Endocrine Flashcards
The 10 signs of HYPERTHYROIDISM
WWE GB TAP DL
Weight loss
Warm Skin/ HEAT INTOLERANCE
Exophthalmos
Goitre (+/- bruit heard via stethoscope)
BRISK REFLEXES
TREMOR
ANXIETY
PALPITATIONS
DIARRHOEA
LID LAG
The three causes of HYPERTHYROIDISM
Graves’- autoimmune- distinguishable from others via OCULAR changes and PRETIBIAL MYXOEDEMA
Toxic Multinodular Goitre/ Toxic Solitary Nodule Goitre- Higher risk in old people and females
DE QUERVAIN’s THYROIDITIS- develops after viral infection
- Transient hyperthyroidism
- Period of hypothyroidism may follow
Investigations for Hyperthyroidism (4 things)
TFTs (LOW TSH, HIGH T3/T4)
US scan of nodules
FNA of solitary nodules to exclude malignancy
Isotope scan to assess hot and cold thyroid nodules
Treatment of Hyperthyroidism (4 things)
Symptomatic control-
- Palpitations and tremors- BETA BLOCKERS
- Eye symptoms- EYE DROPS for LUBRICATION
Anti-thyroid medication-
- CARBIMAZOLE
- PROPYLTHIOURACIL
- Side effects- AGRANULOCYTOSIS (monitor bloods carefully)
Radioactive iodine ablation-
- Definitive treatment
- Patient MUST BE EUTHRYOID before commencing
Surgical- subtotal tyroidectomy
- Patient MUST BE EUTHYROID before commencing
- Give patient POTASSIUM IODIDE before surgery as it decreases thyroid gland vascularity
Complications of Hyperthyroidism (4 things)
Atrial fibrillation
Cardiomyopathy
High Output Cardiac Failure
OSTEOPOROSIS
Two types of Hypothyroidism and 4 things about each
Primary hypothyroidism
- Iodine deficiency
- Hashitmoto’s autoimmune
- Post-thyroidectomy/ radioactive iodine therapy
- Drug-induced (Lithium/ overtreatment of hyperthyroidism)
Secondary hypothyroidism
- Dysfunction of hypothalamus-pituitary axis
- Pituitary ADENOMA
- Sheehah’s Syndrome (ischaemic necrosis of the pituitary gland after child birth)
- Inflitrative disease (TB/ Haemochromatosis)
8 Signs and Symptoms of Hypothyroidism
- Weight GAIN
- Cold skin/ Cold intolerance
- Constipation
- DELAYED reflexes
- Bradycardia
- Depression
- THINNING of SKIN
- DRY SKIN
Investigations for Hypothyroidism
FBC (anaemia)
TFTs (HIGH TSH, LOW T3/T4)
Guthrie Test for congenital screening
Cholesterol (as it is a complication)
Treatment for Hypothyroidism
Lifelong treatment with LEVOTHYROXINE
Complications of Hypothyroidism
Hypercholesterolaemia
Hyperthyroidism from overtreatment
MYXOEDEMA COMA
4 types of Thyroid Carcinomas
Papillary-
- Most common
- Spreads to CERVICAL LYMPH NODES
- GOOD prognosis
Follicular-
- More common in LOW IODINE areas
- Spreads to BONES and LUNGS
- GOOD prognosis
Medullary-
- Arises from PARAFOLLICULAR CELLS
- CALCITONIN is a biochemical marker
- Associated with M.E.N.
- Spreads to LYMPH NODES
Anaplastic-
- Affects older patients
- AGGRESSIVE
- Spreads to LYMPH NODES as well
- POOR PROGNOSIS
Investigations of Thyroid Carcinoma
- Bloods to assess TFTs
- FNA Cytology
- Diagnostic Lobectomy
- Thyroid isotope scan (hot nodules less likely to indicate malignancy)
Treatment for the 4 Thyroid Carcinomas
Papillary/ Follicular-
- Lesion<1cm- Thyroid Lobectomy then lifelong LEVOTHYROXINE and ANNUAL THYROGLOBULIN measurements
- Lesion>1cm- Total Thyroidectomy/ Radio-iodine ablation then lifelong LEVOTHYROXINE and ANNUAL THYROGLOBULIN measurements
Medullary-
- Same as lesion>1cm and SCREEN FAMILY for M.E.N.
