Endocrine Flashcards
1st line treatment for diabetes (hbA1c aim)
- some benefits
- caution
- what if rapid response is needed
What if CI
Metformin, aiming 48- if rises to 58 on 3 months, add
- sick day rules, reduces certain cancer risks
- avoid if egfr <30, caution if <45
- glicazide if rapid response needed
Hypo drug or dual agent = 53
Consider SGLT2 in HF
Other patients is either a DDP4, SU or pioglitazone
What are Sitagliptin, Linagliptin examples of
- some benefits + risks
What are exenatide + linaglitide
DPP4 inhibitors
- no hypos + weight neutral
- avoid in pancreatitis
- Linagliptin good in renal impairment and pregnancy
GLP-1 inhibiors
- np hypos, reduce appetite, weight loss advantage in BMI >30
- pancreatitis risk, spenny injection
Glicazide. + Pioglitazone
SU
- rapid improvement, cheap
- HYPO RISK, weight gain
Thiazolidnones
- no hypos
- weight gain, avoid HF, # risk
- risk of getting bladder ca
Dapaglifozine, Empaglifozin
SGLT2 inhibitor
- no hypo, weight loss
- Diuretic gives CV benefit
Good in CKD + HF (add in as soon at metformin tolerated)
Rex : Sick day rules, avoid ever <60, UTIs, thrush, distal limb ischaemia, Fournier gangrene, DKA
When would you consider stepping up to insulin
What are the requirements
How should you change dose for low BMs, or high
Do you give a long side metformin
If no response on 2 or more drugs (targets <53) every 3 months
0.5 - 1 units/kg - if really low requirement ?MODY 3
Honeymoon period at T1DM often have low requirements initially
10% up if raise
20 % down if hypos
Yes e.g long acting insulin with metformin
Or in T1 basal-bolus of insulin but with metformin if bmi >25
What are the HBA1c targets in
- lifestyle/ single drug
- in 2 drugs
- 48 (6.5%)
- 53 (7%)
What primary prevention who you consider in diabetics
Atrovstatin 20mg in those disease >10years or QRISK >10%
ACE i if hypertensive or ACR >3
Pregnancy advice for those with diabetes
5mg folic acid till 12 weeks
Only drugs allowed are metformin and insulin
STOP ACe i and statins
Aspirin from 12 weeks to reduce pre-eclampsia
Additional hearts an at 20weeks
What is risk factors and then the work up for gestational diabetes
Is glibenclamide an option
When tested if hx of gestatsional diabetes
follow up
BMI >30, previous big baby, family history, high risk ethnicity
OGTT is offered at booking appointment for 24-28 weeks ( positive is FG >5.6, 2hour GT >7.8)
If really high (FG >7 or macrosomia) start insulin +/- metformin
Advised monitoring
Yes, only if can’t tolerate metformin
Tested straight away
Fasting plasma glucose check at 6–13w post-delivery
ABPI where caludication might be present
diabetes
<0.5
>1.4 - calcification
What further Ix should you do at a Na of 129
d/w medics
serum osmo - >275 ?hyperglycaemia
urine osmo <100 - primary polydipisa, high water and toast intake
urine na
results indicating SIADH
some drug causes
low serum osmo + Na
high urine osmo + na
Anti - Ds = SSRIs,, amitriptyline,
anti - E = lamotrigine, valproate, carbamaazpine
cardio - amiordarone, fibrates
others = desmopressin, PPI, ectasy,
Diuretics - more hypovolemic
diabetes inspidus
- different between cranial and renal
- causes of both
another ddx cause of hypernatremia
- cranial (works with desmopressin) - tumour, wolfrans, sheehans
- renal needs thiazide or amiloride - congeneital, hypercalacemia, hypokalaemia, chronic renal disease, lithium, demoolocyline
Dehydration
Differences between a neuropathic and vascular ulcer
- diabetics often have coexisting peripheral neuropathy and peripheral vascular disease
N = warm foot, pressure points, pulses good, normal ABPI, painless, punched out
V = cool foot, absent pulses, reduced or high ABPI, at extremities (between toes), painful
Classification of retinopathy
- treatment
Other bits of diabetic eye
- x 4
Non - proliferative
- aneurysm (blocked swollen vessels), exudate (leaky vessles)
