Endocrinological Conditions Flashcards
Addison’s disease (pathophysiology, trigger, hallmark signs, presentation, diagnosis, adrenal crisis - symptoms and management, monitoring)
Pathophysiology: Insufficient production of glucocorticoids and mineralocorticoids (+/- androgen). Both adrenal glands
are affected.
Trigger: autoimmune-related (usually); others include infection, metastatic cancer and some drugs.
Hallmark signs: fatigue, anorexia and weight loss, postural hypotension, and skin and mucosal hyperpigmentation.
May be accompanied by hyperkalaemia and hyponatraemia.
Presentation:
● Dehydration, hypotension, orthostasis
● Absence of axillary and pubic hair and decreased body hair (female)
● Increased pigmentation of skin and mucous membranes +/- areas of vitiligo (long-standing)
Diagnosis: confirmed by combination of
● Positive short Synacthen test (30 and 60 mins after injection)
● Elevated ACTH
● Elevated plasma renin
Adrenal crisis: triggered by illness or surgery resulting in acute cortisol deficiency. EMERGENCY
● Signs and symptoms: Nausea, vomiting, diarrhoea, hypoglycaemia and hypercalcaemia
● Treatment: Start treatment ASAP - do not wait for lab results
○ Hydrocortisone 100 mg IV STAT or prednisolone 40 mg PO
○ Start fluid resuscitation with sodium chloride 0.9%
○ Inform endocrinology team
Monitoring:
● Annual review once stable
● Pathology (serum sodium, potassium and plasma renin concentrations)
● Ask about:
○ Glucocorticoid excess e.g. weight gain, peripheral oedema, bone mineral density (** assess every
2 years), hyperglycaemia
○ Glucocorticoid deficiency e.g. LOA, progressive skin pigmentation, lethargy
○ Mineralocorticoid excess e.g. HTN
○ Mineralocorticoid deficiency e.g. postural hypotension, tachycardia, hyperkalaemia
● Treatment: aim for upper-normal reference of plasma renin concentration
42
● Prevention: higher chance of other autoimmune disease. Counsel patients for signs and symptoms of
coeliac, thyroid, T1DM. Screen with pathology after 1 year and then 5 yearly.
● Patient education for self-care:
○ Increase glucocorticoid dose during intercurrent illness
○ Recognise early features of adrenal crisis
○ Carry injectable hydrocortisone when away from medical care
○ Wear an alert bracelet or necklace
○ Carry a wallet card with detail about condition and treatment
Carcinoid syndrome (clinical features, potential locations, Ix)
Clinical features:
● Classic triad - skin flushing (face), diarrhoea (with abdominal cramp), valvular heart disease
● Other - wheezing, telangiectasia, hypotension, cyanosis
Potential locations: appendix/ileum, stomach, bronchi
Investigations: 24 hour urinary excretion of 5-HIAA
Cushing’s syndrome ( Hx and Ex, when to test, Ix)
History and examination suggestive of Cushing’s: decreased libido, obesity/weight gain, plethora, round face, menstrual changes, hirsutism, HTN, ecchymoses, lethargy, dorsal fat pad, impaired glucose tolerance)
When to consider testing:
● Unusual findings for age (osteoporosis or hypertension in young adults)
● Multiple progressive features of Cushing’s (facial plethora, proximal myopathy, striae and easy bruising)
● Adrenal incidentalomas
Investigations: Low suspicion = 1 test, high suspicion = 2 tests
● Late-night salivary cortisol (two measurements)
● 24 hour urinary free cortisol excretion (two measurements)
● Overnight 1mg dexamethasone suppression test
Diabetes - Type 1 (presentation, investigations)
Key point
● Mostly in children but can occur in adults
Suspicion if:
● Ketosis/ketonuria
● Polyuria
● Acute weight loss (>5% in 1 month)
● < 50 years of age
● Family history of autoimmune disease
● Acute onset
Managing if suspicion:
● Assess ketone level and treat hyperglycaemia (seek help immediately if ketone >1.5)
● Confirmatory test
○ IAA, ICA, GAD (present in 90% of cases)
○ C-peptide (<0.2 on non-fasting samples)
Diabetes - type 2 (screening)
Yearly
- Aboriginal and Torres Strait Islander from 18 years
- Individuals with impaired glucose tolerance test or
fasting glucose
3 yearly
- AUSDRISK (from 40 years) >=12
- Previous CVD
- History of gestational diabetes
- PCOS
- Antipsychotic drugs
Diabetes - type 2 (diagnosis)
Symptomatic
One of the following:
● Patient presenting with hyperglycaemic crisis
● Single elevated BSL (fasting) >=7
● Single HbA1c >= 6.5%
● BGL (random) >=11.1
** Second test not required unless diagnostic uncertainty remains
Asymptomatic
● HbA1c >=6.5% on two separate occasions
○ May not be elevated in early diagnosis, does not exclude is there is elevated blood glucose
● BSL (fasting) >=7 or BSL (random) >=11.1 on two separate occasions
T2DM medications - metformin
MOA: reduces glucose production in the liver and reduces insulin requirements.