Anaplastic- Debulking surgery and palliative care unfortunately
Complications of Thyroid Carcinoma
HYPOTHYROIDISM
Complications of surgery-
- Damage to Recurrent Laryngeal Nerve
- HYPOPARATHYROIDISM
The two textbook risks of Diabetes Type 1 and Type 2
Type 1- KETOACIDOSIS
Type 2- HYPEROSMOLAR STATE
3 extra causes of DIabetes
CHRONIC Pancreatitis
Gestational Diabetes
Cystic Fibrosis
6 signs of GENERAL DIABETES and 4 signs of TYPE 1
- Polyuria
- Polyphagia
- Polydipsia
- Blurred Vision
- Glycosuria
- Sign of MICROVASCULAR and MACROVASCULAR disease
- Acetone breath
- WEIGHT LOSS
- KUSSMAUL BREATHING
- Nausea and Vomiting
Investigations of Diabetes
HbA1c>6.5%
Fasting Plasma glucose>7mmol/L
FOR borderline cases-
- Impaired glucose tolerance test- Fasting plasma glucose <7mmol/L
Treatment of Diabetes
- Dietary advice
- Smoking Cessation
- Decrease alcohol intake
- Regular blood glucose and HbA1c monitoring
- Encourage exercise
ANTIDIABETIC AGENTS
4 Microvascular and 4 Macrovascular Complications of diabetes
Microvascular-
- Nephropathy
- Peripheral neuropathy
- Retinopathy
- Erectile dysfunction
Macrovascular-
- Hypertension
- Increased risk of STROKE
- MI
- Diabetic foot
7 Antidiabetic Agents
Biguanides (Metformin)
Sulfanylureas
Meglitinides
Thiazolidinediones
Incretins (Exenatide)
Incretins (Saxagliptin)
Alpha-glucosidase
Amylin analogues
Biguanides
- Mechanism
- Uses
- Side effects
- Contraindications
- Drug interactions
Mechanism-
- Increase in PERIPHERAL insulin resistance
- Increase in GLUCOSE UPTAKE into skeleton
- Decrease in HEPATIC GLUCOGENESIS
- Decrease in INTESTINAL GLUCOSE ABSORPTION
Uses-
- POI
- T2 DM
Side effects-
- Lactic ACIDOSIS
- GI DISTURBANCES
- Nausea/ Vomiting
Contraindications-
- Renal/ Cardiac/ Hepatic/ Respiratory Failure
Drug Interactions-
- ACE inhibitors
- Alcohol
- NSAIDs
- Steroids
Sulphonylureas and Meglitinides (-glinides)
- Mechanism
- Uses
- Side effects
- Contraindications
- Drug interactions
Mechanism-
- Block POTASSIUM CHANNELS on PANCREATIC BETA CELLS- stimulating INSULIN RESISTANCE
Uses-
- T2 DM
Side effects-
- Hypoglycaemia (extreme glucose control)
- Weight gain
- GIT disturbances (SULPHONYLUREAS)
Contraindications-
- Hepatic failure
- Pregnancy and Breastfeeding
- Renal failure/ Porphyria (SULPHONYLUREAS)
Drug interactions (SULPHONYLUREAS (same as BIGUANIDES))-
- ACE inhibitors
- Alcohol
- NSAIDs
- Steroids
Drug interactions-
- CICLOSPORIN
- TRIMETHOPRIM
- CLARITHROMYCIN
Thiazolidinediones (-glitazones)
- Mechanism
- Uses
- Side effects
- Contraindications
- Drug interactions
Mechanisms-
- Activates NUCLEA PPAR (receptor)
Uses-T2 DM
Side effects-
- Hypoglycaemia
- Weight gain
- HEPATOTOXICITY
Contraindications-
- TYPE 1 DM
- LIVER DISEASE
- HEART FAILURE
- BLADDER CANCER
Drug interactions-
- RIFAMPICIN
- Paclitaxel
Exenatide (INCRETIN)
- Mechanism
- Uses
- Side effects
- Contraindications
- Drug interactions
Mechanism-
- Analogue of GLP-1 (glucagon-like peptide)
Uses- T2 DM
Side effects-
- GIT disturbances
- Acute PANCREATITIS
Contraindications-
- –> M.E.N.
