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CP3 Management > Endocrinology > Flashcards

Endocrinology Flashcards

1
Q

Tx Hyperthyroidism in primary care

A

Beta blockers for symptomatic relief

e.g. propanolol 20-40mg t.d.s. for rapid relief

Referral to specialist endocrinologist

Potentially commencement of carbizamole

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2
Q

Tx of hyperthyroidism in secondary care

A

if graves - Antithyroid drug (TPO inhibitor)
1st line - carbimazole
2nd line - propylthiouracil

Radioactive iodine if a non-graves pathology is first line (2nd line in graves)

surgery indicated if:
medical failure
?malignancy
large toxic goitre

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3
Q

side effects of antithyroid drugs

A

Rashes

Agranulocytosis/thrombocytopenia - WBC/FBC should be immediately performed if there is suspicion of an active infection

Carbizamole may lead to cholestatic jaundice

propylthiouracil may cause acute liver impairment (1 in 10,000)

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4
Q

what isotope is used for radioactive iodine

A

131-I

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5
Q

what are principles of management for radioactive iodine

A

you must discontinue antithyroid drugs 1 week before treatment

Patients should avoid close contact with children 3 weeks after treatment and should not attempt to concieve within 6 months of treatment

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6
Q

contraindications for radioactive iodine therapy

A

pregnancy

active graves opthalmopathology

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7
Q

post operative complications of thyroidectomy

A

Haematoma formation causing asphyxia
Emergency removal of sutures required

Hypothyroidism (10%)

Hypocalcaemia – due to hypoparathyroidism

Vocal cord paresis due to recurrent laryngeal nerve damage

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8
Q

Tx of hypothyroidism

A

Levothyroxine

Start low and titrate up

Recheck TFTs every 4-6 weeks until TSH is in the lower half of the normal reference range - only if primary condition, TSH is unreliable for secondary conditions, and T4 should therefore be used

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9
Q

Tx of thyroiditis

A

Treatment is with propanolol in the thyrotoxic phase, with simple analgesia

Occasionally 30mg prednisolone is used

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10
Q

investigation and management of a solitary thyroid nodule

A

History and Examination

USS

Technetium scans
Hot = adenoma
Cold = malignancy

FNAC

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11
Q

Tx of hypocalcaemia

A

Mild/moderate
Adcal – vitD + calcium

Severe 
Calcium gluconate (stabilise myocardium) 
10ml 10% solution  
Start AdCal 
Find and treat cause
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12
Q

Tx of prolactin secreting adenoma

A

Dopamine agonists
Ropinarole/bromocriptine

Treatment usually shrinks the tumour down reducing the mass effects without the surgical risks

Symptoms usually recur when stopping drugs

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13
Q

side effects of dopamine agonists

A

N+V

Dizziness

Syncope

Associated with pulmonary, cardiac and retroperitoneal fibrosis

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14
Q

monitoring in dopamine agonist therapy

A

regular CXR/Echo

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15
Q

Tx for acromegaly

A

Somatostatin analogues may be used to shrink the tumour

Long term if surgical removal isnt possible

Surgical management is via transphenoidal approach

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16
Q

Tx of confirmed pituitary adenoma causing cushings

A

Surgical management is via transphenoidal approach

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17
Q

Tx of Addisons

A

Long term replacement for glucocorticoids
15-25mg hydrocortisone daily in 3 divided doses
Avoid giving late in day as can cause insomnia

Long term mineralocorticoid cover
Required if there is electrolyte disturbance or postural hypotension
Fludrocortisone 50-200mcg daily

Steroids should never be abruptly stopped
Extra doses required for exercise
Double dose for febrile illness, surgery or trauma

Patients should carry a card/bracelet on them at all times and carry emergency IM hydrocortisone in case of an Addisonian crisis

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18
Q

Tx of an addisonian crisis

A

IV fluids

IV hydrocortisone

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19
Q

Tx of congenital adrenal hyperplasia

A

as per addisons:

