Endocrine Flashcards
What is type 1 diabetes?
Chronic metabolic disorder as a result of destruction of Beta-cells in the islet of Langerhans resulting in abrupt cessation of insulin production
What are signs and symptoms of DM?
Polydipsia, polyuria, polyphagia, weight loss. Blurred vision, fruity breath, ketones in urine
What are microvascular complications of DM
Retinopathy, nephropathy, neuropathy
What are macrovascular complications of DM
Atherosclerosis, CAD, MI
What are risk factors for T2DM
- BMI >25
- Abdominal Obesity
- Sedentary lifestyle
- Metabolic Syndrome
- Family Hx
- Hispanic, black, Asian, pacific islander or American Indian descent
- Hx of GDM
- Impaired FBG
Dx criteria for DM
A1C >/= 6.5% *
FPG >/= 126 mg/dL *
OGTT >/= 200mg/dL *
Random glucose >200mg/dL
*Requires confirmation on repeat test unless hyperglycemia is unequivocal
Impaired FBG is defined by an A1C of between ____ and/or _____, FPG between ____ and ____, and/or 2hr OGTT (75g) between ____ and _____
A1C 5.7%-6.4%
FPG: 100-125mg/dL
OGTT: 140-199mg/dL
What is the goal A1C according to the ADA in
a) Most T2DM
b) Older patients
c) T1DM and pregnancy
a) 7%
b) 8%
c) 6%
You should check A1C q____ months until target or when adjusting therapy then ____
3 months then 6-12 months
What labs aside from A1C should be ordered in a newly diagnosed DM
Fasting lipids, lytes, TSH, LFTs, Kidney Function, Microalbuminuria
At every visit with a diabetic patient what should you assess?
BMI
BP
Feet
Blood glucose control
What is the ADA’s screening recommendation for T2DM
1) Annually with a BMI >25 with 1 or more risk factor
2) Q3 years in individuals 45 years old or older
In Impaired fasting glucose when would you consider adding metformin?
- A1C 5.7-6.4%
- <60 years old
- BMI >35
- Hx of GDm
What is 1st line treatment for T2DM
Metformin
What are the side effects of metformin?
GI upset (nausea, vomiting, diarrhea), lactic acidosis
What decrease in A1C is noted with metformin use?
1-2%
What is level 1 HYPOglycemia?
Blood glucose = 70mg/dL
What is level 2 HYPOglycemia?
Blood glucose = 54 mg/dL
What are the signs and symptoms of hypoglycemia?
Sweaty palms, fatigue, dizziness, rapid heart rate, confusion, weakness, hand tremors, anxiety, coma, death
What drug can blunt the body’s hypoglycemic response?
Beta Blockers
What is the function of FSH?
- Stimulates ovaries to enable growth of follicles
- Stimulates production of estrogen
What is the function of LH
- Stimulates ovaries to ovulate
- Stimulates production of progesterone by corpus luteum
- In males stimulates the testicles (leydig cellst to produce testosterone)
What is the function of TSH?
Stimulates the thyroid to produce T3 and T4
What is the function of ACTH?
Stimulates the adrenal glands to produce cortisol and aldosterone
What is the Dawn Phenomenon
An hormonal event causing elevations in the FPG daily in the am (between 4-8am)
- Without a normal insulin response, there will be a rise in FPG
- Normally people produce enough insulin to combat
What is the Somogyi Effect?
Severe nocturnal hypoglycemia stimulates counterregulatory hormones (ie. glucagon) into systemic circulation resulting in an increase in FPG by 7am
What is the treatment for hypoglycemia
-Rule of 15s
15g of Carbs to raise BG in 15 minutes
How should a T2DM adjust BG and meds with illness and surgery
No change to meds unless FBG is lower than normal
-Frequently monitor BG
What are fundoscopic eye changes that can be noted on exam of a patient with diabetic retinopathy?
- Neovascularization
- Microaneurysms
- Cotton Wool Spots
- Soft and Hard Exudates
What is Charcots Foot
Deformity of the foot and ankle caused by bone and joint deformity (dislocation and fracture) related to neuropathy and loss of sensation
What are examples of Sulfonylureas?
Glipizide, Glyburide
What is the MOA of sulfonylureas
Stimulates beta cells to secrete more insuline
What are AE of Sulfonylureas
Increase risk of CV mortality, hypoglycemia, blood dyscriasis, weight gain
What drop in A1C is expected with a sulfonylurea?
1-2%
What is an example of a thiazolidinediones
Pioglitazone (Actos)
What is the mechanism of action of a thiazolidinedione?
Enhances insulin sensitivity in the muscle tissue (decreasing peripheral resistance) and decreasing hepatic glucagon production
What are contraindications to thiazolidinediones?
Heart failure (causes water retention and edema), bladder cancer, active liver disease, T1DM and pregnancy
What is an expected drop in A1C with Actos?
0.7%
What is the MOA of Bile Acid Sequestrants in DM?
-Decreases hepatic glucose production and decreases intestinal absorption of glucose
What are side effects of bile acid sequestrants?
- Nausea
- Bloating
- Constipation
- Increased triglycerides
What is an example of a meglitinide (glinides)
Repaglinide (Prandin), nateglinide (starlix)
What is the MOA of Meglitinide?
Stimulates pancreatic secretion of insulin
If a patient has irregular meal times, what T2DM could be considered?
Meglitinide r/t rapid action
What is the onset of rapid acting insulin
Lispro/aspart/glulisine
15 minutes
What is the peak of rapid acting insulin
Lispro/aspart/glulisine
0.5-2.5 hrs
What is the duration of rapid acting insulin
Lispro/aspart/glulisine
4.5 hrs
What is the onset of short acting regular insulin?
