endocrine Flashcards
management of hyperkalaemia
calcium gluconate
management of a pituitary adenoma
trans-sphenoidal surgery
dopamine agonists- cabergoline
causes of primary, secondary and tertiary hyperparathyroidism
primary- pituitary tumour
secondary- poor absorption of vitamin D (ckd/ digestive problem) or low vitamin D
tertiatry- excess PTH due to hyperplasia of the parathyroid gland from secondary hyperparathyroidism
functions of PTH
vitamin D uptake
enhances vitamin D
increase osteoclast activity
increased calcium absorption in gut
calcium levels in primary, secondary and tertiary hyperparathyroidism
primary- high
secondary- low/ normal
tertiary- high
symptoms of hypercalcaemia
bone pain
renal stones
abdo groans- n&v, constipation
psychiatric moans- depression, fatigue, psychosis
management of hypercalcaemia
correct dehydration
bisphosphonates
what is cushings
excess cortisol
difference between cushings disease and syndrome
syndrome- excess cortisol
disease- excess cortisol due to a pituitary tumour secreting acth
causes of cushings syndrome
excess exogenous steroids
paraneoplastic tumour (usually a Small cell lung cancer secreting ACTH)
adrenal adenoma
presentation of cushings
moon face
central obesity
abdominal striae
buffalo hump
proximal limb muscle wasting
hypertension
T2DM
depression
diagnosis and management of cushings
Dx- oral dexamethasone suppression test, 24 hour urinary free cortisol test
tx- underlying cause
what is a normal anion gap and how to calculate it
normal is 10-18 mmol/L
calculate by positive ions subtract negative ions
side effects of metformin
- gi problems- nausea, diarrhoea
- lactic acidosis
- poor vitamin B12 absorption
cushings disease- metabolic findings
hypokalaemic metabolic alkalosis
what are the functions of aldosterone?
raise BP- increase Na reabsoprtion, increase potassium and hydrogen secretion
what is primary hyperaldosteronism?
adrenal glands producing too much aldosterone
serum renin is low- As excess aldosterone increased BP (due to sodium reabsorption)
causes- bilateral adrenal hyperplasia (most common), adrenal adenoma (Conn’s), familial hyperaldosteronism
what is secondary hyperaldosteronism?
excess renin stimulates more aldosterone
high serum renin and high aldosterone
causes- renal artery stenosis, renal artery obstruction, HF
this is because the decreased blood flow to the kidney results in a decreased BP in the kidney, so therefore renin is secreted to raise blood pressure
features of hyperaldosteronism
hypertension
hypokalaemia
alkalosis
investigations in hyperaldosteronism
aldosterone/ renin ratio
high aldosterone, low renin= primary
high aldosterone, high renin= secondary
BP, serum electrolytes, ABG
CT/ MRI to check for tumour
treatment of hyperaldosteronism
aldosterone antagonists- spironolactone/ eplerenone
surgical removal of adenoma
phaeochromocytoma- presentation
HTN, headaches, palpitations, sweating, anxiety
what is a phaeochromocytoma?
catecholamine secreting tumour (adrenaline)
what are phaeochromocytoma’s commonly associated with?
MEN 2, neurofibromatosis,
investigations to confirm a diagnosis of a phaeochromocytoma
24 hour urine catecholamines
Plasma free metanephrines (metanephrines are the breakdown product of catecholamines, so last longer in the blood, hence less variability, hence this is a more accurate measurement than plasma free catecholamines)
management of a phaeochromocytoma
surgery is definitive
alpha blockers (1st line)- phenoxybenzamine
beta blockers (labetalol)
diabetes- most appropriate second line management (after metformin) if the patient has CVD/ high risk of CVD
SGLT2 inhibitor- dapagloflozin
thyrotoxicosis + tender goitre= ?
