Endocrine Flashcards
(141 cards)
1
Q
Where is ADH produced
A
Hypothalamus
2
Q
Where is ADH stored
A
Pituitary gland
3
Q
When is ADH released and its role
A
When water in body to low, retains water in the body by reducing water loss in the kidneys
4
Q
Affects on ADH in diabetes insipidus
A
Reduced production - kidneys don’t retain water - water loss
5
Q
Signs and symptoms of Iapetus insipidus
A
Extreme thirst
Polyuria
Dilute urine
6
Q
2 types of diabetes insipidus
A
- Pituitary (cranial) - lack of vasopressin production
- Nephrogenic (partial) - kidneys don’t respond to ADH
7
Q
Treatment of partial diabetes insipidus
A
Vasopressin / desmopressin
8
Q
Treatment of nephrogenic diabetes insipidus
A
Thiazide diuretic
9
Q
Affects of desmopressin vs vasopressin
A
More potent
Longer duration
No vasoconstrictor effects
10
Q
Desmopressin side effects
A
Hyponatraemia
Nausea
11
Q
Result of inappropriate increase in ADH secretion
A
Body stores more water, diluting blood salt concentration causeing hyponatraemia
12
Q
Treatment of increased ADH (3)
A
- Fluid restriction
- Demeclocycline - blocks renal tubular effect of ADH
- Tolvaptan - vasopressin antagonist (avoid rapid correction - osmotic demyelination - serious neurological effects)
13
Q
Action of mineralcorticosteroids
A
High fluid retention - low anti inflammatory effect
14
Q
2 mineralcorticosteroid
A
Fludrocortisone
Hydrocortisone
15
Q
Side effects of mineral corticosteroids
A
Sodium + water retention - hypertension
Potassium loss - hypokalaemia
Calcium loss - hypocalcaemia
16
Q
Action of Flucocorticosteroid
A
Low fluid retention - high ant inflammatory effect
17
Q
5 glucocorticosteroids
A
Dexamethasone
Betmethasone
Prednisone
Prednisolone
Deflazacort
18
Q
Glucocorticosteroid side effects
A
Diabetes
Osteoporosis - osteoporotic fractures
Avascular necrosis of femoral head and muscle wasting
Gastric ulceration and perforation
19
Q
General side effects of corticosteroids
A
MHRA - chorioretinopathy - report vision disturbance
Psychiatric reactions - insomnia, irritability, behaviour
Adrenal suppression - can last years after treatment
Infections - immunosuppressive
Chicken pox - risk of severe
Measles
Insomnia
Cushing syndrome - moon face, hirsutism
20
Q
Treatment for Managing Cushing syndrome
A
Metyrapone
Ketaconazole
21
Q
Effects of corticosteroid use (CORTICOStEROIDUSE)
A
Cushing syndrome, osteoporosis, Retard growth, Thin skin, Immunosuppression + Insomnia, Chorioretinopathy, Oedema, Striae, Emotional disturbance, Rise in BP, Obesity, Increased hair growth, Diabetes mellitus, Ulcers, Suppression, Electrolyte imbalance
22
Q
Managing steroid side effects 5
A
Lowest effective dose minimum period
Single dose in morning,
Total dose for 2 days can be single dose on alternative days
Intermittent therapy with short course
Local treatment rather than systemic
23
Q
When to gradually withdraw steroid use 6
A
> 40mg prednisolone/equivalent daily for >1 week
Repeat evening doses
3 week treatment
Recently received repeated courses
Taken short course within 1 year of stopping long term therapy
Other causes of adrenal suppression
24
Q
Mild topical corticosteroid
A
Hydrocortisone
25
Moderate potency topical steroid
Clobetasone
26
Potent topical corticosteroid
Betamethasone
27
Very potent topical corticosteroid
Clobetasol
28
Treatment of adrenal insufficiency - Addison’s disease / congenital hyperplasia
Hydrocortisone
Primary adrenal insufficiency - Fludrocortisone as well
29
Symptoms of adrenal crisis
Severe dehydration, hypovolemic shock, altered conscious, seizures, stroke, cardiac arrest
30
Treatment of adrenal crisis
Hydrocortisone Rapidly
31
Diabetes type where deficient insulin secretion
Type 1
32
Diabetes type where resisistance to action of insulin
Type 2
33
Diabetic driving requirements in group 1 (2)
Adequate hypo awareness
No more than 1 severe hypo whilst awake in 12 months
34
Diabetic driving requirements for group 2 (5)
Report all severe hypos including during sleep
Full hypo awareness
NO severe hypos in 12 months
Use blood glucose meter with 3 months memory
Notify DVLA of visual complications
35
DVLA advise for diabetics
If treated with insulin - always carry monitor and strips
Check levels max 2hrs before driving then every 2hrs while driving
