1
Q
What is adrenal insufficiency?
A
When adrenal glands do not make sufficient steroid hormones
2
Q
What hormones are made in the adrenal cortex?
A
Cortisol and aldosterone
3
Q
Are cortisol and aldosterone gluco- or mineralo- corticoids?
A
Cortisol = glucocorticoid
Aldosterone = mineralocorticoid
4
Q
Roles of glucocorticoids?
A
↑ Alterness
↑ Blood glucose
↑ Metabolism
↑ CVD function
↓ Immunity/inflammation
5
Q
Roles of mineralocorticoids?
A
BP control
↑ Na+
↓ K+ and H+
6
Q
What is the hypothalamic-pituitary-adrenal (HPA) axis?
A
-ve feedback loop
Corticotropin-releasing hormone > adrenocorticotropic hormone > cortisol
7
Q
What is Addison’s disease?
A
Primary adrenal insufficiency
Damage to adrenal glands = reduced cortisol and aldosterone secretion
8
Q
Most common cause of primary adrenal insufficiency?
A
Autoimmune disease
9
Q
What happens to CRH and ACTH in primary adrenal insufficiency?
A
They increase (-ve feedback)
10
Q
What is secondary adrenal insufficiency?
A
Inadequate ACTH due to damaged pituitary gland - no stimulation of adrenal gland
11
Q
What are some causes of secondary adrenal insufficiency (4)?
A
Tumours (adenoma)
Surgery/trauma
Radiotherapy
Sheehans - PPH > avascular necrosis
12
Q
What is tertiary adrenal insufficiency
A
Inadequate CRH release from hypothalamus (less ACTH > less cortisol)
13
Q
What is the most common cause of tertiary adrenal insufficiency?
A
Sudden withdrawal of long term exogenous steroids (>3w)
14
Q
Why do long term steroids cause adrenal insufficiency?
A
Suppress the hypothalamus > sudden withdrawal = slow response of hypothalamus to ‘wake up’ > no steroids produced
15
Q
How must long-term steroids be stopped?
A
They must be tapered
16
Q
Presentation of adrenal insufficiency?
A
Fatigue
Muscle weakness/cramps
Dizziness/fainting
Thirsty + craving salt
Weight loss
Abdominal pain
Depression/low libido
Bronze hyperpigmentation
Hypotension
17
Q
What causes bronze hyperpigmentation in adrenal insufficiency?
A
Excess ACTH
ACTH stimulates melanocytes
18
Q
What will be found on bloods in adrenal insufficiency?
A
↓ Na+, glucose
↑ K+, Ca+, creatinine
Early morning cortisol may be falsely positive
Autoantibodies if autoimmune
19
Q
Which investigation should be done for suspected adrenal insufficiency?
A
Short synacthen test
20
Q
What is a short synacthen test?
A
Completed in morning
- Give synthetic ACTH
- Check blood cortisol 30m before and 60m after
- Should at least double
21
Q
If checking ACTH levels directly, when will these go up/down? (Primary and secondary adrenal insufficiency)
A
Primary ↑
Secondary ↓
22
Q
What is the management of adrenal insufficiency?
A
Steroids:
Hydrocortisone (cortisol)
Fludrocortisone (Aldosterone)
23
Q
What should be given to those with adrenal insufficiency (non drug extras)?
A
Steroid card, ID tag, emergency letter, emergency IM hydrocortisone injection
24
Q
What are sick day rules for steroids?
A
Double dose of steroids
If can’t take PO = IM hydrocortisone
25
What is adrenal crisis?
Acute presentation of severe adernal insufficiency
26
Adrenal crisis presentation (5)?
Reduced consciousness
Hypotension
Hypoglycaemia
Hyponatraemia, hyperkalaemia
27
Management of adrenal crisis?
ABCDE
IM/IV hydrocortisone
IV fluids
Correct glucose
Close monitoring
28
Which hormones are released from the posterior pituitary?
ADH (vasopressin)
Oxytocin
29
Which hormones are released from the anterior pituitary (6)?
LH/FSH
TSH
Prolactin
GH
ACTH
30
Which hormones are released from the hypothalamus?
GnRH
TRH
PRH
GHRH
CRH
31
What is Cushing's syndrome?
Prolonged high levels of glucocorticoids (cortisol)
32
What is Cushing's **disease**?
Cushing's syndrome caused by pituitary adenoma
33
Presenting features of Cushing's?
Moon face
Central obesity
Proximal limb muscle wasting
Abdominal striae
Fat pad on upper back
Hirsutism
Easy bruising/poor skin healing
Hyperpigmentation (only in disease)
34
Additional effects of Cushing's (conditions) (6)?
Hypertension
Cardiac hypertrophy
T2DM
Dyslipidaemia
Osteoporosis
Adverse mental health
35
Causes of Cushing's syndrome?