subacute (De Quervain’s) thyroiditis
contraindications to metformin
- chronic kidney disease: NICE recommend that the dose should be reviewed if the creatinine is > 130 µmol/l (or eGFR < 45 ml/min) and stopped if the creatinine is > 150 µmol/l (or eGFR < 30 ml/min)
metformin may cause lactic acidosis if taken during a period where there is tissue hypoxia. Examples include a recent myocardial infarction, sepsis, acute kidney injury and severe dehydration
iodine-containing x-ray contrast media: examples include peripheral arterial angiography, coronary angiography, intravenous pyelography (IVP); there is an increasing risk of provoking renal impairment due to contrast
nephropathy; metformin should be discontinued on the day of the procedure and for 48 hours thereafter
alcohol abuse is a relative contraindication
Diabetes management: Biguanide’s
- examples of drugs in class
- action
- side effects
metformin
increase peripheral insulin sensitivity, decrease gluconeogenesis in the liver
SE’s- diarrhoea, abdo pain, lactic acidosis
notes:
- DOES NOT CAUSE HYPOGLYCAEMIA
- if SE’s- can use modified release
Diabetes management: Thiazolidinedione’s
- examples of drugs in class
- action
- side effects
- pioglitazone
- increase peripheral insulin sensitivity, decrease gluconeogenesis in the liver
- SE’s- weight gain, fluid retention, HF
notes:
- DOES NOT CAUSE HYPOGLYCAEMIA
- contraindicated in HF due to fluid retention
Diabetes management: Sulfonylurea’s
- examples of drugs in class
- action
- side effects
- gliclazide, glimepinide, glipizide, tolbutamide
stimulate insulin secretion
SE’s- weight gain, hypoglycaemia
notes:
- increased CVD risk if used as a monotherapy
Diabetes management: DPP-4 inhibitors
- examples of drugs in class
- action
- side effects
sitagliptin, linagliptin, saxagliptin
inhibit DPP4 enzyme- hence increasing the activity of GLP-1 (an incretin)
SE’s- GI upset, URTI, dizziness
Diabetes management: GLP-1 mimetics
- examples of drugs in class
- action
- side effects
exanitide, lixisenatide, dilaglutide
mimic the action of GLP-1 (an incretin)
SE’s- WL, dizziness, GI upset, hypoglycaemia
action of incretins
produced in GI tract
increase insulin secretion
decrease glucose production
slow GI absorption
Diabetes management: SGLT-2 inhibitors
- examples of drugs in class
- action
- side effects
empagliflozin, canagliflozin, dapagliflozin
cause glucose secretion in urine
SE’s- glycosuria causes recurrent UTI’s, WL, DKA
what is Trousseau’s sign and what is it seen in?
Trousseau’s sign: carpal spasm on inflation of BP cuff to pressure above systolic
hypocalcaemia
why is C-peptide used to differentiate between T1DM and T2DM?
C-peptide will be low in individuals with type 1 diabetes mellitus (as the pancreas is not making enough insulin precursor, which breaks down to form C-peptide and insulin) , and normal or high in individuals with type 2 mellitus.
DM- if a patient develops CVD (has an MI etc) what medication must be started?
In patients with T2DM, SGLT-2 (dapagliflozin) should be introduced at any point they develop CVD, a high risk of CVD or chronic heart failure
side effect of SGLT-2- glucosuria- thrush
acute DKA- insulin regime
In the acute management of DKA, insulin should be fixed rate (0.1 units/kg/hour) whilst continuing regular injected long-acting insulin but stopping short actin injected insulin
Addisons- how is the steroid (hydrocortisone) dose split?
Patients with Addison’s disease require steroid replacement therapy to manage their condition. This usually takes the form of standard-release hydrocortisone for glucocorticoid replacement and fludrocortisone for mineralocorticoid replacement. Standard-release hydrocortisone is usually given as two doses, with the larger dose being given in the morning as this more closely resembles the natural daily variation in cortisol secretion from the adrenal glands. A smaller dose is given in the evening.
complication of DKA Tx
cerebral oedema
cushings- metabolic abnormality
hypokalamic metabolic alkalosis
DM- cause of sudden visual loss
vitreous haemorrhage
DM- if need to stop metformin, what monotherapy can be used?
linagliptin
management of proliferative retinpoathy in diabetes
panretinal laser photocoagulation
intravitreal VEGF inhibitors
management of a thyrotoxic storm
beta blockrs, propylthiouracil and hydrocortisone
pregnant woman presents with hyperthyroidism in first trimester- management?
In pregnant woman who develop hyperthyroidism in the first trimester, propylthiouracil is preferred over carbimazole due to lower risk of foetal malformation
first line investigation of a thyroid nodule
Ultrasonography is the first-line imaging of choice when investigating thyroid nodules
