Endocrinology Flashcards
characteristic cutaneous signs of thyrotoxicosis
hair loss
pretibial myxoedema
onycholysis
bulging eyes (exophthalmos/proptosis)
characteristic cutaneous signs of hyothyroidism
hair loss
eyebrow loss outer part
cold, pale skin
characteristic face
characteristic cutaneous signs of cushing’s syndrome
central obesity
wasted limbs ('lemon on sticks')
moon face
buffalo hump
supraclavicular fat pads
striaecharacteristic cutaneous signs of addisons disease
hyperpigmentation (face, neck, palmar creases, mouth)
characteristic cutaneous signs of acromegaly
acral (distal) and soft tissue overgrowth
big jaws (macrognathia), hands and feet
skin is thick
facial features are coarse
characteristic cutaneous signs of hyperandrogenism (females)
hirsutism
temporal balding
acne
characteristic cutaneous signs of hypopituitarism
pale or yellow tinged thinned skin
fine wrinkling around eyes and mouth
characteristic cutaneous signs of pseudohypoparathyroidism
short stature
short neck
short 4th and 5th metacarpals
characteristic cutaneous signs of hypoparathyroidism
dry, scale, puffy skin
brittle nails
coarse hair
microvascular complications of hyperglycaemia
retinopathy
nephropathy
neuropathy
macrovascular complications of hyperglycaemia
stroke
renovascular disease
limb ischaemia
heart disease
symptoms of hyperglycaemia (DM)
polyuria polydipsia unexplained weight loss visual blurring genital thrush lethargy
diagnosis of DM if symptomatic
fasting BM ≥7 OR
random BM ≥11.1
(only one reading required if symptomatic)
HbA1c ≥48 (6.5%)
diagnosis of DM if asymptomatic
fasting BM ≥7 OR
random BM ≥11.1 OR
OGTT 2h value ≥11.1
(need 2 readings if asymptomatic)
HbA1c ≥48 (6.5%)
what is type 1 DM
Insulin deficiency from AUTOIMMUNE DESTRUCTION of insulin-secreting pancreatic beta-cells
Patients must have insulin, and are prone to ketoacidosis and weight loss
what is LADA
o Latent autoimmune diabetes of adults (LADA) is a form of type 1 DM, with slower progression to insulin dependence in later life.
usually have glutamic acid decarboxylase autoantibodies (GADA).
what is type 2 DM
Reduced insulin secretion ± increased insulin resistance
Associated with obesity, lack of exercise, calorie and alcohol excess
≥80% concordance in identical twins, indicating STRONGER GENETIC INFLUENCE THAN IN TYPE 1 DM.
o Typically progresses from a preliminary phase of impaired glucose tolerance or impaired fasting glucose.
what is MODY
Maturity onset diabetes of the young (MODY) is a rare autosomal dominant form of type 2 DM affecting young people with a positive family history.
what is impaired glucose tolerance
known as pre-diabetes.
- Fasting plasma glucose <7mmol/l and OGTT 2h glucose ≥7.8mmol/l but ≤11.1mmol/l
OGTT is not used routinely now – this has been replaced by HbA1c which indicates that a HbA1c of 42-47 (6-6.4%) indicates pre-diabetes and therefore a high risk of diabetes.
what is impaired fasting glucose
- Fasting plasma glucose between 6.1 and 6.9 mmol/L and;
- A blood glucose of <7.8 mmol/L after a 2h OGTT
which factors increase your risk of IGT or IFT
overweight/obese FHx of diabetes sedentary lifestyle hypertension high cholesterol gestational diabetes
secondary causes of DM
steroids, anti-HIV drugs, atypical antipsychotics, thiazides
Pancreatic - pancreatitis, surgery (>90% pancreas removed), trauma, pancreatic destruction (haemochromatosis, CF), pancreatic cancer.
cushing's disease acromegaly phaeochromocytoma hyperthyroidism pregnancy
complications of gestational diabetes
miscarriage pre-eclampsia macrosomia shoulder dystocia pre-term labour congenital malformations worsening of diabetic complications e.g. retinopathy, nephropathy.
who is at risk of gestational diabetes
age >25y FHx positive weight gain non-caucasian HIV positive previous gestational DM
pre-conception advice to prevent gestational DM
control/reduce weight
aim for good glucose control
offer FOLIC ACID 5mg OD for 12 weeks
how to diagnose gestational DM
oral glucose tolerance test - if risk factors at booking visit e.g. previous gestational DM
if previously diabetic, how would you change their medications
oral hypoglycaemic - stop
metformin - continue
features suggesting type 1DM
weight loss
persistent hyperglycaemia despite diet and meds
presence of autoantibodies –> islet cell antibody and anti-glutamic acid decarboxylase antibodies.
ketonuria on dipstick
what is metabolic syndrome
combination of diabetes, high blood pressure and obesity.
CENTRAL OBESITY \+ 2 of: - BP ≥130/85 - triglycerides ≥1.7 - HDL ≤1.03 (male)/ 1.29 (female) - fasting glucose ≥5.6 or - DM
complications of metabolic syndrome
vascular events (MI) DM gallstones pancreatic cancer microalbuminuria neurodegeneration fertility problems
treatment of metabolic syndrome
exercise weight loss ± mediterranean (?keogenic) diet - antihypertensives - hypoglycaemic (metformin) - statins
first line for diabetic who is overweight and
hbA1c to aim for
metformin + lifestyle advice
HbA1c of 48 mmol/mol (6.5%)
if GI side effects - try metformin MR
stop metformin if eGFR <30 (lactic acidosis risk)
when would you start 2 medications in a diabetic
and
HbA1c aimed for
HbA1c >58 (7.5%) consider: - metformin + DPP4 inhibitor (gliptins) - metformin + pioglitazone - metformin + gliclazide - metformin + SGLT-2
aim for HbA1c of 53mmol/mol (7%)
when would you start 3 medications in a diabetic patient and what hbA1c to aim for
if HbA1c remains above 58 despite dual therapy.
consider:
- metformin + gliptin + SU
- metformin + pioglitazone + SU
or
- start insulin based treatment
aim for HbA1c ≤53 (7%)
if metformin is contraindicated, what is first line for type 2 DM
DPP4 inhibitor OR
pioglitazone OR
sulphonylurea
C/I to pioglitazones
heart failure or history of heart failure
hepatic impairment
diabetic ketoacidosis
current, or a history of, bladder cancer
uninvestigated macroscopic haematuria.
general advice for DM management
structured education programme
offer lifestyle advice
start statin
control BP
give foot-care advice
advise informing DVLA and not to drive if hypoglycaemic episodes not in control
if triple therapy is not effective, not tolerates or C/I then NICE advices what
- metformin + sulfonylurea + GLP-1
o BMI ≥35kg/m2 AND specific psychological or other medical problems associated with obesity OR
o BMI <35kg/m2 AND for whom insulin therapy would have significant occupational implications or weight loss would benefit other significant obesity related comorbidities (only continue if there is a reduction of at least 11mmol/l in HbA1c and a weight loss of at least 3% of initial body weight in 6 months.
sick day rules for diabetics
- Increase frequency of blood glucose monitoring to 4 hourly or more
- Encourage fluid intake aiming for at least 3 litres in 2h
- In struggling to eat, may need sugary drinks to maintain carbohydrate intake
- Continue to take insulin, as increased cortisol levels during stress can increase glucose levels in the body for which insulin is required.
2nd line treatment if metformin C/I and DM still not controlled
gliptin + pioglitazone
gliptin + SU
pioglitazone + SU
3rd life treatment if metformin C/I
consider insulin-based treatment
