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Pradeepa's notes > Endocrine System > Flashcards

Endocrine System Flashcards

1
Q

what is diabetes insipidus

A

excess dilute urine = extreme thirst

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2
Q

how is concentrated urine produced

A

-hypothalamus produces vasopressin (ADH) + stores in pituiltary gland
-ADH is release when H20 in body is too low
-ADH retains H20 in body by reducing H20 lost in kidneys
= concentration urine

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3
Q

how is dilute urine produced in diabetes insipidus

A

-reduced prod of ADH
-kidneys don’t retain as much water
-too much water released from body causing extreme thirst/polyuria
-more dilute urine

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4
Q

how do you tx lack of vasopressin

A

with vasopressin or desmopressin

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5
Q

how do you tx if kidneys dont respond to ADH

A

Thiazide diuretic

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6
Q

desomepressin

A

-more potent and longer duration of action than vaso
-no vasoconstrictor effect
-s/e; hyponatraemia and nausea

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7
Q

inappropriate ADH production

A

-more ADH - body stores too much water - dilutes salt conc in blood - hyponatraemia
-tx; fluid retention, demeclocycline (blocks renal tubular effect of ADH), tolvaptan - if used rapidly can cause osmotic demyelination (vaso antagonist)

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8
Q

what are the two types of corticosteroids and the difference

A

-mineral corticosteroids = high fluid retention low anti-inflammatory effect
-glucocorticoids = low fluid retention and high anti-inflammatory effect

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9
Q

mineral corticosteroid with most activity

A

1)fludrocortiosne
3) 2) hydrocortisone

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10
Q

fludrocortisone tx and side effects

A

-used for postural hypotension
-s/e:
-> water and sodium retention - hypertension
-> Odema
-> hypokalaemia
-> hypocalcaemia

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11
Q

most potent glucocorticoids

A

dexamethasone and betamethasone

then prednisolone, prednisone, deflazlort

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12
Q

glucocorticoids s/e

A

-diabetes
-osteoporosis
-avascular necrosis of femoral head and muscle
wasting
-gastric ulceration and perforation

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13
Q

corticosteroid s/e more detail

A

-report blurred vision and visual disturbance (MHRA)
-psychiatric reactions (seek help and stop)
-adrenal suppression (prolonged use = acute adrenal atropy or abrupt stop = acute adrenal insuff, hypotension or death)
-infections due to immunosupression - chicken pox, measles
-insomina
-children = stunt growth
-skin thinning
-prolonged = cushing syndrome

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14
Q

most common corticosteroid s/e

A

CORTICOSTEROID USE
-cushing syndrome
-osteoporosis
-retardation of growth
-thin skin
-immunosuppression + insomnia
-chorioretinopathy
-oedema
-striae
-emotional disturbance
-rise in BP
-obesity
-increased hair growth (hirsutism)
-diabetes mellitus (hypogly)
-ulcers (peptic)
-suppression (adrenal)
-electrolyte imbalance (hypokal)

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15
Q

managing s/e of corticosteroids

A

-lowest effect dose for min period
-single dose morning
-if 2DY course = AD
-short courses
-local tx rather than systemic

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16
Q

when corticosteroids gradual withdrawal

A

-40mg+ predn OD 1WK
-repeat evening doses
- >3wk tx
-recently repeated course
-taking short course within 1yr of stopping longterm therapy

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17
Q

topical steroid potency

A

-mild = hydrocortisone
-moderate = clobetasone
-potent = bethamethasone
-v.potent = clobetasol

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18
Q

adrenal insufficiency + tx

A

-due to Addison’s disease or congenital adrenal hyperplasia
-tx - hydrocortisone
- also can use fludrocortisone if primary
-can lead to adrenal crisis (severe dehydration, hypokalaemia shock, altered consciousness, seizures, stroke, cardiac arrest) tx hydrocortisone

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19
Q

description of diabetes

A

-persistent hyperglycaemia
-causes/types
-> deficient insulin secretion (type1)
-> resistance to action of insulin (type2)
->pregnancy (gestational)
->medications (steroids secondary)

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20
Q

driving + diabetes mellitus

A

-all drivers tx = insulin must inform DVLA
-drivers should be assessed on awareness of hypoglycaemia = capability of bringing their vehicle to a safe controlled stop

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21
Q

diabetes group 1 drivers

A

-adequate awareness of hypoglycaemia
- no more than 1 episode of severe hypoglycaemia while awake in 12MT

