Endocrinology Flashcards
Classification of Pre-diabetes
Hb1Ac- 42-47
Medication for T2DM and examples
Thiazindine- pioglitazone
Gliptins- sitagliptin
Sulphonlyureas- glicazide, glibenclamide
SGLT2- dapaflozin
CI and uses of T2DM medications
Metformin- lactic acidosis, <GFR 30
Sulphonylureas- CI Ketoacidosis as causes hypos, caution in high BMI as causes weight gain
Thiazol- pioglitazone- weight gain, abnormal LFT, bladder cancer- CI in HF and bladder cancer
Gliptins- Good to use if overweight
Caution if GFR <45
DPP4 inhibitor- increase incretin- increase insulin
Empagliflozin- CI GFR <60 - good for HF, can help loos weight?
When to add medications in T2DM
Metformin when >48
Add another if >58
What medication to use if CKD 4 and T2DM
Sitagliptin or gliclazide
Signs and sx of DM
Fatigue, polydipsia, polyuria
Neuropathy- gastroparesis, neuropathic pain
Foot- screen annually
Nephropathy- ACR yearly, microalbuminurea first sx
Mx of secondary symptoms of DM
Gastroparesis- metoclopramide
Neuropathic pain- amitriptyline
Nephropathy- ACEi- protective in DM and CKD but toxic in AKI
if ACR >30
Monitoring ACEi in DM nephropathy
Expect a drop since dilation
If GFR drop >20% stop
If less continue
Diagnosis of DKA
DM- BM >11
Ketones >3
Acidosis- ph <7.3
Develops rapidly
Causes of DKA
Infection
Alcohol
Trauma
Insulin missed
Tx of DKA
Fluid bolus 500ml in 15 mins- then 1L/hr
Insulin- 0.1g/kg/hr
Potassium
10% dextrose when BM <14
VTE prophylaxis
Dx of HHS
pH >7.3
BM >30
Osmolarity- >320
Develops over few days
Tx of HHS
1L in first hour
then 500ml/hr for 4 hours
250ml for next 4 hours
When to investigate neck lump
> 1cm- USS +/- FNA
Cause of simple goitre
Iodine deficiency
Several hot nodules with thyrotoxicosis vs single hot
Plummers vs
Single toxic adenoma
Causes of diffuse goitre
De Quervains- painful, hx of infection- reduced uptake
Graves- exophthalmos, pretibial myxoedema
Mx of Graves
40 mg Carbimazole
Propanolol
Or radioiodine- CI with eye disease, pregnanacy
2nd- PTU
Causes of hypothyroid
Hashimotos
Iodine deficiency
Viral thyroiditis- hypo phase
Types of thyroid cancer and Tx
Papillary- common- thyroidectomy
Follicular- “
Medullary- parafollicular C cells - phaeo screen- “
Anaplastic - palliative
Complications of thyroid surgery
Early
Haematoma- obstruction- remove clips
Recurrent laryngeal nerve pasy- right side- damage to 1- hoarse voice, both- obstruction- tracheotomy
Hypoparathyroid- low calcium
Thyroid storm- propanolol and antithyroid
Tx of myoxedema coma
IV thyroxine
IV fluids
IV HC
Sx of Addisons
WT loss
N/V, abdo pain, GI
Hyperpigmentation
Postural hypotension
Vitiligo
Causes of Addisons
AI
TB
Mets
Haemorrhage- Waterhouse Friedrichson
CAH
Addisonian Crisis Sx
Shocked- high HR, cpostural drop, confused
Hypoglycaemia
Cause of Addisonian Crisis
Infection- sepsis, meningoccocoaemia- WHF
Trauma
Surgery
Stopping steroids
Ix for Addisons
SynthACTHen - measure cortisol
Mx of Addisonian crisis
IM/IV HC- 1st
IV fluid bolus - 2nd
Continue fluids and convert to PO dex
Main types of pituitary tumours
Prolactinoma> non secreting > GH secreting > ACTH secreting
Sx of hyperprloactinaemia
Amenorrhoea
Infertility
Galactorrhoea
↓ libido
ED
Sx of acromegaly
Coarse face
Macroglossia
Proximal weakness
Headache
DM
Increase BP
Ix of acromegaly
IGF1 then OGTT with serial GH measurements
Mx of acromegaly
Trans-sphenoidal
2nd- octretide
Causes of Cushings
Exogenous- GC therapy
Endogenous- Cushing disease- ACTH dependent pituitary
ACTH independent- adrenal adenoma
Ix for Cushings
11pm salivary cortisol- if low not Cushings
- LDDST- 1mg DM- measure cortisol before 9am
Measure ACTH too
Confirm Cushings- IPSS- determines whether pituitary or ectopic
Tx of Cushings
Pituitary adenoma- surgery
Adrenal mass- adrenalectomy + steroids replace- can cause nelson syndrome- don’t do bilateral- enlargement of pituitary- compression ++ACTH- hyperpigmentation
Ectopic- ketoconazole
