Endocrine Flashcards
Criteria for type two DM Screening in pediatrics (at age of 10, or onset of puberty) whatever occur first and at interval of 3 years
Obese (>95%) or overweight (>85%) with at least one of the following:
1- Maternal DM or GDM during child gestation
2- Family history of DM-2 in 1st or 2nd degree relative
3- High risk race
4- signs of insulin resistance (acanthosis nigracins) or conditions associated with insulin resistance (htn, dyslipidemia, pcos, small for gestational age birth weight)
Criteria for type two diabetes screening in adults
1- age 35
2- HIV
3- Prediabetes
4- Overweight or obese (25 bmi or 23 bmi in asian american) PLUS
- First degree relative with dm
- high risk ethnicity
- HTN >140/90 or on anti-HTN medications
- HDL <35 or Triglyceride >350
- Hx of CVD
- PCOS or physical inactivities
- Acanthosis nigracin, severe obesity
- Women with history of GDM or delivered a baby >4 kg
Cut off for DM screening
- Fasting 126
- HA1C 6.5
- 2hr post prandial 200
Pre-diabetes, when to consider metformin
- Age 25-59
- BMI >35
- prior GDM
- fasting 110
- A1C 6
Weight loss recommended for DM or predm
7% weight loss
Bad medications for HF diabetic patients
- TZD
- Sexagliptin
Bone fracture causing anti DM medication
TZD
Diabetic arthropathy definition
Charcot joint (loss of planter arch). Usually not developed until years of DM neuropathy but can progress rapidly leads to joint disorgnization within month. Dm ulcer may coexit. Often present with haemorrhgic effusion along with subluxation and joint instability, additional findings include erythema and edema. Usually not present with tenderness or induration, fever, high WBC, in opposite to cellulitis
DM retinopathy classes
- non proliferative: Hard exudate (fluid leak), micro-aneurysm, hemorrhage, cottol whool spots (microinfarction of nerves fibers)
- Proliferative: neovascularization
Diabetic cataract versus macular edema
Cataract: opacification of the lens, present with visual changes like diplopia and watering of the eyes
Macular edema: permenant vision loss
Diabetic cardiopathy
- established LVH, causing diastolic HF
- Alcohol, idiopathic, viral Cardiomyopathy are characterized by Systolic HF
DKA clinical presentation and management
- 3P, fatigue, abdominal pain, rapid breathing, dehydration, ketonic breath.
- Labs: Hyperglycemia > causing hyperosmolarity and hyponatermia. Metabolic acidosis and respiratory alkalosis
An average pt with DKA has a deficit of 6L of fluid. Start with 1L/hr. Then reasses. Continued rapid infusion can result in cerebral edema. As Sodium corrected. Change fluid to 0.45% saline
Insulin 0.10 unit/kg/hr
How to calculate anion gap?
Na - (HCO3 + cL )
MILD MODERATE SEVERE DKA
Ph 7.25-30
Ph 7.24-7
Ph <7
Alert
Alert/drowsy
Stupor/coma
When to refer for bariatric surgery?
▫️Candidates for drug therapy:
⁃ BMI ≥30 kg/m2
⁃ BMI of 27 to 29.9 kg/m2 with weight-related comorbidities
▫️Candidates for bariatric surgery:
⁃ BMI ≥35 kg/m2
⁃ BMI of 30 to 34.9 kg/m2 with weight related comorbidities.
💡 Make sure that candidates had not met weight loss goals (loss of at least 5% of total body weight at three to six months) with a comprehensive lifestyle intervention “do not jump directly to meds/surgery”
🧷 [UTD]
Acute porphyria after recent bariatric surgery
Symptoms: abdominal pain, progressive neurological symptoms, hematuria without RBC
Causes: Negative Carb balance
Diagnostic: Urine porphobilinogen
Weight loss medications from most to least suffienct with CI
- Semaglutide and Liraglutide: Pancreatitis, MTC,MEN-2, Gallbladder diseases
- Phentermine/Toprimate ER: Hyperthyroid, glaucoma, Urolithiasis, Metabolic acidosis
- Naltrexone/Buproprion: Seizure, Uncontrolled HTN, Chronic opoid use
- Orlistat: Urolithiasis (oxalate), cholestasis, organ transplant
- Phentermine: Hyperthyrodism, UNcontrolled HTN, Hyperthyroid, agitation
MODY
Mature Onset Diabetes of Young
- 30 years or less at the time of diagnosis
- Family history of diabetes diagnosed before age of 45
- absence of insulin resistance, not obese
- no history of dka
- Negative Antibodies
- C peptide >100 pmol/L outside honeymoon period “not useful in first years of diagnosis”
Diagnosis: Refer to endocrinologist for MODY genetic testing and treat accordingly
DIABETES GENES ORG MODY CALCULATER
Osteoprosis interesting test?
N-telopeptide
Sign of osteoprosis?
- height decrease 2cm
- weight decrease 5kg
- occiput to wall increase 2cm
- rib to pelvis distance DECREASE 2 fingers
What medication showed DPP trial benefits for preDM?
First choice is metformin..
Other approved meds:
TZD: specially for patients with hx of stroke or MI. Weight benefit and risk (fracture, weight gain and edema)
Liraglutide (Victoza)
A1 glucosidase inhibitor
What factors decrease the A1C?
Decrease RBC lifespan
1- Any hemolytic disease [ SCD, Thalasemia, G6PD, Spherocytosis]
2- Erythropoietin therapy
3- Recovery from acute hemorrhage
4- Hypersplenism
Hemodilution
1- Pregnancy
2- Blood transfusion
Decrease glycation
1- High dose of vitamin C or E
2- Some antibiotics such as trimethoprim cotrimoxazole
Chronic Liver Disease [ Cirrhosis]
What factors increase A1C?
