Metabolic and Endocrine Flashcards
HbA1c target for T2DM managed by lifestyle and diet?
48 mmol/mol
HbA1c target for T2DM managed by combination of diet/lifestyle and single drug not associated with hypoglycaemia?
48 mmol/mol
HbA1c target for T2DM managed by a drug associated with hypoglycaemia or 2 or more antidiabetic drugs in combination?
53 mmol/mol
How often should HbA1c be monitored in people with T2DM?
3-6 monthly until stable HbA1c on unchanging treatment, then 6 monthly.
In those with T2DM managed with 1 drug at what HbA1c should diabetes management be intensified?
58 mmol/mol
When should a person with T2DM be offered self monitoring of glucose?
- on insulin therapy
- e/o hypoglycaemic episodes
- on drug which increases patients’ risk of hypoglycaemia whilst driving or operating machinery
- person pregnant or planning to become pregnant
Most common features of Klinefelters syndrome (47, XXY)?
infertility and small firm testes
Most common cause of end stage renal failure in the UK?
diabetes
Recommended monitoring for development or progression of CKD in patients after AKI even if serum creatinine returned to baseline?
for at least 2-3 years
What duration must abnormalities of kidney function and/or structure be present for to have diagnosis of CKD?
more than 3 months
e.g. if pt not previously tested has eGFR of <60, confirm that with rpt test in 2 weeks-if still at this level will need rpt in 3 months to make CKD diagnosis
Advice on initial detection of proteinuria in patients with suspected CKD?
early morning urine for ACR-if between 3 and 70 mg/mmol, confirm by subsequent morning sample (rpt within 3 months), if >70 no need to repeat
ACR of 3mg/mmol or more is clinically significant proteinuria
as part of initial investigations urine should be dipped for haeamaturia-if 1+ or more then arrange MSU to exclude UTI
Which patients with CKD should be offered a renal ultrasound?
- accelerated progression of CKD-sustained decrease in GFR of 25% or more and change in GFR category in 1 year OR sustained decreased in GFR of 15ml/min/year.
- visible or persistent invisible haematuria
- sx of urinary tract obstruction
- eGFR<30
- FH of PKD and age>20
- considered by nephrologist to need a renal biopsy
NICE guidance on statins in CKD?
offer atorvastatin 20mg OD as primary prevention for all patients with CKD
Why does chronically raised prolactin lead to the development of osteoporosis?
high prolactin inhibits the release of GnRH through negative feedback, suppressing oestrogen production that normally maintains bone health
1st line drug for treatment of prolactinoma?
cabergoline (dopamine agonist)
if resistant to rx, surgery and radiotherapy are the 2nd and 3rd line tx options
Most common cause of hyperprolactinaemia?
prolactinomas
Which drugs can reduce the absorption of levothyroxine?
iron tablets
calcium carbonate tablets
should be given at least 4 hours apart
Defining features of metabolic syndrome (syndrome X)?
HTN disturbance of blood lipid levels central/abdominal adiposity fatty liver insulin resistance and a tendency to develop thrombosis
How is T2DM diagnosed in an asymptomatic person?
Requires 2 abnormal HbA1c or fasting plasma glucose results-HbA1c 48 or higher, or fasting plasma glucose 7 or higher.
In which patients should HbA1c NOT be used to diagnose T2DM?
- children and young people aged under 18
- end stage renal disease
- HIV
- patients with high diabetes risk who are acutely unwell
- pregnant women or 2 months post partum
- sx of diabetes for <2 months
- on drugs that may cause hyperglycaemia e.g. steroids
- acute pancreatic damage e.g. surgery
interpret with caution if anemia, recent blood transfusion, altered red cell lifespan or abnormal Hb.
