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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
type 1 diabetes mellitus + features
-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
26
blood glucose monitoring
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
27
insulin regimens type 1
-always receive insulin therapy -multiple daily inj basal-bolus insulin regimen (1st line) -bipharic mixture -continous SC insulin infusion
28
multiple daily inj basal-bolus insulin regimen type 1
-basal (long/intermediate acting) OD/BD AND -bolus (short/rapid acting) before meals -first line basal = DETEMIR BD -2nd line basal = glargine OD
29
bipharic mixture insulin regimen type 1
short acting mixed with intermediate insulin inj 1-3 times a day
30
continuous SC insulin infusion (insulin pump) insulin regimen type 1
adults = suffer disabling/uncontrolled hypoglyc
31
insulin requirements for more insulin
infection stress trauma
32
insulin requirements for less insulin
-physical activity -intercurrent illness -less food intake -impaired renal function -thyroid disorders -coeliac disease -addisons disease
33
insulin administration
-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
34
types of short acting soluble insulin
-human + bovine/porcine -inj 15-30 before food -onset 30-60mins -peak action 1-4hr -duration up ro 9hr
35
types of rapid acting insulin
-lispro, aspart, glulisine -inj immediately before meals -onset <15mins -duration 2-5hr
36
types of intermediate-acting insulin
-bisphasic isophane, biphasic aspart, lispro (isophane inj mixed with SA insulin -onset = 1-2hr peak affect 3-12hr -duration = 11-24hr
37
types of long-acting insulin
-detemir (BD), degludec (OD), glargine(OD) -onset 2-4DY to reach steady statr -duration: 36hr
38
type 2 diabetes
-insulin resistance -later development -prediabetes
39
prediabetes
-hb1ac = 42-47mmol/mol -can try prevent via lifestyle -diabetic considered when hb1ac = 48
40
Tx of diabetes low cvd risk
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
tx of diabetes high CVD risk
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
tx of diabetes if metformin resistant
-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
metformin (biguanide)
-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
short acting sulphonylureas
-augments insulin secretion -gliclazide -tolbutamide
45
long-acting sulphonylurea
-glibericlamide -glimepiride -avoid in elderly assoc with prolonged and fatal cases of hypoglyc
46
s/e sulphonylurea
-high risk of hypoglyc - tx hosp (target = 7.0% x 6.5%) -avoid in acute porphyria -avoid in hepatic + renal failure
47
pioglitazone
-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
Dipeptidyl peptidase 4- inhibitors (DPP-4i)
-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
sodium glucose co-transporter 2 inhibitors (SGLT-2i)
-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
GLP-1 agonist
- 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
acarbose
-delays digestion + absorption of starch and sucrose -high risk of GI s/e may decrease dose
52
meglitides
-nateglinide or repaglinide -stimulates insulin secretion -stress exposure tx interruption + replacement with insulin to maintain glycaemic control
53
antidiabetic effect on weight
-weight gain : sulphonylureas, insulin, pioglitazone -neutral weight: DPP-4i, metformin -weight loss: GLP-1 + SGLT-2i
54
diabetic complication
-cardiovascular disease -diabetic nephropathy -diabetic neuropathy -visual impairment
55
diabetic complication - cardiovascular disease
-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
diabetic complication - diabetic nephropathy
-pt - nephropathy causing proteinuria - tx = AECi/ARB -ACEi can potentiate hypoglyc effect on antidiabetic/insulin
57
diabetic complication - diabetic neuropathy
-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
diabetic complication- visual impairment
yearly eye tests
59
diabetic ketoacidosis (DKA)
-severe hypergylcaemia -symptoms: ->polyurea -> thirsty -> peardrop breath smells (ketones) ->deep or fast breathing ->lethargy/unconcious ->confusion
60
diabetic ketoacidosis monitoring
-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
DKA tx
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
insulin during surgery
-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
Insulin post surgery
-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
sick day rules
-sugar levels = blood glucose check regularly -insulin = carry on taking -carbs = keep eating + hydrating -ketones = check ketones regularly
65
diabetes = pregnancy + BF
-high risk to women and fetus = risk dec by effective blood-glucose control -before pregnancy: -> aim hb1ac <48mmol/l -> folic acid 5mg
66
Diabetes pregn medications
-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
gestational diabetes
-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
hypoglycaemia
-<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
osteoporosis risk factors
-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
lifestyle changes for osteoporosis
-inc exercise -smoking cessation -maintain ideal BMI -lower alcohol intake -inc intake of vit D + CA+ supplements
71
osteoporosis tx
-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
Glucocorticoid induced osteoporosis
-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
bisphosphonates MHRA warning
-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
osteoporosis tx s/e
-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
oestrogens and HRT
-osteogrens: ->natural; estradiol, estrone, estriol ->synthetic; ethinylestradiol + menstranol -progestrones; norethisterone, levonorgestrel, desogestrel -tibolone; oestrogenic, progestogenic _ weakly adrongenic
76
HRT
-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
HRT + risks
-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
choosing HRT
-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
HRT + surgery
-elective surgery ; stop hrt 4-6ek before surgery + restart when fully mobile -non-elective surgery; prophylactic heparin, graduated compression stockings
80
reasons to stop HRT
-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
Thyroid hormones
-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
hyperthyroidism
-high t3+t4 low TSH -SIGNS ->hyperactivity ->insomnia ->heat intolerance -> high appetite ->weight loss ->diarrhoea ->goitre
83
tx of hyperthyroidism
-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
hypothyroidism
-low T3 +T4 high TSH -signs: ->fatigue ->weight gain ->constipation ->depression ->dry skin ->intolerance to cold ->menstrual irregulaties
85
tx of hypothyroidism
-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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