Endocrine Flashcards
1
Q
What is diabetes insipidus
A
excess dilute urine = extreme thirst due to too little ADH
2
Q
hormones in the urine process in a normal person
A
- hypothalamus produces vasopressin (ADH) - stored in pituitary gland
- ADH released when water in body too low
- ADH retains water in body by reducing amount of water lost through kidneys
= more concentrated urine
3
Q
hormones in the urine process in diabetes insipidus
A
- reduced vasopressin so reduced ADH
- kidneys don’t retain as much water
- too much water passed from body = extreme thirst/polyuria
= more dilute urine
4
Q
Two types of diabetes insipidus
A
- pituitary (cranial)
- nephrogenic (partial)
5
Q
What is pituitary (cranial) diabetes insipidus
A
- lack of vasopressin (ADH) production
- most common type
- Tx = vasopressin or desmopressin
6
Q
What is nephrogenic (partial) diabetes insipidus
A
- you have ADH but kidneys don’t respond to it
- Tx = thiazide like diuretic (paradoxical effect)
7
Q
Desmopressin information
A
- more potent and longer duration of action than vasopressin
- no vasoconstrictor effect
- side effects = hyponatraemia, nausea
8
Q
What does too much ADH cause
A
- body stores too much water = dilutes the salt conc in blood = hyponatraemia
9
Q
Too much ADH treatment
A
- fluid restriction
- demeclocycline (blocks renal tubular effect of ADH)
- tolvaptan (vasopressin antagonist)
- avoid rapid correction of hyponatraemia with tolvaptan as it causes osmotic demyelination = serious neurological events
10
Q
What is diabetes mellitus
A
- persistent hyperglycaemia
- type 1 = deficient insulin secretion
- type 2 = resistance to action of insulin
- gestational = pregnant
- secondary to medications
11
Q
Diabetes and fitness to drive
A
- treatment with insulin = notify DVLA
- assess on awareness of hypoglycaemia - capability of bringing vehicle to a safe stop
12
Q
Diabetes and group 1 driver rules
A
- ‘normal’ drivers
-adequate awareness of hypoglycaemia - no more that 1 episode of severe hypo while awake in last 12 months
13
Q
Diabetes and group 2 driver rules
A
- HGV/lorry/bus drivers
- report all episodes of severe hypo including in sleep
- full awareness of hypo
- no episodes of severe hypo in last 12 months
- must use glucose meter with sufficient memory to store 3 months of readings
- visual complications = notify DVLA and don’t drive
14
Q
DVLA advice for diabetics
A
- tx with insulin = always carry glucose meter and strips
- check glucose 2 hours before and every 2 hours during driving
- glucose always > 5, if < 5 have a snack
- ensure supply of fast-acting carbohydrate in vehicle e.g. glucose tablets, glucose drinks, full sugar soft drinks, sweets, biscuits
15
Q
Hypoglycaemia whilst driving rules
A
- considered as < 4mmol/L
1. stop vehicle
2. engine off, remove keys, move from drivers seat
3. eat/drink suitable source of sugar
4. wait 45 minutes after blood glucose back to normal - DONT drive if hypo awareness lost - notify DVLA
16
Q
what is type 1 diabetes
A
- insulin deficiency - destroyed b-cells in islets of langerhans
- commonly before adulthood
17
Q
Features of type 1 diabetes
A
- hyperglycaemia (>11mmol/L)
- ketosis
- rapid weight loss
- BMI<25
- age < 50
- family history of autoimmune disease
18
Q
Type 1 diabetes blood glucose monitoring frequency and targets
A
- at least QDS including before meals and bed
- on waking = 5-7
- fasting before meals/other times of day = 4-7
- 90 mins after eating = 5-9
- when driving = > 5
19
Q
Type 1 diabetes insulin regimen
A
- basal-bolus regimen
- basal = long/intermediate
- bolus = short/rapid - before meals
20
Q
name the long acting insulins
A
- detemir - BD
- glargine - OD
- degludec - OD
21
Q
name the rapid acting insulins
A
- asparte
- lispro
- glulisine
22
Q
Name intemediate acting insulin
A
- biphasic isophane
- biphasic asparte/lispro (isophane + short acting)
