Endocrine System Flashcards
1
Q
How to prevent adrenal crisis?
A
Give a glucocorticoid medication
2
Q
Managing adrenal crisis?
(Treatment)
A
prompt treatment with hydrocortisone and rehydration
3
Q
Hydrocortisone is unsuitable for what (disease)?
A
suppression (diseases/immune system) because it has high mineralcorticoid properties.
4
Q
MHRA alert for corticosteroids
A
- Risk of central serous chorioretinopathy
- Early recognition and treatment of adrenal crisis
5
Q
Who do you not use HBA1C monitoring in?
A
- Type 1
- Children
- Pregnancy
- 2 months postpartum
6
Q
What do you do If a patient becomes symptomatically hyperglycaemic?
A
can give sulphonylureas or insulin. Review once the patients better
7
Q
Targets for type 2 diabetes?
A
48 - diet/lifestyle/ metformin
53 - hypoglycaemic drug/ 2 or more
58 - intensify treatment - step up
8
Q
Pt with ….
Diabetic + chronic HF
A
metformin and SGLT2
Metformin first and once tolerated start SGLT2
9
Q
Short acting sulfonylureas
A
gliclazide / tolbutamide
10
Q
Long acting sulfonylureas?
A
Glibenclamide and glimepramide
11
Q
When to give GLP1 receptor agonist
A
- BMI 35kg/m2 or more and psychological/medical problems associated with obesity.
- BMI < 35 and for those insulin therapy have significant occupational implications
- If weight loss would benefit other obesity associated problems
12
Q
When do you review GLP1 receptor agonists
A
- after 6 months and it has to be beneficial more than 11mmol/mol and weight loss of 3%
13
Q
What insulin is used for patients with type 2 diabetes?
A
- human isophane insulin
- Human isophane + short acting insulin (particularly appropriate if HBA1c is above 75)
- Determir/glargine
- Biphasic preparations
14
Q
How do reduce cardiovascular risk in patients with diabetes?
A
- ACEi
- Statins
15
Q
Treatment of diabetic nephropathy
A
ACR of 3mg/mmol or more - ACEi
3 - 30mg consider ACE and SGLT2i
Above 30mg/mmol - combine both
16
Q
Diabetic neuropathy
1. Nerve Pain
2. Diabetic diarrhoea
3. Gastroperesis
4. Postural hypotension
5. Gustatory sweating
6. Neuropathic oedema
7. Erectile dysfunction
A
Pain - simple paracetamol
- Amitriptyline Duloxetine/venlafaxine Gabapentin and Pregablin
- Combined therapy - opioid and gabapentin
Autonomic -
- diabetic diarrhoea - tetracycline or codeine
- Gastroperesis- erythromycin
- Postural hypotension - increased salt intake, fludrocortisone, midodrine.
- Gustatory sweating - propantheline bromide
- Neuropathic oedema - ephedrine
- Erectile dysfunction- sildenafil
17
Q
DKA
1.causes
2.characteristics
3.signs and symptoms
4.treatment
A
- Causes of DKA
Discontinuing or inadequate insulin, acute illness like MI, pancreatitis , stress, surgery or trauma - Characterised
Hyperglycaemia above 11, ketouria, ketonaemia and acidosis - Signs and symptoms
Dehydration, weight loss, tiredness, reduced consciousness, rapid breathing, nausea vomiting, abdominal pain, acetone breath - treatment
Iv fluid replacement, iv insulin, potassium and glucose depending on levels
18
Q
HHS (hyperosmolar hyperglycaemic state)
A
- causes
Infection, inadequate insulin or oral antidiabetics drug or stress - features
Hypovoleamia, hyperglycaemia (blood glucose 30mmol/L or above),hyperketonaemia, acidosis - signs and symptoms
Dehydration, weakness and weight loss, tachycardia, dry mucous membrane, hypotension, acute cognitive impairment and shock. - treatment
19
Q
Elective surgery, minor procedure with good glycemic control.
A
Good glycemic control - < 69mmol/mol
Day before - Pts usual insulin is given as normal and once daily long acting is reduced by 20%
20
Q
Elective surgery, major procedure / poor glycemic control.