Long term replacement for glucocorticoids
15-25mg hydrocortisone daily in 3 divided doses
Avoid giving late in day as can cause insomnia

Long term mineralocorticoid cover
Required if there is electrolyte disturbance or postural hypotension
Fludrocortisone 50-200mcg daily

Steroids should never be abruptly stopped
Extra doses required for exercise
Double dose for febrile illness, surgery or trauma

Patients should carry a card/bracelet on them at all times and carry emergency IM hydrocortisone in case of an Addisonian crisis

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20
Q

Tx of conns syndrome

A

Unilateral adenoma
Laporoscopic adrenalectomy to remove the adenoma

Spironolactone pre-op to control hypertension/hypokalaemia

Bilateral

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21
Q

Tx of primary hyperparathyroidism

A

Parathyroidectomy

Indicated even in asymptomatic cases due to potential long term adverse effects

Serum calcium should be normal 24 hours post surgery

May even be post operative hypocalcaemia

Treated with adcal 14 days

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22
Q

Tx of secondary hyperparathyroidism

A 
treat underlying cause of hypocalcaemia
(Vitamin d deficiency  
Acute pancreatitis 
Alkalosis 
Acute hyperphosphataemia)
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23
Q

Tx of tertiary hyperparathyroidism

A

Parathyroidectomy

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24
Q

Tx of acutely raised calcium

A

IV fluids
0.9 NaCl to increase calcium clearance
Aim for 3-6L over the first 24 hours

Single dose of pamidronate (bisphosphonate)
Lowers calcium over 2-3 days

consider calcitonin if life threatening

dialysis is last resort

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25
Q

what is part of the annual diabetic review

A 
Cardiovascular risk review  
Smoking?  
BMI 
BP 
ECG 
Blood lipids  
Assess for microvascular complications 
Eye check  
Feet  
Pain?  
Erectile dysfunction ? 
Neurovascular status 
Urine dip 
Assess diabetic control  
HBA1C  
Assess concordance to diet/lifestyle advice  
Assess for lifestyle events 
Hospitalisation  
Symptoms of hypoglycaemic episodes  
Medication side effects 
Injection site reactions

DrivinG?
DVLA require informing?

Depression/anxiety screen

26
Q

what cardiological monitoring and protection is done for diabetic patients

A

Control blood pressure <140/80

<130/80 if there are any microvascular complications

QRISK - Atorvostatin if >10% 10 year risk

27
Q

Lifestyle advice for Diabetes (mainly T2DM)

A

Dietary advice
General, stick to what is generally considered healthy

Weight loss
5-10% aim

Increase physical activity
30 min per day (low-medium intensity)

Smoking cessation

Alcohol advice
Alcohol may exacerbate/prolong effects of hypoglycaemia and may make hypoglycaemic episodes unclear
Limit intake and always have carbohydrates at the ready if alcohol is being consumed

28
Q

Medical therapy for T2DM

A

1st line – metformin
500mg with breakfast 1st week, then with breakfast and dinner the next week, then after each of the 3 meals thereafter

Alternative if contraindicated
Gliptin (DPP4is)
Thiazolidinedione/pioglitozone (PPARy activators)
Sulphonylurea

2nd line
Metformin + any of drugs mentioned above (Sulphonurea tends to be used more commonly)

3rd line
Triple therapy
Metformin + SU + gliptin/pioglitozone

4th line
Insulin

29
Q

Tx for T1DM

A

Insulin therapy

Basal bolus regime with long-acting insulin with mealtime short-acting insulin adjustments tends to be the best regime

30
Q

what considerations should there be for poor control in T1DM

A

Non-adherence

Poor technique

Non rotation of injection sites

Innapropriate dose titration

Psychosocial issues

Organic causes

31
Q

complications of insulin therapy

A

General
Weight gain
Insulin resistance

Local (injection site)  
Pain 
Redness 
Swelling 
Injection site abscess  
Lipohypertrophy
32
Q

what are the glucose monitoring targets for diabetes

A

4x daily glucose monitoring at least 2x a week is the mimimum requirement

Optimal targets are :