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22
Q

diabetes group 2 drivers

A

-must report all episodes of severe hypoglyc incl sleep
-full awareness of hypoglyc
-no episodes in 12MT
-most use blood glucose meter = sufficient memory to store 3MT of readings
-visual impairment inform DVLA x drive

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23
Q

DVLA advice diabetes mellitus

A

-if insulin tx must carry glucose metere + blood glucose strips
-check conc no more than 2hr before driving and every 2hr while driving
-readings >5mmol/l
-if <5 = snack

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24
Q

hypoglyc while driving

A

-<4mmol/l
-driver should:
-> safely stop
->turn off car and move from drivers seat
-> eat/drink sugar source
->wait until after 45min blood gluc has returned to normal before driving
-> x drive if hypoglyc awareness

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25
Q

type 1 diabetes mellitus + features

A

-insulin deficiency - destroyed beta cells in islet of langerhans
-most commonly before adulthood
-typical features:
->hyperglycaemia >11mmol/l
->ketosis
->rapid weight loss
->BMI <25
-> <50yr
-> FH of autoimmune disease

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26
Q

blood glucose monitoring

A

3 meals always
-QD before each meal + before bed
-5-7 walking
-4-7 fast BG before meals
-5-9 90 mins after eating
- >5 driving

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27
Q

insulin regimens type 1

A

-always receive insulin therapy
-multiple daily inj basal-bolus insulin regimen (1st line)
-bipharic mixture
-continous SC insulin infusion

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28
Q

multiple daily inj basal-bolus insulin regimen type 1

A

-basal (long/intermediate acting) OD/BD AND
-bolus (short/rapid acting) before meals
-first line basal = DETEMIR BD
-2nd line basal = glargine OD

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29
Q

bipharic mixture insulin regimen type 1

A

short acting mixed with intermediate insulin inj 1-3 times a day

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30
Q

continuous SC insulin infusion (insulin pump) insulin regimen type 1

A

adults = suffer disabling/uncontrolled hypoglyc

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31
Q

insulin requirements for more insulin

A

infection
stress
trauma

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32
Q

insulin requirements for less insulin

A

-physical activity
-intercurrent illness
-less food intake
-impaired renal function
-thyroid disorders
-coeliac disease
-addisons disease

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33
Q

insulin administration

A

-inactivated by GI enzymes - given SC
-inj into body area = SC fat (abdomen - fast outer thigh/buttocks - slower)
-rotate inj site - lipohypertropy can occur due to repeatedly inj same small area - erratic absorption of insulin

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34
Q

types of short acting soluble insulin

A

-human + bovine/porcine
-inj 15-30 before food
-onset 30-60mins
-peak action 1-4hr
-duration up ro 9hr

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35
Q

types of rapid acting insulin

A

-lispro, aspart, glulisine
-inj immediately before meals
-onset <15mins
-duration 2-5hr

36
Q

types of intermediate-acting insulin

A

-bisphasic isophane, biphasic aspart, lispro (isophane inj mixed with SA insulin
-onset = 1-2hr peak affect 3-12hr
-duration = 11-24hr

37
Q

types of long-acting insulin

A

-detemir (BD), degludec (OD), glargine(OD)
-onset 2-4DY to reach steady statr
-duration: 36hr

38
Q

type 2 diabetes

A

-insulin resistance
-later development
-prediabetes

39
Q

prediabetes

A

-hb1ac = 42-47mmol/mol
-can try prevent via lifestyle
-diabetic considered when hb1ac = 48

40
Q

Tx of diabetes low cvd risk

A

1) assess hb1ac, kidney function, cardiovascular risk
->tx metformin
-> aim = individually agreed threshold
2) if hb1ac is above individually agreed threshold
-> add DPP-4i (gliptins), proglitazone, sulfonylurea or SGLT-2i (flozins)
3) if hb1ac is above individually agreed threshold
->triple therapy by adding or swapping class of anti-diabetic
->aim = individually agreed threshold

41
Q

tx of diabetes high CVD risk

A

1) assess HbA1C, kidney function + cardiovascular risk
->inc risk: established atherosclerotic CVD.HF or a QRISK2 >10%
-> tx metformin
->once metformin tolerated add SGLT-2i
->aim for individually agreed threshold
2) if HbA1c above individually agreed follow guidelines for dual therapy as low CVD risk
-> if pt develops high risk then consider SGLT-2i