A
These patients will require a variable rate IV insulin infusion
Aim is to achieve blood glucose conc of 6-10mmol/L but upto 12mmol/L by infusing a constant glucose along side the insulin.
21
Q
Diabetes in pregnancy?
- Target
- medication
- what not to give
A
Aim for target of 48mmol/mol
- Only metformin and insulin
- Advise folic acid 5mg
- Insulin - isophane insulin is the best. Can continue long acting insulin if already using before pregnancy.
- Women with pre-existing diabetes, who are using insulin are at increased risk of hypo in the post natal period. Therefore, reduce dose immediately.
- ACEi to be discontinued and other drug in hypertension to be used.
- No statins
22
Q
- Gestational diabetes
A
Fasting blood glucose < 7mmol/L = change lifestyle and diet. If target not met in 1-2 weeks then give METFORMIN. Alternative is INSULIN.
FBG > 7mmol/L = INSULIN +/- METFORMIN
FBG 6-6.9mmol/L and complication = insulin +/- metformin.
After birth discontinue all medication
23
Q
Drugs - Metformin
A
- safe in pregnancy
- Vitamin B12 deficiency
- Stop if lactic acidosis or ketoacidosis
- Interrupt treatment if dehydration occurs
- Avoid eGFR less than 30
- Symptoms of lactic acidosis - shortness of breath, muscle cramps, abdominal pain, hypothermia.
24
Q
- drugs - DPP4i gliptins
A
- reduce dose of sulfonylureas, insulin, metformin and pioglitazone
- Discontinue if symptoms of PANCREATITIS
(Persistent abdominal pain)
25
Drugs - GLP1 receptor agonists
(Dulaglutide - trulicity, exenatide, liraglutide - victoza and saxsenda, semaglutide - ozempic)
- MHRA: reports of DKA when insulin was reduced or discontinued rapidly
- Prescribed and dispensed by brand - biological medicine
- Acute pancreatitis
- Dehydration - potential risk of dehydration in relation to GI side-effects and to take precautions to avoid fluid depletion
- Missed doses
26
Drugs - SGLT2i
- MHRA alerts
1. Risk of DKA - signs and symptoms (rapid weight loss, nausea and vomiting, abdominal paid, fast deep breathing, sweet smell on breath, sleepiness), test for raised ketones, use with caution if there’s risk factors for DKA (restricted food intake, dehydration, increased insulin requirements, sudden reduction in insulin), to discontinue treatment if DKA develops and treat.
2. May need to interrupt treatment for pts admitted in hospital for major surgeries or acute serious illness.
3. Monitor blood ketones during interruption of SGLT2i
4. Risk of lower limb amputation - to stop the SGLT2i if patient has risk factors such as osteomyelitis, skin ulcer or gangrene.
5. Fourniers gangrene (symptoms - severe pain, redness, erythema, swelling in genitals)
- correct any hypovolemia before starting treatment
- Interrupt treatment if volume depletion occurs.
27
Drugs - sulfonylureas
Sulfonylureas
- prescription inappropriate in elderly if long acting (glibenclamide and glimepirimide)
- Risk of hypoglycaemia if used with other glucose lowering drugs
- Drivers need to be careful to avoid hypo
28
Drugs - pioglitazone
Pioglitazone
- MHRA
1. Risk of cardiovascular safety - incidence of HF is increased when combined with insulin especially in people with previous MI. Pts need to be closely monitored for signs of HF and discontinue if there deterioration in cardiac status
2. Risk of bladder cancer - should not be used in active bladder cancer, past history of bladder cancer and uninvestigated macroscopic haematoria. - review after 3-6 months - pts advised to report, haematuria, dysuria and urinary urgency.
- reports of liver dysfunction - discontinue of jaundice occurs. Pts to seek immediate medical attention if symtoms of liver dysfunction .
29
Drugs - insulin
Insulin
- risk of harm if withdrawing from the pens
- Not to abbreviate units
- Risk of cutaneous amyloidosis. - due to injecting insulin, it leads to deposits of amyloid protein under the skin. Differential from lypodystrophy. To rotate injection site.
