High yield comprehensive revision notes on Endocrinology. Written by a top decile Cambridge University Student.
It will be covering:
- Diabetes Mellitus
- Thyroid Disorders
- Pituitary Axis
- Adrenal Gland
- Blood Pressure control
- Calcium metabolism
Signs
- Necrobiosis lipoidica diabeticorum – shiny, painless areas of
yellow/red. Associated with telangiectasia.
Complications
- Diabetic ketoacidosis
- Macrovascular
o Ischaemic heart disease
o Cerebrovascular disease
o Peripheral vascular disease
- Microvascular
o Retinopathy
o Neuropathy e.g. glove and stocking, autonomic dysfunction,
mononeuritis multiplex
o Nephropathy (nephrotic syndrome)
Pathology
- Autoimmune condition
o Reduction in pancreatic B cells and lack of insulin synthesis
o Antiglutamic acid decarboxylase (GAD) autoantibodies
found in large amount of patients
o Some evidence it may follow an environmental trigger e.g.
virus
Investigations
GP may take urinalysis / capillary glucose
WHO guidelines:
- Fasting plasma glucose >7mM
, - Plasma glucose >11.1 mM when take 2 hours after ingesting 75g of
glucose (oral glucose tolerance test)
HbA1c
- Should be monitored every 3-6 months
- Target of 48mmol/mol or lower
Management
Conservative
- Self-monitoring of blood glucose
o 4x per day, before each meal and bed
o More frequent if: hypoglycaemic episodes, during period of
illness, surrounding sport, planning pregnancy, during
pregnancy, breastfeeding
o Targets:
5-7mmol/l on waking
4-7mmol/l before meals
Medical
- Typical Insulin Regime
o Basal/background – 1-2 injections per day/insulin pump e.g.
twice-daily detemir. Second-line: once-daily glargine
o Bolus – to cover sugar/carbohydrate in food e.g. aspart,
lispro, glulisine
- Alternative
o Twice-daily mixed insulin regime – 1-3 daily injections of short
+ intermediate acting insulins mixed.
- Consider metformin if BMI >25
2. Type II Diabetes Mellitus
Overview
- Most common cause of diabetes in the developed world
- Relative deficiency of insulin due to excess of adipose tissue
- Prediabetes
o People who haven't yet met T2DM criteria but are likely to
develop the condition over the next few years
o Require close monitoring/lifestyle interventions e.g. weight
loss
Presentation
Often picked up routinely in blood tests
Other signs:
- Polydipsia
- Polyuria
Investigations
Diagnosis
, - Symptomatic patients:
o Fasting glucose >/= 7mmol/l
o Random glucose >/= 11.1 mmol/l (or after 75g oral glucose
tolerance test)
- Asymptomatic patients - above demonstrated on two separate
occasions
- HbA1c
o >/= 48mmol/mol is diagnostic of diabetes mellitus (6.5%)
o Misleading Hb1Ac can be caused by increased red cell
turnover:
Haemoglobinopathies
Haemolytic anaemia
Untreated iron deficiency anaemia
Suspected gestational diabetes
Children
HIV
Chronic kidney disease
Medications causing hyperglycaemia
Manage
ment
Conservative
- Monitoring and treating for complications related to diabetes
- Modifying cardiovascular disease risk factors
- Dietary advice
o High fibre, low glycaemic index sources of carbohydrates
o Low-fat dairy products and oily fish
o Control intake of foods containing saturated fats
o Weight loss
Medical
- First-line is metformin
o Stop during intercurrent illness - increased risk of lactic
acidosis
o CI: CKD (stop if eGFR <30); iodine-containing contrast; alcohol
abuse
- Second-line drugs include sulfonylureas, gliptins and pioglitazone
- If oral medication is not controlling blood glucose - insulin is used
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