Endocrinology Flashcards
What are the features of addisons disease?
fatigue, weakness, GI symptoms, confusion, syncope and irritability
How often should insulin dependant diabetics check their blood sugars when driving?
Before driving and every 2 hours
Which sign can you use to distinguish between primary and secondary adrenal insuffiency?
Skin hyperpigmentation - only seen in primary
What is kallmann syndrome?
A pituitary disorder - causes anosmia and hypogonadotrophic hypogonadism
Give an example of a sulfonylureas
gliclazide, glimepiride, tolbutamide
Which antibody is most specific for rheumatoid arthritis?
Anti-CCP
What investigation should you do in people with suspected rheumatoid?
X-Ray hands and feet
What are the blood levels in primary hyperparathyroidism?
high calcium
low phosphate
high ALP
high PTH
What are the blood levels in secondary hyperparathyroidism?
low calcium
high phosphate
high PTH
normal/high ALP
What is the management of symptomatic subclinical hypothyroidism? (raised TSH, normal T4)
trial Levothyroxine
What does exogenous mean?
From outside the body
What is the most common cause of cushing’s syndrome?
- glucocorticoid therapy
- pituitary adenomas - most common endogenous cause
What is the target HbA1c for diabetics?
48mmol/mol
What is the first line medical management of DMT2?
Metformin - titrate up slowly to avoid GI upset
if standard-release not tolerated, try modified release
When do you add SGLT-2 Inhibitors for T2DM management?
- if CVD risk > 10%
- if patient has established CVD
- If patient has chronic heart failure
- if hbA1c is > 58mmol/mol
- metformin should be established first
What drugs can be given for hyperthyroidism?
Carbimazole - 1st line
Propylthiouracil - 2nd line
Radioactive iodine (not with thyroid eye disease)
What are the features of sick euthyroid syndrome (non-thyroidal illness)?
- low thyroid hormones and sometimes TSH
- no treatment needed - treat underlying cause
What is the most common cause of Addisons?
Autoimmune
What are the main features of addisons?
lethargy, weakness, anorexia, nausea & vomiting, weight loss, ‘salt-craving’ (hyperpigmentation in primary)
What is multiple endocrine neoplasia?
A group of 3 inherited endocrine disorders - autosomal dominant
What is MEN type 1?
3 Ps - parathyroid, pituitary, pancreas
What is MEN type 2a?
2Ps
Medullary thyroid cancer, parathyroid, phaechromocytoma
What is MEN type 2b?
1P. Medullary thyroid cancer, phaechromocytoma, marfanoid body habitus and neuromas
Name some SGLT-2 Inhibitors
Dapagliflozin
What are the actions of SGLT2 inhibitors?
lowers blood sugar by reabsorbing of glucose from the kidneys
How does pioglitazone work?
Lowers insulin sensitivity
What are the contrainidications of using pioglitazone?
with insulin, heart failure, bladder cancer
What is hashimotos thyroiditis?
chronic autoimmune thyroiditis, usually hypothyroid but can have acute thyrotoxicosis
What is the difference between thyrotoxicosis and hyperthyroidism?
Thyrotoxicosis = high T3/T4
Hyperthyroid = type of thyrotoxicosis caused by excess endogenous thyroid hormone production
What conditions are associated with hashimotos thyroiditis?
Other autoimmune conditions, MALT lymphoma
What is the management of diabetic ketoacidosis?
- fluid replacement (saline)
- IV insulin 0.1 unit/kg/hr - once blood glucose < 14mmol/l add 10% dextrose infusion
- correct electrolytes disturbances
What is the HbA1c level for a pre-diabetic?
42-47 mmol/mol
What is the cause of an impaired fasting glucose?
hepatic insulin resistance
What is the cause of an impaired glucose tolerance?
muscle insulin resistance
What is the definition of impaired glucose tolerance?
OGTT 2hrs, between 7.8 and 11.1mmol/l
What are the results for an impaired fasting glucose?
6.1-7.0mmol/l
What is graves disease?
Autoimmune thyrotoxicosis
Which auto-antibodies are commonly seen in graves disease?
TSH receptor stimulating antibodies, anti-thyroid peroxidase antibodies
Which drugs commonly cause gynaecomastia?
spironolactone, digoxin, cannabis, finasteride, GnRH agonists - goserelin, buserelin, oestrogens and anabolic steroids
What is the management of a hyperosmotic hyperglycaemic state?
- fluid replacement - IV NaCl - 0.5/1L per hour
- insulin - should not be given unless glucose stops falling while giving IV fluids
- thromboembolism prophylaxis
What blood marker should you check in patients with subclinical hypothyroidism?