23
Q
what is biphasic insulin
A
- short acting mixed with intermediate - 1-3x a day
24
Q
Long acting insulin onset and duration
A
- onset = 2-4 days to reach steady state
- duration = 36 hours
25
Name soluble insulins
- human + bovine/porcine
26
Soluble insulin details
- 15-30 minutes before meals
- onset = 30 to 60 minutes
- peak action = 1-4 hours
- duration = up to 9 hours
27
Rapid insulin details
- immediately before meals
- onset < 15 minutes
- duration = 2-5 hours
28
Intermediate insulin details
- onset = 1-2 hours
- peak affect = 3-12 hours
- duration = 11-24 hours
29
What is used for disabling/uncontrolled hyperglycaemia
continuous subcutaneous insulin infusion (insulin pump)
30
When to increase/decrease insulin
- increase insulin when - infection, stress, trauma
- reduce insulin when - physical activity, intercurrent illness, reduced food, reduced renal function, thyroid disease, addisons, coeliacs
31
Insulin administration
- inactivated by GI enzymes - give subcut into fat e.g. abdo (fastest absorption), outer thigh, buttocks (slower absorption)
- rotate site - lipohypertrophy = erratic absorption of insulin
32
What is type 2 diabetes
- insulin resistance later in life
- pre diabetes = HbA1c: 42-47
- diabetes = 48 mol/mol
- offer lifestyle advice 1st line
33
Type 2 diabetes treatment (low CVD risk)
- assess HbA1c, kidney function and CVD risk
1. Metformin
2. + DPP-41 (gliptin), pioglitazone, sulfonylurea or SGLT2i (flozin)
3. triple therapy (add/swap)
4. specialised e.g. insulin, GLP1 agonist
34
Type 2 diabetes treatment (high CVD risk)
- assess HbA1c, kidney function, CVD risk (high risk = established attherosclerotic CVD/HF or QRISK > 10%)
1. metformin
2. SGLTi (flozin)
3. +DPP-4i (gliptin), pioglitazone or sulfonylurea
4. triple therapy (add/swap)
- if at any point develops high risk - consider SGLT2i
35
Type 2 diabetes metformin resistant treatment
- if due to GI side effects - use MR prep
- assess HbA1c, kidney function, CVD risk
1. DPP-4i (gliptin), pioglitazone, sulfonylurea OR SGLT2i (flozin - in high CVD risk)
2. DPP-4i + pioglitazone OR DPP-41 + sulfonylurea OR pioglitazone + sulfonylurea
3. insulin
- aim for individually agree threshold for HbA1c through tx
36
Diabetic complications - CVD treatment
- low dose statin (T1DM, age > 40, diabetes > 10 yrs, nephropathy, other CVD)
- ACEi to reduce CVD risk
37
Diabetic complications - diabetic nephropathy
- nephropathy causing proteinurea = ACEi (including black and >55)/ARB
- ACEi/ARB potentiate hypoglycaemic effect of anti diabetic drugs/insulin
38
Diabetic complications - diabetic neuropathy
- painful peripheral neuropathy
- anti-depressant, gabapentin, pregabalin
39
Diabetic complications - diabetic foot
- treat pain
- manage infection
40
Diabetic complications - autonomic neuropathy
- treat diarrhoea with codeine or tetracyclines
41
Diabetic complications - neuropathic postural hypotension
- increase salt intake
- OR fludrocortisone
42
Diabetic complications - gustatory sweating
- antimuscarinic (propantheline bromide)
43
Diabetic complications - erectile dysfunction
- sildenafil
44
Diabetic complications - visual impairment
- annual eyes test - free
45
Metformin (biguanide) MoA
reduces gluconeogenesis and increases peripheral utilisation of glucose
46
Metformin side effects
- lactic acidosis (DONT use if eGFR < 30)
- GI effects (increase dose slowly/MR)
- reduces vitamin B12
- hold if AKI
47
Sulphonylureas MoA
augments insulin secretion
48
Name short acting and long acting sulphonylureas
- short-acting: gliclazide, tolbutamide
- long-acting: glibenclamide, glimepiride
49
Sulphonylureas side effects
- prolonged/fatal hypoglycaemia (avoid elderly) (target - 7%)
- avoid in acute porphyrias
- avoid in hepatic and renal failure
50
Pioglitazone MoA
reduces peripheral insulin resistance
51
