Endocrinology Flashcards
What levels of HbA1c and glucose are diagnostic for diabetes?
HbA1c >48
Random glucose >11
Fasting glucose >7
Medical management of type II diabetes
1st line - metformin
2nd line (if HbAa1c >58) - add 2nd drug from other diabetes drugs
3rd line - (if HbA1c remains above 58) - consider insulin therapy
Name the most common sulphonylurea medication and it’s mechanism of action
Gliclazide
Increases insulin release from pancreas
Name the common thiazolidinedione and its MOA
Pioglitazone
Increases insulin sensitivity
Name the common SGLT2-inhibitors
Empagliflozin, canagliflozin, dapagliflozin
Name the common DDP4 inhibitor and it’s MOA
Sitagliptin
Inhibits breakdown of GLP-1 (which in turn stimulates insulin release)
Name the common GLP-1 Mimetic
Exenatide
Which diabetes medication class increases the risk of bladder cancer
Thiazolidinediones e.g, pioglitazone
Which diabetes medication is contraindicated in patients with heart failure?
Thiazolidinediones e.g, pioglitazone
Which diabetes medication class increase the risk of fournier’s gangrene?
SGLT-2 inhibitors e.g, empagliflozin
Which diabetes medication is preferable in patients who are overweight
DPP4 inhibitors e.g, sitagliptin
Pathophysiology of hyperosmolar hyperglycaemic state (HHS)
Hyperglycaemia leads to osmotic diuresis with associated loss of sodium and potassium
Severe volume depletion leads to raised serum osmolarity
Hyperviscosity of blood can lead to vascular complications
Clinical features of Hyperosmolar hyperglycaemic state (HHS)
Nausea, vomiting
Polydipsia
Neurological symptoms e.g, reduced GSC, headaches, weakness
Cardiovascular symptoms - hypotension, tachycardia
Significantly raised serum osmolarity
Hypovolemic
Hyperglycaemic (>30)
Management of HHS
Admit
Normalise osmolality (gradually) - isotonic solution (normal saline)
IV fluid and electrolyte replacement
Normalise blood glucose (Gradually)
Medical management of diabetic neuropathy
Amitriptyline Duloxetine Gabapentin Pregabalin Topical capsaicin - may be used for localised neuropathic pain
Management of gastrointestinal autonomic neuropathy in type II diabetes
Metoclopramide
What are the diabetes sick day rules
Continue meds are normal
Increase frequency of BM monitoring
Encourage fluid intake
May need sugary drinks
Presentation of diabetic ketoacidosis
Abdominal pain Polyuria/polydipsia Dehydration Kussmaul respiration Acetone smelling breath
Management of diabetic ketoacidosis
IV Fluid replacement - isotonic saline
Fixed rate IV insulin replacement: 0.1 units/kg/hour
Correction of hypokalaemia
- if 3.5-5.5 give 40mmol/L in infusion
- if <3.5 seek senior review for additional K+
What should happen in regular insulin medication during diabetic ketoacidosis
Stop short acting
Continue long acting
What are the risks of diabetic ketoacidosis managemetnt
Arrthymias - secondary to hyperkalaemia
Cerebral oedema - secondary to fluid infusion, more common in children and needs to be closely monitored
Acute respiratory distress syndroem
AKI
What is maturity onset diabetes of the young (MODY)?
Development of type II diabetes in patients <25 years old
Typically autosomal dominant condition
Medical management of MODY
Sulfonylureas e.g, gliclizide
Features of insulinoma
Hypoglycaemia
Rapid weight gain
Raised insulin
Raised C-peptide
Clinical Features of Hyperthyroidism
Weight loss Restlessness Heat intolerance Palpatiations Diarrhoea Oligomenorrhoea
Signs specific to Graves’ disease
Exophthalmos
Pretibial myxoedema
Digital clubbing
Medical management of Graves Disease
Propanolol - for symptom relief
Carbimazole - titration or block and replace
Main side effect to consider when starting carbimazole
Agranulocytosis
Need to monitor FBCs
Need to warn patient what to do if they get sore throat etc
Alternative management of Graves’ disease if medical management is unsuccessful
Radioactive idodine
Surgery
What is a thyroid storm?
