Endocrinology: top- decile quiz SBA Quiz Quiz Dr Shuaib Siddiqui, MB BChir MRCP FY3 doctor Endocrinology series Content reviewed on the 05/05/2020.
SBA Quiz • Interactive SBA quiz competition • Some answers are scored based on speed as well as accuracy • Topics covered: endocrinology • Total 14 questions • All answers to the SBAs will be uploaded after the webinar 2 www.bitemedicine.com Instagram: @bitemedicine Facebook: /biteemedicine
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Acromegaly: pathophysiology 4 www.bitemedicine.com Instagram: @bitemedicine Facebook: /biteemedicine
Acromegaly: investigations Beside • ECG: acromegaly can cause cardiomyopathy and heart failure Bloods • Insulin-like growth factor 1: first line investigation and raised in disease • Oral glucose tolerance test: a glucose load should cause suppression of GH normally. In acromegaly, there is failure of GH suppression Imaging • Pituitary MRI: visualisation of pituitary adenoma • CT chest, abdomen and pelvis: very rarely can be due to an ectopic source Special tests • Visual field testing 5 www.bitemedicine.com Instagram: @bitemedicine Facebook: /biteemedicine
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Prolactinoma: pathophysiology
Prolactinoma: management Medical Dopamine agonist: cabergoline is preferred; dose increased for larger tumours • Surgical • Trans-sphenoidal surgery: if unresponsive or unable to tolerate medical therapy Pregnancy Discontinue dopamine agonist as soon as possible (most patients) • Selected patients with macroadenomas may continue medical therapy • 8 www.bitemedicine.com Instagram: @bitemedicine Facebook: /biteemedicine
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Hyperthyroidism: aetiology 10 www.bitemedicine.com Instagram: @bitemedicine Facebook: /biteemedicine
Primary hyperthyroidism: aetiology Graves’ disease • Anti-TSH receptor antibodies • Most common cause of hyperthyroidism (75%) • Diffuse goitre and thyroid eye signs Toxic multinodular goitre • Iodine deficiency • Compensatory TSH secretion • Nodular goitre formation • Nodules become TSH-independent and thyroid hormones (1) 11 www.bitemedicine.com Instagram: @bitemedicine Facebook: /biteemedicine
Secondary hyperthyroidism: aetiology Pituitary adenoma Ectopic tumour Hypothalamic tumour • • • TSH-secreting pituitary T4 secreting tumour (struma Excessive TRH secretion • adenoma ovarii) Rare cause of • hCG-secreting tumours (e.g. hyperthyroidism choriocarcinoma) Choriocarcinoma (2) 12 www.bitemedicine.com Instagram: @bitemedicine Facebook: /biteemedicine
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Thyroid disease: autoantibodies Thyroid autoantibodies Autoantibody Condition Prevalence Anti-TSH receptor Graves’ disease 90-100% Hashimoto’s thyroiditis 0-5% Anti-TPO Graves’ disease 70-80% Hashimoto’s thyroiditis 90-95% Anti-thyroglobulin Graves’ disease 20-40% Hashimoto’s thyroiditis 30-50% 14 www.bitemedicine.com Instagram: @bitemedicine Facebook: /biteemedicine
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Graves’ disease: management Antithyroid medication: • Carbimazole: usually first-line • Propylthiouracil : first-line pre-pregnancy or in the first trimester • Titration : titrate down to lowest effective dose • Block and replace : levothyroxine is added as needed Radioiodine: • First-line definitive management in Graves' and toxic multinodular goitre • Contraindicated in pregnancy, breastfeeding, and thyroid eye disease • Offer patient advice Surgery : total or hemithyroidectomy • Requires pre-operative optimisation • Be aware of the risks Other : consider propranolol for symptomatic relief 16 www.bitemedicine.com Instagram: @bitemedicine Facebook: /biteemedicine
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Hypothyroidism: aetiology TSH Free T4 ↑ ↓ Overt hypothyroidism ↑ Subclinical ↔ hypothyroidism 19 www.bitemedicine.com Instagram: @bitemedicine Facebook: /biteemedicine
Hypothyroidism: management Overt hypothyroidism: • Levothyroxine (T4): offer levothyroxine with regular review of symptoms and TSH every 3 months • Pregnancy: increase dose • Ischaemic heart disease: reduce dose • Iron supplementation: reduces absorption so take 4 hours apart Subclinical hypothyroidism: • The below must be measured on 2 separate occasions 3 months apart: • TSH > 10 mU/L and normal T4: consider levothyroxine if TSH persistently > 10mU/L • TSH < 10 mU/L and normal T4: consider levothyroxine if symptomatic and < 65 years old • In all other cases observation is indicated 20 www.bitemedicine.com Instagram: @bitemedicine Facebook: /biteemedicine