Pioglitazone side effects
- avoid in history of heart failure
- increase risk of bladder cancer - review in 3-6 months, report haematuria, dysuria, urinary urgency
- increased risk of bone fractures and liver toxicity - report NV, abdo pain, fatigue, dark urine
52
Dipeptidylpeptidase-4 inhibitors MoA
- alogliptin, linagliptin, saxagliptin, sitagliptin, vildagliption (new hepatotoxic)
- inhibits DPP-4 to increase insulin secretion and lower glucagon secretion
53
DPP-4i side effects
cause pancreatitis - stop if persistent, severe abdo pain
54
Sodium Glucose Co-transporter 2 inhibitors MoA
- canagliflozin, dapagliflozin, empagliflozin
- inhibits SGLT2 in renal proximal convoluted tubule
55
SGLT2i MHRA warnings
- life threatening/fatal DKA - monitor ketones
- fourniers gangrene (necrotising fasciatis of genitalia/perineum)
- canagliflozin: lower limb amputation (mainly toes)
56
SGLT2i side effects
- volume depletion - correct hypovolaemia, monitor renal function
57
GLP1 Agonist MoA
- dulaglutide, eventide, liraglutide, lixisenatide
- increase insulin secretion, suppresses glucagon secretion, slows gastric emptying
58
GLP1 agonist MHRA warning
- DKA with concomitant insulin rapidly reduced
59
GLP1 agonist side effects
- acute pancreatitis - persistent, severe abdo pain
- dehydration - GI side effects
60
Acarbose MoA and side effects
- delays digestion and absorption of starch and sucrose
- GI effects = reduce dose
61
Meglitides (nateglinide or repaglinide) MoA and side effects
- stimulates insulin secretion
- stress exposure = tx interruption and replacement with insulin to maintain glycemic control
62
Diabetes medications affecting weight
- gain: pioglitazone, sulphonylureas
- neutral: DPP-4i
- loss: metformin, GLP1 agonist, SGLT2i
63
what is diabetic ketoacidosis
- severe hyperglycaemia
64
DKA symptoms
- polyurea
- thirsty
- pear drop breath (ketones)
- deep/fast breathing
- 4Ts: thin, thirst, toilet, tired
65
DKA monitoring
- check blood sugar if > 11mmol/L, check ketones (urine/blood) if:
= 0.6 - 1.5 mmol = slight risk (retest 2 hours)
= 1.6 - 2.9 mmol = increased risk (GP)
= 3 mmol + = medical emergency (hospital)
66
DKA treatment
1. If BP < 90, restore volume with 500mL IV NaCl 0.9%
2. Once BP > 90 = maintenance IV NaCl 0.9%
3. IV insulin with NaCl at rate so ketones fall at 0.5 mmol/L/hr and blood glucose falls at 3 mmol/L/hr
4. when BG < 14 mmol/L give IV glucose 10%
5. continue insulin until ketone < 0.3 mmol/L and pH > 7.3
6. when able to eat, give fast acting insulin with meal
7. stop tx 1 hour after food
67
Insulin adjustment for elective & minor surgery
- reduce OD basal by 20% day before surgery
68
Insulin adjustment for elective and major surgery
- reduce OD basal by 20% day before surgery
- on the day = reduce OD basal by 20% - stop other insulin until eating, IV infusion of KCl + glucose + NaCl, variable rate IV insulin (soluble human) in NaCl via pump, hourly blood glucose measurements for first 12 hours, IV glucose 20% if drops under 6 mmol/L
69
Insulin requirements post surgery
- back to subcut when pt can eat/drink w/o vomiting
- basal-bolus - restarted with first meal - infusions until 30-60 minutes after first meal that includes the short acting glucose administration
- long-acting - continue at reduced by 20% until leaves hospital
- BD regimen = restart at breakfast or evening meal - infusions until 30-60 minutes after first meal
70
Sick day rules
- Sugar levels - check BG regularly
- Insulin - continue taking
- Carbohydrates - keep eating, stay hydrated
- Ketones - check ketones regularly
71
Diabetes in pregnancy and breast feeding
- diabetes in pregnancy = increase risks to mum and foetus - effective glucose control to reduce risk
- before preg = if HbA1c > 48 mmol/mol, take folic acid 5mg
72
Diabetes medication in pregnancy