CAPE
Cushing's disease (pituitary adenoma)
Adrenal adenoma
Paraneoplastic syndrome (e.g. SSC)
Exongenous steroids
36
What is paraneoplastic syndrome in relation to Cushing's?
ACTH is released from a tumour elsewhere in the body
Most common = small cell lung cancer
37
How is Cushing's diagnosed?
Dexamethasone suppression test
Normal response = suppressed cortisol
38
What are the 3 dexamethasone suppression tests and what are they used for?
Low-dose overnight - screening to exclude Cushing's
Low-dose 48 hour - in suspected Cushing's
High-dose 48 hour - determines cause
39
Summarise the low-dose overnight dexamethasone suppression test
1mg at night (10/11pm)
Cortisol checked at 9am next day
Abnormal result = further assessment
40
Summarise the low-dose 48 hour dexamethasone suppression test
0.5mg every 6 hours for 8 doses
Starting at 9am
Cortisol checked 9am day 1 and day 3
Normal = 3 day cortisol suppressed
41
Summarise the high-dose 48 hour dexamethasone suppression test
2mg every 6 hours for 8 doses
Cortisol checked 9am day 1 and day 3
42
What are the results for the high-dose 48 hour dexamethasone suppression test in different conditions?
Pituitary adenoma = high dose is enough to suppress cortisol
Adrenal adenoma = no suppression
Ectopic ACTH = no suppression
43
Bloods findings in Cushing's syndrome?
FBC - High WCC
U&E's - low K+ (if adrenal adenoma is also secreting aldosterone)
44
Which imaging may be used in Cushing's syndrome?
MRI brain - pituitary adenoma
CT chest - small cell lung ca
CT abdomen - adrenal tumours
45
What is Nelson's syndrome?
ACTH producing tumour due to removal of the adrenal glands.
- Skin pigmentation
- Bitemporal hemianopia
46
What is metyrapone used for?
Reduces production of cortisol in adrenals
47
What is the thyroid axis?
Hypothalamus release TRH > Ant. pituitary release TSH > thyroid gland release T3/T4
48
What is the growth hormone axis?
Hypothalamus releases GHRH > Ant. pituitary releases GH > liver produces IGF-1
49
What are the actions of growth hormone?
Stimulates muscle growth
Increases bone density and strength
Stimulate cell regeneration and reproduction
Stimulates growth of internal organs
50
What is the parathyroid axis?
Parathyroid glands release PTH in response to low serum calcium levels
51
What is the RAAS system?
Low blood pressure stimulates renin release > renin converts angiotensin to angiotensin I > ACE converts ANGI to ANGII > ANGII stimulates aldosterone release from adrenals > BP increases
52
Blood findings in hypothyroidism?
↑ TSH
↓ T3/T4
53
Blood findings in hyperthyroidism?
↓ TSH
↑ T3/T4
54
Which antibodies are found in Graves' disease?
TSH receptor antibodies (TRAb)
55
Which antibodies are found in Hashimoto's disease?
Anti-thyroid peroxidase (TPO) antibodies
Anti-thyroglobulin antibodies (Tg)
56
What the cause**s** of primary hyperthyroidism (4)?
**GIST**
Grave's disease
Inflammation (thyroiditis)
Solitary toxic nodule
Toxic multinodular goitre
57
What is Grave's disease?
Autoimmune hyperthyroidism
58
What is thyroiditis?
Thyroid gland inflammation
Initial hyperthyroidism followed by hypothyroidism
59
What are causes of thyroiditis?
De Quervain's
Postpartum
Hashimoto's
Drug-induced
60
What is De Quarvain's thyroiditis?
Subacute thyroiditis causing temporary inflammation of throid gland
Thyrotoxicosis > Hypothyroidism > Return to normal
61
How is De Quarvain's treated?
Self-limiting
NSAIDs, B-blockers, levothyroxine
62
What are the symptoms of thyrotoxicosis?
Excess T3/T4, swelling/tenderness, flu-like illness, ↑ESR/CRP
63
What is a solitary toxic nodule (thyroid)?
Single nodule releasing excessive T3/T4
Usually benign adenoma
64
What is a toxic multinodular goitre?
Multiple nodules on the thyroid continuously producing thyroid hormone
65
What is a thyroid storm?
Thyrotoxic crisis
Rare, severe presentation of hyperthyroidism needing additional supportive care
66
Symptoms of thyrotoxic crisis?
Tachycardia, fever, delirium
67
Drug management of hyperthyroidism?
1st line - Carbimazole 12-18 months titrated to levels
OR complete block and replace with levothyroxine
2nd line - Propylthiouracil
68
What are the risks with carbimazole/PTU?
**Agranulocytosis**
Sore throat
Mouth ulcers
Rash
Easy bruising
69
What are the management options for hyperthyroidism?
Drugs - carbimazole/PTU
Radioactive iodine - single dose
Beta blockers - for symptom control
Surgery - definitive treatment
70
What is thyroid eye disease (TED)?
