Endocrinology Flashcards
What is diabetes
Metabolic disorder. Hyperglycaemia caused by limited insulin secretion and insulin resistance
Drivers + Diabetes
Warn DVLA, carry glucose meter/strips, check <2hrs before driving and every 2 hours (must be >5mmol)
Typical T1DM features
BMI<25, Young, glucose>11, ketosis
T1DM HbA1C recommendation
<48mmol/mol (6.5%)
Waking glucose(fasting):
4-7mmols/l
Before food - glucose fasting
5-7mmols/l
90 minutes after food (glucose fasting level)
5-9mmols/l
When does insulin need decrease
Intercurrent illness, reduced food intake, impaired renal function, endocrine disorders e.g. Addison’s, coeliac disease, renal/ hepatic impairment
When does insulin need increase
Trauma (accidental/surgery), infection, stress, puberty
What T1DM patients benefit from metformin
> 25 BMI/ >23 in South Asian people to minimise effective insulin dose
Who is continuous insulin offered to
Disabling hypos, high HBA1c>69
What insulin regimen is preferred in T1DM
Basal bolus
T2DM treatment goals
Reduce micro/macrovascular complications by maintaining effective glucose and maintaining HBA1c
Microvascular
Retinopathy, neuropathy, nephropathy
Macrovascular
Ischemic heart disease, peripheral vascular disease, and cerebrovascular disease
Metformin effect
Lowers glucose, increases insulin sensitivity, inhibits gluconeogenesis, inhibits glycogenolysis
Metformin contraindications
Renal impairment (<30), heart failure, liver failure, recent MI
Key metformin side effect
lactic acidosis
What diabetic drugs cause hypos
Sulfonylurea
Meglitinide
Sulfonylureas end in:
Ide = tolbutamide, gilbenclamide
When is long acting sulphonylurea not recommended:
Older patients because of hypos and confusion
When to stop HRT
Severe chest pain, breathlessness, swelling in one calf, severe stomach pain, liver problems , Hypertension, immobile, neurological issues
What activity does Tibolone have
It has oestrogenic, progestogenic and weak androgenic activity
What is vasopresin and desmopressin, and what are they used for
Antidiuretic hormones used to treat pituitary cranial diabetes insipidus
Key differences between vasopressin and desmopressin
Desmopressin is more potent and has longer duration
Sulfonylureas side effects
Weight gain Hypos G6PD deficiency caution Abdominal pain diarrhoea nausea
Sulfonylurea mechanism of action
Increase insulin acting on pancreatic beta cells (augmenting insulin secretion)
Acarbose mechanism of action
Slows digestion to reduce rate of glucose release
Meglitinide mechanism of action
Similar to Sulfonylurea but act on different receptor to stimulate insulin release
Thiazolidinone manifestation - e.g. pioglitazone
Reduces insulin resistance
Cautions/What to look out for with pioglitazone
Heart failure, nausea, toxicity, dark urine, bladder cancer
DPP4 mechanism of action
Inhibit glucagon release, increases insulin secretion
Dpp4 warnings
Pancreatitis
SGLT2 inhibitors mechanism of action
Prevent reabsorption of glucose in kidneys
GLP1 Receptor antagonist mechanism of action
Produce insulin as they are incretin mimetics, (increase insulin secretion, suppressing glucagon secretion,
slow gastric emptying)
When to take Exanatide
1 hour before food and 6 hours apart, never after food
Exanatide warning
Pancreatitis
GLP1 MHRA Warning
Diabetic ketoacidosis when concomitant insulin was rapidly reduced or discontinued
SGLT2i MHRA warnings
SGLT2 inhibitors: monitor ketones in blood during treatment interruption for surgical procedures or acute serious medical illness
Increased risk of lower-limb amputation (mainly toes)
reports of Fournier’s gangrene (necrotising fasciitis of the genitalia or perineum)
Risk of diabetic ketoacidosis with sodium-glucose co-transporter 2 (SGLT2) inhibitors
SGLT2i side effects
Balanoposthitis; constipation; dyslipidaemia; increased risk of infection;
nausea;
thirst;
urinary disorders; urosepsis