- stop all oral anti diabetic meds except metformin and replace with insulin
- isophane is first choice as basal in preg
- if taking statin/ACEi/ARBs - discontinue
- aware of hypoglycaemia risk and always carry fast acting glucose
73
What is gestational diabetes
developed during preg, stop treatment after birth as it is due to pregnancy
74
Gestational diabetes treatment if FBG < 7 mmol/L
1. diet & exercise
2. metformin
3. insulin
- move to next step if requirement not met in 1-2 weeks
75
Gestational diabetes treatment if FBG > 7mmol/L
- diet and exercise + insulin +/- metformin
76
Gestational diabetes treatment if FBG 6 - 6.9 mmol/L with complication
- insulin +/- metformin
77
Hypoglycaemia (< 4 mmol/L) symptoms
- sweating
- lethargic
- dizziness
- hunger
- tremor
- tingling lips
- palpitation
- extreme moods
- pale
78
Hypoglycaemia treatment if conscious and able to swallow
- fast acting carbohydrate by mouth e.g.:
- 4-5 glucose tabs
- 3-4 heaped teaspoons of sugar
- 150-200mL fruit juice
- repeat every 15 minutes for 3 cycles
79
Hypoglycaemia treatment if patient unconscious/oral doesn't work
- IM glucagon
- then if unresponsive after 10 minutes, IV glucose
80
Hypoglycaemia awareness
awareness of hypoglycaemia can become blunted preventing early recognition - can happen through increases numbers of hypos or taking b-blockers
81
What is osteoporosis
progressive bone disease causing reduced bone mass and density = increased risk of fractures
82
osteoporosis risk factors
- postmenopausal
- men over 50
- long term glucocorticoids
- age increase
- vitamin D and calcium deficiency
- reduced exercise
- low BMI
- smoking, drinking
- history of fractures
- early menopause
83
osteoporosis life style advice
- increase exercise
- stop smoking
- reduce alcohol intake
- maintain ideal BMI
- increase vitamin D and calcium inake
84
Osteoporosis treatment
1. oral bisphosphonates (alendronic/risedronate)
- review after 5 years (3 years for zoledronic)
85
Oral bisphosphonates alternatives for treatment of osteoporosis in different patient groups
- postmenopausal = ibandronic, denosumab, raloxifene, strontium
- younger menopausal = HRT or tibolone
- severe osteoporosis = teriparatide
- men = zoledronic, denosumab, teriparatide, strontium
- glucocorticoid induced = zoledronic, denosumab, teriparatide
86
Glucocorticoid induced osteoporosis prophylaxis
- for women 70 yrs+, previous fragility fracture, pred > >7.5mg daily or equivalent
- for men > >70 yrs AND previous fragility fracture or pred > >7.5mg daily or equivalent
- large doses of corticosteroids for > 3 months
87
Bisphosphonates MHRA warnings
- atypical femoral fractures - report thigh, hip, groin pain
- osteonecrosis of jaw - report dental pain, swelling, non-healing sores, discharge
- osteonecrosis of external auditory canal - report ear pain, discharge, infection
88
Bisphosphonates side effects
- oesophageal reactions - take with full glass of water whilst standing and remain upright for 30 minutes after
- alendronic = 30 mins before breakfast/other meds
- risedronate = 30 minutes before breakfast or leave 2 hours before and after food/drink if at other time in the day
89
Mineral corticosteroids MoA
- high fluid retention, low anti-inflammatory effect
- highest mineral corticosteroids activity = fludrocortisone
- hydrocortisone also mineral corticosteroid activity
90
fludrocortisone indication
hypotension
91
mineral corticosteroids side effects
- sodium and water retention (oedema)
- hypokalaemia
- hypocalcaemia
- these effects negligible with high potency glucocorticoids (betamethasone & dexamethasone)
92
Glucocorticoids MoA
- high anti-inflammatory effect, low fluid retention
- highest glucocorticoid activity = dexamethasone/betamethasone
- also prednisolone, prednisone, deflazacort
93
glucocorticoids side effects
- diabetes
- osteoporosis -> fractures
