Endocrinology Flashcards
Drugs that cause raised prolactin?
metoclopramide, domperidone
phenothiazines
haloperidol
very rare: SSRIs, opioids
Blood glucose target before meals at other times of the day?
4-7 mmol/L
Adverse effects of thiazolidineinones?
weight gain
liver impairment: monitor LFTs
fluid retention - therefore contraindicated in heart failure. The risk of fluid retention is increased if the patient also takes insulin
recent studies have indicated an increased risk of fractures
bladder cancer: recent studies have shown an increased risk of bladder cancer in patients taking pioglitazone
What levels are the C-peptide in a person with T1DM
C-peptide is made in the pancreas along with insulin; therefore, in patients with deficient insulin production (T1DM), it is low
DKA insulin management?
an intravenous infusion should be started at 0.1 unit/kg/hour
once blood glucose is < 14 mmol/l an infusion of 10% dextrose should be started at 125 mls/hr in addition to the 0.9% sodium chloride regime
Why does praimry adrenal failure cause skin hyperpigementation?
ACTH is derived from a larger precursor called pro-opiomelanocortin (POMC), which also happens to be a precursor for beta-endorphin (which isn’t important in this case) and melanocyte stimulating hormone (MST). MST, as the name suggests, stimulates melanocytes giving the hyperpigmentation that can be seen in primary adrenal failure.
Thyrotoxicosis cardiac features?
palpitations, tachycardia
high-output cardiac failure may occur in elderly patients, a reversible cardiomyopathy can rarely develop
Symptoms of gastroparesis in T1DM?
erratic blood glucose control, bloating and vomiting
If patient is symptomatic
What fasting gluocse and random glucose levels are needed to diagnose diabetes?
fasting glucose greater than or equal to 7.0 mmol/l
random glucose greater than or equal to 11.1 mmol/l (or after 75g oral glucose tolerance test)
What can levothyroxine interact with?
iron, calcium carbonate
absorption of levothyroxine reduced, give at least 4 hours apart
Side effects of sulfonylureas?
hypoglycaemic episodes (more common with long acting preparations such as chlorpropamide)
weight gain
syndrome of inappropriate ADH secretion
bone marrow suppression
liver damage (cholestatic)
peripheral neuropathy
What is the management of bilateral adrenocortical hyperplasia
aldosterone antagonist e.g. spironolactone
What is the main drug that can’t be taken with lithium?
NSAIDs
What should be started for T2DM if high risk of CVD, established CVD or chronic HF?
Metformin and SGLT-2 inhibitor
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Mneumonic for thyroid cancers. Most to least common
Please Feel My Awkward Lump
Papillary>Follicular>Medullary>Anaplastic>Lymphoma
Mechniasm of orlistat
inhibiting gastric and pancreatic lipase to reduce the digestion of fat
§What are the phases of De Quervian’s thyroiditis?
phase 1 (lasts 3-6 weeks): hyperthyroidism, painful goitre, raised ESR
phase 2 (1-3 weeks): euthyroid
phase 3 (weeks - months): hypothyroidism
phase 4: thyroid structure and function goes back to normal
Features of addison’s disease?
lethargy, weakness, anorexia, nausea & vomiting, weight loss, ‘salt-craving’
hyperpigmentation (especially palmar creases)*, vitiligo, loss of pubic hair in women, hypotension, hypoglycaemia
hyponatraemia and hyperkalaemia may be seen
crisis: collapse, shock, pyrexia
What is the TSH, thyroxine and T3 levels in sick euthyroid syndrome?
Low TSH, thyroxine and T3
Suppressed ACTH and not suppressed cortisol cause?
Cushing’s syndrome due to other causes (adrenal adenoma)
What is thyroid eye disease specific to?
Graves disease
Acromegaly second line if transpehonidal surgery doesn’t work?
Somatostatin analogue (octerotide)
Management in DKA?
- fluid replacement
- most patients with DKA are deplete around 5-8 litres
- isotonic salineis used initially, even if the patient is severely acidotic
- please see an example fluid regime below.
- insulin
- an intravenous infusion should be started at0.1 unit/kg/hour
- once blood glucoseis < 14 mmol/l an infusion of 10% dextrose should be started at 125 mls/hrin additionto the 0.9% sodium chloride regime
- correction of electrolyte disturbance
- serum potassium is often high on admission despite total body potassium being low
- this often falls quickly following treatment with insulin resulting in hypokalaemia
- potassium may therefore need to be added to the replacement fluids
- if the rate of potassium infusion is greater than 20 mmol/hour then cardiac monitoring may be required
- long-acting insulin should be continued, short-acting insulin should be stopped
How much does thyorxine dose change during pregnancy?
Increased dose of thyroxine during pregnancy
Drug causes of gynaecomastia?
- spironolactone (most common drug cause)
- cimetidine
- digoxin
- cannabis
- finasteride
- GnRH agonists e.g.goserelin, buserelin
- oestrogens, anabolic steroids
SGLT-2 inhibitors should also be given if any of the following apply?
- the patient has a high risk of developing cardiovascular disease (CVD, e.g. QRISK ≥ 10%)
- the patient has established CVD
- the patient has chronic heart failure
What is phaeochromocytoma?
Rare catecholamine secreting tumour
Features in primary hyperaldosteronism?
Hypertension, hypokalaemia, metabolic acidosis
What is tertiary hyperparathyroidism?
Prologned secondary hyperpatathyroidism leading to tertiary hyperparathyroidism
First line for phaeochoromocytoma?
Give phenoxybenzamine before beta blockers
What is myxoedema coma?