What sort of T2DM drug is needed for elderly
Short acting e.g. tolbutamide, gluclazide
When are GLP1 agonists used
After triple therapy
Meglitinide examples
Repaglinide, nateglinide
What antidiabetic is used concomitantly with weight management products
GLP1 agoists
How/when are meglitinides used
In combination with metformin when metformin alone inadequate
When to use short acting insulin
15-30 minutes before food
Soluble insulin peak
1-4 hours
Soluble insulin duration
9hrs
Rapid insulin names
Aspart, glulisine, lispro
Rapid insulin onset time
<15 minutes
Rapid insulin duration
2-5hrs
When to use rapid insulin
Just before meal
Intermediate insulin name
Isophane
Intermediate onset
1-2 hours
Intermediate peak
3-12hours
Intermediate action
11-24 hours
Biphasic insulin consists of what
Intermediate +short/rapid
Long acting insulin duration
Up to 36 hours
How long does it take for long acting to get to steady state
2-4 days
Diabetes pregnancy HbA1C aim
48
What oral diabetes medicine can be used in pregnancy
Only metformin possibly gilbenclamide during breastfeeding
Insulin in pregnancy preference
Isophane firstline then rapid, (long acting if good control)
When to pharmacologically treat Gestational diabetes
> 7mmol/l fasting plasma
https://bnf.nice.org.uk/treatment-summary/diabetes-pregnancy-and-breast-feeding.html
Gestational diabetes treatment
Metformin, insulin or gilbenclamide
https://bnf.nice.org.uk/treatment-summary/diabetes-pregnancy-and-breast-feeding.html
Insulin adaptation for minor elective surgery in patient with good control
Normal but long acting reduced by 20% onday of surgery
Insulin adaptation for major surgery in patient or poor glycaemic control
Rate adjusted, long acting 80% and others normal. On the day only long acting (80%) , no other insulin until eating, iv infusion of KCl w/glucose and NaCl to prevent hypo
When should BD mixed insulin regimes be restarted after surgery
Breakfast/dinner
DKA symptoms
Nausea, drowsy, pear drop, vomiting
DKA treatment
Soluble insulin, KCl, NaCl, (and then long acting insulin)
Hypoglycaemia symptoms
‘like hungry’, agitated, drunk-like, confusion, sweating, Excessive sweating, pallor, palpitations, trembling
When is ACE/ARB given for diabetes
Three positive serum creatinine tests
What to with Sulfonylurea in patients having surgery
Stop until first meal after surgery
What to with SGLT2i in patients having surgery
Stop until stable
What to do with metformin when insulin given during surgery
Metformin does not need to be stopped
How to tackle nephropathy in diabetes patients
Attempt to lower BP and start ACE/ARB
How to treat diabetic foot infections
Flucloxacillin
DKA treatment
500ml 0.9% NaCl over 10-15min
Give KCl
Start IV soluble insulin Give long acting insulin subcutaneously
Aim to reduce glucose by 3mmol/hour and ketone by 0.5mml/l/hr once glucose below 14 give glucose with NaCl (continue insulin until patient can eat)
Examples of SGLT2
gliflozin’s canagliflozin, dapagliflozin
Examples of DPP4i
gliptins, linagliptin, sitagliptin
What diabetes meds put patients at risk of pancreatitis
DPP4i, Meglitinide
Thiazolidinediones examples
Pioglitazone
Rosiglitazone
Liothyronine vs levothyroxine
Liothyronine more rapidly metabolised
Hyperthyoidism drug treatment
Carbimazole if not then propylthiouracil. 12–18 month course using either a block and replace regimen (combination of fixed high-dose carbimazole with levothyroxine sodium), or a titration regimen (dose based on thyroid function tests). Radioacive iodine is however first line.
Thyrotoxicosis treatment
Propranolol/nadolol (beta blocker)+ radioactive iodine
What is a blocking replacement regimen
Giving combo of hyper and hypo thyroidism drugs
Hypothyroidism definition
Thyroid stimulating hormone (TSH) levels above the reference range and free thyroxine (FT4) levels below the reference range.