Proliferative
- new vessels
Maculopathy
- invloves the macula
Laser treatment haunts progression but doesn’t restore vision
Cataract
Glaucoma (not increase risk compared to general pop)
Retinal detachment
Ocular nerve palsies
How many diabetics are effected by polyneuropathy
40-50%
Optimise blood glucose in key
Can’t be reverse but amyotrophy (muscle wasting) is reversible with better blood sugar control
Rules for driving on insulin
Have to inform the DVLA (not if only short term e.g. 3months or pregnancy)
1 severe (ie need help) hypo - tell DVLA, 3months off
Should take a blood sugar 2 hour before and 2hour into drive
What BMI is overweight
What BMI is obese
> 25
30
Drug causes of obesity
Steroids, antipyschotics, contraceptives esp depot, SUs, insulin
Obesity aims of treatment
Aim to loose 0.5-1kg/week - target BMI 25
Orlistat - BM >30 or BM >28 with co-morb (BP, DM)
- 3months review, aim 5% weight loss
Surgery - >BMI 40 or 34 with condition that could be improved with weight loss
Meningitis
- tx
- prophylaxis
Benpen 1.2g IM, 600mg <9year, 300mg <1yr (ceftriaxon is alternative for pen)
Prophylaxis is oral ciprofloxacin 500mg single dose or rifampicin 600mg BD or may be used
What levels of hyponatremia would you do emergency admission
Or discuss with medics
<125
125-129
What drugs cause hyponatremia
Diuretics - thiazides mostly, indapamide + hydrochlothiaizide
- loops not as bad, but if given along ACE or spur
SSRI and carbamazepine
Less so - PPI, antipsychotics, TCAs, opiates, NSAIDs, ACEi
What are some causes of spurious hyperNa
Hyperglycaemia (serum osmo high)
High proteins e.g. paraproteinuria in myeloma
Lipids e.g. triglycerides
If suspects SIADH - what biochemistry are you expecting
Causes
Low serum Na
Serum osmo <275
High urine Na
High urine osmo
Malignancy - lung (SCLC), gastric, urinary, lymphoma, sarcoma
Resp - Pneumonia, TB, asthma
Neuro - stork, tumour, meningitis
Endo - hypothyroid
Mild hypo (130-135)
- reviews meds, when repeating
2 weeks with osmolalities
Differentials for hypovolaemic hyponatraemia
GI loses, sweating, renal losses (dieurtics)
Primary adrenal insufficiency (raised K, raised urinary excretion of Na)
Third space los - sepsis, pancreatitis, GI obstruction
Hypernatraemia numbers - commoners cause
> 160 = emergency admission
150-159 = specialist advice
145 = managed primary care
Dehydration
- serum osmo high too is gold standard
What other causes of hypernatreamia
Dehydration, diarrhoea - ask in history. Stop dieurtics, encourage fluids
Euvoleic - diabetes insidious? (Cranial +ve suppression test, or renal = thiazide)
Hypervolaemic = conns/hyperaldosteormi, too much fluid
What are some of the drugs causes of hyperkalaemia
NSAIDs
ACE/ARB
Heparin
Trimethoprim, co-trimazole
Laxatives - macrogel
Spironolactone, Eplerenone
(BB + dig tox can potentate risk too)
If mod k (numbers)
- what are you doing
- what in mild
6 - 6.4 = rpt in 24hours, admit if unwell
5.5 - 5.9 = rpt in 2 weeks if well, if AKI or unexpected, r/v and rpt in 3 days
In hypokalaemia - what levels are you thinking admission for IV
What is treatment plan in mild
<2.5 = admit!, 2.5-3 = r/v + most likely admit as will need IV
3.1 - 3.5 = rpt in 3 days, review meds
Only really giving supplements in stable causes such as stoma output
Main causes of hypokalaemia
Fluid loss
Loop, thiazide, insulin, salbutamol, ripserdone, quetiapine, theophylline, corticosteroids, excessive laxative use
Hypomagnesioa ! In 40% - alcoholics, chronic diarrhoea, PPI
Some food sources of K
Mackerel, crisps, liquorice, honey dew melon, banana, mild chocolate
Most appropriate screening test for primary hyperaldosteron
- hypokalaemia, hypertension
Spot renin and aldosterone level
Salin surpression is confirmatory
CT for ?adenoma or hyperplasia
test for ?cushing syndrom
- what is ?cushing disease
high dose dex for disease