Definition of impaired glucose tolerance?
blood glucose of 7.8 or more but less than 11.1 after a 2hr OGTT
Management of a child suspected of having T2DM in primary care?
r/f immediately (same day) to multi-disciplinary paediatric diabetes care team who can confirm the diagnosis and provide immediate care
With which 2 other medications can dapagliflozin be combined with for triple therapy in managing T2DM?
metformin and a sulfonylurea
If 1st line tx ineffective, what are the options for 2nd line pharmacological tx of T2DM if metformin is CI or not tolerated?
gliptin plus pioglitazone OR
gliptin plus sulfonylurea OR
pioglitazone plus sulfonylurea
SGLT-2i instead of a gliptin if pioglitazone or sulfonylurea not appropriate
3rd line tx of T2DM in those where metformin CI or not tolerated?
consider starting insulin-based treatment
When to consider tx in T2DM with a GLP-1 agonist e.g. exenatide?
if triple therapy with metformin and 2 other anti-diabetic drugs has failed, consider combination tx with metformin, a sulfonylurea and GLP-1 mimetic if:
- BMI 35 or over and specific psychological/medical problems associated with obesity
- BMI <35 and insulin therapy would have significant occupational implications, or weight loss would benefit other significant obesity-related comorbidities.
Requirements for continuing therapy with GLP-1 mimetic?
HbA1c reduction of at least 11mmol/mol (1%) and weight loss of at least 3% of initial body weight in 6 months
Important foods to include in diet for people with T2DM?
high fibre
low glycaemic index e.g. fruit, vegetables, wholegrain and pulses
low fat dairy products
oily fish (salmon, sardines, mackerel, trout, pilchards, sprats, herring)
Initial body weight loss target in people with T2DM who are overweight (BMI 25 or greater)
5-10%
Recommended weekly exercise for adults in the UK?
moderate intensity exercise e.g. brisk walking/cycling over a week should be at least 150 mins (2.5hrs) in bouts of 10min or more
muscle strengthening exercise should also take place on at least 2 days a week
Clinic BP target for patients with T2DM under age of 80?
<140/90
aim <130/80 if also have CKD
If 1 parent is affected by familial hypercholesterolaemia, by what age should their child be referred to a specialist?
By the age of 10
by the age of 5 if both parents are affected
Definition of impaired fasting glucose?
fasting serum glucose 6.1-6.9
These patients should then be offered an OGTT to r/o a diagnosis of diabetes
1st line recommended insulin regime for patients with T1DM?
multiple daily basal-bolus regimen
1st line screening test for primary hyperaldosteronism (most common secondary cause of HTN)?
plasma aldosterone/renin ratio
Indication for pneumococcal vaccination for children with diabetes?
if they need insulin or oral hypoglycaemic drugs
Minimal paediatric diabetes clinic attendance recommended per year for children with T2DM?
4 times a year
When does annual retinopathy screening start for children with T2DM?
age 12
Initial tx of MODY?
if symptoms then start with tx to stimulate the pancreas, usually sulfonylureas e.g. gliclazide, first line.
When should drugs be considered in the management of obesity?
if overweight (BMI25-29.9) and comorbidities present obesity I and comorbidities present obesity II (BMI 35-39.9) and III irrespective of waist circumference or comorbidities
orlistat can be considered if BMI 30 or more (or 28 or more with RFs)
When should surgery be considered in the management of obesity?
if obesity II (BMI 35 or greater) and comorbidities or if obesity III (BMI 40 or greater)
(if other measures failed)
(BMI of 50 may warrant immediate bariatric referral)
When should patients who are obese be referred to tier 3 services?
if underlying causes need to be assessed
conventional tx unsuccessful
considering surgery
drug tx being considered when BMI over 50
complex disease states or needs unable to be managed in tier 2 e.g. learning disability
specialist interventions e.g. very low calorie diet, may be needed
When is drug treatment of obesity recommended in children?
Orlistat is recommended for children aged 12 and over if physical comorbidities or severe psychological comorbidities are present. Start in specialist paediatric setting. May be used in exceptional circumstances in children under 12.
Criteria for use of orlistat to manage obesity in adults?