Sx of Conns syndrome
Med resistant HTN
Hypokalaemia - causing muscle weakness
Paraesthesia
Sx of Cushings
Metabolic hypokalaemia alkalosis
Proximal myopathy
DM
Striae
HTN
Moon face
Fat pad
ECG changes with Conns
Flat/Inverted T waves
ST depression
U waves
Long QT and PR
Ix of Conns
Plasma aldosterone/ renin ratio - high low
Then HR-CT + adrenal vein sampling- differentiates between bilateral hyperplasia
Tx of Conns
Spironolactone then surgery
Causes of secondary hyperaldosteronism
RAS- high renin due to poor perfusion
Aldo : renin- high high
Cause of hypernatraemia
Conns syndrome
RAS- high RAS
GI loss
Diabetes insipidus
Signs of hyponatraemia
Hypovolaemia- tachycardia, low urine Na- best
Hypervolaemia- high JVP, peripheral and resp oedema
Causes of hyponatraemia
Hyper- excess water, ADH
Cardiac failure
Cirrhosis- vasodilation due to excess NO- low BP- high ADH
Renal failure
Euvolaemic- SIADH, hypovolaemia, adrenal insufficiency
Hypo- D+V, diuretics
Causes of SIADH
4 Cs
CNS pathology- stroke
Cancer- SCLC
Chest- pneumonia
Carbmazepine and SSRI, TCA, PPI
Surgery
Ix of euvolaemic hyponatraemia
TFTs
Short SynACTHen - adrenal
plasma and urine osmolatrity- SIADH
Causes of hyperkalaemia
Low GFR
NSAIDs
DM
ACEi and ARB
Addisons
Spironolactone
Mx of hyperkalaemia
10ml 10% Calcium glutinate
10U insulin
120ml 20% dextrose
Causes of hypokalaemia
GI Loss
Hyperaldosterone- RAS/Conns
Diuretics
Insulin
Alkalosis
Mx of hypokalaemia
Oral KCl- 2.5-3.5
Severe <2.5- IV KCl
Types of HyperPTH
Primary- adenoma
Secondary- CKD, vit D def
Tertiary- end stage renal
Types of MEN
1- pituitary adenoma, parathyroid, pancreatic
2A- parathyroid, medullary, phaeo
2B- marfanoid, neuroma, medullary, phaeo
What can cause a lower than expected HbA1c
Sickle
G6PD
HS
Haemodialysis
DM has CKD and previous MI what prescribed
No metformin
SGLT2
When to stop IV insulin to SC in DKA
When eating and drinking normally
Ketones <0.6
pH >7.3
Bicarbonate >15
If struggling to dx between T1DM and T2 what test can you use
C peptide
Primary, secondary and tertiary hyperparathyroid biochem
Primary
PTH high
Ca High
P Low
Secondary
PTH High
Ca Low/N
Vit D low
Tertiary
PTH V high
Ca High
P high
Tx of hypercalcaemia
Fluids 3-4L daily
Bisphosphonates ?
What to do If ketonaemia and acidosis and not resolved by 24 hours
Endocrine review
Sx of hypocalcaemia
Cramps, twitching, spasms
Trousseau sign
Chvosek
Mx of hypocalcaemia
Severe- tetany, spase, prlonged QT
IV calcium- 10ml 10% in 10 mins
Max rate of potassium from peripheral line
10mmol/hr
So 40 mmol in 4 hours
What electrolyte deficiency can cause abnormal calcium absorption
Magnesium
Effects of hyperthyroid on the bones
Osteoporosis
MEN 1
Pituitary
Parathyroid
Pancreatic- can cause Zollinger ellison- many ulcers
MEN 2A
Parathyroid
Phaeo
Medullary thyroid
MEN 2B
Medullary thyroid
Marfanoid
Phaeo
What requirements are there for insulin dependant DM for driving
Check blood sugar every 2 hours
Sick day rules of DM
Increase monitoring of glucose
Normal regime
Rate of fixed insulin rate in DKA
0.1 units/kg/hour
so if 70kg in 2hrs
14 units
What is acropachy and what is it associated with
Swelling/clubbing of fingers
Graves disease
Addisons treatment for those who are vomiting
IM HC until vomitting stops
MOA of gliptins
DPP4 inhibitors- increase incretins GLP
MOA of exanitide
GLP1 mimics
If hyperkaleamia first thing you do
ECG
Ca gluconate with insulin and dextrose if >6.5
Daily HC treatment of addisons
Majority in the first half of day
Less in evening
e.g 20mg in morning, 10 in eve
TX of HTN in afro carribean with DM
ARB
Sodium <120 tx
Hypertonic solution 3%
When does a diabetic need to surrender their licence
If 2 hypoglycaemic episodes requiring help
Scintigraphy of Graves vs thyroiditis
Uptakes is high in Graves
Thyroid disease affecting periods
Hyper- oligo /ameno
Hypo- menorrhagia
Sick day rules T1DM
Increase frequency of glucose monitoring
3L of fluid
