Endocrinology

Question 1

Factors affecting HbA1c (besides glycemia)

Answer 1

Increase A1c:
- ethnicity (higher in Black, Native, Latino, Asian)
- iron deficiency
- B12 deficiency
- alcoholism
- CKD
- Chronic opioid use

Decrease A1c:
- Supplemental Fe, B12, vit C, vit E
- ASA
- Hemoglobinopathy
- Chronic liver disease
- CKD
- antiretroviral

Question 2

Diabetes Dx criteria

Answer 2

8h fasting glucose >7
Random glucose >11
2h 75g OGTT >11
HbA1c >6.5

If asymptomatic, repeat test on another day to confirm Dx.
(if random BG, confirm with another modality)

Question 3

Transplant options for T1DM

Answer 3

Pancreas transplant
Pancreas islet allotransplant
ESRD: kidney transplant

Question 4

Typical distribution of basal and bolus insulin

Answer 4

40% basal
60% bolus (20% per meal)

Question 5

Meds for vascular protection in DM (and their indications)

Answer 5

Statin
- macrovascular disease
- OR age 40+
- OR age 30+ and DM >15 years
- OR microvascular disease
- OR according to lipid guidelines

ACEI/ARB
- CVD
- OR microvascular complications
- OR age 55+ and additional factor (albuminuria, retinopathy, LVH, etc.)

ASA
- Only if CVD (not primary prevention)

Question 6

Cardiorenal benefits of SGLT2 and GLP1

Answer 6

SGLT2:
CKD, HF (kidney failure, heart failure)

GLP1:
ASCVD and risk factors (smoking, obesity, HTN, lipids)

Question 7

Diabetes meds to hold or not to hold during illness

Answer 7

Metformin: hold
SGLT2: hold
DPP4: don’t hold
GLP1: don’t hold
Secretagogues: hold

Question 8

Side effects and adverse events of SGLT2i’s

Answer 8

Euglycemic DKA
Hypotension, OHT
AKI
Urosepsis/UTI
Mycotic infections
Fractures
Dapagliflozin contraindicated in bladder cancer

Question 9

Side effects and adverse events of GLP1’s

Answer 9

N/V
Pancreatitis
Pancreatic cancer (Seems this isn’t real…)
Contraindicated if Hx or fam Hx of thyroid Ca or MEN2

Question 10

Side effects of metformin

Answer 10

GI symptoms
decreased vit B12

Question 11

What is Kussmaul breathing

Answer 11

Deep, rapid breathing.
Occurs in metabolic acidosis, especially DKA.

Question 12

Typical glucose values in DKA and HHS

Answer 12

DKA: 14+ (pts on SGLT2 can have euglycemic DKA)
HHS: 34+

Question 13

Investigations for pts with DKA/HHS

Answer 13

Glucose
Creat
AG: Na - Cl - HCO3
OG: 2NA + 2K + BUN + glucose
Beta-hydroxybutyrate
Blood gas
Serum + urine ketones

Assess for causes and complications:
Lipase
CBC
Urine and blood cultures
CXR
ECG (risk of K changes)

Question 14

Management of DKA/HHS

Answer 14

Hydration: start with NS, then D5-1/2NS or D5W later.

IV insulin: start at 0.1 u/kg/h.
(after starting NS and ensuring K >3.3)

K: up to 40mmol/L, depending on K.

Question 15

Causes of / conditions associated with hyperPTH

Answer 15

Meds: thiazides, lithium
Radiation, radioactive iodine
MEN (1 and 2a)
Neonatal severe hyperPTH
Familial hypocalciuric hypercalcemia (FHH)
Familial hyperPTH

Question 16

Hypercalcemia symptoms

Answer 16

Stones (nephrolithiasis)
Bones (bone pain, fragility fractures)
Groans (N/V, constipation, PUD, pancreatitis)
Psych overtones (lethargy, depression, psychosis, coma)

Also:
Cardiac (short QT, ventricular arrhythmia)
Gout, pseudogout

Question 17

Treatment for hyperPTH

Answer 17

Primary hyperPTH
- Parathyroidectomy
- For hyperCa: volume, loop diuretic, zoledronate

For FHH (familial hypocalciuric hypocalcemia)
- no parathyroidectomy

Question 18

Risk factors for hyperthyroidism

Answer 18

goiter
T1DM
Autoimmune disorder
Family Hx
Meds: amiodarone, lithium, iodine

Question 19

Causes of hyperthyroidism (algorithm)

Answer 19

Low TSH, high/normal fT4+T3:
- Measure radioiodine
-> low uptake: thyroiditis, ectopic T4 (metastatic thyroid cancer, ovarian tumours), exogenous T4
-> high uptake: Graves (diffuse), toxic multinodular goiter (multiple), toxic adenoma (single hot spot)

High TSH, high T4+T3: 2ary hyperthyroidism
- MRI to assess for TSH-secreting pituitary adenoma

Question 20

Treatment for primary hyperthyroidism

Answer 20

Betablockers (e.g. propranolol)
Methimazole (Tapazole) x 12-18 mo then taper
Propylthiouracil (2nd line)
Radioactive iodine (single treatment)
Subtotal thyroidectomy (Tx of choice in pregnant/young)

Question 21

Signs and symptoms of thyroid storm

Answer 21

Fever
CNS (agitation, psychosis, seizure, coma)
Tachycardia, Afib
CHF
GI (N/V/D, pain, jaundice)

Question 22

Treatment of thyroid storm

Answer 22

Methimazole (reduce thyroid synthesis)
K iodide (inhibit hormone release)
Propranolol (reduce HR)
Support circulation (steroids, fluids, O2, cooling)

Question 23

Causes of hypothyroidism

Answer 23

Primary:
- Hashimoto
- Postpartum thyroiditis
- Meds: amiodarone, lithium, iodine
- Radioactive iodine, radiation
- Surgery, trauma
- Cancer
- Agenesis/dysgenesis

Central:
- Pituitary adenoma
- Pituitary damage (surgery, trauma)
- Pituitary infiltration (TB, sarcoid, granulomatous)

Question 24

When to check T3 hormone

Answer 24

To r/o T3 thyrotoxicosis
(in pt with undetectable TSH and normal fT4)

Question 25

Non-thyroid lab abnormalities due to hypothyroidism

Answer 25

HypoNa
Macrocytic anemia
Increased lipids
Elevated CK

Question 26

When to treat subclinical hypothyroidism

Answer 26

Elevated TPO antibodies
Goitre
Pregnancy
Strong family Hx of autoimmune disease
TSH >10 (or >20) and/or symptomatic

Question 27

What is subacute granulomatous thyroiditis

Answer 27

Often preceded by URTI
Thyroid pain / painful goitre
Hyperthyroid, then hypothyroid, then self-resolves