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Medicine - Finals > Endocrinology > Flashcards

Endocrinology Flashcards

1
Q

Define the HbA1c limits for a diagnosis of pre-diabetes and diabetes?

A

HbA1c of greater than or equal to 48 mmol/mol (6.5%) is diagnostic of diabetes mellitus

If the patient is symptomatic:
fasting glucose greater than or equal to 7.0 mmol/l
random glucose greater than or equal to 11.1 mmol/l (or after 75g oral glucose tolerance test)

If asymptomatic demonstrate these levels on 2 separate occasions

42-47 is pre-diabetes

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2
Q

What BG results imply impaired fasting glucose?

A

A fasting glucose greater than or equal to 6.1 but less than 7.0 mmol/l implies impaired fasting glucose (IFG)

Impaired glucose tolerance (IGT) is defined as fasting plasma glucose less than 7.0 mmol/l and OGTT 2-hour value greater than or equal to 7.8 mmol/l but less than 11.1 mmol/l

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3
Q

Symptoms of hypoglycaemia

A 
Common symptoms are:
sweating
anxiety
hunger
tremor
palpitations
dizziness
confusion
drowsiness
visual disturbance
seizures

Patients act drunk

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4
Q

Anti-TRAb

A

Grave’s Disease (hyperthyroidism)

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5
Q

Management of hyperthyroidism

A

Symptoms - propanolol
Disease –> Carbimazole, Propylthiouracil (2nd line unless pregnancy desired)
Grave’s eye disease –> Steroids

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6
Q

What is the main risk to be aware of in patients on Carbimazole?

A

Agranulocytosis

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7
Q

Anti-TPO

A

Hashimoto’s (hypothyroidism)

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8
Q

Causes of Hypercalcaemia (CHIMPANZEES)

A 
Calcium supplements 
Hyperparathyroidism
Iatrogenic or immobilisation
Multiple myeloma
Parathyroid adenoma
Alcohol
Neoplasia
Zollinger-Ellison Syndrome
Excessive Vitamin A
Excessive Vitamin D
Sarcoidosis
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9
Q

What is the difference between primary and secondary hyperparthyroidism?

A

1 - high calcium - therefore inappropriate PTH secretion

2 - low calcium - therefore appropriate PTH secretion

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10
Q

Management of hypercalcaemia

A

bisphosphonates

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11
Q

Signs of hypocalcaemia

A

paraesthesia, facial twitch (Chvostek’s), muscle cramps (Trousseau’s -> carpopedal spasm when BP cuff inflated for 3 mins), tiredness, anxiety, dry hair/skin

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12
Q

Which genetic condition is associated with congenital lack of parathyroid gland?

A

DiGeorge

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13
Q

Management of hypocalcaemia due to hypoparathyroidism

A

Calcium carbonate and vitamin D supplements

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14
Q

Order of hormonal loss in pituitary

A

GGAT

Gonadotropins
GH
ACTH
TSH

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15
Q

How can panhypopituitarism be investigated quickly

A

Insulin tolerance test - give insulin to cause BG to fall below 2.5 this should stimulate GH and Cortisol (via ACTH) release

MRI pituitary

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16
Q

JAK2

A

Haemochromatosis
Polycythaemia vera
Myelofibrosis

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17
Q

Which endocrine disorder is associated with a proximal myopathy (unable to stand from seated position)?

A

Cushings

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18
Q

Testing for Cushings

A

Dexamethasone suppression test

  • 1mg overnight normally should reduce cortisol to <50nmol/L
  • If fails, 3 day-test –> low dose 0.5mg every 6 hours to see if suppression occurs
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19
Q

Management of PRL-oma

A

1 - Carbergoline (dopamine agonist)

2 - Quinagolide or Bromocriptine

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20
Q

Ix GHoma

A

Initial GH and IGF-1 levels

Glucose tolerance test - glucose should suppress GH

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21
Q

What biochemistry would you expect with Diabetes Insipidus?

A

high plasma osmolality

low urine osmolality

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22
Q

Diagnosing Diabetes Insipidus?

A

Water deprivation test –> less water should reduce urine output

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23
Q

Management of Diabetes Insipidus?

