Endocrinology Flashcards
Tx Hyperthyroidism in primary care
Beta blockers for symptomatic relief
e.g. propanolol 20-40mg t.d.s. for rapid relief
Referral to specialist endocrinologist
Potentially commencement of carbizamole
Tx of hyperthyroidism in secondary care
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
side effects of antithyroid drugs
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)
what isotope is used for radioactive iodine
131-I
what are principles of management for radioactive iodine
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
contraindications for radioactive iodine therapy
pregnancy
active graves opthalmopathology
post operative complications of thyroidectomy
Haematoma formation causing asphyxia
Emergency removal of sutures required
Hypothyroidism (10%)
Hypocalcaemia – due to hypoparathyroidism
Vocal cord paresis due to recurrent laryngeal nerve damage
Tx of hypothyroidism
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
Tx of thyroiditis
Treatment is with propanolol in the thyrotoxic phase, with simple analgesia
Occasionally 30mg prednisolone is used
investigation and management of a solitary thyroid nodule
History and Examination
USS
Technetium scans
Hot = adenoma
Cold = malignancy
FNAC
Tx of hypocalcaemia
Mild/moderate
Adcal – vitD + calcium
Severe Calcium gluconate (stabilise myocardium) 10ml 10% solution Start AdCal Find and treat cause
Tx of prolactin secreting adenoma
Dopamine agonists
Ropinarole/bromocriptine
Treatment usually shrinks the tumour down reducing the mass effects without the surgical risks
Symptoms usually recur when stopping drugs
side effects of dopamine agonists
N+V
Dizziness
Syncope
Associated with pulmonary, cardiac and retroperitoneal fibrosis
monitoring in dopamine agonist therapy
regular CXR/Echo
Tx for acromegaly
Somatostatin analogues may be used to shrink the tumour
Long term if surgical removal isnt possible
Surgical management is via transphenoidal approach
Tx of confirmed pituitary adenoma causing cushings
Surgical management is via transphenoidal approach
Tx of 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
Tx of an addisonian crisis
IV fluids
IV hydrocortisone
Tx of congenital adrenal hyperplasia
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
Tx of conns syndrome
Unilateral adenoma
Laporoscopic adrenalectomy to remove the adenoma
Spironolactone pre-op to control hypertension/hypokalaemia
Bilateral
Tx of primary hyperparathyroidism
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
Tx of secondary hyperparathyroidism
treat underlying cause of hypocalcaemia (Vitamin d deficiency Acute pancreatitis Alkalosis Acute hyperphosphataemia)
Tx of tertiary hyperparathyroidism
Parathyroidectomy
Tx of acutely raised calcium
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
what is part of the annual diabetic review
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
what cardiological monitoring and protection is done for diabetic patients
Control blood pressure <140/80
<130/80 if there are any microvascular complications
QRISK - Atorvostatin if >10% 10 year risk
Lifestyle advice for Diabetes (mainly T2DM)
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
Medical therapy for T2DM
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
Tx for T1DM
Insulin therapy
Basal bolus regime with long-acting insulin with mealtime short-acting insulin adjustments tends to be the best regime
what considerations should there be for poor control in T1DM
Non-adherence
Poor technique
Non rotation of injection sites
Innapropriate dose titration
Psychosocial issues
Organic causes
complications of insulin therapy
General
Weight gain
Insulin resistance
Local (injection site) Pain Redness Swelling Injection site abscess Lipohypertrophy
what are the glucose monitoring targets for diabetes
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
what are the sick day rules for diabetes
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)
what are the DVLA rules around diabetes
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
how do biguianides like metformin work
Decreased hepatic glucose production and increased peripheral insulin sensitivity
contraindications for metformin
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
side effects of metformin
GI effects
N+V
Abdo pain
Anorexia
Lactic acidosis
Rare but serious
Caused by drug accumulation
More common when combined with alcohol
examples of sulphonylureas
tolbutamide (short acting)
gliclazide (medium acting)
glibenclamide (long acting)
mechanism of action for sulphonylureas
increases insulin secretion
what diabetic drugs increase risk for hypoglycaemia + what does this mean
Insulin
SUs + metglinides
caution prescribing in elderly due to increased risk of hypoglycaemic events
what diabetic drugs cause weight gain
insulin
SUs
Thiazolidinediones (PPAR-y activators)
mechanism of action of Thiazolidinediones
PPAR-y activators increasing peripheral insulin sensitivtiy
mechanism of action of Gliptins
increase post-prandial insulin release via DPP4 inhibition
when are gliptins contraindicated
cardio/hepatic/renal dysfunction
side effects of gliptins
GI disturbance
rarely Acute pancreatitis
example of a GLP1 agonist
enaxatide
what is the only real indication for enaxatide therapy in T2DM
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
side effects of enaxatide
GI disturbance
Rarely acute pancreatitis
side effects of Thiazolidinediones
Weight gain – redistibutes ectopically stored lipids
Fluid retention – avoid in CCF
Liver dysfunction – monitor LFTs
Linked to bladder cancer – assess risk factors
how can you identify an exogenous insulin overdose
high insulin levels but low C-peptide levels
c-peptide is produced with endogenous insulin but not in exogenous insulin
urgent DKA Tx
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
when should you consider a crit care review in DKA
Severe DKA (pH <7.1)
Drowsy
Pregnant
Sats <94% on 40% O2
Persistent hypotension (<90SBP) after 2L of NaCl
post-acute Tx for DKA
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
post recovery protocols for DKA
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
Tx for HHS
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
Tx for hypoglycaemia in the patient able to swallow
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
out of hospital Tx for hypoglycaemic if patient is unconcious/unable to swallow
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
hospital Tx for hypoglycaemia if patient unconcious/unable to swallow
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
Tx for proliferative diabetic retinopathy
Pan-retinal photocoagulation
Aim is to burn off the new developing vessels
Vitrectomy if there is persistent haemorrhage
Tx for diabetic maculopathy
Focal laser treatment
Mixed maculopathies require more complex treatments
Tx of diabetic renal disease
any diabetic patient with microalbuminurea should be started on an ACE inhibitor regardless of symptoms