Blood glucose should be above 5mmol/L
Keep supply of fast acting carbs
36
Features of type 1 diabetes
Hyper >11mmol/L
Kenos is
Rapid weight loss
BMI <25kg/m2
<50yrs
Family history of autoimmune
37
Frequency of blood glucose monitoring in type 1
4 times a day - before each meal and before bed
38
Type 1 diabetes blood glucose targets
Waking and fasting - 5-7mmol/L
Fasting BG before meals at other times of day - 4-7mmol/L
90 mins after eating - 5-9mmol/L
When driving - >5mmol/L
39
First line insulin regimen for type 1 diabetes
Basal- bolus multiple daily injection
40
How basal bolus insulin regimen works
Basal - long/intermediate acting insulin - OD/BD
Bolus - short/rapid acting insulin - before meals
41
First line basal bolus regimen
Basal - Detemir BD
Bolus - glargine OD
42
What is biphasic insulin regimen
Short acting mixed with intermediate - 1-3x daily
43
When to increase insulin (3)
Infection
Stress
Trauma
44
When to decrease insulin (5)
Physical activity
Inter current illness
Reduced food intake
Impaired renal function
Endocrine disorders
45
Insulin injection technique (3)
Subcutaneous - inactivated orally
Inject into body area with plenty of sc fat
Rotate injection site
46
How does lipohypertrophy occur
Repeatedly injecting at same sight - erratic absorption
47
4 insulin types
Short acting
Rapid acting
Intermediate acting
Long acting
48
Particulars of short acting insulin (4)
1. Human, bovine, porcine
2. Injected 15-30 mins before meals
3. Onset of 30-60mins - peak at 1-4hrs
4. Duration up to 9 hrs
49
Particulars of rapid acting insulin
1. Lispro, aspart, glulisine
2. Inject immediately before meals
3. Onset <15 mins
4. Duration 2-5hrs
50
Particulars of intermediate acting insulin
1. Biphasic isophane, biphasic aspart/lispro (isophane mixed with short acting)
2. Onset 1-2hrs - peak at 3-12hrs
3. Duration 11-24hrs
51
Particulars of long acting insulin
1. Detemir, degludec, glargine
2. InjectOD (BD detemir)
3. Onset2-4 days to reach steady state
4. Duration 36hrs
52
Features of prediabetic
HbA1c 42-47 mol/mol
Lifestyle advise to prevent
53
Diabetic diagnostic HbA1c level
48mmol/mol
54
Type 2 diabetes treatment in low CVD risk
1. Metformin
2. If above target - ADD DPP4i (gliptin), piogitazone, sulfonylurea, SGLT-2I (flozin)
3. If still above target - triple therapy ADD/SWAP
55
Treatment of Type 2 diabetes in high CVD ris
1. Metformin, once tolerated ADD SGLT-2I (Metformin not tolerated, flozin monotherapy)
2. Above target - follow dual and triple therapy guideline
56
Treatment of type 2 diabetes in Metformin resistance
1. DPP-4I (gliptin), pioglitazone, sulfonylurea, SGLT-2I
2. If above target DPP-4I + Pioglitazone OR DPP-4I + Sulfonylurea OR pioglitazone + Sulfonylurea
3. If above target still - insulin
57
Mechanism of action of Metformin
Decrease glucose genesis and increase peripheral utilisation of glucose
58
Side effects of Metformin
Lactic acidosis - avoid if eGFR <30
GI side effects
Reduce Vitamin B12
59
Sulphonylurea mechanism of action
Augments insulin secretion
60
Long acting sulfonylurea
Gilbenclamide
Glimepiride
61
Short acting sulfonylurea
Gliclazide
Tolbutamide
62
Side effects of sulfonylurea
High risk of hypo
Avoid prescribing in acute porphyria
Avoid in hepatic and renal failure
63
Pioglitazone mechanism of reaction
Reduces peripheral insulin resistance
64
Risks associated wit pioglitazone
Increased risk of bladder cancer - review safety and efficacy after 3-6 months - stop treatment if inadequate response - report haematuria, dysuria, urinary urgency
Increased risk of bone fractures
Increased risk of liver toxicity - report nausea vomiting, abdominal pain, fatigue, dark urine
65
DPP- 4I mechanism of action
Inhibits DPP 4 to increase insulin secretion and lower glucagon secretion
66
Risks associated with DPP4I
Pancreatitis - discontinue if persistent severe abdominal pain
Villa gliptin - hepatotoxic
67
Mechanism of action of SGLT-2I
Inhibits SGLT2 in renal proximal convulated tube
68
SGLT2I MHRA warning
Life threatening , fatal cases of dka- monitor ketones if treatment interrupted
Farniers gangrene - necrotising fascitis of genitalia/perineum
69
GLP1 agonist moa
Increase insulin secretion, suppress glucagon secretion, slows gastric emptying
70
GLP1 risks