A

Vasopressin (ADH)

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24
Q

Management of SIADH

A

Water restriction 1-1.5L
Demeclocycline
Tolvaptan

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25
Adrenal cortex hormones
Remember GFR:AGM Zona Glomerula --> Mineralocorticoid (Aldosterone) Zona Fascicular --> Glucocorticoid (Cortisol) Zona Reticularis --> Androgen (DHEA)
26
Which part of the adrenals is formed from neural crest tissue?
Medulla
27
Action of aldosterone
Causes Na absorption in kidneys (replaced by potassium), water follows, BP increases
28
Autoimmune adrenal insufficiency
Addison's
29
Aldosterone adenoma
Conn's
30
Ix for Addison's
Synacthen test | - synthetic ACTH given to see if cortisol increases
31
Management of Addison's
Mineralocorticoid --> Fludocortisone | Corticosteroid--> Hydrocortisone
32
Resistant hypertension is associated with which endocrine disorder
Conns - give spironolactone
33
If unfit for surgery which drug can be used in Cushing's
Metyrapone
34
Management of phaeochromocytoma
alpha blockers - for 6 weeks first (e.g. phenoxybenzamine) Beta blockers if still tachcardic then surgical removal once optimal blockade
35
What is the 10% rule for phaeochromocytoma
Remember BiGEM 10% Bilateral, 10% Genetic (MENII, VHL), 10% Extra-adrenal, 10% Malignant,
36
Anti GAD
T1DM
37
Anti IL2
T1DM
38
C-peptide levels in T1 &2 DM
T1DM --> low | T2DM --> initially high (low after 20 years)
39
Which has a higher mortality? HHS or DKA
HHS > DKA
40
Side effects of metformin
Diarrhoea and abdominal pain. This is dose dependent and reducing the dose often resolves the symptoms Lactic acidosis Does NOT typically cause hypoglycaemia
41
Side effects of Pioglitazone
``` Weight gain Fluid retention Anaemia Heart failure Extended use may increase the risk of bladder cancer Does NOT typically cause hypoglycaemia ```
42
How does Pioglitazone work?
It increases insulin sensitivity and decreases liver production of glucose
43
How does Metformin work?
It increases insulin sensitivity and decreases liver production of glucose
44
Side effects of Sulfonylurea
Weight gain Hypoglycaemia Increased risk of cardiovascular disease and myocardial infarction when used as monotherapy
45
How does Sulfonylurea work?
Sulfonylureas stimulate insulin release from the pancreas
46
Mechanism of action. Incretins (relevant for DPP-4 inhibitors and GLP-1 mimetics) DPP-4 inhibitors - Sitagliptin GLP-1 mimetics - Exenatide, Liraglutide
Incretins are hormones produced by the GI tract. They are secreted in response to large meals and act to reduce blood sugar. They: Increase insulin secretions Inhibit glucagon production Slow absorption by the GI tract The main incretin is “glucagon-like peptide-1” (GLP-1). Incretins are inhibited by an enzyme called “dipeptidyl peptidase-4” (DPP-4). A recent meta-analysis (JAMA 2018) showed that GLP-1 mimetics were associated with a reduction in all cause mortality whereas DPP-4 inhibitors were not.
47
DPP-4 inhibitors - Sitagliptin. Side effects
GI tract upset Symptoms of upper respiratory tract infection Pancreatitis
48
GLP-1 mimetics - Exenatide, Liraglutide. Side effects
GI tract upset Weight loss Dizziness Low risk of hypoglycaemia
49
SGLT2 inhibitors - Empagliflozin. Side effects
Glucosuria (glucose in the urine) Increased rate of urinary tract infections Weight loss Diabetic ketoacidosis, notably with only moderately raised glucose. This is a rare complication Lower limb amputation appears to be more common in patients on canagliflozin. It is not clear if this applies to other SGLT-2 inhibitors
50
Management GHoma
For patients with a pituitary tumour which is enclosed, the first line treatment is transsphenoidal surgery. Somatostatin analogues are first line for unresectable tumours or if surgery fails to achieve remission of acromegaly.
51
Acromegaly. effect on heart
Cardiomyopathy - HOCM
52
What is the correct rate of insulin you should prescribe during DKA according to current NICE guidelines?
0.1 unit/kg/hr
53
DKA resolution is defined as:
