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TCD Endocrine > Diabetes and Endocrine Disease > Flashcards

Diabetes and Endocrine Disease Flashcards

1
Q

Which cells of the pancreas produce insulin?

A

Beta cells (in the Islets of Langerhans)

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2
Q

What is C peptide?

A

A by-product of insulin production used as a measure of endogenous insulin.

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3
Q

What metabolic processes in the liver are promoted by glucagon? (2)

A

Glycogenolysis and gluconeogenesis

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4
Q

Name three conditions that Graves’ disease is associated with.

A

Type 1 diabetes
Vitiligo
Alopecia areata

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5
Q

What is candidal balanitis?

A

A fungal infection of the male genitalia caused by Candida yeast.

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6
Q

What is balanitis circinata?

A

A skin condition associated with reactive arthritis which presents with ring-shaped dermatitis on the glans penis.

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7
Q

What is Balanitis Xerotica Albicans?

A

Lichen sclerosis affecting the male genitals.

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8
Q

What are the criteria for diagnosis of diabetes mellitus in a symptomatic patient? (3)

A

-HbA1c of 48 mmol/mol (6.5%) or more (diagnostic for type 2 only)
OR
-Fasting Glucose Test greater than or equal to 7
OR
-Random Glucose Test greater than or equal to 11.1

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9
Q

How do the criteria for diagnosis of diabetes mellitus change in an asymptomatic patient?

A

Same criteria as given for symptomatic patients, but must be met on 2 separate occasions.
[WHO suggests this is on a ‘subsequent day’. In practice a HbA1C is often used to confirm diagnosis.]

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10
Q

When should you not use HbA1c results for diagnosing diabetes? (6)

A

-In children or young people less than 18 years of age
-Pregnant women/women 2 months postpartum.
-Patient with symptoms of diabetes for < 2 months.
-Acutely ill patients.
-Patients taking medication that may cause hyperglycaemia
-People with acute pancreatic damage (including pancreatic surgery), end-stage renal disease (ESRD), or HIV infection)

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11
Q

What are the hallmark symptoms of type 2 diabetes mellitus? (5)

A

-Tiredness
-Polydipsia/polyuria
-Increased hunger
-Unintentional weight loss
-Blurred vision

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12
Q

What is acanthosis nigricans?

A

Areas of dark skin (e.g in armpits/neck) sometimes seen in asymptomatic T2DM patients due to insulin resistance.

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13
Q

What is type 1 diabetes mellitus?

A

A condition in which the body doesn’t make enough insulin, due to a type IV hypersensitivity response where a person’s own T cells attack beta cells in the pancreas, destroying them.

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14
Q

What is type 2 diabetes mellitus?

A

A condition in which the body still makes insulin, but the tissues don’t respond well to it (reason not fully understood but to do with insulin resistance). Beta cell hypertrophy and hyperplasia initially cause increased insulin production, however this is not sustainable and beta cells eventually decrease, causing decreased insulin and increased blood glucose.

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15
Q

What are the roles of insulin and glucagon respectively?

A

-Insulin = lowers blood glucose levels by aiding transportation of it from the blood into cells
-Glucagon = increases blood glucose levels by causing generation of new glucose molecules by the liver and breakdown of glycogen into glucose to allow it to be moved into the blood

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16
Q

What causes polyuria in diabetes?

A

Hyperglycaemia in diabetes leads to glucose ‘leaking’ into the urine when blood is filtered through the kidneys; because glucose is osmotically active, water tends to follow it, resulting in an increase in urination.

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17
Q

What is diabetic ketoacidosis (DKA)?

A

A severe lack of insulin in the body means cells can’t use glucose for energy, so begin to use fat instead; this process leads to release of ketones, which can build up and make the blood acidic.

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18
Q

What are the classical symptoms of diabetic ketoacidosis (DKA)? (6)

A

-Polyuria/polydipsia
-Nausea and vomiting
-Weight loss
-Acetone smelling breath
-Dehydration (and subsequent hypotension)
-Altered consciousness

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19
Q

How is diabetic ketoacidosis (DKA) treated? (3)

A

-IV fluids (for dehydration)
-Insulin (to lower blood glucose)
-Electrolyte replacement (i.e potassium) as required

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20
Q

Which cells of the pancreas produce glucagon?