Life threatening complication of thyroidtoxicosis
Risk factors for thyroid storm
Thyroid surgery
Trauma
Infection
Acute iodine load e.g, CT contrast media
Clinical Features of Thyroid Storm
Fever Tachycardia Confusion Nausea/vomiting Hypertension Abnormal LFTs - jaundice may be seen clinically
Management of thyroid storm
Beta blockers - IV Propanolol
Propylthiouricil
IV hydrocortisone - blocks conversation of T4 to T3
Antibodies in Graves’ disease
Anti-TSH
Antibodies in Hashimotos
Anti-TPO
Drug causes of hypothyroidism
Lithium
Amiodarone
Clinical features of hypothyroidism
Weight gain Lethargy Cold intolerance Dry skin Oedema Constipation Menorrhagia Decreased reflexes
Cause of secondary hypothyroidism
Pituitary insufficiency
Management of hypothyroidism
Levothyroxine
What is myxoedema coma
Complication of longstanding untreated hypothyroidism
Presentation of myxoedema coma
Confusion Hypothermia Odema Reduced respiratory drive Seizures
Management of myxoedema coma
IV thyroid replacement
IV fluids
IV corticosteroids
What is subclinical hypothyroidism
TSH raised
T3/T4 normal
When would you treat subclinical hypothyroidism
TSH between 4-10
<65 years and symptomatic - trial levothyroxine
If asymptomatic - no treatment
TSH >10
<70 years - start treatment even if asymptomatic
>80 - no treatment
What is de Quevain’s thyroiditis
Hyperthyroidism following viral infection
May present with painful goitre and raised ESR
Period of hypothyroidism following a few months of hyperthyroidism
No treatment needed
Types of thyroid cancer and age groups typically found in
Papillary (65%) - seen in young females
Follicular (20%) - seen in women >50 years
Medullary
Anaplastic (Rare) - occurs in elderly patients
Thyroid tumour markers for different cancers
Papillary and follicular - thyroglobulin
Medullary - calcitonin (originates from parafollicular cells)
Management of hyperthyroidism in pregnancy
1st trimester - replace carbimazole with propylthiouracil as increased risk of congenital abnormalities
2nd trimester - switch back to carbimazole
Monitor thyroixine levels throughout pregnancy - should be kept in upper 1/3rd of normal limit to avoid fetal hypothyroidism
Management of Hypothyroidism in pregnancy
Levothyroxine should be increased in pregnancy - 50% increase in dose as early as 4-6 weeks of pregnancy
What is sick euthyroid syndrome
Deranged thyroid levels during infection or viral illness
Low/normal TSH
Low T3
Low T4
Clinical features of primary hyperparathyroidism
Hypercalcemia
Low phosphate
Polyuria/Polydipsia - due to raised calcium
PTH may be raised or inappropriately normal due to raised calcium
Kidney stones
What would an X-ray head show in primary hyperparathyroidism
Pepper pot skull
Management of primary hyperparathyroidism
Surgery - total parathyroidectomy
Conservative management may be considered if patient is older and has no end organ damage
Cinacalcet considered in patients unsuitable for surgery
Blood results on secondary hyperparathyroidism
PTH - high
Calcium - Low or normal
Phosphate - High
Blood results in tertiary hyperparathyroidism
PTH - very high
Calcium - normal or high
Phosphate - normal or low
Blood results in primary hyperparathyroidism
PTH - normal or high
Calcium - high
Phosphate - low
Causes of primary hyperaldosteronism
Idiopathic bilateral adrenal hyperplasia
Conns syndrome
Adrenal carcinoma
Features of primary hyperaldosteronism
Hypertension
Hypokalaemia - due to increased aldosterone
Alkalaosis - due to raised bicarbonate associated with increased aldosterone
Diagnostic test in primary hyperaldosteronism
Plasma aldosterone/renin ratio - shows high aldosterone and low renin ratio
Management of primary hyperaldosteronism
Bilateral adrenocortical hyperplasia - spironolactone
Adrenal adenoma - surgery
What is Addison’s disease
Autoimmune destruction of adrenal glands
Leads to reduction in cortisol and aldosterone production
Clinical features of Addison’s
Lethargy, weakness, anorexia
Hyperpigmentation - especially in palmer creases
Hypotension
Salt craving
Increased thirst - as sodium and water is being lost due to reduced aldosterone
Blood results in Addison’s
Hyponatraemia
Hyperkalamia
Hypoglycaemia
Diagnostic test for Addison’s
Short synacthen test
- ACTH is given which would usually increase cortisol
- in Addison’s cortisol will not rise in response due to defective adrenal gland
Medical management of Addison’s
Glucocorticoid replacement - hydrocortisone
Mineralcorticoid replacement - fludrocortisone
Advise on medication changes for Addison’s patients when they have intercurrent illness
Double glucocorticoid dose (double hydrocortisone)
Management of Addisonian crisis
IV hydrocortisone
IV saline with dextrose
What is Cushing’s syndrome
Symptoms due to excess cortisol
Common causes of Cushing’s syndrome
Cushings disease - pituitary secreting ACTH
Ectopic ACTH production e.g, small cell lung cancer
Adrenal adenoma
Iatrogenic - excess steroids
Differentiating between causes of cushings
Dexamethasone suppression test
Low dose - will not suppress pituitary tumour OR other causes
High dose - will suppress pituitary tumour releasing ACTH
High dose - will NOT suppress ectopic ACTH production or adrenal adenoma
Measuring ACTH to help differentiate - this will be low in adrenal adenoma
What is a phaeochromocytoma?
Catecholamine secreting tumour of the adrenal glands
Symptoms of phaeochromocytoma
Hypertension Headache Palpitations Sweating Anxiety
Diagnosis of phaeochromocytoma
24hr collection of urinary meranephrines
Management of phaeochromocytoma
Surgery
Pt must be stabilised with alpha blocker first e.g, phenoxybenzamine
MEN type 1
Parathyroid hyperplasia
Pituitary hyperplasia
Pancreas - e.g, insulinoma, gastrinoma
MEN Type IIa
Parathyroid hyperplasia
Phaeochromocytoma
MEN type IIb
Thyroid cancer
Phaeochromocytoma
What is kallman’s syndrome
Hypogonadotrophic hypogondism
X linked recessive trait
Leads to delayed puberty in boys
Hormone levels in Kallmann syndrome
Low testosterone
Low LH and FSH
Clinical presentation of kallman’s syndrome
Delayed puberty
Anosmia
Reduced sex hormones
Normal or above average height
What is Klinefelter syndrome
Genetic disease causing XXY in men
Hormone levels in Klinefelter syndrome
Low testosterone
Increase LH and FSH
Clinical features of Klinefelter syndrome
Taller than average Lack of secondary sexual characteristics Small, firm testes Infertility Gynaecomastia
