Endocrinology Flashcards
How do you diagnose diabetes?
If positive, need to confirm on a second day. No need if positive AND symptomatic:
A1c > 6.5%
Fasting glucose > 7
2h 75g oGTT >= 11.1
Random glucose >= 11.1
how do you prevent/treat atypical femoral fractures?
Prevent: consider drug holiday on oral bisphosphonates for 5 years (IV for 3 years) - DO NOT STOP IN HIGH RISK PTs
Treat: stop bisphosphonate. Consult ortho. ? teriparatide
How do you screen and diagnose acromegaly?
Screen: IGF1 level
Diagnose: 75g glucose suppression
How do you screen for cushing’s?
Need 2/3 of:
Midnight salivary cortisol
1mg dex suppression test
24 hour urine free cortisol
How do you treat hypoglycemia episode?
Mild to moderate - 15g glucose/sucrose tabs
Severe (require assistance) 20g glucose tab
If taking acarbose, NEED TO GIVE DEXTROSE OR MILK OR HONEY
Unconscious = 1mg glucagon IM or 10-25g of dextrose IV
How do you treat Paget’s disease of the bone?
IV bisphosphonate
How does ACTH help in diagnosis of Cushing’s?
If ACTH high, consider pituitary or ectopic source. Need 8mg Dex supp test. If suppressible, likely pituitary source. Otherwise CT chest for ectopic source.
If ACTH low, consider adrenal adenoma/carcinoma. NEED CT ADRENAL
How does Mg affect Ca balance?
Low Mg reduces PTH secretion and causes PTH resistance
Low Mg = hypoPTH = High PO4 and LOW Ca
How does PTH affect calcium and phosphate?
Increases calcium and decreases phosphate
How does thiazide affect PTH?
May cause low PTH due to associated hypercalcemia, but can also unmask primary hyperPTH and cause increase in PTH
how does vitamin D affect calcium and phosphate?
Both go same direction.
I.e granulomatous disease = hyper Ca hyper PO4
How much do you expect to reduce LDLs with initiation of statins?
20-40% reduction for starting dose
Additional 6% for each doubling of dose
What are “automatic” high risk features for future osteoporotic fractures?
- Prior fragility fracture AND prolonged use of steroids (>=7.5mg/d x 3 months)
- Hip or Spine fracture
- > 1 fragility fracture
What are 3 benefits to switch from basal bolus regimen to continous subcutaneous insulin infusion for type 1 diabetics?
Small improvement in A1c
Increased treatment satisfaction and QoL
Reduction in severe hypoglycemia if high rates of baseline severe hypos
What are 3 situations when target of A1c should be < 8.5%
Recurrent severe hypo/hypo unawareness
Decreased life expectancy
Frail elderly with dementia
What are antithyroid drug options? When should you use them?
Methimazole and PTU
MMZ > PTU EXCEPT
Pregnancy
Thyroid storm
Minor MMZ reactions
What are components of MEN1 syndrome?
PPP
Parathyroid
Pituitary adenoma
Pancreatic (insulin, gastrin, VIP)
What are components of MEN2A syndrome?
PMP
Parathyroid
Medullary thyroid
Pheochromocytoma
What are components of MEN2B syndrome?
MMP
Marfanoid, mucosal neuromas
Medullary thyroid
Pheochromocytoma
What are contraindications to radioactive iodine ablation?
Pregnancy, breast feeding, moderate to severe orbitopathy (can worsen orbitopathy)
Need to stop methimazole for 2-3 days prior
If given with orbitopathy, need steroids
What are high risk features of thyroid nodule ultrasound?
hypoechoic irregular margins Microcalcifications or interrupted rim calc. Taller than wide, extend beyond thyroid lymphadenopathy >20% increase in 2 dimensions
What are indications for surgery for primary HyperPTH?
Stay The Fudge Away U Silly Calcium
Serum calcium > 0.25 upper limit T score < 2.5 at L spine, hip, femoral neck or distal radius Fractures Age < 50 Urine calcium > 10mmol/d (>400mg/d) Stones or nephrocalcinosis Creatinine clearance <60ml/min
What are indications for surgery in tertiary hyperparathyroidism?
Refractory hyperPTH despite vit D analogues/calcimimetics
Hypercalcemia severe/symptomatic
Calciphylaxis
Progressive bone dx
What are JAMA RCE findings of osteoporosis?
