MedEd diabetes and pituitary Flashcards
What gene is T1DM associated with?
HLA DR3/4
What is T2DM associated with?
Obesity
HTN
Inactivity
Dyslipidaemia
What state causes polyuria in T1DM?
Osmotic diuresis
What are some signs of DKA?
Nausea and vomitting
Abdo pain
Kaussmal breathing
What are some signs of T2DM?
Acanthosis nigricans
Signs of peripheral disease/ complications
What is random glucose in diabetes?
> 11.1
What is fasting glucose in diabetes?
> 7
What is HbA1c in diabetes?
> 48
What antibodies are associated with T1DM?
Anti GAD antibodies
Islet cell antibodies
What test should you always do for T1DM in GP and what will you see?
Urine dip- positive glucose and ketones
How is insulin given in T1DM?
Basal bolus regimen
What is the first line treatment for T2DM?
Lifestyle advice= diet, exercise, education
What is the first line pharmacological treatment for glycaemic control in T2DM?
Metformin
What is the first line pharmacological treatment for blood pressure management in T2DM? What is second and third line
Ace inhibitor, if black ARB
Then add CCB or thiazide
Then ACEi/ARB with CCB and thiazide
What glucose level is classed as hypoglycaemia?
<3.6 mmol/L
What are signs of hypoglycaemia?
Palpitations, tremors, sweating, pallor, anxiety, drowsiness, confusion, coma
How is hypoglycaemia managed?
If conscious- eat sugary food
If consciousness is impaired - IM glucagon 1g
What triad signifies DKA?
Hyperglycaemia
Ketonaemia
Metabolic acidosis
Why is ketonaemia harmful?
Acidity causes enzyme dysfunction which can lead to coma and death
How is DKA managed?
Hydration with IV fluid
Insulin to reduce ketones
What is HHS? How does it present?
Hyperosmolar hyperglycaemic state- hyperglycaemia with no ketonaemia
Dehydration, kussmaul breathing, nausea and vomitting
How can you differentiate DKA and HHS based on signs and symptoms?
They are the same but no abdo pain in HHS
How are DKA and HHS managed?
Start IV saline (and potassium chloride if K+ <5.5)
IV insulin (fixed rate) after fluids (only when K+ is not <3.5)
Include dextrose in fluids if <14
Treat underlying cause eg abx
What is plasma glucose in DKA?
> 11
What is plasma glucose in HHS?
> 30
What are the 4 stages of retinopathy?
1= background retinopathy= blot and dot haemorrhage/ hard exudates 2= pre prolif= background and cotton wool spots 3= proliferative= non proliferative and new vessels on disk (neovascularisation) 4= maculopathy= hard exudates and near macular
What is neovascularisation associated with?
Retinal detachment with retinal detachment and vitreoud haemorrhage with visual loss
How is retinopathy managed?
Backgorund= improve glycaemic control
Pre proliferative and proliferative= pan retinal laser photocoagulation
Maculopathy= anti VEGF injections
How does diabetic nephropathy present?
Oedema, polyuria, lethargy, hypertension
What is the first line investigation for diabetic nephropathy? What will you see?
Urinalysis
Will show a high albumin: creatinine due to microalbuminuria
How is diabetic retinopathy managed?
ACEi/ARB
Improve glycaemic control
What causes diabetic neuropathy?
Blockage of the vasa vasorum (blood vessels that supply the vasa vasorum)
What distribution is associated with diabetic peripheral neuropathy?
Glove and stocking
What are some signs and symptoms of diabetic neuropathy?
Loss of sensation (especially feet)
Loss of ankle reflex
Injuries to foot
Fractures
What are the 3 types of diabetic neuropathy?
Peripheral
Autonomic
Mono
How will autonomic diabetic neuropathy present?
GI tract symptoms= difficulty swallowing, bladder dysfunction, delaye dgastric emptying Postural hypotension (collpase on standing) Cardiac autonomic supply
How will diabetic mononeuropathy present?
Sudden motor loss eg wrist drop, foot drop, 3rd nerve palsy
What is seen on third nerve palsy?
Eye down and out
Pupil responds to light
What is diabetes insipidus?
Inadequate secretion or sensitivity to vasopressin/ADH causing production of dilute urine
What are causes of cranial diabetes insipidus?
Pituitary tumor, infection, sarcoidosis, TB
How will someone with diabetes insipidus present?
Polyuria
Nocturia
Polydipsia
Dehydration (tachycardia, dry mucous membranes)
What are first line investigations for DI? What will you see?
UEs (ca/k for cause)
Glucose
Water deprivation test
How is the water deprivation test carried out?
Restrict them of water for 8 hours
Then give desmopressin and monitor UEs every hour
What will be the result of water deprivation test in a normal person, cranial and nephrogenic DI?