Immediate:
● Up to 2g, divided doses
Modified:
● Up to 2g daily
ADRs: GI effects, B12 deficiency, lactic acidosis (rare)
Contraindicated: eGFR <30
T2DM medications - sulphonylurea (e.g. gliclazide)
MOA: increase insulin secretion via the pancreatic sulfonylurea receptor
ADRs: weight gain, hypoglycaemia
Caution:
● Avoid glibenclamide and glimepiride in kidney impairment
● Reduce dose of gliclazide and glipizide if CrCl <30
T2DM medications - DPP-4i (-gliptin)
MOA: increase endogenous concentrations of incretin hormone that are produced in
the gut
Example: linagliptin 5 mg orally daily
Caution: Adding DPP-4i to GLP-1 does not improve glycaemic control. Reduce dose in
CKD (except linagliptin).
ADRs: pancreatitis (rare), MSK pain.
Contraindication: previous pancreatitis, heart failure.
T2DM medications - GLP-1 RA (-tide)
MOA: increase insulin secretion and delay gastric emptying
Example: exenatide MR 2mg subcut weekly
ADRs: nausea (improves over time), pancreatitis (rare)
Contraindications: pancreatitis (acute or history), Fhx thyroid cancer or endocrine
neoplasia, CrCl <30 (liraglutide CrCl <15)
T2DM medications - SGLT2-i (-flozin)
MOA: inhibit reabsorption of glucose from proximal convoluted tubule of kidney
Example: empagliflozin 10mg orally daily (max 25mg)
Caution: avoid in patients with low-carb diet, not effective in patients with impaired
kidney function, be mindful of patients on frusemide.
Advantages: reduces secondary CVD including mortality
ADRs: UTI, reversible increase in creatinine
Contraindication: CrCl =<45
T2DM medications - insulin
MOA: supplement endogenous insulin production Strategies: ● Basal insulin ● Once-daily fixed-dose combination ● Twice-daily fixed-dose combination Strategy for commencement: Start with once-daily basal insulin, uptitrate by 2-4 units every 3-7 days ADRs: hypoglycaemia, weight gain
Combination
● Metformin should be continued for as long as possible
● Caution of sulfonylurea due to risk of hypoglycaemia.. Should cease when on
BD insulin.
● GLP-1 effective with basal insulin (minimise hypoglycaemia and weight gain)
● DPP-4i should be temporarily ceased when starting basal insulin
● SGLT2 can reduce weight gain
T2DM medication considerations - CVD
Sulfonylurea: Increased risk when used alone (gliclazide, glimepiride) but neutral when
used in combination with metformin
SGLT2i and GLP-1 RA have selective benefit
** Saxagliptin (DPP-4i) has increased hospitalisation rate for heart failure
T2DM medication considerations - hypoglycaemia
Sulfonylurea:
● Gliclazide has fewer hypoglycaemic episodes compared to others
● Glibenclamide has the highest risk especially in older people
T2DM medication considerations - GI symptoms
Worse with:
Metformin
GLP-1 RA (trulicity, exenatide)
T2DM medication considerations - weight
Sulfonylurea:
● Gliclazide has neutral effect
● Others have modest weight gain
SGLT2i and GLP-1 RA have moderate weight loss
T2DM medication considerations - renal impairment
Metformin ● Reduce dose by 50% if eGFR 30-60, cease if CrC <30 Sulfonylurea ● Cease if CrC <15 DPP-4i ● Can be used in all stages with nil dose reduction SGLT2i ● Cease if eGFR =<45 GLP-1 RA ● Cease if eGFR < 30 ● Dulaglutide <15
T2DM and HTN
Automatically high risk for CVD
Aim BP 130/80
T2DM and CVD
Automatically high risk
Manage cholesterol and BP
SGLT2 recommended (decreased CVD events and risk of hospitalisation for heart failure) ● Empagliflozin 10mg daily with food