Inflammation + swelling muscles/tissue in orbit due to ↑TSH receptors in orbital tissue
71
What are the risk factors for TED?
Smoking
Previous radioiodine
Men with more severe disease
72
Symptoms of thyroid eye disease (6)?
Excesive watering
Gritty sensation
Red eye
Photophobia
Eye pain
Blurred vision
73
Findings of examination for TED?
Eyelid retraction
Proptosis
Lid lag
Lid oedema
Incomplete lid closure
74
Findings on MRI/CT/USS for TED?
Extraocular muscle enlargement
75
Findings in primary hyperthyroidism?
Due to thyroid pathology
↓ TSH
↑ T3/T4
76
Findings in secondary hyp**er**thyroidism?
Due to hypothalamus/pituitary
↑ TSH
↑ T3/T4
77
Findings in subclinical hyp**er**thyroidism?
↓ TSH
Normal T3/T4
78
Bloods findings in primary hyp**o**thyroidism?
Thyroid pathology
↑TSH
↓T3/T4
79
Findings in secondary hyp**o**thyroidism?
↓TSH
↓T3/T4
80
Causes of primary hyp**o**thyroidism (4)?
Hashimoto's
Iodine deficiency
Treatments for hyperthyroidism (meds, radioiodine, surgery)
Drugs - lithium, amiodarone
81
What is Hashimotos?
Autoimmune thyroiditis
Inflammation of the thyroid gland
82
Which antibodies found in Hashimoto's?
Anti-thyroid peroxidase (anti-TPO)
Anti-thyroglobulin (anti-Tg)
83
Which drugs can cause hyp**o**thyroidism and how?
Lithium - inhibits production of T3/T4
Amiodarone - causes both hypothyroid and thyrotoxicosis
84
Causes of secondary hyp**o**thyroidism?
Damage to pituitary gland
Tumours
Surgery
Radiotherapy
Trauma
Sheehan's syndrome
85
What is Sheehan's syndrome?
Avascular necrosis of the pituitary gland following postpartum haemorrhage
86
Presentation of hyp**o**thyroidism?
Weight gain
Dry skin
Fatigue
Coarse hair/hair loss
Constipation
Cold intolerance
Heavy/irregular periods
Fluid retention
87
What are the two types of amiodarone induced thyrotoxicosis?
Type 1 = exacerbation of current thyroiditis
Type 2 = destructive thyroiditis
88
Management of hyp**o**thyroidism?
Levothyroxine = synthetic T4
- Metabolised to T3 in the body
- Titrated to TSH level
Alternative = liothyronine if levo not tolerated
89
Where is parathyroid hormone made?
Chief cells of the parathyroid
90
How does PTH act to increase Ca2+ (3)?
Bone - increases osteoclast activity (break down bone)
Kidneys - calcium reabsorption and phosphate excretion in distal tubule
Kidneys - convert vitamin D to calcitriol
91
Normal serum calcium level?
2.2-2.6 mmol/L
92
What is the role of parathyroid hormone?
To increase calcium levels
93
Role of phosphate in calcium levels?
Binds to free calcium = reducing serum levels
Stimulates PTH due to these lower levels
94
What is the role of calcitonin and where is it secreted from?
Secreted by thyroid
Role = lower calcium levels
95
How does calcitonin act?
Inhibits osteoclast activity
Inhibits calcium reabsorption from urine
96
What are the main causes of hypercalcaemia (4)?
Calcium/vitamin D supplements
Hyperparathyroidism
Cancers
Renal failure (reduced excretion)
97
Roles of calcitriol in calcium regulation?
Increase calcium and phosphate absorption in small intestine and in urine
Inhibit PTH release (-ve feedback)
98
What is hyperparathyroidism?
In appropriately high levels of PTH resulting in raised calcium levels
99
Symptoms of hypercalcaemia?
**Stones, bones, groans, moans**
Stones - kidney stones
Bones - bone pain/osteoporosis
Groans - constipation, N+V
Moans - depression, psychosis, fatigue
Also:
Polydipsia
Polyuria
Anorexia
100
What is primary hyperparathyroidism and how is it treated?
Tumour of the parathyroid
Tx = sugery
101
What is secondary hyperparathyroidism and how is it treated?
Low vitamin D or CKD = ↓calcium absorption = ↑PTH
Tx = correct vitamin D/CKD
102
What is tertiary hyperparathyroidism and how is it treated?
When secondary hyperparathyroid results in hyperplasia of parathyroid gland - it continues to secrete high levels PTH
Tx = surgery
103
What is cinacalcet?
Calcimimetic used to treat hyperparathyroidism (reduces PTH production)
104
When is calcitonin given?
To treat hypercalcaemia caused by malignancy IM/SC
105
Differential diagnosis for primary hyperparathyroidism?
FHH - familial hypocalciuric hypercalcaemia
106
What is FHH (endocrine) and how is it treated?