Thyroid autoantibodies (increased risk of progressing to overt hypothyroidism)
What is the first line management of an afro-caribbean with type 2DM?
ACE-I or ARB
What are the main features of SIADH?
hyponatraemia, reduced plasma osmolality and increased urine osmolality
What is the action of ADH?
It causes more aquaporin utilisation in the collecting duct. causing more water to be retained, diluting electrolytes in the blood and making urine more concentrated
Which cancers commonly cause SIADH?
small cell lung cancer, pancreas and prostate
What are the most common causes of primary hyperaldosteronism?
bilateral idiopathic adrenal hyperplasia, then adrenal adenoma
What are the main features of primary hyperaldosteronism?
hypertension, hyperkalaemia (muscle weakness), metabolic alkalosis
What is the first line investigation for supposed hyperaldosteronism?
aldosterone/renin ratio
then do abdo CT and adrenal vein sampling
Which drug is an aldosterone antagonist?
spironolactone
Why is ALP raised in primary hyperparathyroidism?
increased bone turnover. ALP is produced by osteoblasts
What is the action of metformin?
increases peripheral insulin sensitivity and gluconeogenesis
What is the mechanism of action of gliptins?
reduces peripheral breakdown of incretins such as GLP-1 (glucagon-like-peptide) (glipTIN and increTIN)
What are the features of Subacute (De Quervain’s) thyroiditis?
usually occurs following viral infection and presents with hyperthyroid, progresses to hypothyroid and then goes back to normal
How do you diagnose Subacute thyroiditis?
thyroid scintigraphy - globally reduced uptake of iodine-131, raised ESR
What is Conn’s syndrome?
primary hyperaldosteronism from an adrenal adenoma
What are the two main signs of primary hyperaldosteronism?
- hypertension
- hypokalaemia - muscle weakness
What is the first line investigation in suspected primary hyperaldosteronism?
plasma aldosterone/renin ratio (should show ^aldosterone but low renin)
What is an incretin?
A hormone that causes blood glucose levels to decrease
Name some Dipeptidl peptidase-4 inhibitors
Sitagliptin, Vildagliptin - reduce the peripheral breakdown of incretins - helpful in obese patients
What are the features of De Quervain’s thyroiditis?
- hyper, euthyroid, then hypo, then normal
- following viral illness
- reduced uptake of iodine-131
Which diabetic medication should be used in those with CVD risk?
SGLT-2 inhibitor - empagliflozin
What is a contraindication to driving with diabetes?
- severe hypoglycaemic event in last 12 months
What is the first line insulin regimen in children with DMT1?
Basal-bolus regimen with long acting insulin once daily, and rapid-acting insulin before meals
What is the first line management of hypertension in a black patient with T2DM?
ARB
What is the first line test for acromegaly?
igf-1
What are the side effects of SGLT-2 inhibitors?
urinary and genital infections
normoglycaemic ketoacidosis
increased risk of lower limb amputation
weight loss
Which type of hyperthyroidism causes a tender goitre?
De Quervain’s thyroiditis
What are the features of an addisonian crisis?
hyperkalaemic metabolic acidosis
abdo pain, confusion, nausea and vomiting
What parathyroid abnormality is seen with CKD?
parathyroid hyperplasia - compensation for lack of Vit D activation causing low Ca2+ levels
What levels are seen in sick euthyroid syndrome?
TSH normal/low, low T4 and T3 - usually resolve upon the recovery of the illness
What is the treatment of toxic multinodular goitre?
radioiodine therapy
Why do you get gastroparesis in diabetics?
autonomic neuropathy
What are the features of gastroparesis?
delayed gastric emptying: erratic blood glucose control, bloating and vomiting
How can you manage gastroparesis?
prokinetic agents: metoclopramide, domperidone
What medication is used to treat cranial diabetes inspidus and which is used to treat nephrogenic?
Cranial: Desmopressin (as ADH not produced)
Nephrogenic: Thiazide diuretic (helps some salts get lost in urine)
What would see on blood gas in someone with cushings?
hypokalaemic metabolic alkalosis
- due to cortisol causing sodium loss and K+ reabsorption
- low K+ causes H+ ion secretion to balance
What is the first line and confirmatory testing for acromegaly?
1st line: serum IGF-1
Confirming: Oral glucose tolerance test with serial GH measurements
What acid-base balance would you expect to see in Cushing’s syndrome?
hypokalaemic metabolic alkalosis
excess steroid binds to mineralocorticoid receptors, increasing potassium and H+ excretion
What acid base balance would you expect to see in addisons?
Hyponatraemia and hyperkalaemia
sodium loss, K+ retention
What are the different type of multiple endocrine neoplasia?