Increase Rbc Span
1- Splenectomy
Decrease reticulocytes
1- Aplastic Anemia
Increase glycation
1- Iron, vitamin B12, Folate deficiency
Others:
Alcohol, uremia, smoking, aspirin, hyperbilirubenmia or triglyceridemia
DM is common risk factor for Herpes zoster (shingles), define its stages and how to treat?
Stages:
3 days: Erythromatous papules
3 days: Pastular/ haemorrhage
3 days: crusted, no longer infectious
Most common complications:
Post-heretic neuralgia (3 months persistent pain at the same dermatome)
If within 72 hours of appearance of rash:
- Acyclovir
- Valacyclovir
- Famciclovir
Treatment of postherpatic neuralgia
- Lidocaine 5% patch
- Capsaicin 8% patch
- Oral medications are the mainstay of treatment: Pregabalin, gapabentin, TCA
Vaccine: 50 y.o, two doses
Pediatric dextrose concentration in hypoglycemia
<1y: D10
1-8y: D25
>8y: D50
Hypoglycemia is the most common metabolic problem in neonates
Perioperative DM management
Pre-Op:
- Continue insulin ( but basal dose decreased by 30-50% on the day of surgery )
- D/C SGLT-2 Three to Four days before surgery
- D/C sulfunylurea and meglitinides 1 day before surgery
- D/C metformin and others in the morning of surgery
Intra-OP:
Finger stick every 1-2 hours
Maintain at range of 140-170
Surgery <2hours: Short acting subq insulin as necessary
Surgery >2hours: IV insulin infusion
Post-OP:
Maintain 140-180
- Restart metformin after 1 day of surgery (or when oral intake established)
- don’t restart SGLT-2 in inpatient settings
Breast feeding decrease risk of Diabetes in both mothers with GDM and neonates, what other benefits?
- mother:
Breast Cancer
Hyperlipidemia
Hypertension
DM
Obesity
Ovarian cancer
MI and Heart diseases - Baby:
Dm
HTN
Obesity
Gi INFECTIONS
Atopic dermatitis and asthma
Leukemia
Metformin rule in PCOs?
- Control Hyperglycemia and insulin sensitivity
- Restore Ovulation
- Reduce serum androgens levels
PCOS wants to become pregnant
- start metformin, then discuss pro and cons of initiating Insulin once she get pregnant
- Laterazole or Clomphine? LETRAZOLE
MEDICATIONS INDUCED DM
Glucocorticoids
Immunospresseant
Some Antipsychotic
Anti retroviral
MODY typical age
<25 years old
FIRST DEGREE not SECOND
Children and adultscent anti DM medications
- Metformin
- Insulin
- GLP-1A (age 10 years or above)
HF and anti-DM medications?
HF and NYHA-3/4: DON’T GIVE TZD
ADHF: DON’T GIVE METFORMIN > LACTIC ACIDOSIS
Edema with TZD> Also macular edema so any visual changes u should conduct detailed eye examination
SGLT-2 Inhibitors side effects
Genital mycotic infections (eg, candidiasis) specially in women
Tx: continue sglt-2 and treat the infection
Recurrent? Consider discontinue
Single in men? Consider discontinue
GLP-1 Agonists
Semaglutide:
Glycemic control: Semaglutide at form of Ozempic (2mg), or rybelsus
Weight loss regardless of diabetes status: Semaglutide at form of Wegovy (2.5mg)
Liraglutide:
Approved for both weight loss and glycemic control
Weight loss percatage is MILDLY LOWER
DM and Alcohol users
Should not be started on medications that increase risk of:
- Lactic acidosis (Metformin)
- Hypoglycemia (Insulin, Sulfonylurea, Meglitidines)
Metformin immediate release 2g, GI side effects, how to deal with?
- The evidence is to start low, and titrate slow (first line) > resume at 500mg of
- Second line is to restart 500-1000 dose in the XR formulation ( patient based practice, without evidence )
PCOS criteria
1- Persistant oligomenorrhea
2- Clinical or biochemical evidence of hyperandrogenism
3- other possible causes excluded
Biochemical: elevated testosterone level
Preferred screening test for DM: OGTT
Tight glycemic control, and micro/macrovascular complications
- moderate evidence that it will delay progression of microvascular complications
- little evidence that it will reduce incidence of macrovascular complications
Less stringent control of A1C defines as?
- up to 8.5 according to ADA
- up to 9 according to American geriatric society
MODY
- less than 25 years old ( usual range is 10-45)
- strong family history of diabetes started at young age
- Normai BMI
- Normal C peptide
- Negative antibodies
Hemochromatosis
Most commonly in men
Four cardinal features:
1- Hypogonadism
2- Hyperglycemia
3- Arthritis
4- Elevated AST/ALT
X-RAY: chondrocalcinosis
Most effective bariatric surgery for diabetes remission
Bypass
Metabolic adverse effects of Olanzapine
Atypical antipsychotics: obesity, DM, DKA
Medications associated with onset of DM
Statins
BB
Thiazide diuretics
Continuous blood glucose monitoring interpretation
Data suffiency (device worn): >70%
Time in range 70-180: >70% “or 50% fratility of high hypoglycemic risk”
Time below 70: <4%
Time below 54: <1%
Time above 180: <25%
Time above 250: <5% “or <10% is hypoglycemia is a risky”
Variability: <36%