- –> Thyroid cancer
Drug interactions-
- Bexarotene
Saxagliptin (INCRETIN)
- Mechanism
- Uses
- Side effects
- Contraindications
- Drug interactions
Mechanism-
- Inhibits DPP-4 (dipeptidul peptidase
Uses- T2 DM
Side effects-
- GIT disturbances
- UTI/ Respiratory infection
- HEPATOTOXICITY
- Peripheral oedema
Contraindications-
- History of HYPERSENSITIVITY REACTIONS
Drug interactions-
- THIAZOLIDINEDIONES
Only one of the seven drugs that can be used in T1 DM
Amylin analogues (Pramlintide)
Antidiabetics that don’t cause GI disturbances
Thiazolidinediones (glitazones)
Meglitinides (glinides)
Antidiabetics that shouldn’t be used in:
- Heart failure
- Renal failure
- Respiratory failure
- Hepatic failure
Heart failure-
- Biguanides
- Thiazolidinediones (glitazones)
Renal failure-
- Biguanides
- Sulphonylureas
Respiratory failure-
- Biguanides
Hepatic failure-
- Biguanides
- Sulphonylureas
- Meglitinides (glinides)
Insulin Types
Rapid acting- Short acting- Intermediate acting- Long acting- Biphasic-
LSIGI
Insulin LISPRO SOLUBLE Insulin ISOPHANE Insulin Insulin GLARGINE Biphasic ISOPHANE Insulin
The two Tyrosine Kinase receptors (involved in insulin action)
MAP KINASE- cell growth/ proliferation
PI-3K- transport of GLUT-4 to cell surface membrane- responsible for protein, lipid and glucose synthesis
4 side effects of Insulin
Weight gain
Hypoglycaemia
LOCALISED LIPOATROPHY
HYPOKALAEMIA
5 drug interactions of INSULIN
LEVOTHYROXINE- decreases effects of insulin
THIAZIDE DIURETICS- decreases effects of insulin
CORTICOSTEROIDS- decreases effects of insulin
REPAGLINIDE (anti-diabetic)- increases risk of HYPOGLYCAEMIA and MYOCARDIAL INFARCTION
MAO INHIBITORS- may increase insulin secretion
Causes of Cushing’s- ACTH independent, ACTH dependent and one other
Prescription of GLUCOCORTOIDS for ASTHMA
ACTH DEPENDENT-
- Occurs when ACTH produced from a pituitary ADENOMA
- Use low dose DEXAMETHASONE test to confirm
- ECTOPIC ACTH production - like from SMALL CELL CANCER
ACTH INDEPENDENT (CARS)
- Cancer (adrenal carcinoma)
- Adrenal nodular hyperplasia
- Rare cause (McCune-Albright Syndrome)
- Steroid use
Signs and Symptoms of Cushing’s (10 things)
- Moon face
- Purple striae
- Buffalo hump
- Central obesity
- Proximal muscle wasting
- Vertebral collapse
- Acne
- HYPERTENSION
- HYPERGLYCAEMIA
- PSYCHOSIS
Investigations for Cushing’s
- URINARY FREE CORTISOL
- LOW and HIGH DEXAMETHASONE suppression test
- CXR to look for LUNG CANCER and VERTEBRAL COLLAPSE
- Dual Energy X-ray (DEXA) scan
Treatment of Cushing’s
- DECREASE ALCOHOL
Medical-
- KETOCONAZOLE
- METYRAPONE
- MITOTANE