42
Q

tx of diabetes if metformin resistant

A

-if due to S/E use MR
1)assess hb1ac, kidney function, cardiovascular risk
-> tx DPP-4i, pioglitazone, SU, SGLT-2i
->if high risk of CVD then SGLT2i
->aim for individually agreed threshold
2)above individual agreed threshold
->tx DPP-4i + pioglitazone or PP4i + SU or P+SU
->aim for individual agreed threshold

43
Q

metformin (biguanide)

A

-only works if some Bcells work in islet of langherhans
-decreases glucogenesis + inc peripheral utilisation of glucose
-s/e
->lactic acidosis - avoid if EGFR <30
-GI s/e = high dose slowly or give MR
-can lower vit B12
-stop if pt = AKI

44
Q

short acting sulphonylureas

A

-augments insulin secretion
-gliclazide
-tolbutamide

45
Q

long-acting sulphonylurea

A

-glibericlamide
-glimepiride
-avoid in elderly assoc with prolonged and fatal cases of hypoglyc

46
Q

s/e sulphonylurea

A

-high risk of hypoglyc - tx hosp (target = 7.0% x 6.5%)
-avoid in acute porphyria
-avoid in hepatic + renal failure

47
Q

pioglitazone

A

-low preipheral insulin resistance
-avoid in pt - hx of HF
-high risk of bladder cancer
->review safety + efficacy after 3-6MT
-> x tx if pt = inadequate response
->report; haematuria, dysuria, urinary urgency
-> high risk of bone factors
-> high risk of liver toxicity
-> report nausea, vomiting, abdominal pain, fatigue + dark urine

48
Q

Dipeptidyl peptidase 4- inhibitors (DPP-4i)

A

-inhibits DPP-4i to inc insulin secretion and lower glucagon secretion
-can cause pancreatitis
-> x if symptoms of acute pancreatitis develop
-> persistent, severe, abdominal pain
-most hepatotoxic = vildagliptin
-aloglipitin, linagliptin, saxagliptin, sitagliptin

49
Q

sodium glucose co-transporter 2 inhibitors (SGLT-2i)

A

-inhibit sodium gloucse co-transporter 2 in renal proximal convulated tubule = more urine = less blood glucose level
-MHRA warning
->life-threatening + cases of diabetic ketoacidosis
-> monitor ketones if tx interrupted for surgery/illness
-> Fournier’s gangrene (necrotising fasciitis of genitalia or perineum)
->canagliflozin only: risk of lower-limb amputation (toes)
->volume depletion correct hypovolaemia before starting tx
-> monitor renal function

50
Q

GLP-1 agonist

A
  • inc insulin secretion, supress glucagon secretion, slows gastric emptying
    -MHRA risk of diabetic ketoacidosis when concimitant insulin was dec rapidly
    -acute pancreatitis - pt warned of severe abdominal pain
    -dehydration risk due to GI s/e avoid fluid deplation
    -dulaglutide, exenatide, liraglutide, lixesenatide
51
Q

acarbose

A

-delays digestion + absorption of starch and sucrose
-high risk of GI s/e may decrease dose

52
Q

meglitides

A

-nateglinide or repaglinide
-stimulates insulin secretion
-stress exposure tx interruption + replacement with insulin to maintain glycaemic control

53
Q

antidiabetic effect on weight

A

-weight gain : sulphonylureas, insulin, pioglitazone
-neutral weight: DPP-4i, metformin
-weight loss: GLP-1 + SGLT-2i

54
Q

diabetic complication

A

-cardiovascular disease
-diabetic nephropathy
-diabetic neuropathy
-visual impairment

55
Q

diabetic complication - cardiovascular disease

A

-strong risk factor for cardiovascular disease
-low dose atorvastatin for type 1:
->40+, diabetic 10+yr, nephropathy or other CVD factors
-> ACEi lower cardiovascular disease risk

56
Q

diabetic complication - diabetic nephropathy

A

-pt - nephropathy causing proteinuria - tx = AECi/ARB
-ACEi can potentiate hypoglyc effect on antidiabetic/insulin

57
Q

diabetic complication - diabetic neuropathy

A

-painful peripheral neuropathy: antidepressants, gabapentin, pregabalin
-> diabetic foot = tx pain + manage infection
->autonomic neuropathy tx diarrhoea = codeine or tetracycline
->neuropathic postural hypotension=inc Na+ intake or fludrocortisone
->gustatory sweating = antimuscarinic (propantheline bromide)
->erectile dysfunction = sildenafil

58
Q

diabetic complication- visual impairment

A

yearly eye tests

59
Q

diabetic ketoacidosis (DKA)

