Endocrinology Flashcards
What causes t1 diabetes
autoimmune destruction of beta cells of the islets of langerhans in the pancreas causing reduced/ no insulin production
Insulin autoantibodies can be detected in genetically predisposed individuals from 6-12 months
how does t1 diabetes present
- polyurea
- polydipsia
- weight loss
- lethargy
- frequent UTIs
- may present in DKA: reduced GCS, vomiting, hyperventilation, dehydration
How should suspected T1 diabetes be investigated and what are the criteria for diagnosis
- Random blood glucose >11 or fasting >7 + symptoms
- Two fasting glucose >7
- Hba1c > 48/ 6.5%
- Venous blood glucose >11 two hrs after a 75g glucose (oral glucose tolerance test)
- Albumin: creatinine ratio
- TFTs
- Full lipid profile
- U&Es and eGFR
What lifestyle advice is given to those with t1 diabetes
- Regular physical activity is important
- Smoking cessation
- Medical emergency ID bracelet
- Dietary advice (++ fruit and veg, low gi foods, dietician rv) and carb counting training
- DESMOND course
- always have chips after a night out to prevent hypo
How is insulin therapy managed in t1 diabetes
- Multiple daily injection basal–bolus insulin regimens: injections of short‑acting insulin or rapid‑acting insulin analogue before meals, together with 1 or more separate daily injections of intermediate‑acting insulin or long‑acting insulin analogue. Offer pump therapy if this is not appropriate
- Training relatives on glucagon usage and educate on hypos
- Give rapid acting insulin analogues for use during intercurrent illness or hypers- educate about sick day rules
How are pts with T1 diabetes monitored (9)
- clinic appts 4 times a year
- regular dental checks
- eye exam every 2 yrs
- real time continious monitoring if severe frequent hypos, high levels of physical activity or unable to communicate symptoms of hypos
- thyroid disease screen yrly
- ACR from first urine sample of day for CKD from age 12
- HTN yrly from age 12
- BMI monitoring
- injection sites
What targets are given to those with T1 diabetes with regard to glucose and Hba1c levels?
- BM of 4-7 on waking and before meals
- BM of 5-9 after meals
- at least 5 when driving
- Hba1c <6.5%
- measure at least 5 times a day before meals
What causes hypos in t1 diabetes
- alcohol
- exercise
- too much insulin
- missing meals
- illness
How should mild- moderate hypos (bm<3.9, conscious) be managed?
- 10-20g glucose by mouth (2-4 spoons of sugar in water// 200ml glucojuice)
- recheck in 15 mins and repeat if persists
- give complex carb eg toast
How should severe hypos be managed in hospital and in community?
hospital: 10% glucose IV up to 500mg/ kg
community: 1mg IM glucagon if >25kg or 8yrs, 0.5mg if <25kg or 8yrs. if symptoms persist for >10 mins get assistance. Give complex carb when normoglycaemic
Other than hypos, give 7 complications of t1 diabetes
- juvenile cateracts
- DKA
- necrobiosis lipodica
- addisons (schmidt syndrome)
- CKD
- diabetic retinopathy
- diabetic neuropathy
- CVD
How is juvenile cataracts managed?
- lens replacement surgery same as in adults
- it is rare and other causes eg rubella, measles, chicken pox, herpes and metabolic disorders need to be excluded
What is necrobiosis lipoidica?
- Irregularly shaped callous lesions with reddish- brown pigmentation and central atrophy
- Caused by collagen degeneration with granulomatous response associated with thickened blood vessels and fat deposition
- Pretibial is commonest, face, scalp, trunk and upper arms are also common
- Often not painful due to neuropathy but can be very painful
How is necrobiosis lipoidica managed?
- very hard to managed
- avoid trauma to prevent ulcers
- good wound care
- steroids
- immunomodulatory drugs
- phototherapy
- aspirin
- excision
What is schmidts syndrome and how does it present
- Addisons + t1 diabetes= Schmidt syndrome
- CFs: muscle weakness/ pain, hyperpigmentation of skin, fatigue, mood irregularity, salt craving, postural hypotension, weight loss, nausea and/ or diarrhoea, abdo pain
How should DKA be managed (if unwell/ vomiting/ dehydrated/ not alert)?
- ABCDE and 2x large bore cannula
- 10ml/kg NS over 1 hr (if BP <90mmHg give 20ml/kg over 15 mins, then reassess, call ITU if still low after 2nd bolus)
- add 50 units human actrapid to 50ml NS and start fixed rate infusion at 0.1 units/ hr/kg (0.5 if age<5) and continue until resumes normal insulin regime
- monitor closely, aim for drop of 3mmol/L/hr glucose and increase insulin if needed- check VGB at 2, 4, 8, 12 and 24 hrs
- give next L fluid over 2 hrs, next over 4 and next over 12 until fluid replaced - aim to replace fluid over 48hrs
- K+ will start moving back into cells so add 40mmol K+/ L bag to subsequent bags
- when glucose is <14 start 10% dextrose at 125ml/hr alongside saline to avoid hypos, if ketones <3 reduce insulin to 0.05unit/kg/hr
- if glucose ever <6, DONT STOP INSULIN IF KETONES still<1- increase dextrose
- continue with fixed rate infusion until ketones <1 and ph >7.3 and drinking normally then start SC insulin and stop infusion 30 mins after
- Hourly BMs, fluid balance and neuro obs (worry about cerebral odema), U&Es 2 hrly then 4 hrly, ketones 1-2 hrly
- find and treat cause
What may cause congenital hypothyroidism
- insufficient iodine intake in pregnancy
- levothyroxine intake in pregnancy
- defect/ aplasia of thyroid gland
- 30% resolve by age 3 but most need replacement throughout life
What may cause acquired hypothyroidism in children
- hasimotos
- lack of iodine
- radiation
- lithium
- infiltrative disease
How does hypothryoidism present in children?
- CFs similar to adults: fatigue, constipation, coarse dry hair, weight gain
- CFs only in children: slow growth, delayed puberty, delayed tooth development, goitre
What is screened for antenatally?
- sickle cell and thalasssemia early (blood test)
- downs (screening blood test and USS at 12/13 weeks)
- other abnormalities eg cardiac, limb, GI at detailed 20 week scan
- infectious diseases in mother (HIV, syphilis, Hep B, rubella)
- preeclampsia, diabetes and placenta previa screening also