- Treat complications such as hypertension and diabetes mellitus
Surgery-
- TRANS-SPHENOIDAL SURGERY to remove PITUITARY ADENOMA
- BILATERAL ADRENALECTOMY to remove ADRENAL ADENOMA
7 Complications of Cushing’s
- Diabetes mellitus
- Hypertension
- Striae formation
- Cataracts
- Osteoporosis
- ULCERS
- IMMUNOSUPPRESSION
3 Functions of Cortisol
- mAke glucose in liver
- Anti-stress pathway
- Anti-inflammatory pathway
Causes of PRIMARY ADRENAL DEFICIENCY (ADDISON’s DISEASE)
MAIL-
- Metastases from breasts, lungs and renal cancers
- Autoimmune
- Infections (TB most common) and CMV in HIV patients)
- Lymphomas
+ Postadrenalectomy
Causes of SECONDARY ADRENAL DEFICIENCY
Prolonged PREDNISOLONE use
Pituitary adenoma
SHEEHAN’s SYNDROME
7 Signs and Symptoms of Adrenal Deficiency
- BODY HAIR LOSS
- SKIN PIGMENTATION
- POSTURAL HYPOTENSION (BP drops when standing up)
- Unintentional weight loss
- Myalgia
- DEPRESSION
- Nausea/ Vomiting
Investigations in Adrenal Deficiency
- ACTH and cortisol measurements
- Insulin tolerance tests
- SHORT SYNACTHEN TEST
Blood Tests-
- LOW Na/ HIGH K
- SERUM CALCIUM
Radiology-
- CXR- look for LUNG CANCER
- CT and MRI scan of adrenal glands
Complications of Adrenal Deficiency
- ALOPECIA
- HYPOGLYCAEMIA
- HYPERKALAEMIA
- EOSINOPHILIA
Conditions that Addison’s disease is associated with
3PGH
- Pernicious anaemia
- Premature ovarian failure
- Polyglandular syndrome
- GRAVES’
- HASHIMOTO’s
5 parts of ADRENAL CORTEX and MEDULLA (from outside to inside)
CAPSULE-
- In= mesoderm
ZONA GLOMERULOSA-
- Out= ALDOSTERONE
ZONA FASCICULARIS-
- Out= CORTISOL
ZONA RETICULARIS-
- Out= ANDROGENS
MEDULLA-
- In= neural crest
- Out= ADRENALINE/ NORADRENALINE
Causes of Acromegaly (results from excessive growth hormone)
- PITUITARY ADENOMA- most common
- GHRH production from BRONCHIAL CARCINOID
Signs and Symptoms of ACROMEGALY
- LOWER PITCH OF VOICE
- CARPAL TUNNEL SYNDROME
- Increased Jaw/ Hand/ Tongue size
- Ask to see old photos to compare appearances
Investigations in Acromegaly
- –> Bloods-
- GH levels
- IGF 1 levels (raised in acromegaly)
- HIGH PROLACTIN
ECG and ECHO to assess for cardiac complications
—> Visual field testing to test for BILATERAL HEMIANOPIA
Treatment for Acromegaly
- Inform patients bone changes will NOT REVERT after TREATMENT
Medical-
- Somatostatin analogues (OCTREOTIDE)
- Dopamine agonists (CABERGOLINE)
- –> GH antagonists (PEGVISOMANT)
—>Surgery- TRANS-SPHENOID surgical excision of the ADENOMA
Complications of Acromegaly
- Hypertension
- Diabetes
- Increased risk of colon cancer
- Increased risk of cardiovascular disease
- Erectile Dysfunction
- Postsurgical complications (infection/ CSF leak)