BMI 28 or more with associated risk factors OR
BMI 30 or more
Continue orlistat beyond 3 months only if pt has lost at least 5% of their initial body weight since starting drug tx
When should an expedited assessment for bariatric surgery be offered to overweight adults with T2DM?
if BMI 35 or more with recent onset (in last 10yrs) of T2DM as long as they are/will receive assessment in a tier 3 service
Diagnostic criteria for gestational diabetes?
Fasting plasma glucose of 5.6 or more
2hr plasma glucose level post OGTT of 7.8 or more
NICE recommended investigation if incidental finding of NAFLD e.g. fatty changes on US?
enhanced liver fibrosis (ELF) blood test
Diagnosis of subclinical hypothyroidism?
TSH above normal reference range with normal free T4 levels. In non-pregnant people, TFTs should be repeated after 3-6 months to exclude other causes of a transiently raised TSH and confirm the diagnosis.
*hypothyroidism should be suspected in pregnancy with raised TSH above trimester specific level alone
When should serum thyroid peroxidase antibodies be checked?
suspicion of AI hypothyroid disease
subclinical hypothyroidism suspected-as predicts risk of development to overt hypothyroidism-risk also increased by female sex and higher TSH levels
if suspect hypothyroidism in pregnancy
Management of subclinical hypothyroidism in non pregnant people if TSH>10 and free T4 within normal reference range on 2 separate occasions 3 months apart?
consider offering levothyroxine (LT4) monotherapy
should recheck TSH levels every 3 months, then annually once stable
consider checking FT4 if person has ongoing sx on treatment
In which patients should a 6 month trial of levothyroxine be considered in subclinical hypothyroidism with TSH<10?
in adults under 65 years of age with TSH above reference range but <10 and FT4 within reference range in 2 tests 3 months apart and pt has symptoms of hypothyroidism
What structured education should be offered to all adults with T1DM?
DAFNE-dose adjustment for normal eating, 6-12 months after diagnosis
Insulin regime of choice for patients with T1DM?
multiple daily injection basal-bolus regimen
Which patients with T1DM should be considered for real time continuous glucose monitoring?
must commit to using it at least 70% of the time, calibrate as needed and any 1 of the below despite optimised insulin therapy and conventional BG monitoring:
- > 1 severe hypo in last 1 year with no obvious precipitating cause
- complete loss of awareness of hypos
- > 2 episodes a week of asymptomatic hypos causing problems with daily activities
- extreme fear of hypos
- hyperglycaemia-HbA1c 75 or higher that persists despite testing 10 times a day. Continuous monitoring only to be continued if HbA1c can be sustained at or below 53mmol/mol and/or there has been a fall in HbA1c of 27mmol/mol or more.
1st line basal insulin therapy for patients with T1DM?
insulin detemir (levemir) BD (insulin analgoue)
When might metformin therapy be considered in addition to insulin therapy in pt with T1DM?
if BMI 25 or above (23 or above if SA and minority ethnic groups) and pt wants to improve their blood glucose control while minimising their effective insulin dose
Which anti-emetic has most evidence behind it for management of vomiting due to gastroparesis in T1DM?
domperidone
however, must consider safey profile-cardiac risk
therefore consider alternating use of erythromycin and metoclopramide rather than domperidone
When does post partum thyroiditis develop?
- this is a PAINLESS autoimmune inflammatory condition, typically occurs 2-6 months following delivery or miscarriage, and most women affected will become euthyroid by 1 year
- May have thyrotoxicosis, hypothyroidism or thyrotoxicosis followed by hypothyroidism
- if thyrotoxic pattern r/f to endocrine, if hypothyroid pattern to TFTs discuss with endocrine about starting LT4 in primary care
- untreated asymptomatic women should have TFTs checked every 4-8 weeks until normalise
- annual TFT monitoring once PPT resolved
How should subclinical hyperthyroidism in non pregnant person be managed?
refer to endocrinology if 2 successive TSH levels <0.1, 3 months apart, and sx of thyrotoxicosis or +ve TSH receptor antibodies or goitre
refer 2ww H+N if suspect thyroid cancer
Target BP in T1DM?
below 135/85
if also diabetic nephropathy or 2 or more features of metabolic syndrome then aim below 130/80 (same target as T2DM with CKD)
When should an SGLT-2 inhibitor be considered for first intensification of treatment for patient with T2DM not controlled with metformin and diet?
if a sulfonylurea is contraindicated or not tolerated, or pt is at significant risk of hypoglycaemia or its consequences
1st line Ix to confirm dx of NAFLD?