- 4-7mmol throughout day.. before meals after meals is upto 9mmol/L
- Prescribe and dispense by brand
- Avoid hypoglycaemia
30
Hypoglycaemia
- symptoms
- what to do if
1. symptoms of hypo & BG > 4mmol/L
2. With or without symptoms < 4mmol/L
CONSCIOUS AND ABLE TO SWALLOW
3. With or without symptoms < 4mmol/L
UNCONSCIOUS, AGGRESSIVE or SEIZURES
Hypoglycaemia
- Symptoms of hypoglycaemia - sweating, feeling tired, dizziness, tingling, feeling shaky, trembling, tachycardia, easily irritated, anxious, turning pale. Weakness, blurred vision, confusion, sleepy, seizures, collapsing or passing out.
1. Symptoms of hypo & BG> 4mmol/L - small carbohydrate (bread or normal meal)
2. With or without symptoms < 4mmol/L CONSCIOUS AND ABLE TO SWALLOW - fast acting carb - glucose tablet/drink, and then snack providing long acting carbohydrate. Hypoglycaemia HAS NOT RESPONDED. Give IM glucagon or IV 10% glucose
- repeat treatment after 15 minutes upto max of 3 times.
- Alcoholic pts - to also give thiamine with it after iv glucose
3. UNCONSCIOUS, AGGRESSIVE or SEIZURES - IM GLUCAGON, 10% glucose or 20% glucose. Not 50% increases risk of extravasation injury. Then huge long acting carb after above 4mmol/L
- hypoglycaemia caused by long acting insulin or sulfonylureas - it may persist for upto 24-36 hours.
- Blood glucose monitoring should be continued for 24-48 hours
31
Type 1 diabetes targets?
Driving - atleast 5mmol/L
On waking -
Before meals -
After eating -
32
Bromocriptine
How it works?
Indication?
A stimulant of dopamine receptors in the brain; it inhibits release of prolactin by the pituitary and also inhibits the release of growth hormones.
Used for glactorrhoea and prolactinoma.
33
MHRA alert for bromocriptine
1. Fibrotic reactions
- Bromocriptine has been associated with pulmonary, retroperitoneal, and pericardial fibrotic reactions.
- Patients should be monitored for dyspnoea, persistent cough, chest pain, cardiac failure, and abdominal pain or tenderness.
2. Impulse control disorders because it’s an dopamine receptor agonist (including pathological gambling, binge eating, and hypersexuality).
Other
- withdraw treatment if GI bleeding occurs
- advise sudden onset of sleep and hypotensive reactions can occur especially in the first few days of treatment.
34
Suppression of lactation l?
Drugs used? (2)
Although bromocriptine and cabergoline are licensed to suppress lactation, they are not recommended for routine suppression (or for the relief of symptoms of postpartum pain and engorgement) that can be adequately treated with simple analgesics and breast support.
If a dopamine-receptor agonist is required, cabergoline is preferred.
Quinagolide is not licensed for the suppression of lactation.
35
Mastalgia (breast pain)
Rule out any underlying cause
Treatment
Mild non cyclic breast pain - simple analgesic.
Moderate to severe/cyclic pain/ or longer than 6 months - specific treatment
- Danazol
- Tomoxifen (unlicensed) - and when it’s related to cyclic oestrogen production
Treatment needs review after 6 months
Symptoms can come back within 2 years of withdrawing treatment.
36
Hyperthyroidism
- Signs and symptoms
- complications
- risk factors
- causes
Signs and symptoms
- hyperactivity, palpitations, anxiety
- disturbed sleep, fatigue
- heat intolerance
- increased appetite, weight loss, diarrhoea
Complications
Graves orbitipathy, thyroid storm, pregnancy complications, reduced bone mineral density, heart failure and AF
Risk factors
Smoking, family history, co-existing autoimmune disease, and low iodine intake.
Causes
- Graves’ disease
- Toxic nodular goitre
- drug induced thyrotoxicosis
37
Non drug treatment for hyperthyroidism
Radioactive iodine
Surgery
(Whilst awaiting treatment anti-thyroid drug should be offered)
38
Drug treatment for hyperthyroidism
Thyroid storm - medical emergency.