T2DM and CKD
Metformin - Dose reduction for eGFR 30-60 - Cease if eGFR <30 DPP-4 - No dose adjustment required for linagliptin - Reduce dose of others if eGFR <60 ** Saxagliptin if eGFR <15 Sulfonylurea - Review dose as CKD increases risk of hypoglycaemia SGLT2 (e.g. empagliflozin) - Can use if eGFR >=45 GLP-1 RA - Avoid using if CrCl <30
T2DM and lifestyle goals
BMI
- Overweight: 5-10% weight loss
- Obese (>35 w/ comorbidities or >40 without): more aggressive approach
Physical activity
- Children and adolescents: 60 mins/day PLUS muscle and bone strengthening
activities 3x per week
- Adults: 150 mins of aerobic PLUS 2-3 sessions of resistance exercise
Smoking
- Cease
Alcohol
- <2 per day
Glucose monitoring
- 4-7 fasting, 5-10 postprandial
- Self-monitoring: insulin, diabetes in pregnancy, intercurrent illness
Lipids
- Cholesterol <4
- HDL >1
- LDL <2 (or <1.8 if CVD)
- Triglycerides <2
Blood pressure
- <130/80
Diabetes and surgical procedures
Aim:
● Avoid hypoglycaemic episode, prevention of ketoacidosis and avoidance of marked hyperglycaemia
● Aim for BSL 6.1-10 mmol postoperative
Medications:
● Oral hypoglycaemic agents/non-insulin injectables: Withhold on morning of surgery
○ SGLT2i - for patients to advise team
● Cease 3 days prior to surgery or procedures that require one or more days in hospital to prevent DKA
● Cease on day of day procedure
● Insulin: continue subcut preoperatively at reduced rate for simple procedures. Consider IV insulin if long and complex.
Diabetes and sick days
Definition: periods of minor illness, around 1-4 days, that requires changes in usual diabetes self-management.
A plan prevents:
● Hyperglycaemic or hypoglycaemic emergencies
● Hyperosmolar hyperglycaemic state
● DKA (SGLT2 can cause euglycemic DKA)
Action plan for T2DM:
- Commencement: When patient starts to feel unwell
If BGL >15 on two consecutive readings
- Frequency of BGL: monitoring 2-4 hourly
More frequently if BGL low
- Medication: Continue insulin or diabetes medications
Consider cessation of metformin, SGLT2i and GLP-1 RA if vomiting or
dehydration is a concern
- Food and water: Increase fluid intake
If vomiting or diarrhoea, SGLT2i and metformin should be ceased
If LOA and reduced carbohydrate, SGLT2 should be ceased
If BGL
● >15, use non-glucose containing fluids
● <15 use oral rehydration solutions
If unable to tolerate fluids and BGL continues to drop, to attend ED
- Seek assistance: If unwell and unable to follow plan
54M presenting for T2DM review. Diet-controlled. PHx gout (allopurinol 300mg). O/E HR 68, BP 150/90, CV exam normal, pulses normal, sensation normal, BMI 25. Ix BSL (fasting) 6.5, HbA1c 8%, hypercholesterolaemia, eGFR 50, ACR elevated.
- What complication is demonstrated?
- You decide to start him on perindopril arginine 5 mg daily. Aside from postural hypotension, what serious
complications may occur in the short-term? - Other than lifestyle measures, what specific management would you recommend?
What complication is demonstrated?
○ Diabetic nephropathy
You decide to start him on perindopril arginine 5 mg daily. Aside from postural hypotension, what serious
complications may occur in the short-term?
○ Hyperkalaemia
○ Acute renal failure or deterioration of renal function
○ Angioedema (rare but avoid in patients with history of angioedema)
Other than lifestyle measures, what specific management would you recommend?
