Endocrine

Question 1

Total daily insulin requirement

Answer 1

0.5-0.7 Units / kg

Question 2

Causes / Types of diabetes

Answer 2

1. Type 1 DM - autoimmune destruction of
   beta cells.
2. Type 2 DM - insulin resistance/insulin
   deficiency
3. Maturity onset diabetes of young -
   genetic defect of beta cell function.
4. Disease of pancreas - pancreatitis,
   neoplasm, CF, hemochromatosis.
5. Endocrinopathy - acromegaly, cushings,
   hyperthyroid, pheo, glucagonoma.
6. Drug-induced - steroids, B2 agonists,
   thyroid hormone, thiazides, phenytoin,
   clozapine.
7. Infection - congenital rubella, CMV, cox
8. Genetic conditions - DS, Turners.

Question 3

Common insulin regimens:

Answer 3

1. BD biphasic regimen
   
   • twice daily premixed insulin by pen.
   • Novomix 30 (30% short, 70% long)
   • Good for type 2 and type 1’s with
     regular lifestyle.
2. QDS regimens
   
   • Before meal ultra fast insulin
   • Bedtime long acting
   • Useful in type 1 for achieving flexible
     lifestyle = adjusting dose with meals
     and exercise.

Question 4

Guidelines on starting oral hyperglycemic agents in newly diagnosed diabetic patients

Answer 4

- Try a 3 month period of weight loss, 
  exercise and diet to see if it can control 
  blood sugars.
-  If unsuccessful after 3mo = start 
   medication.
-  OR if HbA1C > 9% = start meds 
   immediately.

Question 5

Things to review in diabetes: KNIVES

Answer 5

Kidney
- Urine dipstick for macroalbuminuria
- Urine albumin creatinine ratio for
microalbuminuria.

Neuropathy
- Check feet for sensory loss, deformities.

Infection

Vascular

• CAD
• Stroke risk factors
• PVD

Eyes

• Fundoscopy yearly
• Retinopathy / early cataracts

Sugar
- HbA1c every 3mo

Question 6

Hypoglycemia: Definition & Cause

Answer 6

Defintions:
Plasma glucose < 3mmol/L
Very concerned if < 1.7 mmol regardless of symptoms.

Cause
1.  Fasting hypoglycemia with  
    hyperinsulinemia
    -  Insulinoma, sulfonylurea, insulin 
       injection. congenital HH

2.  Fasting hypoglycemia without hyper
     insulinemia
     -  Pancreatic neoplasm
     -  Alcohol binge
     -  Pituitary insufficiency
     -  Addison's disease

3. Post-prandial hypoglycemia
   
   • Post - gastric / ‘bariatric surgery =
     dumping syndrome.
   • Occurs in some type 2 diabetics

Mnemonic:
EXPLAIN
Exogenous drugs - insulin, oral hypo's
Pituitary insufficiency
Liver failure
Addison's disease
Islet cell tumor = insulinoma
Non-pancreatic neoplasm

Question 7

Treatment of hypoglycemia

Answer 7

• Oral sugar
• 50mL 50% glucose IV
• Glucagon 1mg IM if no IV access

Question 8

Diagnosing diabetes

Answer 8

1. Symptoms of diabetes: polyuria, polydypsia, WL, nocturia, vision changes, ketonuria.
2. Random glucose > 11.1 mmol/L
3. Fasting > 7 mmmol/L
4. OGTT > 11.1 mmol/L

Question 9

List and describe the medications used in diabetes

Answer 9

1. Biguanide - Metformin
   
   • Sensitizes peripheral tissues to
     insulin
   • First line for type II obese patients
     with high TG
   • SE: WL, GI upset, anorexia, LA
2. Sulfonylureas - glyburide
   
   • Increases insulin secretion
   • Can add on to metformin
   • SE: WG, hypoglycemia
3. Thiazolidinedione - Pioglitazone
   
   • Insulin sensitizer
   • Cannot be combined with insulin
   • CI in liver and heart disease
   • SE: pulm edema, CHF, WG
4. Glucosidase inhib - acarbose
   
   • Inhibits CHO absorption in the gut
   • Decreases postprandial hypergly
   • CI in bowel disease
   • SE: GI upset
5. DDP-IV inhibitor - sitagliptan
   
   • Inhibits degradation of endogenous
     incretin = antihyperglycemic hormone
   • CI in type I DM
   • SE: URTI, headache