- avascular necrosis of the femoral head and muscle wasting
- gastric ulceration and perforation
94
All corticosteroids MHRA warning
central serous chorioretinopathy - report blurred vision/disturbances
95
All corticosteroids side effects
- psychiatric reactions = insomnia, irritability, mood change, suicidal thoughts, behavioural disturbances
- adrenal suppression = prolonged use = adrenal atrophy. abrupt withdrawal = adrenal insufficiency, hypotension, death. illness, trauma, surgical procedure = increase dose
- infection - immunosuppressed
- chickenpox - vaccinate
- measles - prophylactic AM normal immunoglobulin
- insomnia - morning dose - when cortisol produced
- children - stunted growth (incl. ICS), skin thinning (topical)
- prolonged use = Cushing's syndrome = moon face, striae, hirsutism, acne, managed with metyrapone, tx with ketoconazole
96
CORTICOSTEROID USE acronym
- Cushing's
- Osteoporosis
- Retardation of growth
- Thin skin
- Immunosppressed, Insomnia
- Chlorioretinopathy
- Oedema (water retention)
- STriae
- Emotional disturbance
- Rise in BP
- Obesity (truncal)
- Increased hair growth (hirsutism)
- Diabetes (hyperglycaemia)
- Ulcers (peptic)
- Suppression (adrenal)
- Electrolyte imbalance (reduced K+)
97
Managing corticosteroid side effects
- lowest effective dose for minimum period
- single dose in morning
- total dose for 2 days can be taken as single dose on alternate days
- intermittent therapy with short courses
- local tx rather than systemic e.g. cream, intra-articular injections, inhalations, eye drops, enemas
98
Gradually withdraw steroids if
- > 40mg pred (or equiv) daily for >1 weeks
- repeat evening doses
- > 3 weeks treatment
- recently received repeated courses
- taken short course within 1 year of stopping long-term therapy
- other possible causes of adrenal suppression
- all patients to be given steroid card
99
Topical steroid potencies
- mild: hydrocortisone
- moderate: clobetasone
- potent: betamethasone
- very potent: clobetasol
100
What is adrenal insufficiency
- medical emergency
- caused by addison's or congenital adrenal hyperplasia
- can lead to adrenal crisis = severe dehydration, hypovolaemic shock, altered consciousness, seizures, stroke, cardiac arrest = death if untreated
101
adrenal insufficiency treatment
- hydrocortisone mainly
- fludrocortison as well if primary adrenal insufficiency
102
Name natural oestrogens
- estradiol
- estrone
- estriol
103
Name synthetic oestrogens
- ethinylestradiol
- mestranol
104
Name progestogens
- norethisterone
- levenorgestrel
- desogestrel
105
Tibolone
= oestrogen, progestognenic, and weekly androgenic
106
HRT treatments
- oestrogens (+ progestogen if uterus) alleviates menopausal symptoms e.g. vaginal atrophy (topical), vasomotor instability (systemic), reduces postmenopausal osteoporosis
- clonidine for vasomotor symptoms, but large side effects profile
107
HRT risks
- benefits > risks especially age < 60
- breast cancer - increased in combined over oestrogen only
- endometrial cancer with tibolone - if uterus - reduced risk with combined over oestrogen only
- ovarian - small risk, disappears after stopping
- DVT
- stroke - slight increase, tibolone increased by 2.2x in first year of tx
- coronary heart disease - increased risk with combined if started more than 10 years after menopause
108
Choosing HRT if have uterus
- oestrogen throughout with cyclical progestogen for last 12-14 days of cycle
- continuous oestrogen and a progestogen
- avoid continuous combined and tibolone in perimenopausal or if within 12 months of last menstrual period
109
Choosing HRT if dont have uterus
- continuous oestrogen use
- if endometriosis = + progesterone
110
HRT and surgery
- elective = stop HRT 4-6wks before surgery, reinitiate when fully mobile
- non-elective = prophylactic heparin, graduated compression stockings
111
