GP- Endocrinology Flashcards
Obesity BMI classifications
Management of obesity
Criteria of qualification for taking orlistat
- BMI of 28 kg/m^2 or more with associated risk factors (like HTN and T2D), or
- BMI of 30 kg/m^2 or more
- continued weight loss e.g. 5% at 3 months
- orlistat is normally used for < 1 year
Criteria for qualification for taking liraglutide in obesity
- person has a BMI of at least 35 kg/m²
- prediabetic hyperglycaemia (e.g. HbA1c 42 - 47 mmol/mol)
Orlistat side effects
faecal urgency/incontinence and flatulence
fatty or oily stools
Liraglutide side effects
nausea and diarrhea
When is bariatric surgery recommended by NICE?
Essentially NICE recommend that very obese patients (e.g. BMI 40-50 kg/m^2 etc) are referred early for bariatric surgery, particularly if they have other conditions that may be caused by it (e.g. type 2 diabetes mellitus, hypertension), rather than it being a ‘last resort’.
Types of bariatric surgery
medical causes of obesity
- Genetic syndromes associated with hypogonadism (for example Prader-Willi syndrome and Laurence-Moon-Biedl syndrome).
- Hypothalamic damage (for example due to a tumour, trauma, or surgery).
- Polycystic ovary syndrome.
- Growth hormone deficiency.
- Cushing’s syndrome.
- Hypothyroidism.
Medications, including : - Pizotifen.
- Beta-blockers.
- Corticosteroids.
- Lithium.
- Antipsychotics — especially atypical antipsychotics.
- Anticonvulsants — sodium valproate, gabapentin, vigabatrin.
- Antidepressants — tricyclics, mirtazapine, monoamine oxidase inhibitors (MAOIs).
- Insulin — when used in the treatment of type 2 diabetes.
- Oral hypoglycaemic drugs — sulphonylureas, thiazolidinediones (glitazones).
risk factors for obesity
- Age — in the 2015 Health Survey for England, the highest obesity levels were reported in the 55–64 age group [NHS Digital, 2017].
- Peri-and menopause.
- Prior pregnancy, although this association is confounded by contributing cultural, environmental, and socioeconomic factors.
- Sleep deprivation.
- Less formal education.
- Low socioeconomic status.
Complications of obesity
Obesity is one of the leading causes of death and disability worldwide. Overweight and obesity are associated with the following:
* An increased risk of developing (or exacerbation of) a number of chronic diseases and conditions, including:
* Type 2 diabetes.
* Coronary heart disease.
* Hypertension and stroke.
* Asthma.
* Depression.
* Metabolic syndrome.
* Dyslipidaemia.
* Cancer.
* Gastro-oesophageal reflux disease (GORD).
* Gallbladder disease.
* Reproductive problems.
* Osteoarthritis and back pain.
* Obstructive sleep apnoea.
* Breathlessness.
* Psychological distress.
* Decreased life expectancy
type 1 diabetes presentation
Features of diabetic ketoacidosis (DKA):
* abdominal pain
* polyuria, polydipsia, dehydration
* Kussmaul respiration (deep hyperventilation)
* acetone-smelling breath (‘pear drops’ smell)
* altered consciousness
* hypotension
* nausea and vomiting
Investigations in type 1 diabetes
- urine should be dipped for glucose and ketones
- fasting glucose and random glucose (see below for diagnostic thresholds)
- HbA1c is not as useful for patients with a possible or suspected diagnosis of T1DM as it may not accurately reflect a recent rapid rise in serum glucose
- C-peptide levels are typically low in patients with T1DM
- diabetes-specific autoantibodies are useful to distinguish between type 1 and type 2 diabetes (see below)
Antibodies specific to type 1 diabetes
Diagnostic criteria for type 1 diabetes
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 the patient is asymptomatic the above criteria apply but must be demonstrated on two separate occasions.