Familial hypocalciuric hypercalcemia
Genetic disorder mimics primary hyperparathyroidism
Tx = no surgery, cinacalcet if symptomatic
107
Bloods in hypoparathyroidism?
Low PTH
Low calcium
High phosphate
108
Causes of hypoparathyroidism?
Acquired - surgery, radiation, iron/copper deposition
Transient - alcohol xs, burns, severe acute illness
Genetic - DiGeorge syndrome, autoimmune
109
Symptoms of hypocalcaemia?
Paraesthesia
Muscle pain/cramps
Tetany
Seizures
Laryngospasm - stridor
110
Signs in hypocalcaemia?
Chvostek's sign - tap facial nerve = corner mouth twitches
111
Acute management of hypocalcaemia (2)?
Calcium gluconate bolus followed by infusion (PO replacement if mild)
112
Chronic management of hypocalaemia?
Active vitamin D analogue
Calcium rich diet
113
Signs of hypercalcaemia (6)?
Bones, stones, moans, groans
Dehydration
Hyporeflexia
114
What is diabetes insipidus?
Passing of large volumes of dilute urine (>3L/24 hours)
115
What are the two types of diabetes insipidus?
Cranial = lack of ADH produced
Nephrogenic = Lack of response to ADH
116
What is ADH and where is it secreted?
Anti-diuretic hormone - stimulates water reabsorption from collecting ducts
Posterior pituitary
117
Symptoms of diabetes insipidus?
Polydipsia
Polyuria
Dehydration
Postural hypotension
118
Causes of nephrogenic diabetes insipidus?
Medications e.g. lithium
Genetic mutations
Hypercalcaemia
Hypokalaemia
Kidney disease e.g. polycystic kidneys
119
Causes of cranial diabetes insipidus?
Brain tumour
Brain injury
Brain surgery
Brain infections
Genetic mutations in ADH gene
120
Investigation findings in suspected diabetes insipidus?
Low urine osmolality (diluted with water)
High/normal serum osmolality
>3L on 24 urine collection
121
How is diabetes insipidus diagnosed?
Water deprivation test
122
What is primary polydipsia?
Excessive fluid intake due to behavioural disorder
123
What is water deprivation test?
No fluids for 8 hrs = measure urine
If osmolality still low = given desmopressin
124
What is result of water deprivation test in primary polydipsia?
Urine osmolality will become high after fluid deprivation
125
Water deprivation results in diabetes insipidus?
Cranial = responds to desmopression (urine osmolality becomes high)
Nephrogenic = no response, urine remains low osmolality
126
Management of cranial diabetes insipidus?
Given desmopressin
127
Risks of desmopressin?
Can cause hyponatraemia - monitor and patient education
128
Management of nephrogenic diabetes insipidus?
Ensure access to plenty water
High-dose desmopressin
Thiazide diuretics
NSAIDs
129
What are the layers of the adrenal gland?
Medulla
Cortex (Glomerulosa, fasciculata, reticularis)
130
What do the different layers of the adrenal cortex produce?
GFR = ACS
Glomerulosa = mineralocorticoids (aldosterone)
Fasciculata = glucocorticoids (cortisol)
Reticularis = gonadocorticoids (sex hormones)
131
What is a phaeochromocytoma?
Tumour of the adrenal glands secreing excessive amounts of catecholamines (adrenaline)
132
Where is adrenaline produced?
Chromaffin cells of the **medulla** of adrenal gland
133
What type of cells is phaeochromocytoma a tumour of?
Chromaffin cells
134
Which genetic disorders are associated with phaeochromocytoma?
MEN1
MEN2
VHL
Neurofibromatosis 1
30-40% have genetic cause
135
What is the 10% rule in phaeochromocytomas?
10% bilateral
10% cancerous
10% outside the adrenal gland
136
Presentation of phaeochromocytoma (symptoms) (7)?
Symptoms fluctuate relation to periods when tumour is secreting:
Anxiety
Sweating
Headache
Tremor
Palpitations
HTN
Tachycrdia
137
How is phaeochromocytoma diagnosed (4)?
Plasma free metanephrines
24-hour urine catecholamines
CT/MRI for tumour
Genetic testing for cause
138
What are metanephrines?
The breakdown product of catecholamines (adrenaline)
- Longer half-life and more stable
139
How is phaeochromocytoma managed (3)?
Alpha-blockers e.g. doxazosin
Phenoxybenzamine prior to surgery
Surgical removal of tumour
140
How does aldosterone act on electrolytes?
Increases sodium reabsorption
Increases potassium secretion
141
Whats is hyperaldosteronism vs Conn's syndrome?
Hyperaldosteronism = excessive aldosterone production
Conn's = due to adrenal adenoma
142
What is primary hyperaldosteronism?
Adrenal glands directly producing too much aldosterone
143
Causes of primary hyperaldosteronism (3)?