Reasons to stop HRT
- sudden severe chest pain/SOB - PE
- swelling/severe pain in calf of one leg - DVT
- severe stomach pain - hepatotoxicity
- serious neurological effects - unusual, severe, prolonged headache, fainting, epileptic seizure, motor disturbances, numbness
- hepatitis/jaundice
- BP > 160 systolic of 95 diastolic
- prolonge immobility - risk of VTE
112
Thyroid disorders MoA
- circulated thyroid hormone regulated by negative feedback loop
- increased T3/T4 = suppression of TSH or TRH produced by hypothalamus = inhibits their own production
113
hyperthyroidism signs and symptoms
- high T3/T4, low TSH
- increased metabolism/activity
- hyperactive
- insomnia
- heat intolerance
- increased appetite
- weight loss
- diarrhoea
- goitre
114
Hyperthyroidism treatment
1. carbimazole
2. propylthiouracil
3. b-blockers - symptomatic relief
115
carbimazole MHRA warnings
- neutropenia & agrunolocytosis - sore throat, malaise, fever, bleeding gums
- congenital malformations - use contraception
- acute pancreatitis - report and stop if severe abdo pain
116
propylthiouracil side effects
cautions of liver disorder - jaundice, dark urine, nausea
117
Graves disease treatment (severe hyperthyroidism)
1. radioactive iodine
- if remission likely with anti-thyroids, consider carbimazole
2. carbimazole if iodine or surgery not suitable - block and replace regimen in combo with levothyroxine for 12-18 months
118
hyperthyroidism treatment in pregnancy
- 1st trimester = propylthiouracil (carbimazole = congenital defects)
- 2nd and 3rd trimester = carbimazole (propylthiouracil = hepatotoxicity)
119
Hypothyroidism signs and symptoms
- low T3/T4, high TSH
- reduced metabolise/activity
- fatigue
- weight gain
- constipation
- depression
- dry skin
- cold intolerance
- menstrual irregularities
120
Hypothyroidism treatment
1. levothyroxine
2. liothyronine
121
Levothyroxine details
- monitor TSH every 3 months until stable, then annually
- OM 30 minutes before breakfast/caffeinated drinks
- MHRA - potentially feel symptoms if alternating brands
122
Liothyronine details
- more rapid and potent output than levo (20-25mcg = 100mcg of levo)
- non-UK brands may not be bioequivalent
123
Which statin and dose is used in T2DM and established CVD
atorvastatin 80mg
124
How often should HbA1c be monitored if the patient is stable
every 6 months
125
What should the HbA1c be before another anti diabetic medication is added
58mmol/mol
126
Which anti diabetic medication causes vaginal thrush
SGLT2 inhibitors
127
which anti diabetic medication causes UTIs
dapagliflozin
128
T2DM and HTN - HTN target
- 140/90
- if > 80 years old then 145/95
129
When should a GLP-1agonist be continued
if at least 3% reduction in initial body weight and 1% reduction of HbA1c within 6 months
130
AKI symptoms
- oedema
- SOB
- confusion
- nausea
- seizures
- chest pain
- oliguria (abnormally small amounts of urine)
131
which anti diabetic medications cause hypotension
sulfonylureas
132
which anti diabetic medication has a risk of bladder cancer
pioglitazone
133
why is ramipril cautioned in diabetes
it may lower blood glucose
134
Insulin aspart administration directions
TDS before meals
135
eGFR range that indicates severe renal impairment
- 15-29
- also indicates stage 4 CKD
136
Reasons to stop HRT
- PE (chest pain, SOB)
- DVT (calf swelling, red, hot)
- severe stomach pain (pancreatitis)
- neurological affects
- hepatitis/jaundice/liver enlargement
- BP > 160/95
- prolonged immobility
137
Recommended blood glucose levels if fasting and if not fasting
- fasting < 5.5
- non-fasting < 11.1
138
What is the recommended HbA1c when T2DM is managed by diet alone or with a single anti diabetic drug not associated with hypoglycaemia
48 mmol/mol (6.5%)
139
Rapid insulin administration directions post op
- PRN
- can be adjusted according to glucose levels