Fasting glucose level of 5-7 on waking

Plasma glucose level 4-7 before meals at any other time of the day

Plasma glucose 5-9 90 mins after eating

33
Q

what are the sick day rules for diabetes

A

Do not stop the insuin therapy

Monitor blood glucose every 3-4 hours including overnight

Consider checking blood/urine for ketones

Maintain normal meal pattern where possible

Drink at least 3L of fluid everyday

Go to GP/hospital if there are serious indications of illness (can’t drink fluid due to N+V, ketones in urine/blood, dangerously elevated glucose levels etc)

34
Q

what are the DVLA rules around diabetes

A

DVLA should be notified if:
2 episodes of severe hypoglycaemia in the last 12 months

Reduced awareness of hypoglycaemic episodes

Insulin therapy
Must check BG every 2 hours of a long journey
Must carry enough supplies to avert hypoglycaemic events

35
Q

how do biguianides like metformin work

A

Decreased hepatic glucose production and increased peripheral insulin sensitivity

36
Q

contraindications for metformin

A

EGFR <30ml/min/1.73m2 (standard release) or 45 for modified release

Alcohol addiction

People at risk of lactic acidosis (DKA)

People at risk of tissue hypoxia
Cardiorespiratory failure

37
Q

side effects of metformin

A

GI effects
N+V
Abdo pain
Anorexia

Lactic acidosis
Rare but serious
Caused by drug accumulation
More common when combined with alcohol

38
Q

examples of sulphonylureas

A

tolbutamide (short acting)
gliclazide (medium acting)
glibenclamide (long acting)

39
Q

mechanism of action for sulphonylureas

A

increases insulin secretion

40
Q

what diabetic drugs increase risk for hypoglycaemia + what does this mean

A

Insulin

SUs + metglinides

caution prescribing in elderly due to increased risk of hypoglycaemic events

41
Q

what diabetic drugs cause weight gain

A

insulin

SUs

Thiazolidinediones (PPAR-y activators)

42
Q

mechanism of action of Thiazolidinediones

A

PPAR-y activators increasing peripheral insulin sensitivtiy

43
Q

mechanism of action of Gliptins

A

increase post-prandial insulin release via DPP4 inhibition

44
Q

when are gliptins contraindicated

A

cardio/hepatic/renal dysfunction

45
Q

side effects of gliptins

A

GI disturbance

rarely Acute pancreatitis

46
Q

example of a GLP1 agonist

A

enaxatide

47
Q

what is the only real indication for enaxatide therapy in T2DM

A

Rarely used, only indication is replacing the pioglitazone/gliptins in triple therapy IF the patient:

Has a BMI >35
or
Has a BMI <35 AND Weight loss would be beneficial, Insulin therapy would have negative occupational impacts

48
Q

side effects of enaxatide

A

GI disturbance

Rarely acute pancreatitis

49
Q

side effects of Thiazolidinediones

A

Weight gain – redistibutes ectopically stored lipids

Fluid retention – avoid in CCF

Liver dysfunction – monitor LFTs

Linked to bladder cancer – assess risk factors

50
Q

how can you identify an exogenous insulin overdose

A

high insulin levels but low C-peptide levels

c-peptide is produced with endogenous insulin but not in exogenous insulin

51
Q

urgent DKA Tx

A

A to E

1L 0.9% sodium chloride over 1 hour if SBP >90

500ml bolus over 10 mins if SBP <90, reassess and repeat if poor response

Start IV infusion of insulin
50 units human soluble rapid acting insulin added to 60ml 0.9% NaCl giving 1 unit/ml solution
Start in syringe driver at 0.1units/hour

52
Q

when should you consider a crit care review in DKA

A

Severe DKA (pH <7.1)

Drowsy

Pregnant

Sats <94% on 40% O2

Persistent hypotension (<90SBP) after 2L of NaCl

53
Q

post-acute Tx for DKA

A

Continue fixed rate insulin at 0.1units/kg/hour and continue normal long acting insulin