○ Adjust antihypertensive medication to achieve BP <130/80 mmHg (ACEI)
○ Reduce cholesterol with atorvastatin 40 mg daily
○ Start metformin 500 mg daily
○ Avoid nephrotoxic medications (OTC NSAIDS)
○ Involve a diabetes nurse educator
○ Organise annual podiatry review
Refer for at least biannual eye review by optometrist
Diabetes and screening of complications (timeframe)
- Diabetic retinopathy/Vision
- At time of diagnosis
- Optometry yearly
- Ophthalmologist 1-2 yearly or early as indicated
* * Add fenofibrate if signs of diabetic retinopathy - Diabetic neuropathy
- At time of diagnosis
- Annually
* * 10g monofilament, 128Hz tuning fork - Foot care
- Podiatry if at risk (6 monthly) - Nephropathy
- Urine ACR and eGFR annually
Diabetes insipidus (pathophysiology, causes, differentials, presentation, treatment)
Key words: weakness + polyuria + polydipsia
Pathophysiology: impaired secretion of vasopressin
Causes: postoperative (transient), cranial tumours/infections/infiltrations, anorexia nervosa
Differentials: psychogenic
Presentation: polyuria, nocturia and compensatory polydipsia (3-20L of urine per day)
Treatment: desmopressin (intranasally BD)
Diabetic polyneuropathy (features, signs and symptoms, examination, differentials, management)
Clinical features: distal symmetric sensory polyneuropathy, ‘stocking-glove’ sensory loss
Signs and symptoms:
● Negative symptoms (nerve fiber loss or dysfunction) - numbness and weakness
● Positive symptoms (abnormal function of the surviving nerve fibers) - tingling and pain
Examination: pinprick sensation, 10g monofilament, 128Kh tuning fork, ankle reflexes
Differentials:
** consider if asymmetry, non-length dependence, predominant motor involvement, rapid onset
● B12 deficiency
● Alcohol use
● Cardiovascular
○ Suspect if resting HR > 100 bpm or orthostatic reduction in BP (>20mmHg)
● CKD
● Hypothyroidism
● Chemotherapy
● Idiopathic
** consider in absence of atypical features
● Peripheral artery disease
Recommendations:
● Screen for at diagnosis and annually thereafter
● Assess with 10 g monofilament or tuning fork at dorsum of great toe
Management: Difficult. Refer to the options below with evidence.
● Tricyclic medications (first-line)
● Gabapentin (⅓ of people)
● Pregabalin 300-600mg (high levels of benefit)
Ketosis (alcoholic vs. fasting)
Alcoholic Risk factor: malnourished patients with chronic alcoholism with history of binge alcohol ingestion Clinical manifestations: ● N&V, abdominal pain ● Generalised abdominal tenderness , hepatomegaly, alcoholic hepatitis/pancreatitis ● Hypovolaemia/K+ depletion ● Tachycardia/hypertension ● Increased respiratory rate
Fasting
Timeframe:
● 12-14 hours
● Peaks at 20-30 hours
Osteoporosis - guidelines
Summary
Group: postmenopausal women and men > 50 yrs
- Minimal hip/vertebral trauma = initiate anti-osteoporosis medication
- Minimal trauma at any other site = DEXA = T-score -1.5 refer to specialist
- No history of minimal trauma = assess for risk factors
** Refer to page 217-218 of GP Study Notes
Osteoporosis - risk factors
Non-modifiable
- Parental history of fracture
Modifiable
- Premature menopause
- Multiple falls
- Low physical activity
- Low body weight
- Low muscle mass
- Poor balance
- Smoking
- Alcohol >2 drinks/day
- Vitamin D insufficiency
Disease or conditions
- Rheumatoid arthritis
- Hyperthyroidism
- Chronic kidney disease
- Chronic liver disease
- Diabetes
- Myeloma
- HIV infection
- Depression
Medications
- Prednisolone
- SSRI
- Anti-psychotics
Osteoporosis - non-pharmacological management
Non-pharmacological management ● Adequate dietary calcium intake 1300 mg a day ● Weight bearing exercises ● Maintain vitamin D level above 75 ● Smoking cessation advice ● Implement falls reduction strategies
Calcium supplementation
- Total intake should not exceed 2000mg/day
- Additional supplementation should only be considered if dietary intake is insufficient (max daily dose 500-600mg)
Osteoporosis - pharmacological options (anti-resorptive)
Bisphosphonates
Tip: Must be taken on an empty stomach, at least 2 hours before calcium/iron/magnesium/ antacids
Duration: Beneficial effects can persist for several years after ceasing. Consider ceasing after 5 years of oral therapy or 3 year of IV therapy. Can be continued for up to 10 years for oral therapy or 6 years for IV therapy.
Management after cessation: Measure bone mineral density after 2-3 years. Therapy can be restarted if needed.
Denosumab
Considerations:
● Need to adhere for 6 months
● Life-long therapy or be replaced with bisphosphonate on cessation
● Risk of multiple spontaneous vertebral fractures if delayed for more than 4 weeks
Parameters for prolia: Vit D > 50, corrected calcium normal, CrCl > 30
Dosing: denosumab 60mg subcut every 6 months
Osteonecrosis of jaw
● Rare complication of bisphosphonates and denosumab.