Normal- no change in urine osmolality after desmopressin is given and no more water to reabsorb
Cranial- rapid rise in urine osmolarity
Nephrogenic- urine remains unconcentrated
How is diabetes insipidus managed?
Cranial= Intranasal desmopressin and tell them not to drink lots of water Nephrogenic= thiazide diuretic, low salt and protein diet
What is SIADH?
Excess ADH secretion causing too much water absorption
What happens to serum Na, urine osmolality and urina na in SIADH?
Serum na= low
Urine osmolality= high
Urine na= high
What are causes of SIADH?
CNS= subarachnoid haemorrhage, tumor, TB Pulmonary= pneumonia, bronchiectasis Malignancy= small cell lung cancer Drugs= carbamazepine, SSRI Idiopathic
How is SIADH managed?
Treat cause eg surgery for tumor
Immediate fluid restriction for hyponatreamia
If ineffective oral demeclycycline/IV vaptans
What is normal sodium?
135-145 mEq/L
What are the 3 types of hyponatreamia?
Hypovolemic
Euvolemic
Hypervolemic
What are causes of hypovolemic hyponatreamia? How is it managed
Vomitting
Diarrhoea
Diuretics
Manage with IV fluid
What is urine sodium in hypovolemia hyponatreamia?
Low (<20)
What are causes of euovolemic hyponatreamia? How is it managed
SIADH
Hypothyroidism
Adrenal insufficiency
Manage= Fluid restrict
What are causes of hypervolemic hyponatreamia? How is it managed
Liver, kidney or heart failure
Manage by restricting fluid
How do you treat severe hyponatreamia?
Slow IV saline
What happens if IV saline is given too fast?
Central pontine myelionylysis
Why is SIADH euvolemic?
Posterior pituitary produces lots of ADH
Lots of BNP is produced
This BNP prevents ADH from making you hypovolemic
What is fluid intake restricted to when treating hyponatraemia?
1 litre/ day
What range is hypernatreamia?
> 145 mEq/L
What are causes of hypernatreamia?
Unreplaced water loss eg GI loss, sweating
Renal loss eg HHS, DI
Sodium overload eg cushings, primary aldosteronism, iatrogenic
How will hypernatreamia present?
Lethargy Irritability Thirst Signs of dehydration Confusion Coma Fits
How is hypernatreamia treated?
5% dextrose to correct water deficit
0.9% saline- correct ECF volume depletion
What sodium imbalance is more common?
Hyponatraemua
What stimulates prolactin production? What inhibits it?
Stimulates= TRH Inhibits= dopamine
What are causes of hyperprolactinaemia?
Pregnancy Breast feeding Prolactinoma Pituitary adenoma Primary hypothyrodism
How does hyperprolactinaemia present?
Men=Loss of libido, erectile dysfunction, infertility
Women=Galactorrhea, secondary amenorrhea, loss of libido, infertility
Mass effects= headache, visual field defect
What are the investigations for hyperproloactinaemia? What will you see
Pregnancy test- may be positive
TFTs- may be low if from hypothyroidism
Basal serum prolactin- if crazy high most likely tumor
MRI to image
How is prolactinoma managed? Give first and second line treatment
First line= dopamine receptor agonist eg cabergoline, bromocriptine
Second line= trans sphenoidal surgery
How is hyperglycaemia in T2DM managed?
First line lifestyle advice
Second line metformin if Hba1c is over 48
Third line add pioglitazone, SGLT2 inhibitor, DPP4 inhibitor or sulphonylurea
Fourth line add another drug or try insulin based treatment
How are lipids in T2DM managed?
Atorvastatin 20mg OD if risk of cardiovascualr event in next 10 years is above 10%
Atorvastatin 80mg OD if they have IHD/CVD/peripheral arterial disease
How is hypertension in T2DM managed?
First line ACEi, ARB if black
Second line add CCB or thiazide
Third line ACEi/ARB + CCB + thiazide
How is hyper and hypokalemia managed in T2DM?
Hyperkalemia (>4.5)= beta blocker
Hypokalemia (<4.5)= spironolactone
What antiplatelet medication and what dose is given to diabetics with IHD/CVD/PAD?
Aspirin 75 mg
What needs to be managed in a patient with diabetes?
Hyperglycaemia Hypertension Dyslipidaemia Hyper/hypokalemia Coagulopathy
What 2 molecules are in excess in DKA, what effect does each of them have and how are they reduced?
Excess glucose causes dehydration, this is treated with IV fluids
Excess ketones causes acidosis and enzyme dysfunction, this is treated with insulin
What will ketones, plasma glucose and pH be in DKA vs HHS?
DKA: pH= low/acidic, ketones=high (over 3), plasma glucose high (over 11)
HHS: pH= normal, ketones=normal, plasma glucose high (over 30)
