Endocrinology Flashcards
reference ranges for fasting glucose
below 6 is normal
6.1-6.9 is prediabetes
above 7 is diabetes
reference ranges for HbA1c
below 41 is normal
42-47 is prediabetes
above 48 is diabetes
what value on random glucose would indicate diabetes
11.1
how would you manage an asymptomatic patient with an abnormal HbA1c or fasting glucose
second abnormal reading is required before diagnosis
management of diabetes with HbA1c above 48 and 53
48: lifestyle and metformin
53: lifestyle and drugs which can cause hypoglycaemia
first line management of diabetes
metformin
management of diabetic patients with high risk of CVD/current CVD/ heart failure
establish metformin then add an SGLT2 inhibitor
if metformin contraindicated then monotherapy with SGLT2
management if metformin not tolerated
switch to modified release metformin
second line therapy of diabetes
continue metformin and add one of
DPP-4 inhibitor
Pioglitazone
Sulfonylurea
SGLT2 inhibitor
third line therapy of diabetes
add another drug
start insulin therapy
when would you add a GLP-1 mimetic
under specialist care if triple therapy is not tolerated or contraindicated
which drug reduces the peripheral breakdown of incretins
DPP4 inhibitor e.g. sitagliptin
which patients are DPP4 inhibitors useful in
obese patients
which drug is an agonist of PPAR-gamma receptors and reduces peripheral insulin resistance
pioglitazone
(thiazolidinediones)
2 contraindications for pioglitazone
heart failure
bladder cancer
give an example of a sulfonylurea
gliclazide
2 side effects of sulfonylureas
weight gain and hypoglycaemia
which drug increases urinary excretion of glucose
SGLT2 inhibitors e.g. dapagliflozoin
side effects of SGLT2 inhibitors
UTI, necrotising fasciitis of the genitals, increased urine output, weight loss
how can you distinguish between type 1 and 2 diabetes on blood tests
T1DM has reduced c-peptide levels and anti-GAD autoantibodies
first line treatment of T1 diabetes
basal bolus
2 daily insulin detemir
glucose targets in type 1 diabetes
5-7 on waking
4-7 before meals
sick day rules for people on insulin
continue insulin as normal but check blood sugar levels more frequently
everyone treated with insulin needs what
a glucagon kit for emergencies
management of DKA
initially 0.9% NaCl
0.1 mg/kg/hr fixed rate insulin infusion
withhold for 1 hour in children due to the risk of cerebral oedema
continue long acting insulin
if the ketones and acidosis have not resolved within 24 hours
senior endocrinology review
pH, ketones and bicarb levels in DKA resolution
pH 7.3, ketones 0.6, bicarb 15
presentation and monitoring for hyperosmolar hyperglycaemic state
similar to DKA but hyperglycaemia with no acidosis
monitor the serum osmolarity
management of hypoglycaemia
alert: oral glucose
unconscious: 200ml 20% glucose IV
management of diabetes induced gastroparesis
metoclopramide
inheritance and treatment for MODY
autosomal dominant (strong FHx)
sulfonylureas
HbA1c in hereditary spherocytosis
underestimates blood glucose levels
MOA of orlistat
inhibits gastric and pancreatic lipase to reduce fat absorption
what is the triad in an insulinoma
whipples triad
- hypoglycaemia with fasting/exercise
- reversal of sx when given glucose
- recorded low BMs when sx occur
what are the references for BMI
under 18.5 : underweight
18.5-25: normal
25-30: overweight
30-35: obese class 1
35-40: obese class 2
above 40: obese class 3
2 main causes of hyperthyroidism
toxic multinodular goitre
graves disease
toxic multinodular goitre - treatment and scan findings
patchy uptake on scan
give radioactive iodine
graves disease - treatment and scan findings
increased homogenous uptake
propanolol in new pts for sx control
carbimazole
side effect of carbimazole
agranulocytosis
inform immediately if sore throat, fever, malaise
3 findings in graves disease
thyroid eye disease
pretibial myxoedema
clubbing (acropachy)
management of thyroid eye disease
urgent referral
periods in hyper and hypo thyroid
hyper: oligomenorrhoea or amenorrhoea
hypo: menorrhagia
management of hyperthyroid in pregnancy
propylthiouracil as reduced risk of congenital malformations
risk of over replacement of thyroxine
graves
what effect can thyrotoxicosis have on the heart
high output cardiac failure
3 medications to manage thyrotoxic storm
beta blockers
propylthiouracil
hydrocortisone
how does hypothyroidism often present
brief initial hyperthyroid/thyrotoxic stage followed by hypothyroidism
association with hashimotos
MALT lymphoma
8 causes of hypothyroidism
hashimotos
iodine deficiency
lithium
subacute thyroiditis (de quervains)
postpartum thyroiditis
riedel’s thyroditis
cause of subacute thyroiditis (de quervains)
triggered by viral infection
thyroiditis (de quervains) - treatment and scan findings
reduced uptake of iodine on scan
steroids - self limiting
amiodarone and thyroid issues
can be hypo or hyper
TSH T3 and T4 in sick euthyroid
normal TSH
reduced T3 and T4
A/W systemic illness
TSH and T4 in subclinical hypothyroidism
high TSH
normal T4
management of subclinical hypothyroidism
treat if TSH above 10 on 2 separate occasions 3m apart
watch and wait in elderly
presentation and management of myxoedema coma
confusion and hypothermia
IV corticosteroid and thyroid replacement (exclude adrenal insufficiency)
which thyroid hormone does levothyroxine increase
TSH
when should iron/calcium carbonate be given after levothyroxine
4 hours after levothyroxine
thyroid cancer in a young female with pale empty nuclei on histology, metastases to the lymph nodes and an excellent prognosis
papillary thyroid cancer
thyroid cancer with a solitary nodule
follicular adenoma
thyroid cancer which is encapsulated with vascular invasion
follicular carcinoma
cancer associated with hashimotos
lymphoma
thyroid cancer in an elderly female with pressure symptoms requiring resection as chemotherapy is unresponsive
anaplastic
cancers found in MEN I
presenting complaint is often what?