A

Alpha cells (in the Islets of Langerhans)

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21
Q

What is hyperosmolar hyperglycaemia syndrome (HHS)?

A

A state of illness and dehydration which occurs gradually over several days in people with type 2 diabetes, due to very high blood glucose levels (often >40mmol/L) resulting in a subsequent increased plasma osmolarity (and therefore decreased water in cells as it is all moving to the serum).

[Hyperglycaemia with profound dehydration and an absence of ketosis.]

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22
Q

What are the classical symptoms of hyperosmolar hyperglycaemia syndrome (HHS)? (4)

A

-Polydipsia/polyuria
-Nausea
-Dry skin
-Disorientation and, in later stages, drowsiness and loss of consciousness

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23
Q

What is involved in a fasting glucose test?

A

Patient doesn’t eat or drink (except water) for 8 hours, and then has blood glucose levels measured.

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24
Q

What is involved in a non-fasting or random glucose test?

A

Serum glucose is measured at any time, without the need for fasting or preparation for the test.

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25
Q

What is involved in an oral glucose tolerance test?

A

Patient fasts for at least 8 hours and venous fasting glucose is taken, then 150g of glucose is given and venous plasma glucose is measured two hours later.

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26
Q

What is an HbA1c test?

A

A test which looks at proportion of haemoglobin in the blood with glucose stuck to it, to measure average blood sugar over the last few months.

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27
Q

What are the classical symptoms of mild hypoglycaemia? (3)

A

Weakness
Hunger
Shaking

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28
Q

What are the classical symptoms of severe hypoglycaemia? (2)

A

Loss of consciousness
Seizures

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29
Q

What is checked at an Annual Diabetic Review? (6)

A

-Foot examination (for neuropathy and ulcers)
-Urine (raised ACR can be sign of early diabetic nephropathy)
-Cholesterol and BP (for managing CVD risk)
-Height and weight (BMI)
-Blood sugars and HbA1c (to assess diabetic control)
-Eye tests (to screen for diabetic retinopathy)

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30
Q

What is the first line medical therapy for type 2 diabetes?

A

Metformin - a biguanide which has the dual effect of increasing insulin sensitivity and decreasing hepatic gluconeogenesis.

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31
Q

What is the most common side effect of metformin, and how can it be reduced?

A

Gastrointestinal disturbance - taking metformin with meals or using modified release preparations can reduce GI side effects.

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32
Q

What dose of metformin can be given for management of type 2 diabetes mellitus? (2)

A

-Initial starting regime = 500mg once daily
-Can be titrated up to 1g twice daily if necessary

33
Q

When is insulin therapy considered in type 2 diabetes mellitus?

A

If, despite three medications in combination, the patient’s HbA1c is still above their agreed target.

34
Q

What is Canagliflozin?

A

An SGLT2 inhibitor given to treat type 2 diabetes mellitus, that reversibly inhibits SGLT2 transporters in the renal proximal convoluted tubule to reduce glucose reabsorption and increase urinary glucose excretion.

35
Q

What antihypertensive class is first line for all diabetic patients?

A

ACE inhibitors

36
Q

When are statins recommended in diabetic patients? (2)

A

-In most type 1 diabetes patients
-Type 2 diabetic patients with a QRISK over 10%

37
Q

What is the blood pressure target for a patient with diabetes? (2)

A

-Below 140/80 for all patients with diabetes
-Below 130/80 if there is end organ damage

38
Q

What are the diagnostic criteria for diabetic ketoacidosis (DKA)? (3)

A

Patient must have all three of:
-Capillary blood glucose (BM) >11 (or known diabetes)
-Capillary ketones >3mmol/L (or urinary >2+)
-Venous pH<7.3 or venous bicarb<15mmol/L

39
Q

When can fixed rate insulin infusion following a DKA be changed to subcutaneous insulin?

A

When a patient is eating and drinking normally, and their pH>7.3, or their blood ketones <0.6mmol/L.