A

-severe hypergylcaemia
-symptoms:
->polyurea
-> thirsty
-> peardrop breath smells (ketones)
->deep or fast breathing
->lethargy/unconcious
->confusion

60
Q

diabetic ketoacidosis monitoring

A

-check blood sugar - if DKA sypm
-if blood sugar higher than 11mmol/l check ketone levels (urine/blood)
-0.5-1.5mmol = slight risk retest in 2hr
-1.6-2.9 = high risk inform GP
-3mmol/l = medical emergency

61
Q

DKA tx

A

1) if BP <90, restore vol with 500mL IV NaCl 0.9%
2)bp >90, maintenance IV NaCl 0.9%
3)start IV insulin mixed with NaCl + adminster - rate so that ketone conc falls at 0.5mmol/hr and blood glucose conc falls at 3mmol/hr
4)blood glucose <14mmol/l give IV glucose 10%
5)continue insulin till ketone <0/3mmol/l + ph >7.3
6)pt = eat give fasting acting insulin with meals
7)stop tx 1hr after food

62
Q

insulin during surgery

A

-elective surgery (minor + good glycaemic control)
->day before reduce OD long acting dose b y 20% -rest as usual
-elective surgery (major or poor glyc control)
-> day before reduce to OD long-acting dose by 20% rest as usual
-> on day of procedure; reduce OD long acting dose by 20% STOP other insulin till pt =eating, IV infusion of KCL + glucose + Nacl, variable rate IV insulin (soluble human) in NACL 0.9% via pump, hourly blood glucose measurement for 1st 12hr, give IV glucose 20% if blood glucose <6mmol

63
Q

Insulin post surgery

A

-change to SC when pt=eat/drink w/o vomiting
-basal-bolus regimen restarted with 1st meal - infusion carried till 30-60mins after 1st meal short acting glucose adminstration
-long acting regimen carries on at 20% reduced until leaves hosp
-BD regimen restart at breakfast or evening meal infusion carried on till 30-60mins after 1st meal

64
Q

sick day rules

A

-sugar levels = blood glucose check regularly
-insulin = carry on taking
-carbs = keep eating + hydrating
-ketones = check ketones regularly

65
Q

diabetes = pregnancy + BF

A

-high risk to women and fetus = risk dec by effective blood-glucose control
-before pregnancy:
-> aim hb1ac <48mmol/l
-> folic acid 5mg

66
Q

Diabetes pregn medications

A

-all oral diabetics except metformin should be stopped + replaced with insulin
-isphane insulin = 1st line for long-acting insulin during pregn
-if pt = ARBs/ACEi = stop
-aware of hypglyc risk with insulin + carry fast-acting glucose

67
Q

gestational diabetes

A

-stop meds after birth
-fast BG <7mmol/l
1)diet + exercise if x met then
2)metformin
3)insulin if met CI x effective
-fasting BG >7mmol/l
1) diet excercise + insulin +/- metformin
-fasting BG 6.69mmol with complications
1)insulin +/-metformin

68
Q

hypoglycaemia

A

-<4mmol/l
-sweating
-lethargic
-dizziness
-hunger
-tremor
-tingling lips
-palpitations
-extreme moods
-pale
-if pt = conscious + swallow = fast acting carb via mouth 4.5 glucose tab, 3-4 heaped teaspoons of sugar, 150-200ml of fruit juice, repeat every 15 mins for 3 cycles
-oral adm x work/unconscious - IM glucagon _ if unresponsive after 10 mins IV glucose

69
Q

osteoporosis risk factors

A

-post menopausal women
-men 50+
pt taking long term oral glucocoticoids
-age +
-vit D + CA+ deficiency
-lack of exercise
-low BMI
smoking + drinking
-history of fractures
-early menopause

70
Q

lifestyle changes for osteoporosis

A

-inc exercise
-smoking cessation
-maintain ideal BMI
-lower alcohol intake
-inc intake of vit D + CA+ supplements

71
Q

osteoporosis tx

A

-review need for med after 5yr (3ye - zolendonic)
-1st line
->oral bisphosphonates (alendronic/risedronate)
-alternative therapies
-> postmenopausal; ibandronic acid, denolumab, raloxifene, strontium
–>younger postmenopausal = HRT or tibolone
–> terparatide = severe osteoporosis
-> men = zolendronic acid, denosasumab, teriparatide, strontium
-> glucocorticoid induced; zoledronic acid, dersosumab, teriparatide