Parathyroid
Pituitary
Pancreas
hypercalcaemia
cancers found in MEN II a
MEDULLARY THYROID CANCER
Parathyroid
Phaeochromocytoma
cancers found in MEN II b
MEDULLARY THYROID CANCER
phaeochromocytoma
which gene is associated with MEN II
RET oncogene
pneumonic for hypercalcaemia
stones (renal)
bones (bone pain)
groans (abdo pain, N+V)
thrones (polyuria)
psychiatric overtones (confusion, depression, anxiety, insomnia, coma)
2 common causes of hypercalcaemia
malignancy
primary hyperparathyroidism (pituitary adenoma)
high calcium causes a high what
phosphate
presentation and treatment of primary hypercalcaemia
elderly with severe thirst
total parathyroidectomy
what mineral is needed to absorb calcium
magnesium
which drug can cause hypercalcaemia
thiazides
xray finding in hyperparathyroid
pepperpot skull
what is trosseaus sign
capal spasm on inflation of bp cuff in hypercalcaemia
the following are all causes of what:
- bilateral adrenal hyperplasia
- spironolactone
- conn’s syndrome
primary hyperaldosteronism
what is conn’s syndrome
adrenal adenoma requiring surgery
blood pressure, potassium level and pH in primary hyperaldosteronism
high bp
low potassium (causing muscle weakness)
alkalosis
1st and 2nd line investigations for primary hyperaldosteronism
1st: aldosterone:renin
2nd: CT abdo / adrenal venous sampling
autoimmune destruction of the adrenal glands which causes lethargy, weakness, anorexia, weight loss, nausea, vomiting, salt cravings, hyperpigmentation, vitiligo and hypotension
addisons disease
sodium glucose and potassium in addisons
reduced sodium and glucose
high potassium
shock collapse and pyrexia in addisons
crisis
hydrocortisone injections
diagnosis of addisons disease
short synacthen test (ACTH stimulation test)
SE of glucocorticoids
neutrophilia
sick day rules in addisons
double the glucocorticoid
keep the fludrocortisone the same
glucocorticoid and mineralocorticoid activity in
- fludrocortisone
- hydrocortisone
- prednisolone
- dexa/beta methasone
- fludrocortisone: low GC, high MC
- hydrocortisone: high GC, high MC
- prednisolone: high GC, low MC
- dexa/beta methasone: very high GC, very low MC
ABG in cushings
hypokalaemic metabolic alkalosis
difference between cushings disease and syndrome
cushings syndrome is low cortisol
cushings disease is pituitary adenoma - the most common endogenous cause of cushings syndrome
how do you differentiate between cushings disease and syndrome
low dose dexamethasone test diagnoses cushings syndrome
high dose dexamethasone test diagnoses cushings disease
- cortisol not suppressed but ACTH suppressed if syndrome
- both suppressed if disease
what drug can mimic cushings in excess
alcohol
rapid enlargement of a pituitary corticotroph adenoma (ACTH producing) after a bilateral adrenalectomy for cushings
nelsons syndrome
sweating, palpitations, headaches and severe persistent hypertension
phaeochromocytoma
2 investigations for phaeochromocytoma
urinary metenephrins
CT TAP
management of phaeochromocytoma
phenoxybenzmine then beta blockers
need alpha and beta blockage to prevent a hypertensive crisis
adrenal haemorrhage causing profound sepsis and coagulopathy which can be fatal
waterhouse-friderichsen syndrome
excess growth hormone secondary to pituitary adenoma causing spade hands, large feet and tongue, excessive sweating and frontal bossing
acromegaly
headaches and bilateral hemianopia in acromegaly
tumour
prolactin level in acromegaly
high
diagnosis of acromegaly
increased IGF-1
OGTT and serial GH measurement
management of acromegaly
trans sphenoidal surgery
octreotide if residual symptoms or not fit for surgery
what genetic condition is growth hormone used in the management of
turners syndrome
medical management of prolactinomas
dopamine agonists e.g. carbegoline/bromocriptine to inhibit dopamine release
2 medications which can cause gynaecomastia
goserelin (gnrh agonist for prostate cancer)
spironolactone
what can metoclopramide cause
galactorrhoea
pregnancy, prolactinoma, PCOS, physiological, primary hypothyroidism and phenothiazine, metoclopramide and domperidone are all causes of what
increased prolactin
which endocrine parameters are increased/decreased in stress response
decreased: insulin, testosterone and oestrogen
increased: GH, cortisol, renin, ACTH, aldosterone, prolactin, ADH, glucose
what are the results of water deprivation tests
LEARN THEM
gastrin secreting tumour causing high HCl and duodenal ulcers
zollinger-ellison syndrome
delayed puberty with hypogonadism, very tall, NO SMELL, reduced LH and FSH
treated with testosterone supplementation
kallman syndrome
very tall and infertile with small and firm testes, gynaecomastia and reduced LH and FSH but high testosterone
klinefelters syndrome
child with a palpable abdominal mass
urgent 48 hour referral for wilms tumour