40
Q

What symptoms can be seen in autonomic diabetic neuropathy? (3)

A

-Resting tachycardia
-Urinary frequency
-Erectile dysfunction

41
Q

What is ‘Kussmaul’s breathing’?

A

Deep/laboured breathing in an attempt to reduce CO2 and subsequently acidity of the blood.

42
Q

What are the five common aetiologies of diabetic ketoacidosis (DKA)?

A

The 5I’s:
-Infection
-Inappropriate withdrawal of insulin
-Intoxication
-Infarction
-Intercurrent illness

43
Q

What are the three different types of insulin available in the UK?

A

-Human Insulin (produced by recombinant DNA technology)
-Human Insulin Analogues (insulin modified to produce specific kinetic characteristics, such as duration of action)
-Animal Insulin (rarely used)

44
Q

What are the available modes of administration of insulin? (3)

A

-Basal bolus = long acting insulin given by subcutaneous injection to act as endogenous (basal) insulin, and then rapid acting insulin is given with meals (as a bolus) to replicate a normal response to food.
-Mixed, bi-phasic regime = varied, but usually have one, two or three premixed insulin injections per day, containing insulins with different durations of action.
-Continuous regime = insulin pumps deliver rapid acting insulin at very slow rate as background insulin; extra mealtime insulin given by patient on top of this.

45
Q

What is a basal/bolus insulin regime also known as?

A

Multiple daily injections (MDI)

46
Q

How are dose distributions for a basal/bolus insulin regime calculated in an insulin naïve patient?

A

Calculate the insulin requirements for the past 24 hours; convert 50% of this to long-acting insulin, and the other 50% is split into 3 divided doses of short acting insulin.

47
Q

What is the Dose Adjustment for Normal Eating (DAFNE) course?

A

A course for patients involving five days of structured education to provide vital knowledge and skills needed to manage type 1 diabetes.

48
Q

How many times a day should a type 1 diabetic (or type 2 diabetic on insulin) check their glucose levels?

A

At least 4 times a day (before each meal and before bed)

49
Q

What are the blood glucose targets for diabetes? (2)

A

-On waking = 5-7mmol/L
-Before meals, and at other times of the day = 4-7mmol/L

50
Q

What are the sick day rules for someone with diabetes who is unwell? (4)

A

-Check blood sugar more frequently
-Stay hydrated
-Eat little, and often
-Keep taking medications

51
Q

What thyroid function test (TFT) results would be consistent with primary hyperthyroidism? (3)

A

Elevated free T4 (thyroxine)
Elevated free T3 (triiodothyronine)
Suppressed TSH (thyroid stimulating hormone)

52
Q

Where is thyroid stimulating hormone (TSH) produced?

A

The anterior pituitary

53
Q

What are the three types of thyroid autoantibodies, and what does their presence indicate respectively?

A

-Thyroid peroxidase antibodies (TPOAb) = raised in Hashimoto’s thyroiditis (or autoimmune thyroiditis) and sometimes raised in Graves’ disease.
-Thyroglobulin antibodies (TgAb) = sometimes raised in Hashimoto’s thyroiditis.
-Thyroid Stimulating Hormone Receptor Antibodies (TSHRAb, or TRAb) = raised in Graves’ disease.

54
Q

What is meant by echogenicity?

A

The ability of ultrasound to bounce an echo, i.e a measure of the density of a structure.

55
Q

What ultrasound changes are typically seen in Hashimoto’s and Graves’ disease?

A

Homogenous hypo-echogenicity (reduced density) changes.

56
Q

Why does the thyroid gland move on swallowing?

A

It is attached to the thyroid cartilage and to the upper end of the trachea.

57
Q

Where does the de-iodination of T4 to T3 occur?

A

The peripheral tissues such as the liver and kidney

58
Q

What are the three most common causes of hyperthyroidism in the UK?

A

-Graves’ disease (60-80% cases)
-Toxic multinodular goitre (second most common cause in UK)
-Solitary toxic adenoma (5% cases)

59
Q

What is toxic multinodular goitre?