Potentially fatal complication of longstanding undertreated hypothyroidism. It may be precipitated by illness, stress, and certain drugs. Apart from confusion and hypothermia, patients may have non-pitting periorbital and leg oedema, reduced respiratory drive, pericardial effusions, anaemia, seizures, and other symptoms of hypothyroidism.
First line treatment for diabetic neuropathy?
Amtitriptyline, duloxetine, gabapentin or pregabalin
First line for black patient with T2DM?
ARB like Losartan
Management of thyroid storm?
symptomatic treatment e.g. paracetamol
treatment of underlying precipitating event
beta-blockers: typically IV propranolol
anti-thyroid drugs: e.g. methimazole or propylthiouracil
Lugol’s iodine
dexamethasone - e.g. 4mg IV qds - blocks the conversion of T4 to T3
Management of gastroparesis in diabetic neuropathy?
metoclopramide, domperidone or erythromycin (prokinetic agents)
Adverse effects of SGLT-2 inhibitors
urinary and genital infection (secondary to glycosuria). Fournier’s gangrene has also been reported
normoglycaemic ketoacidosis
increased risk of lower-limb amputation: feet should be closely monitored
Drug causes of raised prolactin?
metoclopramide, domperidone
phenothiazines
haloperidol
very rare: SSRIs, opioids
Adverse effects of sulfonylureas?
hypoglycaemic episodes (more common with long-acting preparations such as chlorpropamide)
weight gain
hyponatraemia secondary to syndrome of inappropriate ADH secretion
bone marrow suppression
hepatotoxicity (typically cholestatic)
peripheral neuropath
How do sulfonylureas work?
Increase pancreatic insulin secretion
GLP-1 mimetics action?
drugs increase insulin secretion and inhibit glucagon secretion.
Major advance of GLP-1 mimetics?
Result in weight loss
most common cause of primary hyperaldosteronism
Bilateral idiopathic adrenal hyperplasia
What is aldosterone?
hormone that helps regulate your blood pressure by managing the levels of sodium (salt) and potassium in your blood and impacting blood volume.
Management of primary hyperaldosteronism?
adrenal adenoma: surgery (laparoscopic adrenalectomy)
bilateral adrenocortical hyperplasia: aldosterone antagonist e.g. spironolacton
TD2M already on 2 drugs - if HbA1c > 58 mmol/mol then one of the following should be offered:
metformin + DPP-4 inhibitor + sulfonylurea
metformin + pioglitazone + sulfonylurea
metformin + (pioglitazone or sulfonylurea or DPP-4 inhibitor) + SGLT-2 if certain NICE criteria are met
insulin-based treatment
SGLT 2 inhibitors should be given in addition to metformin if the following apply?
the patient has a high risk of developing cardiovascular disease (CVD, e.g. QRISK ≥ 10%)
the patient has established CVD
the patient has chronic heart failure
What to do if metformin contraindicated?
If metformin is contraindicated
if the patient has a risk of CVD, established CVD or chronic heart failure:
SGLT-2 monotherapy
if the patient doesn’t have a risk of CVD, established CVD or chronic heart failure:
DPP‑4 inhibitor or pioglitazone or a sulfonylurea
SGLT-2 may be used if certain NICE criteria are met
Second line therapy for T2DM?
metformin + DPP-4 inhibitor
metformin + pioglitazone
metformin + sulfonylurea
metformin + SGLT-2 inhibitor (if NICE criteria met)
If triple therapy is not effective or tolerated consider what?
switching one of the drugs for a GLP-1 mimetic:
BMI ≥ 35 kg/m² and specific psychological or other medical problems associated with obesity or
BMI < 35 kg/m² and for whom insulin therapy would have significant occupational implications or weight loss would benefit other significant obesity-related comorbidities
only continue if there is a reduction of at least 11 mmol/mol [1.0%] in HbA1c and a weight loss of at least 3% of initial body weight in 6 months
Adverse effects of metofrmin?
Commonly GI effects
Lactic acidosis- Metformin increases lactate production and reducers lactate removal by the liver
Be careful in patients with renal impairment as worse at getting rid of lactate
Where does metformin act?
Actives ANPK. Increases insulin sensitivity
Action of insulin?
Insulin receptor agonist
Side effect of insulin?
Weight gain
Hypoglycaemia
Action of sulfonylureas (glybruride, glipizide)
Inhibit potassium ATP channels
Side effects of sulfonylureas (glybruride, glipizide)
Hypoglycaemia
Weight gain
Caution in patients with renal and hepatic disease. Metabolised in lvier and excreted by the kidneys
Action of GLP-1 agonists (tides)
Acitvates GLP-1 receptors
Side effects of GLP-1 agonists (tides)
Hypoglycaemia risk low
Weight loss
GI effects- Nausea and vomiting
Pancreatitis
Contraindicated in patients with thyroid c cell tumours (due to thyroid c cells go hyperplasia)
Decrease in cardiovascular risk- Use in cardiovascular disease with T2DM
Action of TZD (Glitazones)
PPAR gamma receptor.
Sie effects of TZD (Glitazones)
Weight gain
Oedema
Bone loss
Hepatotoxic
Increased risk for bladder cancer
Contraindicated in HF as lead to oedema
Imrpve lipid profile
Mechanism of action of SGLT2 inhibitors (gliflozins)
Inhibit SGLT-2
Side effects of SGLT2 inhibitors (gliflozins)
Weight loss
UTI
DKA
Dehydration
Hypotension
Decreased CV risk
Contraindicated in severe renal impairment
Mechanism of action of DPP-4 inhinbitos (gliptins)
Inhinbit DDP-4
Side effects of DPP-4 (gliptins)
Increased risk of infections (respiratory infection)
Rash
Angioedema
Mechanism of action of alpha glucosidase inhibitors (Acarbose, Miglifol)
Inhibit alpha glucosidase