Distinguishing between type 1 and type 2 diabetes
Diagnose type 1 diabetes on clinical grounds in adults presenting with hyperglycaemia, bearing in mind that people with type 1 diabetes typically (but not always) have one or more of:
ketosis
rapid weight loss
age of onset below 50 years
BMI below 25 kg/m²
personal and/or family history of autoimmune disease
Consider further investigation in adults that involves measurement of C peptide and/or diabetes specific autoantibody titres if:
type 1 diabetes is suspected but the clinical presentation includes some atypical features (for example, age 50 years or above, BMI of 25 kg/m² or above, slow evolution of hyperglycaemia or long prodrome)
Type 1 diabetes management: monitoring and drugs
- Subcutaneous insulin
- Monitoring dietary carbohydrate intake
- Monitoring blood sugar levels upon waking, at each meal and before bed
- Monitoring for and managing complications, both short and long term
- A basal bolus regimen involves a combination of:
Blood glucose targets in type 1 diabetes
5-7 mmol/l on waking and
4-7 mmol/l before meals at other times of the day
Hba1c should be monitored how often?
every 3-6 months
adults with type 1 diabetes should have a target of HbA1c level of
48 mmol/mol (6.5%) or lower
how often should you self monitor blood glucose in type 1 diabetes and when?
- recommend testing at least 4 times a day, including before each meal and before bed
- more frequent monitoring is recommended if frequency of hypoglycaemic episodes increases; during periods of illness; before, during and after sport; when planning pregnancy, during pregnancy and while breastfeeding
Type of insulin used in type 1 diabetes
- offer multiple daily injection basal–bolus insulin regimens, rather than twice‑daily mixed insulin regimens, as the insulin injection regimen of choice for all adults
- twice‑daily insulin detemir is the regime of choice. Once-daily insulin glargine or insulin detemir is an alternative
- offer rapid‑acting insulin analogues injected before meals, rather than rapid‑acting soluble human or animal insulins, for mealtime insulin replacement for adults with type 1 diabetes
When should metformin be used in type 1 diabetes?
NICE recommend considering adding metformin if the BMI >= 25 kg/m²
Short term complications of type 1 diabetes
Long term complications of type 1 diabetes
Pathophysiology of DKA
DKA is caused by uncontrolled lipolysis (not proteolysis) which results in an excess of free fatty acids that are ultimately converted to ketone bodies
pathophysiology of ketogenesis
The most common precipitating factors of DKA are
infection, missed insulin doses and myocardial infarction
Features of DKA
The patient will present with symptoms of the underlying hyperglycaemia, dehydration and acidosis:
- Polyuria
- Polydipsia
- Nausea and vomiting
- Weight loss
- Acetone smell to their breath (“pear drop smell”)
- Dehydration and subsequent hypotension
- Altered consciousness
- Symptoms of an underlying trigger (i.e. sepsis)
- Kussmaul respiration (deep hyperventilation)
Diagnostic criteria for DKA
- Hyperglycaemia (i.e. blood glucose > 11 mmol/l)
- Ketosis (i.e. blood ketones > 3 mmol/l)
- Acidosis (i.e. pH < 7.3)
- bicarbonate < 15 mmol/l
Main principles of management DKA
slower infusion may be indicated in young adults (aged 18-25 years) as they are at greater risk of…
JBDS potassium guidelines when treating DKA
DKA resolution is defined as:
both the ketonaemia and acidosis should have been resolved within …… if this hasn’t happened the patient requires:
both the ketonaemia and acidosis should have been resolved within 24 hours. If this hasn’t happened the patient requires senior review from an endocrinologist
Complications may occur from DKA itself or the treatment:
- gastric stasis
- thromboembolism
- arrhythmias secondary to hyperkalaemia/iatrogenic hypokalaemia
- iatrogenic due to incorrect fluid therapy: cerebral oedema, hypokalaemia, hypoglycaemia
- acute respiratory distress syndrome
- acute kidney injury
- children/young adults are particularly vulnerable to cerebral oedema following fluid resuscitation in DKA and often need 1:1 nursing to monitor neuro-observations, headache, irritability, visual disturbance, focal neurology etc. It usually occurs 4-12 hours following commencement of treatment but can present at any time. If there is any suspicion a CT head and senior review should be sought
Type 2 diabetes simplified pathophysiology
T2DM RF
Non-modifiable risk factors:
Older age
Ethnicity (Black African or Caribbean and South Asian)
Family history
Modifiable risk factors:
Obesity
Sedentary lifestyle
High carbohydrate (particularly sugar) diet
T2DM presentation
Pre diabetes diagnostic criteria
Pre-diabetes is an indication that the patient is heading towards diabetes. They do not fit the full diagnostic criteria but should be educated about the risk of diabetes and lifestyle changes.
