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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
Q

Adrenal cortex hormones

A

Remember GFR:AGM

Zona Glomerula –> Mineralocorticoid (Aldosterone)
Zona Fascicular –> Glucocorticoid (Cortisol)
Zona Reticularis –> Androgen (DHEA)

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26
Q

Which part of the adrenals is formed from neural crest tissue?

A

Medulla

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27
Q

Action of aldosterone

A

Causes Na absorption in kidneys (replaced by potassium), water follows, BP increases

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28
Q

Autoimmune adrenal insufficiency

A

Addison’s

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29
Q

Aldosterone adenoma

A

Conn’s

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30
Q

Ix for Addison’s

A

Synacthen test

- synthetic ACTH given to see if cortisol increases

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31
Q

Management of Addison’s

A

Mineralocorticoid –> Fludocortisone

Corticosteroid–> Hydrocortisone

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32
Q

Resistant hypertension is associated with which endocrine disorder

A

Conns - give spironolactone

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33
Q

If unfit for surgery which drug can be used in Cushing’s

A

Metyrapone

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34
Q

Management of phaeochromocytoma

A

alpha blockers - for 6 weeks first (e.g. phenoxybenzamine)

Beta blockers if still tachcardic

then surgical removal once optimal blockade

35
Q

What is the 10% rule for phaeochromocytoma

A

Remember BiGEM

10% Bilateral,
10% Genetic (MENII, VHL),
10% Extra-adrenal,
10% Malignant,

36
Q

Anti GAD

A

T1DM

37
Q

Anti IL2

A

T1DM

38
Q

C-peptide levels in T1 &2 DM

A

T1DM –> low

T2DM –> initially high (low after 20 years)

39
Q

Which has a higher mortality?

HHS or DKA

A

HHS > DKA

40
Q

Side effects of metformin

A

Diarrhoea and abdominal pain. This is dose dependent and reducing the dose often resolves the symptoms
Lactic acidosis
Does NOT typically cause hypoglycaemia

41
Q

Side effects of Pioglitazone

A 
Weight gain
Fluid retention
Anaemia
Heart failure
Extended use may increase the risk of bladder cancer
Does NOT typically cause hypoglycaemia
42
Q

How does Pioglitazone work?

A

It increases insulin sensitivity and decreases liver production of glucose

43
Q

How does Metformin work?

A

It increases insulin sensitivity and decreases liver production of glucose

44
Q

Side effects of Sulfonylurea

A

Weight gain
Hypoglycaemia
Increased risk of cardiovascular disease and myocardial infarction when used as monotherapy

45
Q

How does Sulfonylurea work?

A

Sulfonylureas stimulate insulin release from the pancreas

46
Q

Mechanism of action. Incretins (relevant for DPP-4 inhibitors and GLP-1 mimetics)

DPP-4 inhibitors - Sitagliptin
GLP-1 mimetics - Exenatide, Liraglutide

A

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
Q

DPP-4 inhibitors - Sitagliptin. Side effects

A

GI tract upset
Symptoms of upper respiratory tract infection
Pancreatitis

48
Q

GLP-1 mimetics - Exenatide, Liraglutide. Side effects

A

GI tract upset
Weight loss
Dizziness
Low risk of hypoglycaemia

49
Q

SGLT2 inhibitors - Empagliflozin. Side effects

A

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
Q

Management GHoma

A

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
Q

Acromegaly. effect on heart

A

Cardiomyopathy - HOCM

52
Q

What is the correct rate of insulin you should prescribe during DKA according to current NICE guidelines?

A

0.1 unit/kg/hr

53
Q

DKA resolution is defined as:

A

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
Q

Androgen insensitivity syndrome

A

X-linked recessive condition
46XY Male Genotype
Female external genitalia
May present with primary amenorrhoea

55
Q

Kallman’s Syndrome

A

Hypogonadotropic hypogonadism
LH & FSH low-normal; Low testosterone
Delayed puberty and anosmia in a male
Normal or above average height

56
Q

Kleinefelter’s Syndrome

A

karyotype 47XXY
Hypergonadotropic hypogonadism - delayed puberty in male
elevated levels of FSH and LH, with low testosterone

57
Q

Initial testing for Phaeochromocytoma

A

Urinary Metanephrines

58
Q

HbA1c monitoring for diabetes

A

HbA1c should be checked every 3-6 months until stable, then 6 monthly

59
Q

HbA1c targets

A

48 if on lifestyle and metformin management
53 if on further treatment with risk of hypos (e.g. Sulfonylurea)

≥58 -> step up management

60
Q

Criteria for initiating and continuing GLP-1 mimetic medication for diabetes

A

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
Q

Considerations before changing over to insulin therapy

A

Implications for occupation - trial with GLP1 mimetic?

Continue on metformin initially

62
Q

Afro-Caribean diabetics first-line for hypertension

A

ARB

63
Q

Lipid modification if QRISK >10%

A

Atorvastatin 20mg (secondary prevention is 80mg)

64
Q

Uses of metformin

A

First-line in type 2 diabetes
PCOS
NAFLD

65
Q

Metformin - mechanism of action

A

increases insulin sensitivity

decreases hepatic gluconeogenesis

66
Q

Side effects of metformin

A

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
Q

Metformin and contrast imaging

A

Should be discontinued on the day of procedure and 48 hours thereafter

68
Q

Metformin contraindications

A

eGFR<30 or creatinine >150
contrast imaging - stop on day of procedure and for 48 hours after
alcohol abuse is a relative contraindication

69
Q

Insulin side effects

A

Hypoglycaemia
Weight gain
Lipodystrophy

70
Q

Sulfonylureas (gliclazide and glimepiride) mechanism of action

A

Stimulate pancreatic beta cells to secrete insulin

71
Q

Sulfonylureas side effects

A

Hypoglycaemia
Weight gain
Hyponatraemia

72
Q

Thiazolidinediones side effects

A

Weight gain
Fluid retention
May precipitate heart failure

73
Q

Thiazolidinediones mechanism of action

A

stimulates adipogenesis

74
Q

DPP4 inhibitors (-gliptins) mechanism of action

A

Increases incretin levels which inhibit glucagon secretion

75
Q

DPP4 (-gliptins) side effects

A

Pancreatitis

76
Q

SGLT-2 inhibitors (-gliflozins) mechanism of action

A

Inhibits reabsorption of glucose in the kidney

77
Q

SGLT-2 inhibitors (-gliflozins) side effects

A 
Urinary tract infection
Weight loss
Fournier's Gangrene 
Normoglycaemic ketoacidosis 
Risk of lower limb amputation
78
Q

GLP1 agonists mechanism of action

A

Incretin mimetic which inhibits glucagon secretion

79
Q

GLP1 agonists side effects

A

Nausea and vomiting
Pancreatitis
Weight loss

80
Q

DKA presentation

A

abdominal pain
polyuria, polydipsia, dehydration
Kussmaul respiration (deep hyperventilation)
Acetone-smelling breath (‘pear drops’ smell)

81
Q

Diagnosing DKA

A

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
Q

Management of DKA

A
  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
Q

Main risk of fluid resuscitation during DKA in the young

A

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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