Bilateral adrenal hyperplasia
Adrenal adenoma (Conn's)
Familial hyperaldosteronism
144
What is secondary hyperaldosteronism?
Due to excessive renin production from kidneys
145
Causes of seconary hyperaldosteronism (3)?
Due to low BP:
Heart failure
Renal artery stenosis
Liver cirrhosis and ascites
146
Blood findings for primary vs secondary hyperaldosteronism (AR ratio)?
Primary = ↑Aldosterone ↓Renin
Secondary = ↑Aldosterone ↑Renin
147
Other findings in hyperaldosteronism?
↑BP
↓K+
Blood gas = alkalosis
148
Investigations for hyperaldosteronism (3)?
CT/MRI for adrenal mass
Renal artery imaging
Adrenal veins sampling
149
Management of hyperaldosteronism?
Medical = spironolactone/eplerenone
Surgical = removal of adenoma
renal artery angioplasty
150
What is type 1 diabetes mellitus?
Autoimmune condition where the pancreas secretes insufficient insulin
151
What are the triad of symptoms for T1DM?
Polyuria
Polydipsia
Weight loss
(May also present with DKA)
152
Where are different pancreatic hormones made (4)? (Endocrine not exocrine)
Insulin = b cells
Glucagon = a cells
Somatostatin = delta cells
Pancreatic polypeptide = pp cells
153
What are ketones a result of?
Fatty acid breakdown
154
What is diabetic ketoacidosis?
Complication of diabetes due to ↓insulin
- Ketoacidosis
- Dehydration
- Potassium imbalance
155
Why is there potassium imbalance in DKA?
Insulin drives potassium into cells. With no insulin it is not stored in cells.
Bloods may be high or normal due to kidneys maintaining homeostasis BUT total body K+ is low
156
Presentation of DKA?
Polyuria
Polydipsia
N+V
Ketone breath
ALOC
Dehydration/weight loss
Hypotension
157
What is seen clinically in DKA?
Hyperlgycaemia
Dehydration
Ketosis
Metabolic acidosis
K+ imbalance
158
How is DKA diagnosed?
Hyperglycaemia (>11mmol/L)
Ketosis (>3mmol/L)
Acidosis (ph <7.3)
159
Management of DKA?
FIG-PICK
F - fluids
I - insulin
G - Glucose
P - potassium
I - Infection
C - Chart fluid balance
K - Ketones
160
What fluids should be given in DKA?
1L 0.9% saline in one hour the 1L 2 hourly (add K+ 20mmol once insulin started)
161
What changes to insulin in DKA?
Start fixed rate infusion 0.1u/kg/hr
Continue long-acting, stop short-acting
162
When should glucose be added to DKA treatment?
Once blood glucose is <14mmol/L
163
When can IV fluids and insulin be stopped in DKA (3)?
Ketosis/acidosis resolved (pH >7.3, ketones
<0.6mmol/L, bicarb >15mmol/L)
Patient eating and drinking
SC insulin started
164
What are the key complications of DKA treatment?
Hypoglycaemia
Hypokalaemia
Cerebral oedema (esp. in young)
Pulmonary oedema
165
Which antibodies are present in T1DM (3)?
Anti-GAD
Anti-islet
Anti-insulin
166
How does C-peptide secretion change with insulin production?
Goes up with high insulin production
Goes down with low insulin production
167
What is long-term management of T1DM?
Basal-bolus insulin regime
Patient education (carb counting)
Monitoring
168
Symptoms of hypoglycaemia?
Hunger
Sweating
Tremors
Irritability
Dizziness
Pallor
169
How should hypoglycaemia be managed?
PO rapid acting glucose 10-20g
If IV access = 20% glucose
IM glucagon
170
Why are there long-term complications of diabetes mellitus?
Chronic ↑blood glucose damages endothelial cells of blood vessels and cause immune dysfunction
171
Macrovascular complications of diabetes?
Coronary artery disease
Peripheral ischaemia (diabetic foot ulcers)
Stroke
Hypertension
172
Microvascular complications of diabetes?
Retinopathy
Peripheral neuropathy
Kidney disease (esp. glomerulosclerosis)
173
Infection related complications of diabetes?
UTIs
Pneumonia
Skin and soft tissue
Fungal (esp. oral/vaginal candidiasis)
174
When should T1 diabetics check their capillary glucose?
Before each meal and before bed
175
Driving rules for diabetic/insulin dependent patients?
Do not drive if <4.0mmol/L
Check every 2 hours
176
What is type 2 diabetes?
Condition where insulin resistance and reduced insulin production results in high blood glucose
177
Risk factors for T2DM?
Age
Ethnicity
FHx
Obesity
Sedentary lifestyle
High carbohydrate (sugar) diet
178
Presentation of T2DM?
Fatigue
Polyuria, polydipsia
Weight loss
Opportunistic infections
Slow wound healing
179
HbA1c levels for pre-diabetes and diabetes?
