warnings: Gliben and glimep are longer acting
Describe pioglitazone
CV benefit: Probable (but fluid retention)
Hypo risk: Low
Weight: Gain
RI: Dose unchanged
Warnings: Heart failure, Bladder Cancer (do not use w/ dapa), Hepatotoxicity, fractures
Describe SGLT2Is
CV benefit: Yes
Hypo risk: Low
Weight: Decrease
RI: Avoid initiation if <60, stop if often <45
Warnings: Atypical DKA, Volume depletion, lower limb amputation, Fournier’s gangrene, UTI/GUIs
Describe DPP4Is
CV benefit: No Hypo risk: Low Weight: Neutral RI: reduce dose Warnings: Pancreatitis, hepatotoxicity
Describe GLP1As
CV benefit: Yes Hypo risk: Low Weight: Decrease RI: avoid if <30 Warnings: DKA if concomitant insulin rapidly withdrawn, Pancreatitis, effective contraception required
Describe HbA1c targets in type 2 diabetes?
- Aim for <48(6.5%) if diet controlled or on a single agent
- Intensify treatment if HbA1c rises to 58 (7.5%)
- If on multiple meds then aim for 53(7%)
Outline daily BG targets
Before meals: 4-7
After meals: 5-9
Bedtime: 6-8
Monitor BG: at least 5 times daily
What is the HbA1c target in type 1 diabetes?
<58 (7.5%)
What are the symptoms of hypoglycaemia?
- Tingling lips
- Pale
- Sweats and shakes
- Dizziness
- Palpitations and tachyC
- Hunger
- Anxiety and tremor
- Drunk behaviour
- BG<4
How is hypoglycaemia treated?
- If conscious: 15-20g rapid acting carbs (100-200ml coke, 50-100ml lucozade, 2-4tsp sugar, 2 tubes glucogel, 4-6 glucose tabs, etc)
- Retest after 10-15 mins
- Repeat if BG<4. If >4 then give long acting carb
What form of HRT are women who have had a hysterectomy (no womb/uterus) given?
-Continuous oestrogen only HRT
What form of HRT are women with a uterus given and why?
- Cyclical or continuous combined HRT
- This is because oestrogen thickens the endometrial lining (Not present if hysterectomy) and progestogens reduce this effect
- Ci pre-menopause
Outline the risks of Cancer with HRT
- All HRT increases risk of breast and Ovarian Cancer
- Oestrogen only HRT increases risk of endometrial cancer
- Combined HRT decreases risk of endometrial cancer
What blood tests signify hyperthyroidism?
- Increased T3 and T4
- Decreased TSH (Caused by negative feedback)
What blood tests signify hypothyroidism?
- Decreased T3 and T4
- Increased TSH
How is hyperthyroidism treated in pregnancy?
- Propylthiouracil in first T
- Carbimazole in 2nd T