An HbA1c of 42 – 47 mmol/mol indicates pre-diabetes.
or fasting glucose of 6.1 to 6.9
Diagnostic criteria for T2DM: if symptomatic, and if asymptomatic
The HbA1C sample is typically repeated after 1 month to confirm the diagnosis (unless there are symptoms or signs of complications).
Conditions where HbA1c may not be used for diagnosis:
haemoglobinopathies
haemolytic anaemia
untreated iron deficiency anaemia
suspected gestational diabetes
children
HIV
chronic kidney disease
people taking medication that may cause hyperglycaemia (for example corticosteroids)
- A fasting glucose greater than or equal to ….but less than … mmol/l implies impaired fasting glucose (IFG)
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
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
Which dietary advice is given to patients with type 2 diabetes
- encourage high fibre, low glycaemic index sources of carbohydrates
- include low-fat dairy products and oily fish
- control the intake of foods containing saturated fats and trans fatty acids
- limited substitution of sucrose-containing foods for other carbohydrates is allowable, but care should be taken to avoid excess energy intake
- discourage the use of foods marketed specifically at people with diabetes
- initial target weight loss in an overweight person is 5-10%
How often to check hba1c
every 3-6 months until stable, then 6 monthly
HBAI1c target if:
just lifestyle management,
lifestyle plus metformin, includes any drug which may cause hypoglycaemia (e.g. lifestyle + sulfonylurea),
Already on one drug, but HbA1c has risen to 58 mmol/mol (7.5%)
Initial drug therapy for type 2 diabetes: first line management
Table summary of first line drug management of diabetes
SGLT-2 inhibitors should also be given in addition to metformin in type 2 diabetes if any of the following apply:
- the patient has a high risk of developing cardiovascular disease (CVD, e.g. QRISK ≥ 10%)
- the patient has established CVD
- the patient has chronic heart failure
- metformin should be established and titrated up before introducing the SGLT-2 inhibitor
- SGLT-2 inhibitors should also be started at any point if a patient develops CVD (e.g. is diagnosed with ischaemic heart disease), a QRISK ≥ 10% or chronic heart failure
T2DM first line manageemnt if metformin is contraindicated:
If the HbA1c has risen to… mmol/mol (7.5%) then further treatment is indicated.
58
Further drug therapy if HbA1c targets are not met table summary
Further therapy in T2DM if third line therapy didn’t work
Type 2 diabetes risk factor modification: blood pressure targets if age less than 80 and if age more thsan 80
same as non-diabetic
ACE inhibitors first line
Antiplatelet and lipids risk medication advice in type 2 diabetes
Antiplatelets
should not be offered unless a patient has existing cardiovascular disease
Lipids
following the 2014 NICE lipid modification guidelines only patients with a 10-year cardiovascular risk > 10% (using QRISK2) should be offered a statin. The first-line statin of choice is atorvastatin 20mg on
NICE criteria for adding a GLP1 drug
Diabetic nephropathy symptoms
Diabetic nephropathy brief pathophysiology
Causes of hypothyroidism and thyrotoxicosis summarised in a table
Hypothyroidism vs thyrotoxicosis summary table of features
summary table of investigation and results for the different thyroid disorders
The principle investigation is ‘thyroid function tests’, or TFTs for short:
* these primarily look at serum TSH and T4 levels
* T3 can be measured but is only useful clinically in a small number of cases
* TSH levels are more sensitive than T4 levels for monitoring patients with existing thyroid problems and are often used to guide treatment
causes of primary hypothryroidism
levothyroxine drug class, MOA, how it is titrated and monitored
Presentation of hyperthyroidism
Solitary toxic nodule definition and treatment
De Quervain’s thyroiditis definition, its 3 phases and treatment
Thyroid storm definition, presentation and treatment
First line drug for hyperthyroidism, how it is taken and the one important rare side effect
TOM TIP: Both carbimazole and propylthiouracil can cause agranulocytosis, with a dangerously low white blood cell counts. Agranulocytosis makes patients vulnerable to severe infections. A sore throat is a key presenting feature of agranulocytosis. In your exams, if you see a patient with a sore throat on carbimazole or propylthiouracil, the cause is likely agranulocytosis. They need an urgent full blood count and aggressive treatment of any infections.
third line treatment for hyperthyroidism and rules for taking it
Pretibial myxoedema is
basic physiology of parathyroid hormone
Primary vs secondary vs tertiary hyperparathyroidism PTH and calcium results