Pre-diabetes = 42-47 mmol/L
Diabetes = 48+ mmol/L
180
HbA1c treatment targets for T2DM?
New T2DM = 48 mmol/L
Patients on >1 antidiabetic drug = 53 mmol/L
181
Medical management flow chart for type 2 diabetes?
1st - Metformin
+/- SGLT2 (if CVD or QRISK 10%)
2nd - Metformin
+ sulfonylrea/pioglitazone/DPP4/SGLT2
3rd - triple therapy or insulin therapy
(If triple fails, switch one for GLP1)
182
When are GLP1 agonists prescribed?
If triple therapy fails in pts with BMI >35
183
What are some complications of T2DM?
Infections
Diabetic retinopathy
Peripheral/autonomic neuropathy
Diabetic foot
CKD
Gastroparesis
HHS (hyperosmolar hyperglycaemic state)
184
What is HHS?
Complication of T2DM
Hyperosmolar hyperglycaemic state
NO ketosis
185
How does HHS present?
Polyuria
Polydipsia
Weight loss
Dehydration
Tachycardia
Hypotension
Confusion
186
How is HHS managed?
Fluids
VTE prophylaxis (viscous blood)
Insulin only if glucose stops falling
187
What is the first line antihypertensive in T2DM?
ACE-inhibitor
188
What class is Metformin and how does it work?
Biguanide
- ↑ insulin sensitivity
- ↓ hepatic gluconeogenesis (AMPK)
189
Side effects of metformin?
Modest weight loss
GI upset
↓ B12 absorption
Lactic acidosis
190
Contraindications for metformin?
CKD - review if eGFR <45mL, stop if <30mL
Hold for IV contrast
Hold in major surgery
191
Examples of sulfonylureas and mechanism of action?
IDE's - gliclazide, glipizide, glimepiride
Increase pancreatic insulin secretion (only work if function b-cells)
192
Side effects of sulfonylureas?
Weight gain
Hypoglycaemia
193
How does pioglitazone work?
Increases insulin sensitivity
Reduces hepatic gluconeogenesis
194
Side effects of pioglitazone (2)?
Weight gain
Liver impairement
195
Contraindications for pioglitazone?
Heart failure (fluid retention)
Insulin use (fluid retention, ↑risk HF)
Current/Prev bladder cancer
Increased fracture risk (elderly, female)
196
Examples of DPP-4 inhibitors and mechanism of action?
GLIPTINs - alogliptin, sitagliptin, linagliptin, saxagliptin
Decreases breakdown of GLP1/GIP
- ↑insulin secretion
- ↓glucagon secretion
- Delayed gastric emptying
197
Side effects of DPP-4 inhibitors?
Headaches
Acute pancreatitis
Weight neutral
198
SGLT-2 inhibitors examples and mechanism of action?
GLIFLOZINs - canagliflozin, empagliflozin, dapagliflozin
Reduce glucose reabsorption
Increase urinary excretion of glucose
199
Side effects of SGLT-2 inhibitors?
Genital/UT infections
Weight loss
Fournier's gangrene
Normoglycaemic ketoacidosis
↑ risk lower limb amputation
Hypo risk if +insulin/sulfonylurea
200
What is a pro of using SGLT-2 inhibitors and which patients should it be used in?
Improves heart failure - ↓BP/weight/HbA1c
Use in T2DM patient with HF or QRISK 10% and above
201
Examples of GLP-1 agonists and mechanism of action?
TIDEs - semaglutide, dulaglutide, liraglutide, exenatide, tirzepatide
Mimics GLP-1
- ↑insulin secretion
- ↓glucagon secretion
- Delayed gastric emptying
202
Side effects of GLP-1 agonists?
Weight loss
N+V+D
Pancreatitis
Reduced appetite
203
What requirement must patients meet to continue on GLP-1 agonists?
Reduce HbA1c >11mmol/L after 6 months
204
Which patients should be initiated on GLP-1 agonists?
BMI ≥ 35 and specific psychological/medical problems associated with obesity
BMI < 35 for whom insulin therapy would have significant occupational implications or weight loss would benefit other significant obesity-related comorbidities
205
Liraglutide can be used in which pre-diabetic patients?
Those with BMI 35+
206
What is most likely to be seen on a blood gas in Cushing's?
Hypokalaemic metabolic alkalosis
207
What are the BM levels for diagnosing T1DM?
Random blood glucose 11mmol/L
(with clinical factors)
- Rapid weight loss
- Ketosis
- Hx/Fhx autoimmune condition
- Low BMI (<25)
208
Why does gestational diabetes (GDM) occur?
Reduced insulin sensitivity during pregnancy
209
Risk factors for GDM?
Previous GDM
BMI >30
Fhx diabetes
Prev. macrosomic baby
Ethnicity
210
How is GDM screened?
Oral glucose tolerance test (OGTT)
211
Who receives an OGTT (4)?
Any risk factors
Large for dates fetus
Polyhydramnios
Glucosuria
212
What is the OGTT?