If unable to eat- sugary drinks
Patients on long term steroids on sick days
Double steroids
SE of thyroxine therapy
OP
Angina worsen
AF
Non functioning pituitary adenoma sx
Headache- pressure affects
Hypopituitism
Medical treatment of prolactinoma
Carbergoline
Dopamine agonist - inhibits prolactin release
Cushing acid imbalance
Hypokalaemia metabolic alkalosis
Due to K+ excretion causing H+ excretion
Polyuria and polydyspia ix order
Calcium then water deprivation test
When is hyperkalaemia treated
> 6.5
ECG changes
Ix of phae
Urine metanephrines
SE of metformin and what to change it to
Diarrhoea
Change to modified release
Drugs that cause prolactinoma
Dopamine antagonist such as metoclopramide
When is exanitide used
If cannot tolerate triple therapy and BMI >35
Addison disease and ill what should you do
Double Hydro
Keep fludro the same
Tx of SIADH
Fluid restrict
Demeclocyline
Subclinical hypothyroidism tx
If 2 separate occasions 3m apart with elevated TSH 5.5-10 and symptoms
or >10
Give thyroxine for 6 months
When to prescribe SGLT2
If T2DM develop CVD, high risk for CVD or CHF
Q risk >10
What tests should men with ED get
Morning testosterone
Lipids
Where should you avoid cannulating in diabetess
In feet due to formation of diabetic ulcer
Main complications of fluid resuscitations in DKA
Cerebral oedema- seizures
Alcoholic KA tx
Saline and thiamine
How to work out how long a person should be on FRII for
Weight x 0.1
To give units per hour
Divide that by how many units given
Which hormone is lost first in pituitary dysfucntion
GH
Which drug can cause thyrotoxicosis
Amiodarone
Hypoglycaemic unawareness mx
Reduce insulin
Set higher glucose targets
If acromegaly but decline surgery mx
Ocretide
SomatoStatin receptor ligand
Removal of thyroid gland and tingling
Hypocalcaemia
Impaired fasting glucose and tolerance
6.1-7- fasting
2hr- 7.8-11.1 tolerance
If thyrotoxicosis what order of tx do you give
Propanolol
Thioamine- PTU/carbimazole
Surgery only for Graves of not suitable , toxic nodules if radio iodine unsuitable
If thyrotoxicosis what order of tx do you give
Propanolol
Thioamine- PTU/carbimazole
Surgery only for Graves of not suitable , toxic nodules if radio iodine unsuitable
Main RF for eye disease in Graves
Smoking
If gyna on spironolactone what should you do
Swap to eplerenone
If TSH low and T4 high on levothyroxine what should you do
Reduce T4
Recheck in 6 weeks
What drugs affect TSH
Ferrous sulphate
Reduce absorption
Raised TSH
Acromegaly affect on prolactin
Raised in 1/3- galactorrhea
Drug that mimics calcium on the sensor causing PTH to lower
Cinacalcet- good if not suitable for surgery
DM with neuro pain and BPH
Amitrip is usually 1st but because its a TCA in BPH can cause urinary retention so should give pregabalin
If Aldo high and CT inconclusive what next Ix
Adrenal venous sampling
Distinguishes between unlateral and bilateral
Sick euthyroid results
Normal TSH
Low T4
During illness
No tx
Steroid therapy TFT results
Low TSH normal T4
Poor compliance With thyroxine TFT
High TSH
Normal T4
Alcohol affect on electrolytes
Hypernatraemia- suppression of ADH
Conns disease affect on urination frequency
Increased urination
Lithium DI test results
Since it causes nephrogenic DI
Urine osmolality will not change after desmopressin
RF of graves
Females
Smoker
30-60
Vit D deficient
Kleinfelters blood results
High LH and FSH
Low test/oest
Primary hypogonadism
DI urine osmolality levels
<600
Give desmo- >600 if cranial
What drug can reduce hypoglycaemic awareness
BB
Since suppress adrenergic sx
When to tx subclinical hypothyroid
If TSH >10- on 2 separate occasions 3m apart
or
<65 and symptomatic and TSH high 3m apart- trail of thyroxine
If >80- watch and wait
What to screen for in t1dm
Coealiac
Tx of nephrogenic DI
Chlorothiazide
Where does papillary thyroid cancer spread to early
Cervical LN
Where does follicular thyroid cancer spread to