US liver
How often should TSH be measured in patients on levothyroxine?
at least annually (initially 3 monthly)
Guidelines for extra steroid cover in patient with Addisons disease who is acutely unwell?
- if fever more than 37.5 or infection/sepsis requiring Abx then double hydrocortisone dose.
- if vomiting, give IM 100mg hydrocortisone immediately and call a doctor
- if severe nausea, take 20mg of hydrocortisone and sip rehydration/electrolyte fluids
- take 20mg PO hydrocortisone immediately for serious trauma/injury to avoid shock.
Usual steroid tx for patients with addisons disease?
PO hydrocortisone 15-30mg daily in 2-3 divided doses, with highest dose given in the morning
fludrocortisone 5-300mcg per day
Which patients should have targeted screening for CKD?
If they have: diabetes HTN established CVD obesity with metabolic syndrome FH of end stage CKD or hereditary disease AKI renal calculi, BPH, renal tract disease multi system disease with systemic involvement nephrotoxic drugs proteinuria or persistent haematuria eGFR<60
If a patient is diagnosed with hypothyroidism, when should they be discussed or referred to endocrine?
- suspected subacute thyroiditis
- goitre, nodule or structural change in thyroid
- suspected associated endocrine disease e.g. addisons
- female and planning a pregnancy-note if hypothyroid/SC hypothyroid and planning a pregnancy should r/f to endocrine and TFTs should be checked before conception
- atypical or difficult to interpret TFTs
- suspected underlying cause e.g. drug tx with lithium or amiodarone-note monitoring of TFTs should continue for 1 year after stopping amiodarone
urgent referral if secondary hypothyroidism suspected
Haemochromatosis screening blood test?
ferritin and transferrin saturation-transferring saturation considered most useful marker
(prior to HFE mutation analysis)
Tx of adrenal crisis in community?
-emergency hosp admission, stabilise with IV saline infusion if able before transfer
-IM or IV hydrocortisone-sodium phosphate-not recommended for use in children or sodium succinate.
For adults-100mg
Children: >6=100mg
1-5 =50mg
up to 1 year =25mg
Starting dose of carbimazole?
40mg
reduced gradually to maintain euthyroidism, typically continued for 12-18months
patients with suspected graves disease should be r/f to secondary care for ongoing management
consider seeking specialist advice if thinking of starting carbimazole in primary care e.g. as beta blocker not tolerated
How long should pregnancy be avoided after radioiodine treatment?
4-6 months
patient must avoid prolonged contact with pregnant women/children for 3 weeks after treatment
Primary care screening test options if suspect endogenous cushings syndrome?
- overnight low dose dexamethasone suppression test (1mg)-given at 11pm, if 9am cortisol <50 then excludes.
- 24hr urinary cortisol (if normal eGFR)
- late night salivary cortisol (if available)
Malignancy associated with cushings syndrome?
small cell lung cancer-due to ACTH secretion
When to consider referral/discussion of new onset hyperthyroidism with endocrinology?
ALWAYS
urgent referral if pituitary or hypothalamic cause suspected
consider prescribing a beta blocker whilst awaiting secondary care assessment
Why is propylthiouracil not used 1st line in management of hyperthyroidism?
small risk of severe liver injury
may be used pre pregnancy or in 1st trimester of pregnancy
Blood test monitoring for patients on carbimazole or proylthiouracil?
Baseline FBC and LFTs
6 weekly TSH, freeT4 and freeT3 until TSH in reference range then TSH every 3 months.
after stopping drugs TSH within 8 weeks then 3 monthly for 1 year then annually