A

A condition where mutated cells proliferate and form autonomously functioning nodules which secrete excess thyroid hormone.

60
Q

What examination signs are specific to Graves’ disease? (4)

A

-Pretibial myxoedema
-Exopthalmos
-Opthalmoplegia
-Thyroid acropachy (nail clubbing, swelling of digits, etc.)

61
Q

What is selenium?

A

A mineral that has been shown to reduce thyroid peroxidase antibodies and thus reduce the severity of hypothyroidism symptoms as well as improve quality of life and outcomes in thyroid eye disease.

62
Q

What is thyroid eye disease?

A

An immunologic disease which can occur with hyperthyroidism, hypothyroidism, or euthyroid, where the patient has ophthalmologic symptoms of thyroid problems due to antibodies usually involved in thyroid disease, but may have normal thyroid hormone levels.

63
Q

What medications can be prescribed for thyroid eye disease? (2)

A

-Teprotumumab (a monoclonal antibody the blocks IGF-1R activation)
-Corticosteroids (to reduce inflammation)

64
Q

What is thyrotoxic crisis (aka ‘thyroid storm’)?

A

A severe, acute complication of hyperthyroidism in which the symptoms and physiologic effects of excess thyroid hormones are suddenly magnified - exact pathophysiology is undetermined.

65
Q

What are some potential triggers of thyroid storm? (3)

A

-Stressors (i.e surgery, trauma, infection, childbirth)
-Abruptly stopping treatment for hyperthyroidism
-Taking too much thyroid hormone (seen sometimes in those being treated for hypothyroidism)

66
Q

What are the classical symptoms of thyroid storm? (3)

A

-Fever (as body is producing more heat)
-Autonomic disturbances (sweating, hyperactivity, agitation, confusion, seizures, coma)
-Cardiac arrhythmias and high output cardiac failure (resulting from tachycardia)

67
Q

How is thyroid storm diagnosed? (2)

A

-Based on severity of symptoms and confirmed by investigations to confirm signs, such as an ECG to detect arrhythmias.
-There typically isn’t much difference in thyroid hormone levels between hyperthyroidism and thyroid storm.

68
Q

What is Hashimoto’s disease (aka chronic lymphocytic thyroiditis)?

A

An autoimmune inflammation of the thyroid gland, leading initially to a goitre but ultimately to atrophy of the thyroid gland due to damage.

69
Q

What is carbimazole?

A

A medication used to treat hyperthyroidism by decreasing inorganic iodine uptake by the thyroid, as well as preventing thyroid peroxidase enzyme from functioning normally, thereby reducing formation of T3 and T4.

70
Q

What is levothyroxine?

A

A medication used to treat hypothyroidism; a synthetic T4 hormone, that can be used to replace low levels of T4 and T3 in the body (as it is metabolised by the body into T3).

71
Q

What are the three main treatment options for hyperthyroidism?

A

-Antithyroid medications (i.e methimazole/carbimazole, propylthiouracil)
-Total thyroidectomy
-Radioactive iodine therapy

72
Q

What are the potentially serious side effects of carbimazole? (2)

A

-Neutropenia (low neutrophil count)
-Agranulocytosis (acute febrile condition marked by severe decrease in blood granulocytes)

73
Q

What is a goitre?

A

An enlarged thyroid.

74
Q

What are thyroid nodules?

A

Solitary thyroid lumps

75
Q

What is Euthyroid Sick Syndrome?

A

Systemic illness causing transiently low T3/4 and TSH.

76
Q

When in the day should levothyroxine be taken?

A

Preferably 30-60 minutes before breakfast, caffeine-containing liquids or other medication.

77
Q

What medications would NICE guidelines recommend for a patient with newly diagnosed type 2 diabetes mellitus and established cardiovascular disease? (2)

A

-Metformin
-Canagliflozin

78
Q

What is the immediate management of a patient who fulfils the diagnostic criteria for diabetic ketoacidosis (DKA)?

A

Fluid resuscitation with careful monitoring of serum potassium, and a fixed rate insulin infusion.

TCD Endocrine (5 decks)

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