75g glucose drink
BM's before and at 2 hoursW
213
What are normal OGTT results?
Fasting: 5.6 mmol/L
2 hours: 7.8 mmol/L
214
Management of GDM?
Fasting <7mmol/L: diet/exercise trial 1-2 weeks > metformin > insulin
Fasting >7mmol/L: insulin +/- metformin
Fasting >6mmol/L + macrosomia = insulin +/- metformin
215
What can be given if women with GDM can't tolerate metformin?
Glibenclamide
216
Monitoring targets for GDM?
Fasting - 5.3 mmol/L
1hr post meal - 7.8 mmol/L
2 hr post meal - 6.4 mmol/L
Avoid <4mmol/L
217
Plans/guidance for pregnant women with pre-exisitng diabetes?
Folic acid 5mg up to 12 weeks
Planned delivery 37-38+6
Sliding scale insulin in labour
218
What are babies of mothers with diabetes at risk of (5)?
Neonatal hypoglycaemia
Polycythaemia
Jaundice
Congenital heart defects
Cardiomyopathy
219
Features of diabetic neuropathy?
Sensory loss not motor
Glove and stocking distribution
Lower legs first
220
Management options for diabetic neuropathy?
1st line - Amitriptyline, Duloxetine, Gabapentin, Pregabalin
Tramadol as rescue therapy for exacerbation
221
What are the GI features of diabetic neuropathy?
Gastroparesis, chronic diarrhoea, GORD
222
Treatment of DM gastroparesis?
Prokinetics - metoclopramide, domperidone
223
What is the screening for diabetic nephropathy?
Albumin:creatinine ratio
Early morning specimen
224
What is management of diabetic nephropathy?
Tight glycaemic control
ACEi or ARB
Aim BP 130/80-140/90
225
What causes diabetic retinopathy?
Increased blood glucose causes ↑ blood flow and abnormal metabolism in vessel walls
226
What is the classification of diabetic retinopathy?
Non-proliferative (NPDR)
Proliferative (PDR)
Maculopathy
227
What are some features of diabetic retinopathy on ophthalmoscopy?
Microaneurysms
Hard exudates
Cotton wool spots
Blot haemorrhages
Neovascularisation
Vitreous haemorrhage
228
How is maculopathy different to proliferative disease?
Macula oedema
229
Complications of diabetic retinopathy?
Vision loss
Retinal detachment
Cataracts
Vitreous haemorrhage
Optic neuropathy
230
Management of diabetic retinopathy?
Close monitoring + tight BM control
Laser photocoagulation treatment
Anti-VEGF injection
Surgery
Dexamethasone (intravitreal implant)
231
What symptoms does gastroparesis cause?
Gastroparesis causes erratic BM control, bloating, N+V, early satiety
232
Side effects of thyroxine therapy?
Hyperthyroidism - due to over treatment
Reduced bone mineral density (osteoporosis/fractures)
Worsening of angina
Atrial fibrillation
233
Bloods in sick euthyroid syndrome?
Low T3/T4 and normal TSH with acute illness
234
How is thyrotoxic storm managed?
Beta-blockers, PTU, and hydrocortisone
235
Which fasting and random blood glucose readings are diagnostic of diabetes mellitus?
Fasting >7.1
Random >11.1
x2 in unsymptomatic
x1 in symptomatic pts
236
What are the numbers for diagnosing hypertension in clinical setting and ambulatory?
Clinical = 140/90
Ambulatory/home = 135/85
237
Causes of secondary hypertension (5)?
ROPED
Renal disease
Obesity
Pregnancy
Endocrine
Drug
238
Complications of hypertension?
Ischaemic heart disease
Stroke
Vascular disease
Retinopathy
Neuropathy
Vascular dementia
LV hypertrophy
Heart failure
239
How can hypertension cause LV hypertrophy?
The left ventricle is working harder to pump blood against increased resistance in the arterial system
240
What are the numbers for stages of hypertension?
Stage 1 - 140/90 (135/85)
Stage 2 - 160/100 (150/95)
Stage 3 - 180/120
241
What is first line for patients under 55 with hypertension?
ACEi/ARB
242
What is first line for T2DM patients with hypertension?
ACEi/ARB
243
What is first line for patients over 55 with hypertension?
CCB
244
What is first line for afro-caribbean patients with hypertension?
CCB
(If adding, use ARB insteadof ACEi)
245
What are BP treatment targets for patients with hypertension?
<80yrs - 140/90
>80yrs - 150/90
246
What is hypertensive emergency?
>180/120 PLUS one of:
Retinal haemorrhages/papilloedema
Confusion
Heart failure
Suspected ACS
AKI
247
When do you add spironolactone vs alpha-blockers in hypertension?
Spiro if K+ <4.5mmol/L
Alpha if K+ >4.5mmol/L
248
When should type 1 diabetics consider having metformin in addition to insulin?