pH >7.3 and blood ketones < 0.6 mmol/L and bicarbonate > 15.0mmol/L Ketonaemia and acidosis should have resolved within 24 hours
54
Androgen insensitivity syndrome
X-linked recessive condition 46XY Male Genotype Female external genitalia May present with primary amenorrhoea
55
Kallman's Syndrome
Hypogonadotropic hypogonadism LH & FSH low-normal; Low testosterone Delayed puberty and anosmia in a male Normal or above average height
56
Kleinefelter's Syndrome
karyotype 47XXY Hypergonadotropic hypogonadism - delayed puberty in male elevated levels of FSH and LH, with low testosterone
57
Initial testing for Phaeochromocytoma
Urinary Metanephrines
58
HbA1c monitoring for diabetes
HbA1c should be checked every 3-6 months until stable, then 6 monthly
59
HbA1c targets
48 if on lifestyle and metformin management 53 if on further treatment with risk of hypos (e.g. Sulfonylurea) ≥58 -> step up management
60
Criteria for initiating and continuing GLP-1 mimetic medication for diabetes
Failed triple therapy + BMI ≥35 or insulin have severe occupational implications Try metformin, sulfonylurea and a GLP1 mimetic Should get >11 reduction in HbA1c and >3% weight loss after 6 month to justify continuation
61
Considerations before changing over to insulin therapy
Implications for occupation - trial with GLP1 mimetic? | Continue on metformin initially
62
Afro-Caribean diabetics first-line for hypertension
ARB
63
Lipid modification if QRISK >10%
Atorvastatin 20mg (secondary prevention is 80mg)
64
Uses of metformin
First-line in type 2 diabetes PCOS NAFLD
65
Metformin - mechanism of action
increases insulin sensitivity | decreases hepatic gluconeogenesis
66
Side effects of metformin
GI upset - diarrhoea (switch to modified release) B12 deficiency Lactic acidosis - rare and usually precipitated by recent myocardial infarction, sepsis, acute kidney injury and severe dehydration
67
Metformin and contrast imaging
Should be discontinued on the day of procedure and 48 hours thereafter
68
Metformin contraindications
eGFR<30 or creatinine >150 contrast imaging - stop on day of procedure and for 48 hours after alcohol abuse is a relative contraindication
69
Insulin side effects
Hypoglycaemia Weight gain Lipodystrophy
70
Sulfonylureas (gliclazide and glimepiride) mechanism of action
Stimulate pancreatic beta cells to secrete insulin
71
Sulfonylureas side effects
Hypoglycaemia Weight gain Hyponatraemia
72
Thiazolidinediones side effects
Weight gain Fluid retention May precipitate heart failure
73
Thiazolidinediones mechanism of action
stimulates adipogenesis
74
DPP4 inhibitors (-gliptins) mechanism of action
Increases incretin levels which inhibit glucagon secretion
75
DPP4 (-gliptins) side effects
Pancreatitis
76
SGLT-2 inhibitors (-gliflozins) mechanism of action
Inhibits reabsorption of glucose in the kidney
77
SGLT-2 inhibitors (-gliflozins) side effects
``` Urinary tract infection Weight loss Fournier's Gangrene Normoglycaemic ketoacidosis Risk of lower limb amputation ```
78
GLP1 agonists mechanism of action
Incretin mimetic which inhibits glucagon secretion
79
GLP1 agonists side effects
Nausea and vomiting Pancreatitis Weight loss
80
DKA presentation
abdominal pain polyuria, polydipsia, dehydration Kussmaul respiration (deep hyperventilation) Acetone-smelling breath ('pear drops' smell)
81
Diagnosing DKA
glucose > 11 mmol/l or known diabetes mellitus pH < 7.3 bicarbonate < 15 mmol/l ketones > 3 mmol/l or urine ketones ++ on dipstick
82
Management of DKA
1. Isotonic Saline (0.9%) 2. Insulin infusion 0.1u/kg/hr (once BG <15mmol/L start 5% dextrose infusion) 3. Potassium Chloride for anyone with K+ of 3.5-5.5 add 40 mmol/l to saline (if rate >20mmol/hr start cardiac monitoring) 4. long-acting insulin continued but short-acting stopped
83
Main risk of fluid resuscitation during DKA in the young
Cerebral Oedema - provide 1 to 1 nursing - usually occurs 4-12 hours after treatment started - CT and senior review if suspected

Medicine - Finals (21 decks)

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