Aim for blood glucose to fall 3mmol/L/hour until <14mmol/L
If glucose not falling check dosage, pump operation, patient weight, reassess concominant illness
Increase rate by 1 unit/hour if necessary

Continue IV 0.9% NaCl 
1L over 1 hour 
Then 1L over 2 hours 
3rd bag = 1L over 2 hours 
4th bag = 1L over 3 hours

When glucose is <14mmol/L add 10% glucose at 125ml per hour
Adjust to keep blood glucose between 8-14mmol/L

Potassium
If potassium <5.4 add 40mmol KCL per litre NaCl
Consider after first liter either way

Reassess hourly for the first 4-6 hours

Regular lab monitoring of glucose, ketones, potassium and bicarbonate

54
Q

post recovery protocols for DKA

A

Transfer to SC insulin once the patient is able to eat and drink normally, and venous pH is >7.3

Stop the IV infusion 1 hour after the next SC injection of insulin

Refer all patients to the diabetes team prior to discharge

55
Q

Tx for HHS

A

Aggressive IV fluids
1L 0.9% NaCl over one hour
Aim for positive balance of 3-6L over 12 hours
There may be an initial rise in Na this is not concerning if osmolality is declining

Low dose fixed dose IV insulin infusion
Ketones = treat as DKA and treat immediately
No ketones = add insulin once fall in glucose is <5mmol/L hr

0.05 units/kg/hour, may not be required

Consider potassium replacement
3.5-5.5, add 40mmol/L
if >5.5, seek senior help

Give prophylactic LMWH
Very high risk of thrombosis

Regular monitoring of vitals, fluid balance, glucose, osmolality, U+E hourly for the first 6 hours

Complete normalisation of fluid/electrolytes may take 72 hours

Transfer to SC insulin when eating and drinking and normally and biochemistry has normalised

Stop the IV infusion 1 hour after starting SC insulin

Refer to diabetes team

56
Q

Tx for hypoglycaemia in the patient able to swallow

A

Promptly consume 10-20g fast acting carbohydrate preferable in liquid form
Avoid chocolates/biscuits as sugar content lower, and fats may delay stomach emptying

Recheck blood glucose levels after 10-15 mins

Hypoglycaemia should be reversed in about 10 mins

Improvements in signs and symptoms may lag behind improvement in blood glucose

If inadequate response repeat as above and recheck again

When symptoms improve, the patient should eat some long-acting carbohydrate

57
Q

out of hospital Tx for hypoglycaemic if patient is unconcious/unable to swallow

A

if available Administer IM glucagon immediately
<8yrs 500mcg
>8yrs 1mg

Glucagon not available, alcohol has been consumed, or patient does not respond to glucagon within 10 mins call 999 for emergency hospital transfer as Glucagon doesn’t work is alcohol has been consumed

If the patient responds to glucagon, advise intake of long acting carbohydrates when able

Vomiting is common during recovery which can precipitate further episodes of hypoglycaemia

If episodes recur the patient may require hospital admission for IV treatment

58
Q

hospital Tx for hypoglycaemia if patient unconcious/unable to swallow

A

Within hospital
100ml 20% glucose can be used as an alternative to glucagon and this can be repeated 3 times
If IV access is not available, administer IM glucagon whilst gaining access
(<8yrs 500mcg, >8yrs 1mg)
Following recovery never omit insulin In patients with T1DM

59
Q

Tx for proliferative diabetic retinopathy

A

Pan-retinal photocoagulation
Aim is to burn off the new developing vessels

Vitrectomy if there is persistent haemorrhage

60
Q

Tx for diabetic maculopathy

A

Focal laser treatment

Mixed maculopathies require more complex treatments

61
Q

Tx of diabetic renal disease

A

any diabetic patient with microalbuminurea should be started on an ACE inhibitor regardless of symptoms

CP3 Management (11 decks)

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