Endocrinology

Question 1

NICE recommendation 1st line treatment for DM

Answer 1

Biguanides - Metformin

Question 2

Which OHA should not be given in a patient with a significant smoking history and frequently exposed to occupational chemotherapeutic agents?

Answer 2

Pioglitazone - High risk of bladder cancer

Question 3

What to do in a CKD patient taking Metformin whose eGFR < 45?

Answer 3

Reduce dose

Question 4

What to do in a CKD patient taking Metformin whose eGFR < 30?

Answer 4

Discontinue

Question 5

Metformin
OHA Class
Risk of Hypoglycemia
Weight Change
Safety Issues

Answer 5

Biguanides

None

Weight Loss

1. Cardiovascular benefits
2. In renal impairment:
   eGFR < 45: Reduce dose
   eGFR < 30: Discontinue

Question 6

Gliclazide
OHA Class
Risk of Hypoglycemia
Weight Change
Safety Issues

Answer 6

Sulphonylureas

With hypoglycemia

Neutral in terms of weight change

In renal impairment, increased risk of hypoglycemia

Question 7

SITAGLIPTIN

OHA Class
Risk of Hypoglycemia
Weight Change
Safety Issues

Answer 7

DPP4 inhibitors

Rare

Neutral

1. Risk of pancreatitis
2. Heart Failure

Question 8

PIOGLITAZONE

OHA Class
Risk of Hypoglycemia
Weight Change
Safety Issues

Answer 8

-

Rare

Weight gain

1. Bladder Cancer
2. CI in Heart Failure

Question 9

Renal-safe oral diabetic medications (can be given even if eGFR is less than 30)?

Answer 9

Repaglinide
Linagliptin
Pioglitazone

Question 10

Low TSH, High FT4, Increased RAI uptake test

Answer 10

Graves’ Disease

Question 11

Low TSH, High FT4, Decreased RAI uptake test

Answer 11

Subacute thyroiditis (De Quervain’s Thyroiditis)
 - usually following URTI

Question 12

High TSH, Low FT4

Answer 12

Primary Hypothyroidism

Question 13

Low TSH, Low FT4

Answer 13

1. Secondary Hypothyroidism

2. Sick euthyroid syndrome

Question 14

High TSH, Normal FT4

Answer 14

1. Subclinical hypothyroidism

2. Poor compliance to thyroxine medications

Question 15

Osteoporosis

Levels of serum Ca, Phosphate, ALP

Answer 15

Normal, Normal, Normal

Question 16

Paget’s Disease

Ca, PO4, ALP

Answer 16

Normal, Normal, High

Question 17

Osteomalacia

Ca, PO4, ALP

Answer 17

Low, Low, High

Question 18

Main cause of hypercalcemia

Answer 18

Primary Hyperparathyroidism

Question 19

Initial Management of severe hypercalcemia

Answer 19

Rehydration with normal saline 3-4L/day

Question 20

What action should be done when you encounter a patient with elevated TSH but normal FT4?

Answer 20

Repeat TSH after 3 months

Question 21

On initial consult, patient presents with elevated TSH and normal FT4. On repeat testing three months after, patient still had elevated TSH. What to do?

Answer 21

Elevated TSH but <10

a. Asymptomatic - NO TREATMENT
b. 65 yrs and above - NO TREATMENT (oversuppression of TSH may cause AF)
c. Below 65 and symptomatic - LEVOTHYROXINE

Elevated TSH but > 10
LEVOTHYROXINE

Question 22

What are the three main differences between Addison and Conn?

Answer 22

ADDISON
Hyponatremia
Hypotension
Hyperkalemia

CONN
Hypernatremia
Hypertension
Hypokalemia

Question 23

Most appropriate management of MODY?

Answer 23

Refer to secondary care (endo)

Question 24

Medication of choice for MODY

Answer 24

Sulphonylureas

Question 25

Test to request for LADA

Answer 25

GAD Antibody

Question 26

When will you start Levothyroxine in a patient with subclinical hypothyroidism?

Answer 26

First, let’s define subclinical hypothyroidism. Subclinical hypothyroidism is diagnosed when a patient presents with elevated TSH and normal T4 on two occasions, 3 months apart.

If patient presents with TSH less than 10 but patient is asymptomatic, no need for treatment.

If patient presents with TSH less than 10 but patient is over the age of 65, no need for treatment as oversuppression of TSH may result in atrial fibrillation.

THerefore, there are two scenarios where you should consider treatment in a patient with subclinical hypothyroidism

1. If patient presents with TSH less than 10 but the patient is SYMPTOMATIC and age less than 65.
2. If the patient presents with TSH more than 10.

Question 27

Calcimimetic agent used for patients who are not suitable for parathyroidectomy

Answer 27

Cinacalcet

***tells the PTH gland to stop secreting PTH

Question 28

Laboratory findings expected on a patient with primary hyperparathyroidism

Answer 28

Elevated PTH (may be normal in 10% of the population)
Elevated Ca
Decreased phosphate

***usually asymptomatic especially with Ca level less than 3