Antithyroid drugs -
1. Carbimazole (risk of acute pancreatitis)
2. Propylthiouricil (alternative)
Before starting antithyroid drug- check LFTs and FBC
39
Treatment of Graves’ disease causing hyperthyroidism
1. Radioactive iodine
2. if mild and uncomplicated and if it’s likely to achieve remission - Antithyroid drug or radioactive iodine.
Carbimazole for 12-18 months as either - block and replace regimen or - a titration regimen.
3. Persistent or relapsed hyperthyroidism - radioactive iodine or surgery
4. PTU for - those who experience side effects to carbimazole - pregnancy - trying to conceive within 6 months - history of pancreatitis.
If agranulocytosis develops then stop and do not restart.
40
Treatment of Toxic nodular goitre as the cause of hyperthyroidism
Under specialist care
Multiple nodules
1. Radioactive iodine
2. Total thyroidectomy or life long Antithyroid drugs
Single module
1. Radioactive iodine or surgery
2. Life long Antithyroid drug
Antithyroid drug = carbimazole
PTU - side-effect to carbimazole - pregnant - trying to conceive within the following 6 months - history of pancreatitis.
41
Hyperthyroidism in pregnancy
Avoid carbimazole and radioactive iodine
Females who received radioactive iodine should avoid getting pregnant for 6 months.
PTU is recommended
Pregnant women with severe symptoms of hyperthyroidism such as thyroid storm should be admitted to hospital.
42
Drug - Carbimazole
Important safety info
- neutropenia and agranulocytosis (report sore throat, mouth ulcers, bruising, fever and malaise - and do WBC count) STOP
- increased risk of congenital malformation - especially in 1st trimester and > 15mg dose - effective contraception required
- risk of acute pancreatitis - stopped immediately and permanently - NOT to use if history of pancreatitis
43
Carbimazole to PTU (dose conversion)
1mg carbimazole = 10mg PTU
44
Drug - Propylthiouricil (2)
Severe hepatic reaction reported which can lead to requiring a liver transplantation. Pts to be told how to recognise signs and symptoms - anorexia, abdominal pain, jaundice, fatigue, vomiting nausea, pruritis and dark urine.
Pregnancy -crosses the placenta and Hugh doses can cause fetal goitre and hypothyroidism.
45
Hypothyroidism
- signs and symptoms
- complications
- causes
Signs and symptoms
- fatigue
- intolerance to the cold
- weight gain
- constipation
- menstrual irregularities
- depression
- dry skin
- reduced body and scalp hair
Complications
- dyslipideamia, coronary heart disease, heart failure
- impaired concentration and memory
- impaired fertility, pregnancy complications
- myxoedema coma (life threatening)
Causes
- iodine deficiency
- autoimmune disease
- radiotherapy, surgery and drugs
46
Treatment of hypothyroidism
1. Levothyroxine
(TSH can take upto 6 months to come back to normal)
Measure TSH levels every 3 months until stable (2 similar results on 2 different occasions) then yearly.
Liothyronine Alone in combination with levothyroxine is not routinely recommended.
47
Hypothyroidism in pregnancy
For those planning pregnancy and thyroid levels are not normal - DELAY conception until stabilised on levothyroxine
TFTs may produce misleading results in pregnancy. Trimester related reference range should be used.
If pregnancy is confirmed, urgently measure TFTs. discuss the initiation or changes to levothyroxine.
48
Drug - levothyroxine (3)
1. MHRA advice - new prescribing advice for patients experience symptoms on switching between different levothyroxine. - healthcare professionals are advised that if a patient reports symptoms after changing to a different tablet of levothyroxine, thyroid function test should be considered.
2. Initial dosage to patients with cardiovascular disorders. - if the metabolism increases too rapidly (causes diarrhoea, nervousness, rapid pulse, insomnia and tremors, and sometime anginal pain) - reduce the dose or withhold for 1 to 2 days and start again at a lower dose.
3. Pregnancy - crosses the placenta, levothyroxine requirement may increase during pregnancy.