If BMI >25
249
Who is offered primary prevention statins and what are they given?
Qrisk >10%
Most T1DM
CKD if eGFR <60ml/min
Atorvastatin 20mg
250
Who is offered secondary prevention statins and what are they given?
Known ischaemic heart disease
Cerebrovascular disease
Peripheral arterial disease
Atorvastatin 80mg
251
When to consider familial hyperlipidaemia?
If total cholesterol >7.5mmol/L
AND/OR
Family history of premature coronary artery disease
252
What are the BMI classifications for obesity?
25-30 overweight
30-35 obese class 1
35-40 obese class 2
>40 obese class 3
253
Risk factors for obesity?
Poor diet
Hypothyroidism
Sedentary lifestyle
Cushing's
Steroid therapy
Low self-esteem
Quitting smoking
254
Management options for obesity?
1st - lifestyle
2nd - Medications (orlistat, semaglutide)
3rd - Surgery (gastric band/sleeve, diversion procedure)
255
What is a prolactinoma?
Benign tumour of pituitary gland (adenoma)
256
Clinical presenting features of prolactinoma in women (4)?
Amenorrhoea
Infertility
Galactorrhoea
Osteoporosis
257
Clinical presenting features of prolactinoma in men?
Impotence
Loss of libido
Galactorrhoea
258
Symptoms of macroadenoma prolactinomas?
Headache
Visual disturbance
Sx of hypopituitarism
259
What is the classical visual field loss in pituitary adenoma?
Bitemporal hemianopia
260
How is prolactinoma/pituitary adenoma diagnosed?
MRI scan
261
Management of prolactinoma?
Dopamine agonists (cabergoline, bromocriptine)
Surgery if fail to respond (tran-sphenoidal)
262
What is acromegaly caused by?
Excess GH
263
Most common cause of acromegaly?
Pituitary adenoma
264
Presentation of acromegaly?
Prominent forehead and brown (frontal bossing)
Coarse, sweaty skin
Large nose
Large tongue
Large hands and feet
Large protruding jaw
265
Possible complications of acromegaly (3)?
HTN
Diabetes
Cardiomyopathy
266
Investigations in suspected acromegaly?
Serum IGF-1 then OGTT
Pituitary MRI
267
Management of acromegaly?
Trans-sphenoidal surgery of pituitary tumour
Meds:
Somatostatin analogue (ocreotide)
Dopamine agonists e.g. bromocriptine
268
What is pituitary apoplexy?
Sudden enlargement of a pituitary tumour secondary to haemorrhage or infarction
269
Possible precipitating factors for pituitary apoplexy (4)?
HTN
Pregnancy
Trauma
Anticoagulation
270
Clinical presenting features of pituitary apoplexy (4)?
Sudden onset headache
Vomiting
Neck stiffness
Visual field defect
271
Investigation in suspected pituitary apoplexy?
MRI
272
Management of pituitary apoplexy (3)?
Urgent steroid replacement due to loss of ACTH
Fluid balance
Surgery
273
Management of hyperkalaemia?
IV calcium gluconate
Insulin/dex infusion
Salbutamol nebs
Calcium resonium
Loop diuretics
274
Inheritance pattern of multiple endocrine neoplasia (MEN)?
Autosomal dominant
275
What are the three main types of MEN?
Type I
Type IIa
Type IIb
276
Most common cancers in MEN type I?
3 P's
Parathyroid
Pituitary
Pancreas
277
Most common cancers in MEN type IIa?
2 P's
Parathyroid
Phaeochromocytoma
278
Most common cancers in MEN type IIb?
1 P
Phaeochromocytoma
279
Which presentation most commonly causes a **tender** goitre and thyrotoxicosis?
Thyroiditis
(De Quervain's)
280
What electrolyte abnormality can hypothyroidism cause?
Hyponatraemia
281
PTH and calcium levels in primary hyperparathyroidism?
↑ Ca
PTH ↑ OR **inappropriately normal**
282
PTH and calcium levels in secondary hyperparathyroidism?
↓ or normal Ca
↑ PTH
283
PTH and calcium levels in tertiary hyperparathyroidism?
↑ Ca
↑ PTH
Finals revision
flashcards
Decks in class (29)
# Cards
-
Endocrine283
-
Neurology261
-
Cardiology255
-
Emergency medicine106
-
Pharmacology29
-
Hepatobiliary93
-
Renal87
-
Respiratory200
-
Haematology172
-
Gastroenterology219
-
Urology106
-
Paediatrics328
-
Geriatrics45
-
Dermatology98
-
Obs + Gynae248
-
ENT91
-
GP + Misc72
-
Infections100
-
Orthopaedics150
-
Ophthalmology90
-
Vascular surgery47
-
Rheumatology120
-
Psychiatry154
-
Breast30
-
Anaesthetics42
-
Radiology11
-
Oncology33
-
Sexual health29
-
Public health133
