Endocrinology Flashcards
Who are the majority of cases of malignant otitis externa seen in?
Diabetes mellitus
What is the HbA1c target for patients on lifestyle + metformin for management of diabetes?
48 mmol/mol
What is the HbA1c target for patients on any drug which may cause hypoglycaemia (e.g. lifestyle + sulfonylurea)?
53 mmol/mol
In patients who are on metformin only for their diabetes, at what threshold should you consider adding a second agent?
58 mmol/mol
What HbA1c level indicates poorly controlled diabetes (and therefore the need for a VRII in peri-operative period)?
≥69 mmol/mol
3rd line therapy options in diabetes?
The following options are possible:
1) metformin + DPP-4 inhibitor + sulfonylurea
2) metformin + pioglitazone + sulfonylurea
3) metformin + (pioglitazone or sulfonylurea or DPP-4 inhibitor) + SGLT-2 if certain NICE criteria are met
4) insulin-based treatment
When is a GLP-1 mimetic (e.g. exanatide) indicated in diabetes?
If triple therapy is not effective or tolerated and have a BMI >35.
What should be used to assess for diabetic neuropathy in feet?
10g monofilament
What are 2 ways of distinguishing between T1DM and T2DM?
1) C-peptide levels
2) Diabetes-specific autoantibodies
How can c-peptide levels be used to distinguish between the two types of diabetes?
T1DM –> low c-peptide
T2DM –> normal c-peptide
What 3 antibodies can be used to distinguish between the two types of diabetes?
1) Antibodies to glutamic acid decarboxylase (anti-GAD)
2) Islet cell antibodies (ICA, against cytoplasmic proteins in the beta cell)
3) Insulin autoantibodies (IAA)
Which type of diabetes do anti-GAD indicate?
Present in around 80% of patients with T1DM
Which type of diabetes do islet cell antibodies indicate?
Present in around 70-80% of patients with T1DM
At what eGFR is metformin contraindicated?
<30 due to risk of lactic acidosis
Features of acromegaly?
1) coarse facial appearance, spade-like hands, increase in shoe size
2) large tongue, prognathism, interdental spaces
3) excessive sweating and oily skin: caused by sweat gland hypertrophy
4) features of pituitary tumour: hypopituitarism, headaches, bitemporal hemianopia
5) raised prolactin in 1/3 of cases → galactorrhoea
What are 95% of cases of acromegaly caused by?
pituitary adenoma
What is serum c-peptide a measure of?
Insulin production (i.e. low in T1D)
What are the 3 types of autoantibodies in T1D?
1) Anti-GAD
2) Anti-insulin
3) Anti-islet cell
Under normal circumstances, what should the rate of potassium infusion not exceed?
Why?
10 mmol/hr
As there is risk of inducing arrhythmia or cardiac arrest.
What should be offered to all adults with T2DM and CKD with an ACR over 30mg/mmol who are taking the highest tolerated dose of ACE inhibitor or ARB?
SGLT-2 inhibitor
What 2 investigations can help to differ between T1DM and T2DM?
1) Serum c-peptide
2) Autoantibodies
What are 2 surgical options in severe T1D?
1) Pancreas transplant
2) Islet cell transplant
Why is the original pancreas left in place in a pancreas transplant?
To continue producing digestive enzymes
Mx of short episodes of hyperglycaemia (once DKA has been excluded)?
Short episodes of hyperglycaemia do not necessarily require treatment.
Insulin injections can take several hours to take effect and repeated doses could lead to hypoglycaemia.
What is the main kidney disease seen in T1DM?
Glomerulosclerosis
To confirm a diagnosis of T2D, when is the HbA1c repeated?
Repeated after 1 month to confirm the diagnosis.
However, if there are symptoms or signs of complications then no repeat is needed.
Infection-related complications of T1D?
(4)
1) Pneumonia
2) UTIs
3) Skin & soft tissue infections
4) Candidiasis (oral and vaginal)
2 key actions of metformin?
1) increases sensitivity to insulin
2) decreases glucose production by liver
Which diabetic drug can potentially lead to a DKA?
SGLT-2 inhibitors
What are the 2 notable side effects of metformin?
1) GI upset
2) Lactic acidosis (e.g. 2ary to AKI)
Mechanism of Pioglitazone?
Same as metformin
Mechanism of SGLT-2 inhibitors?
Increase glucose excreted in urine
Which SGLT-2 inhibitor can increase risk of lower limb amputation?
Canagliflozin
What class of drug is Pioglitazone?
Thiazolidinedione
Which 3 diabetes drugs are associated with weight GAIN?
1) Pioglitazone
2) Sulfonylureas
3) Insulin
What are the notable side effects of Pioglitazone?
(4)
1) Weight gain
2) Increased risk of fractures
3) HF
4) Increased risk of bladder cancer
Which diabetic medication can increase risk of bone fractures?
Pioglitazone
Which diabetic medication can cause HF?
Pioglitazone
Give 2 examples of GLP-1 mimetics?
1) Liraglutide
2) Exenatide
In CKD in patients WITH diabetes, at what albumin-to-creatinine ratio (ACR) are ACEi started?
ACR >3 mg/mmol
What is the role of SGLT-2 in the kidney?
Reabsorb glucose out of the urine and into the blood
In patients with CDK and T2D, what is given when the ACR is >30 mg/mmol (i.e. in addition to the ACEi)?
SGLT-2 inhibitor
What are 2 key side effects of DPP-4 inhibitors?
1) Headache
2) Acute pancreatitis
What class of drug is orlistat?
Pancreatic lipase inhibitor
Role of orlistat?
Can be used in management of obesity.
Orlistat acts by reversibly inhibiting pancreatic lipases. This prevents the hydrolysis of triglycerides, and therefore free fatty acids are not absorbed.
I.e. prevents fat from being absorbed (passed out in poo instead).
Key adverse effects of orlistat?
1) Faecal urgency/incontinence
2) Flatulence
Criteria for using orlistat in obesity?
Either:
1) BMI ≥28 + associated risk factors
2) BMI ≥30
3) Continued weight loss e.g. 5% at 3 months
How long is orlistat usually used for in obesity?
<1 year
What is the 1st line treatment of peripheral neuropathy in diabetes?
Managed as neuropathic pain:
- amitriptyline
- duloxetine
- gabapentin
- pregabalin
What is diabetic neuropathy managed as?
Neuropathic pain
What are the 2 different types of diabetic neuropathy?
1) peripheral
2) autonomic
In CKD in patients WITHOUT diabetes, at what albumin-to-creatinine ratio (ACR) are ACEi started?
≥30
What is the main motor presentation of diabetic neuropathy?
Proximal motor (diabetic amyotrophy):
Severe pain and paraesthesiae in the upper legs, with weakness and muscle wasting of the thigh and pelvic girdle muscles.
What is the step-wise management of obesity?
1) Diet & exercise
2) Medical: orlistat, liraglutide
3) Surgical
Bariatric surgery can be divided into restrictive operations, malabsorptive opertions, and mixed operations.
What is normally the first-line intervention in patients with a BMI of 30-39?
Laparoscopic-adjustable gastric banding (LAGB): this is a primarily restrictive operation.
What is post-obstructive diuresis?
After acute urinary retention, the kidneys may increase diuresis due to the loss of their medullary concentration gradient.
This can lead to volume depletion and worsening of any AKI.