● Benefit of therapy in preventing fractures often outweighs the low risk of osteonecrosis of the jaw.
● Risk is highest after dental extractions or dental implant insertion.
Osteoporosis - pharmacological options (oestrogen)
Raloxifene (60mg PO
daily)
- Reduced postmenopausal bone loss
- Protects from vertebral fractures but not non-vertebral
- Most appropriate in <60 years and women with high risk of breast cancer
Tibolone (2.5mg PO
daily)
- Has oestrogenic and progestogenic effects.
- Generally used for <60 years
Oestrogen
- Less harm is started in women at a younger age
- Required in women with premature ovarian insufficiency until typical age of menopause (regardless of BMD status)
Osteoporosis - pharmacological options (other)
Teriparatide (synthetic PTH) 20 microg subcut once daily
Second line treatment
Strict eligibility criteria
● Must be started by a specialist
● T score -3 or less
● >2 minimal-trauma fractures (including a fracture at least 1 year of antiresorptive
therapy)
Contraindications: <25 years, known/suspected Paget disease, previous radiotherapy of
bone, pre-existing hypercalcaemia/malignancy/severe kidney disease/primary
hyperthyroidism
71F, sharp pain in thoracic spine 4/7. Smoke 20 cigarettes/day. XR spine - anterior wedging of thoracic spine w/ 30% loss at T4-6 consistent with osteoporotic crush fracture.
- Non-pharmacological management
- You decide to start the patient on Alendronate. What are 4 appropriate investigations?
Non-pharmacological management ● Adequate dietary calcium intake 1300 mg a day ● Weight bearing exercises ● Maintain vitamin D level above 75 ● Smoking cessation advice ● Implement falls reduction strategies
You decide to start the patient on Alendronate. What are 4 appropriate investigations? ● Dual-energy XR absorptiometry ● UEC ● Vit D ● Calcium
Paget’s disease
Aim: relieve symptoms and prevent complications.
● Lesions do not always normalise by symptom relief and normalisation of ALP occurs when the lesions
become inactive.
Bisphosphonates ● E.g. zoledronic acid 5 mg IV over 15 minutes ● Requirements for infusion: ○ Vitamin D >50 ○ Corrected calcium in normal range ○ eGFR > 35 ○ Patient well hydrated ● Asymptomatic disease does not need treatment
Analgesia (commonly NSAIDS)
Pheochromocytoma (pathophysiology, presentation, screening test)
Pathophysiology: adrenomedullary tumor that produces catecholamines
Presentation: paroxysmal hypertension, headaches, palpitations and sweating
Screening test: plasma free metanephrines and normetanephrines, or urine total metanephrines
Primary aldosteronism (key points, common causes, considerations for testing, initial evaluation)
Key points
● Underdiagnosed cause of hypertension
● Classic presenting signs are hypertension and hypokalaemia
Common causes: Aldosterone-producing adenomas (Conn syndrome) and bilateral adrenal hyperplasia
Consider testing for in:
● Hypertension with diuretic-induced hypokalaemia
● Severe hypertension or drug-resistant hypertension
● Hypertension with adrenal incidentaloma
● Hypertension with sleep apnoea
● Hypertension with family history of early-onset of HTN or CVA (<40 yrs)
● All hypertensive first-degree relatives of patients with primary aldosteronism
● Hypertension and AF
Initial evaluation: morning blood sample in seated patient = plasma renin activity or plasma renin concentration AND
plasma aldosterone concentration
Primary hyperparathyroidism (work up, management)
Work up ● Urinary calcium excretion ● Vitamin D level ● Serum creatinine and eGFR ● Bone density
Management
● Asymptomatic - work up as above and decide based on findings
● Symptomatic - work up with likely surgery
SIADH (pathophysiology, causes, presentation, management)
Pathophysiology: Inability to suppress the secretion of ADH
Causes: Cancer, pulmonary disorders, intracranial lesions, drugs (carbamazepine, antipsychotics).