MHRA - dka when concomitant insulin rapidly reduced
Cute pancreatitis
Dehydration
71
Acarbose mechanism of action
Delays digestion and absorption of starch and sucrose
72
Side effects of Acarbose
High risk of GI side effects - reduce dose
73
Meglitides mechanism of action
Stimulates insulin secretion
74
Antidiabetics that cause weight gain
Pioglitazone, sulphonylureas
75
Antidiabetics that have no effect of weight
DPP4i
76
Antidiabetics that cause weight loss
Metformin, GLP1, SGLT2I
77
Treatment of diabetic neuropathy causing proteinuria
Ace I / arb
78
Treatment of neuropathic postural hypotension
Increase salt intake
Fludrocortisone
79
Treatment of painful peripheral neuropathy
Antidepressant, gabapentin, pregabalin
80
Treatment of diabetic foot neuropathy
Treat pain and manage infection
81
Treatment of autonomic neuropathy
Treat diarrhoea with codeine / tetracyclines
82
Treatment of gustatory sweating
Antimuscarinic - propantheline bromide
83
Symptoms of DKA
Polyurea
Thirsty
Pear drop breath
Deep/fast breathing
Lethargy/unconsciousness
Confusion
84
Diagnosing dka
1. Check blood sugar
2. Blood sugar >11mmol/L - check ketone levels
85
Ketone level management
0.6-1.5mmol - slight risk - retest in 2 hrs
1.6-2.9mmol - increased risk - contact GP
3mmol + - medical emergency
86
Treatment of DKA (7)
1. BP <90 - restore volume with 500ml IV NaCl 0.9%
2. Once BP >90 - Maintenance IV NaCl 0.9%
3. Start IV insulin mixed with NaCl at a rate;
- ketone conc falls at 0.5mmol/L/hr
- BG conc falls at 3mmol/L/hr
4. When BG <14mmol/L - IV Glucose 10%
5. Continue insulin till Keaton <0.3mmol/L +pH >7.3
6. When pt stable to eat - give fast acting insulin with meal
7. Stop treatment 1hr after food
87
Insulin management during elective surgery (minor procedure with good glycemic control)
Reduce OD long acting insulin dose by 20% the day before
88
Insulin management during surgery (Major or poor glycaemic control)
1. Reduce OD long acting insulin dose by 20% the day before
2. On day of surgery - reduce OD long acting insulin dose by 20% - stop other insulin until patient is eating
IV infusion of KCl + Glucose + NaCl
Variable rate IV insulin in NaCl 0.9% via pump
Hourly BG monitoring for first 12 hours
Give IV glucose 20% if BG <6mmol/L
89
Insulin management post surgery
Convert back to SC insulin when patient can eat/drink without vomiting
Basal-Bolus - Restart with first meal
Long acting regimen - Carries on at 20% reduced until pt leaves hospital
Twice daily regimen - restart at breakfast/evening meal (infusion until 30-60min after 1st meal)
90
Diabetes sick day rules (4)
Sugar levels - Check BG regularly
Insulin - Carry on taking
Carbs - keep eating, stay hydrated
Ketones - Check regularly q
91
Diabetic medications in pregnancy
Stop ALL except Metformin and replace with insulin
92
First line insulin in pregnancy
Isophane
93
Treatment of Gestational diabetes - fasting BG <7mmol/L
1. Diet and exercise
2. Requirement not met 1-2 weeks - Metformin
3. Metformin not tolerated/effective - insulin
94
Treatment of gestational diabetes - fasting glucose >7mmol/L
1. Diet and Exercise + Insulin +/Metformin
95
Treatment of gestational diabetes - Fasting BG 6-6.9mmol/L with complications
Insulin +/ Metformin
96
Symptoms of Hypoglycaemia
Sweating, Lethargic, Dizzy, Hunger, Tremor, Tingling lips, Palpitations, Extreme moods, Pale
97
Treatment of Hypoglycaemia - conscious and able to swallow
Fast acting Carb repeat every 15 mins for 3 cycles
- 4-5 glucose tabs
- 3-4 heaped teaspoons sugar
- 150-200ml fruit juice
98
Treatment of hypoglycaemia - unconscious/oral not work
1. IM glucagon
2. Unresponsive after 10mins - IV glucose
99
Risk factors of osteoporosis
Post menopausal women
Men over 50
Patient taking long term oral corticosteroids
100
Lifestyle changes in osteoporosis
Increase exercise
Smoking cessation
Maintain IBW
Reduce alcohol intake
Increase intake of Vit D + calcium
101
First line treatment of osteoporosis
Oral bisphosphonates - Alendronic acid/Risedronate sodium
102
Second line treatment in Postmenopausal women
Ibandronic acid, Denosumab, Raloxifene, Strontium
103
Second line osteoporosis treatment in young menopausal
HRT, tibolone
104
Second line treatment of severe osteoporosis
Teriparatide
105
Second line treatment of osteoporosis in men