MEN1 = pituitary, parathyroid, pancreas/stomach
MEN2a = Parathyroid, pheochromocytoma
MEN2b = Phaeochromocytoma
What is the most common presentation of hyperparathyroidism?
Hypercalcaemia - causing polyuria and polydipsia
How do you differentiate DeQuervains from Graves disease?
DeQuerVains - viral infection
painful goitre. DeQuerPain
Hyperthyroid then hypo phase
What is the 1st line treatment of Graves disease?
Carbimazole for 12-18months (induces remission) then start thyroxine when euthyroid (block and replace)
Which drugs cause gynaecomastia and which cause nipple discharge?
Spironolactone/GoSerelin makes you sexy
Metoclopramide makes you milky
What feature increases the risk of developing overt hypothyroidism in people with subclinical hypothyroid?
Presence of Thyroid peroxidase antibodies
What is the management of amiodarone induced hypothyroidism?
Carry on with amiodarone, give levothyroxine
When is metformin contraindicated?
When eGFR < 30
pepper-pot skull is a characteristic finding of which condition?
Hyperparathyroidism
When should a second drug be added in DMT2?
When the HbA1c is above 58
What are the blood level ranges for an impaired fasting glycaemia (pre-diabetes)?
6.1-6.9
How do you screen for diabetic neuropathy?
10g monofilament to check sensation
How often should type 1 diabetics check their blood glucose?
before each meal and before bed
How do you treat primary hyperaldosteronism?
Spironolactone (mineralocorticoid receptor antagonist)
Why do you measure renin-aldosterone ratio in suspected hyperaldosteronism?
To assess if it is primary or secondary - primary (aldosterone high, renin low). secondary (aldosterone low, renin high)
Why is bicarb low in DKA?
DKA causes metabolic acidosis, H+ levels follow bicarb levels, so bicarb is used up to lower H+
What is the most common eye problem as a complication of graves ophthalmopathy?
exposure keratopathy - eye cannot close properly and therefore cornea exposed and liable to damage
What are the sick-day rules for insulin?
Keep taking insulin at same dose, for risk of DKA. Make sure patient has someone with them, regularly monitor glucose levels
Which antibody is most sensitive to graves?
Anti-TSH
Why does a prolactinoma cause gynaecomastia?
If the tumour is large enough it can compress the pituitary gland causing hypogonadism
Which antibody is most sensitive to hashimotos thyroiditis?
Anti-TPO
what can be used to as symptomatic treatment initially for graves?
propranolol
Which diabetes medication is contraindicated in patients with bladder cancer?
pioglitazone
What is the first line treatment of peripheral neuropathy in diabetics?
any of: duloxetine, amitryptiline, pregabalin, gabapentin
How do you manage primary hyperaldosteronism?
Spironolactone
Which thyroid disorders have a tender goitre?
De Quervains Thyroiditis (transient thyroiditis following infection)
What is the underlying pathological mechanism for Grave’s disease?
Anti-TSR. (can also be Anti-TPO but this is more common in hashimotos)
What is the first-line management of hypoglycaemia?
Oral glucose - liquid/gel/tablet
Name a vasopressor receptor antagonist?
Tolvaptan - used for SIADH
What electrolyte abnormality is seen in cushings?
hypokalaemic metabolic alkalosis, (due to cortisol binding to mineralocorticoid receptors)
What is the first line and most sensitive test for cushings?
overnight dexamethasone suppression test
What do incretins do?
Inhibit glucagon secretion
What are the blood results in primary and secondary hyperparathyroidism?
Primary - high/normal PTH, high calcium (can be due to high phosphate)
Secondary - low calcium, high PTH
What type of insulin infusion should be given in diabetic ketoacidosis?
A fixed rate infusion at 0.1 units/kg/hour. 0.9% saline must be given first
What is the low dose dexamethasone suppression test for?
It confirms the diagnosis of cushings syndrome and then the high dose can identify the cause
Why do diabetics get impaired hypoglycaemia awareness?
Neuropathy in the autonomic nervous system
What is a myxoedemic coma and how is it treated?
A severe form of hypothyroidism. Treated with thyroxine and hydrocortisone
What is the short SyntACTHen test?
A test for addisons. ACTH is injected, and then cortisol levels are measured. In a normal person cortisol levels should rise, but in addisons they dont
What can be used to treat gastrointestinal autonomic neuropathy?
prokinetic agents- metoclopramide/domperidone
What are the features of a GLP-1 mimetic?
SC injection. Causes weight loss, nausea and vomiting, acute pancreatitis. exanitine/semaglutide.
Increases incretins like DPP4