Presentation: hyponatraemia (from ADH-induced water retention and secondary solute loss), hypoosmolality, and urine osmolality above 100 mosmol/kg
Management: Treat underlying cause, fluid restriction (<800ml/day)
Thyroid disease (causes)
Hyperthyroidism: Graves disease Toxic adenoma Toxic multinodular goitre Postpartum thyroiditis Painful subacute thyroiditis Amiodarone Factitious ingestion
Hypothyroidism: Hasimoto’s thyroiditis Iodine deficiency Amiodarone Lithium
Thyroid disease - indications for investigations
TSH
- Symptoms suggestive of imbalance
- Goitre/nodules present
- Thyroxine replacement
- Preconception and during first trimester in patients with history
F3, F4
- If TSH abnormal
- Suspected pituitary or hypothalamic disease
- Rapidly changing thyroid function
- Thyroxine replacement for central hypothyroidism
Ultrasound
- Structural thyroid abnormality (nodule or goitre)
- Prior to neck surgery for thyroid cancer
- Following thyroid cancer surgery
Antibodies
- Thyroglobulin - Hashimoto’s or Graves, malignancy
- Thyroid peroxidase - Hashimoto’s
- TSH receptor - Graves
Radionuclide thyroid scan
- Aetiology of thyrotoxicosis not evident from pathology
** contraindicated in pregnancy, cease breastfeeding for 2-3 days
post.
Hypothyroidism - signs and symptoms, treatment, when to refer
Signs and symptoms
- constipation
- menorrhagia
- fatigue
- weight gain
Starting treatment
● Thyroxine 25 to 50 microg PO daily
● Adjust dose every 4-8 week as required
** Start at lower end for patient with cardiovascular disease
*** Aim for TSH 0.5-2.5 for patients younger than 60, TSH 1-5 for > 60 years (requirement decreases with age)
When to refer ● Patients < 18 years ● Unresponsive to treatment ● Pregnant patients ● Cardiac patients ● Presence of goitre, nodule or other structural changes
Hyperthyroidism
Graves
- TSH receptor antibodies
- Asymmetrical goitre, proptosis
- Elevated diffuse uptake pattern
Toxic multi-nodular
- Nodular goitre
- Multifocal or focal uptake
Painless postpartum
- Autoimmune destruction
- 1-6 month postpartum, followed by hypothyroidism
- Near absent uptake
Exogenous
- No goitre
- Near absent uptake
Painful subacute
- Viral, destruction of follicles
- Tender goitre, thyrotoxicosis for 1-2 months following by hypothyroidism for 4-5 months
Amiodarone induced
** Refer to pages 284-285 of GP Study Notes
Primary hyperthyroidism - treatment
Initial
First line: Carbimazole 30 to 45 mg oral daily, BD or TDS. Adjust 4-6 weekly as required.
Second line: Propylthiouracil (can cause severe liver disease; use if first-line not tolerated or before conception/first
trimester or thyroid storm).
Dose titration
● Consider down titrating every 4-6 weeks
● Base initial dose adjustment on FT3 and FT4 (TSH can take months to correct)
**Do not stop treatment abruptly once thyroid hormones have normalised
Adverse effects
● Agranulocytosis (rare, first months of treatment)
** Advise to stop medication and seek medical assessment if have acute malaise, fever or infection
Symptoms
● Propranolol 10mg oral BD (can increase up to 40mg) ** do not add a second beta blocker if one ineffective
Subacute thyroiditis (findings, differentials, treatment)
Findings: Elevated ESR, near absent uptake on nuclear thyroid scan
Differentials: acute infectious thyroiditis, haemorrhage into thyroid nodule, Hashimoto’s thyroiditis (rarer), Grave’s
hyperthyroidism (rarer)
Treatment: ** no role for antithyroid drugs during thyrotoxic stage
● Symptoms: propranolol 10mg oral BD
● Pain: Aspirin/ibuprofen (mild), prednisolone 40mg daily (severe)
Goitre (initial investigation)
** Refer to page 287 of GP Study Notes
Vitamin D (classification, when to measure, supplementation)
Classification
- Mild: 30-49
- moderate: 12.5-29
- severe: <12.5
When to measure ● People at increased risk of vitamin D deficiency: ○ Institutionalised or housebound ○ Clothing that covers most of the skin ○ Dark skin (Fitzpatrick V and VI) ○ Medical condition (CLD, CKD) ○ Fat malabsorption (CF, coeliac, IBD) ○ Pregnant women (antenatal screen)
Supplementation
Indication:
● Uncomplicated moderate to severe Vit D deficiency (<30)
● If starting drug therapy for osteoporosis (<50)
● Osteomalacia or rickets
Treatment regimes:
● Mild: colecalciferol 25-50 mcg PO daily or 175-350 mcg PO weekly
● Moderate to severe: 75-125 mcg PO daily for 6 weeks, then 25-50 mcg daily