Zolendronic acid, Densosumab, Teriparatide, Strontium
106
Second line treatment of steroid induced osteoporosis
Zolendronic acid, Densosumab, Teriparatide
107
When to give osteoporosis prophylaxis with steroid treatment
Women - 70yrs+, previous fragility fracture, large doses
Men - 70yrs+ AND previous fragility/Large doses
Large doses for > 3 months
108
Biphosphonates MHRA warnings
Atypical femoral fractures - report thigh, hip, groin pain
Osteonecrosis of jaw - report dental pain, swelling, non-healing sores, discharge
Osteonecrosis of external auditory canal - report ear pain, discharge, ear infection
109
Side effects of biphosphonates
Oesophageal reactions - report and stop it irritation, heartburn, dysphagia
110
Alendronic acid administration
Take 30mins before breakfast and other oral meds with full glass of water
111
Risedronate sodium administration
Take 30 mins before breakfast OR leave 2 hours before food and drink with full glass of water
112
Natural oestrogens(3)
Estradiol
Estrone
Estriol
113
Synthetic oestrogens (2)
Ethinylestradiol
Mestranol
114
Progestogens (3)
Norethisterone
Levonorgestrel
Desogestrel
115
HRT regimen women with uterus (3)
Oestrogen WITH cyclical progestrogen for last 12-14 days of cycle
Continuous oestrogen WITH progestrogen
Continuous combined and tibolone avoided in perimenopause/ within 12 months of last menstrual period
116
HRT breast cancer risk (3)
Increased risk after 1yr - longer use = higher risk
Risk is higher in combined HRT over oestrogen only
Excess risk persists for 10ths
117
HRT endometrial cancer risk (2)
Risk lower in combined HRT
Also increased risk with tibolone
118
HRT ovarian cancer risk (2)
Small increased risk
Disappears few years after stopping
119
HRT VTE risk
Increased risk of DVT with HRT
120
HRT stroke risk (2)
Slight increase with oestrogen only and combined
Tibolone increases risk 2.2x in first year of treatment
121
HRT coronary heart disease risk
Increased risk in combined when >10yrs after menopause
122
HRT regimen women without uterus
Continuous oestrogen use
Consider addition of progesterone in endometriosis
123
HRT in elective surgery
STOP 4-6 weeks before surgery
Reinitiate when fully mobile
124
HRT in non elective surgery
Prophylactic heparin
Graduated compression stockings
125
Reasons to stop HRT (7)
Sudden severe chest pain/breathlessness
Unexplained swelling/ seve pain in calf/leg
Severe stomach pain
Serious neurological effects
Hepatitis/jaundice
BP >160mmHg/95mmHg
Prolonged immobility
126
Reaction of high levels of T3 and T4
Suppress function/production of TSH/TRH
127
Hormone levels in hyperthyroidism (2)
High T3 +T4
Low TSH
128
Signs/Symptoms of hyperthyroidism (7)
Hyperactivity
Insomnia
Heat intolerance
Increased appetite
Weight loss
Diarrhoea
Goitre
129
Hyperthyroidism treatment (3)
FIRST line - Carbimazole
Second line - propylthiouracil
Symptomatic relief - beta blockers
130
Carbimazole MHRA guidance (3)
Neutropenia / Agranulocytosis - report sore throat, malaise, fever
Congenital malformations - women use contraception during treatment
Acute pancreatitis - report + stop immediately
131
Cautions in propylthiouracil
Caution in liver disorder - jaundice, dark urine, nausea
132
Treatment of Graves’ disease (2)
FIRST line - radioactive iodine
Second line - Carbimazole if iodine/surgery not suitable
133
Carbimazole regimen in Graves’ disease
Block and replace regimen in combo with levothyroxine for 12-18months
134
Treatment of hyperthyroidism in pregnancy (2)
FIRST TRIMESTER - Propylthiouracil (Carbimazole congenital defects)
SECOND and THIRD trimester - Carbimazole (propylthiouracil hepatotoxicity)
135
Hormone levels in hypothyroidism
T3 + T4 low
TSH high
136
Signs/Symptoms of hypothyroidism (7)
Fatigue
Weight gain
Constipation
Depression
Dry skin
Intolerance to cold
Menstrual irregularities
137
Treatment of hypothyroidism (2)
FIRST line - Levothyroxine
Second line - Liothyronine
138
Levothyroxine monitoring
Every 3 months till stable then annually
139
Levothyroxine administration
Take in the morning 30 mins before food/caffeine
140
Levothyroxine MHRA warning
Small proportion can feel symptoms alternating brands
141
Levothyroxine Vs Liothyronine
Lio = mor rapid and potent output
20-25mg = 100mg levothyroxine