30 minutes
What is the peak of short acting regular insulin?
1-5 hrs
What is the duration of short acting regular insulin?
6-8 hrs
What is the onset of Intermediate NPH insulin?
1 hr
What is the peak of Intermediate NPH insulin?
6-14 hr
What is the duration of Intermediate NPH insulin?
18-24 hr
What is the onset of basal insulin Lantus (glargine) and Levemir (Detemir)
1 hr
What is the peak of basal insulin Lantus (glargine) and Levemir (Detemir)
None
What is the duration of basal insulin Lantus (glargine) and Levemir (Detemir)
24 hrs
What are examples of GLP-1 receptor agonist?
Exenatide, liraglutide
What is the mechanism of action of GLP-1 RA
stimulates GLP-1 increasing insulin production , inhibiting postprandial glucagon release
-increasing satiety, decreased postprandial hyperglycemia
What are contraindications to a GLP-1 RA
Hx or Fhx of medullary thyroid cancer, multiple endocrine neoplasia syndrome
What is the benefits of a GLP-1 RA
- Decreases CV events
- Renal protective
- Weight loss
What is the expected drop in A1C with a GLP-1 RA
1-1.5%
What are examples of SGLT2i
Canagliflozin (Invokana), Dapagliflozin (Farxiga), empagliflozin (jardiance)
What is the MOA for SGLT2i
Blocks glucose reabsorption by the kidneys in the proximal nephron, increased glycosuria
What are benefits of SGLT2i
- weight loss
- reduced CV events
- renal protective
What are AE of SGLT2i
- DKA
- Polyuria
- Increased creatinine
- Increased UTIs
What are examples of DPP-4 inhibitor
Sitagliptin, saxagliptin, linagliptin
What are adverse effects of DPP-4 inhibitor
Joint pain, angioedema, urticaria, pancreatitis
What is the expected drop in A1C with a DPP-4 inhibitor
0.7%
What is the expected drop of A1C with SGLT2i
0.6-1%
Rapid insulin covers ___
1 meal at a time
Regular insulin lasts ___ to ___
meal to meal
NPH lasts ___ to ____
Breakfast to dinner
Lantus lasts ___
24 hours
What is a recommendation for treatment with an A1C >/= 9
Dual Therapy
What is the recommendation for an A1C >/= 10
Injectable insulin
What med do you need to consider stopping if you are going to initiate insulin therapy and why?
-sulfonylureas because of increased risk of weight gain
What T2DM meds cause weight gain
Sulfonylureas, insulin, TZD
What oral T2DM has highest risk of hypoglycemia
Sulfonylureas
What are symptoms of thyroid cancer
Single thyroid nodule on upper 1/2 of the lobe, cervical lymphadenopathy, hoarseness, swallowing issues
What are RF for thyroid cancer?
Radiation in childhood, low iodine diet, asian, women (3:1)
What are the lab findings for HYPERthyroid
Low or undetectable TSH, elevations in T4 +/- T3
What is the most common cause of HYPERthyroid
Graves- an autoimmune disorder causing hyperfunction and production of excess thyroid hormone
What are sx of HYPERthyroid
Weight loss, anxiety, insomnia, cardiac (palpitations, tachycardia, atrial fibrillation, premature atrial contractions, hypertension), warm/moist skin, opthalmopathy, lid lag, increased frequency of bowel movements, amenorrhea, heat intoleranace, enlarged thryoid (goiter), pretibial myexedma, tremors, brisk reflexes
What are the treatments for HYPERthyroid?
PTU preferred (safe in pregnancy)
Methimazole (Tapazole)
Radioactive iodine
Beta blockers for symptom control
What are the lab values for Hypothyroidism
Elevated TSH (>5mU/L) Low T4
What would be a difference in lab values for a subclinical hypothyroidism
Elevated TSH but normal T4
What is a risk of chronic amenorrhea and hypermetabolism in hyperthyroidism
Osteoprosis
How do you initiate basal insulin
Start at 0.1-0.2 u/kg or 10 units
-Adjust 2-4u 1-2x weekly until you reach target FBG (80-125)
What is the dosing for synthroid
- 6mcg/kg
- In older adults start at 12.5- 25mcg
*Note: 1/2 life of synthroid is 1 week so if overdose sx can take a while to revert
What are risks of levothyroxine (synthroid)
A.Fib, accelerated bone loss
What education should be provided re: insulin pump in water
Disconnect when showering, bathing or swimming
What is a pheochromocytoma
A rare adrenal tumor that releases hormones
What are sx of pheochromocytoma
Diaphoresis, tachycardia, hypertension that occurs episodically
What triggers attacks of hormone surges with a pheochromocytoma?
Stress, physical exertion, anxiety, surgery, anesthesia, foods with tyramine, stimulants, foods that are MAOI rich
What are the characteristics of metabolic syndrome?
1) Abdominal Obesity (men >40 inches, women >35 inches)
2) HTN BP >130/85
3) Hyperglycemia FPG >100 or T2DM
4) Elevated triglycerides (>150mg/dL) or being treated for same
5) Low HDL (<40mg/dL in men, <50mg/dL in women) or tx for same
If a patient has an elevated TSH (>5) what other blood work is needed
-repeat TSH and add a free T4
In a patient with an elevated TSH but normal T4 when should you recheck the TSH and T4?
6 months
How often should you check a TSH when monitoring response to treatment?
q6-8 weeks
*No earlier than 6 weeks
Alopecia of the outer 1/3rd of the eyebrow and myxedema are symptoms of
Hypothyroidism
Lid lag is a symptom of
Graves’ opthalmopathy
If a patient’s A1C is >/= you should consider
Dual therapy or basal insulin,
if already on 2 drugs start basal insulin