Vascular
Most common cause of primary hyperaldosteronism
Bilateral idiopathic adrenal hyperplasia
If have foot problems in DM other than calluses what should you do
Refer to local diabetic foot centre
Common complication of insulin therapy in DKA and its tx
Hypophosphataemia
Infusion given if severe
Why dont you correct hypernatraemia too fast
As it causes cerebral oedema
Other types of DM
LADA- in adulthood- perhaps other AI condition - type 1
MODY- affecting production of insulin - younger
Rapid correction of hyper and hyponatraemia and their sx
Hypo correction- osmotic demyelination syndrome- spastic paresis
Hyper correction- cerebral oedema- confused
What other sx can carcinoid cause
Can secrete ACTH causing Cushing sx
If going to start SGLT2 what do you have to do first
Ensure metformin is titrated up
Max- 1g BD
What should be stoped before contrast
Metformin
When to refer for bariatric surgery
Early if
Very obese 40-40 BMI
Other conditions caused by obesity
When are SGLT2 CI
GFR <60 - T2DM
GFR <30 in CVS
How are GLP 1 delivered
SC
Order of tx in phaechromocytoma
Alpha first- phenoxybenzamine
Beta second
Vision problems after bilateral adrenalectomy
Nelson syndrome- growth of pituitary after surgery
Thyroid cancer with high calcitonin
Medullary
What can mimic Cushings
Alcohol
Lytic vs sclerotic bone lesion causes
Sclerotic- mets
Lytic- Paget and MM
Glucose targets for T1DM
5-7 mmol/l on waking and
4-7 mmol/l before meals at other times of the day
Electrolyte risk with giving packed RBC after blood loss
Hyperkalaemia
Normal anion gap and causes of raised
10-18
Raised- Methanol, Uraemia, DKA, Lactate, ethylene, salicylates
Differentiating between primary and secondary adrenal failure by sx
Primary- hyperpigmented skin
Units per ml of insulin
100
Likely cardiac problems caused by thyrotoxicosis
High output cardiac failure
Dx of T2DM
Symptomatic and >7 fasting or >11.1 random/OGTT
Asymptomatic- 2 abnormal HbA1c or glucose levels
When should you test for C peptide and DM autoantibodies
Type 1 diabetes is suspected but the clinical presentation includes some atypical features
>age 50 years
>BMI of 25 kg/m²
Hashimoto is associated with which cancer
MALT lymphoma
When to surrender licence to DVLA if diabetic
If 2 or more hypos whenever
Pioglitazone SE
Fluid retention
Presents With high HR, BP, AF, purulent sputum what do you give
Beta blockers, propylthiouracil and hydrocortisone
There storm caused by infection
Apart from drug induced, what else can cause hypoglycaemia
Liver failure
Addisons
Pepper pot skull dx
Hyper parathyroid
Tx of Paget
Bisphosphonates
When to refer for Barietric surgery
BMI 40-50 and other co morbidities
Or >50
Cause of gynaecomastia
Hyperprolactinaemia
Testicular atophy
Kleinfelters
Increased oestrogen- liver failure
Spironolactone, anti psychotics
Cause of amenorrhoea
Primary- Turners, anorexia
Acromegaly AI hep
Hyperprolactinaemia
Hyperthyroid
Haemachromatosis
Sarcoid
Cause of amenorrhoea
Acromegaly
Hyperprolactinaemia
AI Hep
Hyperthyroid
Haemachromatosis
Sarcoid
High dex suppression test results
High dex- suppresses ACTH in Cushing disease
Adrenal adenoma- cortisol not suppressed but ACTH suppressed
Ectopic- ACTH not suppressed
Differentiating exogenous insulin and insulinoma
Give insulin
If insulinoma- C peptide will not fall
Others- will fall
Hba1c targets for T2DM
48
53 if on a drug that can cause hypoglycaemia
Or if above 58 and on drug
What drug worsens glucose tolerance
Thiazides
If TPO abs positive but T4 is still normal dx and tx
Subclinical euthyroid
If 2x with TSH >10 3 months apart or TSH 5.5-10 with symptoms- Levothyroxine 6m
Blood tests for thyroid cancers
Medullary- calcitonin
Papillary- Thyroglobulin
SE of radio iodine
Hypothyroid
Causes of cranial DI
Haemachromatosis
Craniopharygoma
Graves with exophthalmos tx
Carbimazole 12-18 months
Amiodarone induced hypothyroid tx
Continue and give thyroxine