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T1DM: management Urgent referral to diabetes specialist team Lifestyle • Diet high in fibre and low in fat, sugar, and salt • Educate regarding carbohydrate counting; allows insulin dose to be matched to intake Insulin therapy • Basal-bolus: first-line, long-acting regularly (basal) with rapid-acting insulin before meals (bolus) • Basal : Levemir (Detemir) given BD. Lantus (Glargine) is an alternative • Bolus : Novorapid (Aspart) • Mixed insulin regimen: mixed insulin comprises a short or rapid-acting and intermediate- acting insulin BD • Used when unable to tolerate basal-bolus regime • Continuous insulin infusion: disabling hypoglycaemia or persist hyperglycaemia (HbA1c >69mmol/mol) 22
T1DM: insulin Type Onset Duration Examples Rapid 15 mins 2-5 hours Novorapid Humalog Short 30 mins 5-9 hours Actrapid Humulin S Intermediate 2 hours 12-24 hours Humulin I Insulatard Long 2-4 hours 16-42 hours Levemir Lantus 23 www.bitemedicine.com Instagram: @bitemedicine Facebook: /biteemedicine
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DKA: diagnostic criteria Triad : hyperglycaemia, acidosis and ketonaemia Joint British Diabetes Societies (2013) Glucose > 11 mmol/L or known DM HCO3 < 15 mmol/L and/or venous pH < 7.30 Ketonaemia (>3 mmol/l) or 2+ ketonuria 25 www.bitemedicine.com Instagram: @bitemedicine Facebook: /biteemedicine
DKA: management Treatment Further information IV fluid SBP < 90 mmHg 1 litre 0.9% NaCl over 15 mins • • Call for senior help as required SBP > 90 mmHg : typical regimen 1 litre 0.9% NaCl over 1 hour • 1 litre 0.9% NaCl with KCl over next 2 hours • 1 litre 0.9% NaCl with KCl over next 2 hours • 1 litre 0.9% NaCl with KCl over next 4 hours • 1 litre 0.9% NaCl with KCl over next 4 hours • 1 litre 0.9% NaCl with KCl over next 6 hours • Insulin Fixed-rate insulin infusion : • Commence at 0.1 U/kg/h • Add in 10% dextrose once glucose levels drop below 14.0 mmol/L • Do not stop long-acting insulin 26 www.bitemedicine.com Instagram: @bitemedicine Facebook: /biteemedicine
DKA: management Serum potassium concentration (mmol/L) Potassium replacement > 5.5 None 3.5-5.5 40 mmol/L < 3.5 Consider HDU/ITU for replacement via central line • Potassium replacement: commence as per the table below • Total body potassium is low and correction of acidosis causes further reduction in potassium • Anticoagulation: patients are at increased risk of VTE • Glucose, pH, bicarbonate, ketone levels, and electrolytes should be closely monitored throughout, 1-2 hourly 27 www.bitemedicine.com Instagram: @bitemedicine Facebook: /biteemedicine
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Please note, upon reviewing this question it has been retracted as the HbA1c in the question should have been > 58 mmol/mol 29 www.bitemedicine.com Instagram: @bitemedicine Facebook: /biteemedicine
T2DM 30 www.bitemedicine.com Instagram: @bitemedicine Facebook: /biteemedicine
T2DM: medication 31 www.bitemedicine.com Instagram: @bitemedicine Facebook: /biteemedicine
T2DM: medication Drug class Side effects Biguanides GI upset AKI Sulfonylureas Hypoglycaemia Weight gain SGLT-2 inhibitor UTI Thiazolidinediones Weight gain Fluid retention DPP-4 inhibitor GI upset GLP-1 inhibitor GI upset Loss of appetite 32 www.bitemedicine.com Instagram: @bitemedicine Facebook: /biteemedicine
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Diabetes: monitoring Glucose HbA1c: measured every 3-6 months • Self-monitoring: only advised if on insulin • Retinopathy Immediate ophthalmology referral upon diagnosis and annually thereafter • Arrange urgent review thereafter if: • Acute reduction in acuity • Pre proliferative or proliferative retinopathy • Diabetic maculopathy • Diabetic foot Should be assessed at least annually; refer urgently to foot protection service if at risk (e.g. ulceration) • Diabetic nephropathy Annual measurement of eGFR and urinary albumin:creatinine ratio • 34 www.bitemedicine.com Instagram: @bitemedicine Facebook: /biteemedicine
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