Weight < 51kg (LR+ 7.3) Wall-occiput distance > 0cm (LR+ 4.6) Rib pelvis distance <2 finger width (LR+ 3.8) Tooth count < 20 (LR+ 3.4) Self-reported hump back (LR+ 3.0)
What are radiographical and biochemical findings of Paget’s disease of bone?
Elevated ALP without other abnormalities
XR: thickened cortices with tunnelling and accentuated trabeculae.
What are redflags for adrenal incidentaloma?
Size >4cm (proceed with surgery)
Hounsfield Units > 10 (>20 need surgery)
<50% delayed contrast washout
What are screening and confirmatory testing for Pheochromocytoma?
Screen: 24hr urine metanephrines/catecholamines
Confirm: MR abdo or CT abdo with delayed contrast washout
What are statin indicated conditions?
Clinical atherosclerosis AAA DM CKD LDL > 5.0
What are surgical indications for pituitary tumours?
Hormonal hypersecretion
Hormonal hypofunction
Mass effect
Hemorrhage
NOT PROLACTINOMA = medical
What are treatments for prolactinoma?
Dopamine agonists
Cabergoline > Bromocriptine
What are vascular indications for statin in diabetes?
Clinical CVD Age >=40 Age > 30 and diabetes > 15 yrs Microvascular disease Other CV risk factors
What are contraindications to GLP-1 agonists?
Concern for retinopathy (Semaglutide), family/personal history of medullary thyroid Ca or MEN2, pancreatitis.
What is screening test for Conn’s?
Plasma Aldo to renin ratio (must be off MRA, ACEi, beta blocker, clonidine etc)
What is the 25-OH vitamin D and Calcium level target for osteoporosis?
> =75nmol/L 25-OH vit D
>= 1200mg/day Ca
What is the 8 AM cortisol cutoff for adrenal insufficiency? What is the cutoff for ACTH stim test?
<83 very likely AI
>500 very unlikely AI
Anthing in between gets ACTH stim
Cortisol should be > 500 at 30min or 60min
If not, then AI
What is the management strategy for subclinical hypothyroidism in pregnancy?
Treat with target < 2.5 if TSH>10, TSH>4 and anti-TPO antibody negative, or TSH>2.5 and anti-TPO antibody positive.
What should the blood glucose be for diabetics to drive?
> 4.0 (4 to DRIVE)
If hypoglycemic episode, should wait 40 minutes after treatment and BG should be > 5.0
When should you treat subclinical hypothyroidism?
Symptomatic Goiter TSH > 10 Pregnancy/prengnancy planning Positive anti-TPO antibodies
When should you instruct diabetics not to drive?
Any episode of severe hypoglycemia while driving in the last 12 months
More than 1 episode of severe hypoglycemia while awake (not driving) in the past 6 months for private, 12 months for commercial
When should you screen for Conn’s syndrome?
Refractory HTN on >= 3 drugs
Spontaneous hypokalemia < 3.5 or severe diuretics induced hypoK < 3
Adrenal incidentaloma
When should you screen for nephropathy? What screens as positive?
5 years after diagnosis in Type 1
All type 2
Random urine ACR > 20, or eGFR < 60
When should you start insulin in a newly diagnosed type 2?
If they have symptoms of hyperglycemia with metabolic decompensation i.e.:
Polyuria Polydipsia Weight loss Volume depletion HHS/DKA
When should you switch agents in osteoporosis?
Treatment failure - fragility # or progressive decline in BMD despite therapy for a yr
FIRST RULE OUT OTHER SECONDARY CAUSES OF OSTEOPOROSIS. Switch to another first line agent. Ensure non-pharma interventions in place
When should you use propanolol for hyperthyroidism?
Symptom control especially for elderly, resting HR >90 or CVD
Which diabetes agents are safe for EGFR < 15?
Lina/sitagliptin
Repaglinide (secretagogue)
Pio/Rosiglitazone
Insulins
Who needs biopsy for thyroid nodule?
- High/intermediate sonographic features > 1cm
- Low suspicion sonographic features > 1.5cm
- Maybe very low suspicion > 2cm
DO NOT BIOPSY PURE CYSTIC NODULES
What are findings of diabetic amyotrophy?
Proximal motor neuropathy, pain, decreased reflexes, asymmetric at onset, no sensory impairment.
What medications must be held prior to testing for hyperaldosteronism (e.g. multiple antihypertensives, adrenal incidentaloma, diuretic-induced hypokalemia)?
ACE/ARB MRA Beta blockers Clonidine, methyldopa DHP-CCB