Hypothyroidism in pregnancy definition
Elevated TSH levels (using trimester-specific reference ranges) regardless of FT4 levels.
Hyperparathyroidism pharmacological treatment
Vitamin D and cincalcet
Hyperparathyroidism symptoms
Hypercalacaemia = thirst high urine output, constipation, fatigue ,memory problems , CVD, kidney stones, osteoporosis, fractures
Hyperthyroidism symptoms
Goitre, hyperactivity, disturbed sleep, fatigue, palpitations, anxiety, heat intolerance, increased appetite with unintentional weight loss, and diarrhoea
Gonadotrophin inhibitors
Cetorelix, ganirelix, danazol
Endometriosis treatment
Danazol, pituitary gonadotrophin inhibitors
How to treat cushings
Metyrapone surgery
Heavy menstruation treatment
Tranexamic acid, NSAID, ulipristal acetate, a levonorgestrel-releasing intrauterine system(first line in less severe),
When should a bisphosphonate free period start
5 years, but continued if they actually have broken something
First line osteoporosis treatment
Alendronic, risedronate
When/how to take bisphosphonate
Empty stomach.
30 mins before first food of the day, 2 hour before/after other meals.
To sit upright. Particularly avoid milk/calcium containing.
Take same time each week
Bisphosphonate counselling points
Osteonecrosis of jaw and auditory canal when taken for more than 2 years so report related issues
Osteoporosis risk factors
Age, low body mass index (BMI), cigarette smoking, excess alcohol intake, lack of physical activity, vitamin D deficiency and low calcium intake, family history of hip fractures, a previous fracture at a site characteristic of osteoporotic fractures and early menopause.
What does HRT alleviate
Menopausal symptoms e.g. Vaginal atrophy or vasomotor instability
Risks that arise due to HRT
Venous thromboembolism, stroke, endometrial cancer (reduced by a progestogen), breast cancer, and ovarian cancer
What hormone should be added to oestrogen in women with a uterus and why
Progestogen to reduce risk of cystic hyperplasia
Hyperthyroidism complications
Graves’ orbitopathy, thyroid storm (thyrotoxic crisis), pregnancy complications, reduced bone mineral density, heart failure, and atrial fibrillation
Graves disease
An autoimmune disorder mediated by antibodies that stimulate the thyroid-stimulating hormone (TSH) recepto
Hyperthyroidism and TSH/FT4/FT3
TSH levels below the reference range and free thyroxine (FT4) and/or free tri-iodothyronine (FT3) levels above the reference range
Non-drug hyperthyroidism treatment
Radioactive iodine or surgery
What laxative safe in pregnancy
Bulk forming as not absorbed
What drug is used in bed wetting
Desmopressin
Where is hydrocortisone (Cortisol) secreted
Adrenal cortex normally secretes
Dopamine-receptor agonists indication
Inhibits release of growth hormone
treats acromegaly
and galactorrhea
Endometriosis treatment
gonadotropin-releasing hormones, pain relief, contraceptive
Glucorticoid vs mineralocoricoid
High glucocorticoid is useless if mineralocorticoid activity is also high e.g. Fludrocortisone
5mg Prednisolone is equivalent to how much dexamethasone and hydrocortisone
20mg hydrocortisone, 750 mcg dexamethasone
Betamethasone mineralo vs gluco
low mineralocorticoid, high glucocorticoid
Dexamethasone mineralo vs gluco
low mineralocorticoid, high glucocorticoid
Prednisolone glucocorticoid vs mineral
Mainly glucocorticoid
Hydrocortisone mineralocorticoid vs glucocorticoid
High mineralocorticoid
When is corticosteroid needed
Asthma , rheumatoid arthritis, haemorrhoids, ulcerative colitis , crohn’s , raised intracranial pressure
Corticosteroid side effects
Insomnia, suicidal thoughts, irritability, euphoria, nightmares
What class of antidiabetic drugs increases likelihood of thrush
SGLT2i
What antidiabetic drugs result in weight loss and increase insulin utilisation
Metformin
What combinations of antidiabetic drugs may result in hypos
Sulfonylurea and DPP4, Dose of concomitant sulfonylurea or insulin may need to be reduced.