72
Q

Glucocorticoid induced osteoporosis

A

-start prophylaxis at onset of glucocortoid tx in:
->women 70+, previus fragility fracture, large dose (pred >7/5mg OD or eq)
-> men = 70+ and or previous fragility fracture, large dose
-> large dose 3MT+

73
Q

bisphosphonates MHRA warning

A

-atypical femoral fractures
->report thigh, hip or groin pain
-osteonecrosis of jaw
->report dental pain, swelling, non-healing sores or discharge
-osteonecrosis of external auditory canal
->report; ear pain, discharge or ear infection

74
Q

osteoporosis tx s/e

A

-oesphageal reactions
->report + stop if irritation, dysphagia, hearburn
-> med = full glass of water whilst standing = remain upright 30 mins after
-alendron acid; 30 mins before breaky/other oral meds
-risderonate; 30 mins before breaky or leave 2hr before and after food drink if at another time in day

75
Q

oestrogens and HRT

A

-osteogrens:
->natural; estradiol, estrone, estriol
->synthetic; ethinylestradiol + menstranol
-progestrones; norethisterone, levonorgestrel, desogestrel
-tibolone; oestrogenic, progestogenic _ weakly adrongenic

76
Q

HRT

A

-ostrogens (combined with progestrone if pt has urterus alleviates menopausal symptoms
->vaginal atropy (topical)
->vasomotor instability (systemic)
-> dec postmenopasual osteoporosis
-clostidine - vasomotor symptoms vut = large s/e profile

77
Q

HRT + risks

A

-benefit must outweight risk <60
-breast cancer
->inc risk after 1yr
->inc risk in combined HRT
->ecess risk in 10+yr
-endometrial cancer
->women = uterus less risk with combined.
->tibolone high risk
-ovarian cancer
->low risk (disappears few years after stopping)
-venous thromboembolism
->high risk of DVT with both types (oestrogen + combined), high risk with prolonged bed rest, obesity, trauma + FH
-stroke
->slight risk (oestrogen + combined)
-coronary heart disease
->high risk combined when started >10yr after menopause

78
Q

choosing HRT

A

-uterus
-> ostrogen = cyclical progestogen for the last 12-14DY of cycle
-> continuous adminstration of an osteo + progest
-> avoid continuouus combined + tibolone in perimenopasual or if within 12MT of last period

w/o uterus
-continous esto use
-if endometrosis occur consider + progestrone

79
Q

HRT + surgery

A

-elective surgery ; stop hrt 4-6ek before surgery + restart when fully mobile
-non-elective surgery; prophylactic heparin, graduated compression stockings

80
Q

reasons to stop HRT

A

-stopped pending investigation + tx
-sudden severe chest pain/breathlessness
-unexplained swelling/severe pain =calf one leg = DVT
-severe stomach pain
-serious neurological effects (unusual severe, prolonged headache, fainting 1st unexplained epileptic seizure, motor disturbances, numbness
-hepatitis/jaundice
-BP >60 sys 95 diast
-prolonged immobility

81
Q

Thyroid hormones

A

-amount of circulating thyroid hormones = regulated = -ve feedback loop
- high levels of t3 + t4 = suppress function + production of TSH or TRH inhibit own production

82
Q

hyperthyroidism

A

-high t3+t4 low TSH
-SIGNS
->hyperactivity
->insomnia
->heat intolerance
-> high appetite
->weight loss
->diarrhoea
->goitre

83
Q

tx of hyperthyroidism

A

-carbimazole
->MHRA neutropenia, agranulocytosis - sore,thorat, malaise, fever, congential malformations - contraception women, acute pancreatitis - report + stop immediately
-propylthiouracil - pt cautious of liver disorder
-beta blockers = symp relief
-graves disease
->radioactive iodine or carbimazole if remission likely
pregnancy
->1st trimester = propylthiouracil (carb = congetial defects)
->2nd/third = carbimazole (propylthiouracil = hepatoxic)

84
Q

hypothyroidism

A

-low T3 +T4 high TSH
-signs:
->fatigue
->weight gain
->constipation
->depression
->dry skin
->intolerance to cold
->menstrual irregulaties

85
Q

tx of hypothyroidism

A

-1st line = levothroxyine
->monitor FSH every 3MT until stable then annually
->medicine morning at least 30 mins before breakfast or caffeinated
-> MHRA small pt number can feel difference in brands
-liothyronine
->high rapid + potent output (20-25mcg = 100mcg of levothroxyine)
-non-uk brands may not be bioequivalent

Pradeepa's notes (12 decks)

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