Endocrine Guidelines Flashcards
Fasting glucose threshold diabetes
<6 is normal
>7 is diabetes
Random glucose threshold diabetes
> 11.1 is diabetes
OGTT threshold diabetes
> 11.1 is diabetes
<7.8 is normal
HBa1C threshold diabetes
48+ is diabetes
<42 is normal
how often should you self monitor for diabetes
4x per day
Daily glucose targets T1DM
4-7
5-7 when waking up
HTN in diabetic black person 1st line
ACEi and CCB
DKA diagnosis
pH <7.3
bicarb <15
ketones ++ or >3
glucose >11 or known diabetes
DKA management
Need fluids: 1 2 2 4 4 6 = litre saline 0.9%
Need potassium replacement = add 40mmol if 3.5-5.5, call senior if below that.
0.1U/kg/hr insulin. Dextrose when <15
T2DM first line
metformin + lifestyle
hba1c target with T2DM
48 (53 on gliclazide)
When do you add a second drug in T2DM
hba1c >58
when do you use GLP1
If triple therapy has not worked (i.e. it is fourth line) and BMI >35 with problem associated with obesity or BMI <35 but insulin would affect their work badly.
HHS management
What do you check doing management
Fluid loss = 10=20% of body weight
Give fluid back (half in 12 hours, half in next 12 hours)
Must check that osmolality is going down (2Na + urea + glucose) so plot it on graph:
- glucose should fall by 5/hr
- sodium should not fall by more than 10 in 24 hour§
Graves disease Mx
18 months of carbimazole or block and replace
TMG Mx
radioidine or lifetime carbimazole
Toxic adenoma Mx
Radioiodinde
Thyroid storm Mx
IV propranolol, Lugol’s iodine, anti-thyroid drugs
When should you start at a lower dose with levothyroxine
Elderly or heart disease (start at 25 instead of 50 ug)
When do you check TFTs after starting Tx for hypothyroidism and what do you aim for
Normal TSH after 6-8w
Levothyroxine dose in pregnancy
Increase by 25-50microgram
levothyroxine dose alongside iron?
No, leave 2 hours in between as iron reduces levothyroxine absorption
Do you treat subclinical hypothyroidism
Depends
If >80, no
If <80 + TSH >10, yes
If TSH only a bit raised (4-10), treat if <65
de quervains thyroiditis Mx
self limiting
steroids may help hypothyroid phase
post-partum thyroiditis
propranolol in hyperthyroid phase
levothyroxine in hypothyroid phase
primary hyperPTH Mx
Parathyroidectomy
Can you ever not treat primary hyperPTH
Yes, if >50, Ca raised by <0.25, no end organ damage
Secondary hyperPTH
calcium and vit D supplementation
Tertiary hyperPTH
- what about if just had a renal transplant
Excision of culprit gland
Wait 12m after a renal transplant as many resolve
how to differentiate between pseudo and real cushings
Best = low dose dex suppression test
Also used = insulin stress test
best test for cushings
overnight dex suppression test - give dex, and cortisol should be reduced the next morning.
First do low dose then do high dose.
Addison’s best test
spank the adrenals with SYnACTHen to see if they work.
measure cortisol before and 30 min after ACTH given.
Addisons ABG
hypoglycaemia, hyponatraemia, hyperkalaemia, metabolic acidosis
Mx of Addisons
hydrocortisone TDS with biggest dose in the morning + fludrocortisone
Addisons crisis management
IV hydrocortisone 100mg (big dose) only
saline + dextrose if needed
prolactinoma 1st and 2nd/definitve
1st = bromocriptine/cabergoline 2nd = surgery
hypoglycaemia
depends on access
- conscious = oral
- unconscious no IV = IM glucagon
- unconscious with IV = dextrose
diabetic foot - who gets followed up
anyone with anything more than a simple callous (so moderate or severe as opposed to mild)
hyponatraemia investigation: what do you do first
exclude pseudohypoNa (test lipid and protein) and exclude compensatory (test glucose)
Steps 1 to 3 for investigating hypoNa
- addisons/diuretic
- vomiting/diarrhoea
- SIADH/hypothyroid
- nephrotic syndrome, CCF, cirrhosis
Step 1 = depleted euvolaemic, overloaded
Step 2 = urinary sodium >20 or <20
Step 3 = imagine the flow diagram and figure out what it is
- addisons/diuretic = dehydrated + UNa >20
- vomiting/diarhoea = dehydrated + UNa <20
- SIADH/hypothyroid = euvolaemic + UNa >20
- failures = overloaded + UNa <20
Treatment of hypoNa
- rate of Na correction
- use of hypotonic saline?
normal saline 0.9% for F1 always
- no more than 10mmol/24 hours
- only in cerebral oedema under senior supervision
severe hypoCa management
10ml calcium glutinate 10% with ECG monitoring
hyperPTH : Ca, PO4, PTH, ALP
high Ca, low PO4, high PTH (or inappropriately normal), high ALP
malignancy with bone met: Ca, PO4, PTH, ALP
High Ca, high PO4, low PTH, high ALP
Mx of hypercalcaenia
- first
- ongoing helper management
3-4L per day of normal saline
Bisphosphonates can be used too but these take 2-3 ays to work with maximal effect at 7d
recurrence of thyroid cancer
yearly check of thyroglobulin antibodies
HypoPTH: PTH, PO4, Ca
hypoPTH vs pseudohypoPTH vs psuedopseudohypoPTH
Best way to diagnose pseudohypoPTH
Low PTH, high PO4, low Ca
pseudo = high PTH, high PO4, low Ca (target cells insensitive to PTH)
pseudopseudo = normal everything but physically looks like pseudo )low IQ, short 4/5th metacarpal, short
BUT
best way to diagnose pseudohypoPTH is by measuring urinary cAMP/PO4 after PTH infusion (stays same in pseudo as not responsive)
Mx of true hypoPTH
alfacalcidol to boost the low calcium
Conn’s syndrome best Ix
aldosterone:renin will be HIGH
ABG in Conn’s
high Na, low K, metabolic alkalosis
Once Conn’s diagnosed, what test do you then do
Need to find out the cause:
Do high resolution CT scan and adrenal vein sampling. helps distinguish between adenoma or hyperplasia
Mx of Conn’s
- adenoma
- hyperplasia
surgery
spironolactone
Pheochromocytoma Ix
metanephrine/VMA in urine (NOT SERUM)
Phaeo Mx
surgery, but give alpha (phenoxybenzamine) then beta blockage in meantime
Acromegaly Ix
FIRST
BEST
first = Serum IGF1
Best (to confirm) = OGTT (to try and suppress axis. in acromegaly GH doesn’t suppress after glucose)
Acromegaly 1st line
other Tx?
surgery
medical Tx includes octreotide (somatostatin analogue) or dopamine agonist (cabergoline/bromocriptine)
GH receptor antagonist (pegvisomant - prevents dimerisation of the receptor)
Diabetes insipidus Ix to confirm
to detect type
Check serum and urine osmolality to confirm
Do desmopressin test to check which
Check for primary polydipsia as cause of polyuria (Ddx for diabetes insipidus)
Water deprivation test (urine conc will eventually go up in primary polydipsia)
Neprhogenic vs cranial DI Mx
Cranial = desmopressin Nephrogenic = thiazides and low salt/protein diet§
What do you do if metformin isn’t tolerated due to GI SEs
You try metformin MR before going to second line treatment
Thyroid eye disease management
topical lubricants
ORAL not injection steroids
radiotherapy
surgery
