METABOLISM & HORMONES 2 2025-2026
Diabetesmellitus-diagnose.........................................................................................................................8
Type1diabetesmellitus...........................................................................................................................11
Type2diabetesmellitus...........................................................................................................................16
Diabetesmellitus-acutecomplicaties......................................................................................................21
Acuteverwikkelingen...............................................................................................................................21
Acutehypoglycemie.................................................................................................................................21
Acutehyperglycemie................................................................................................................................26
Diabetischeketo-acidotischecoma(DKA).........................................................................................26
EuglycemischeketoacidosebijSGLT2-inhibitoren............................................................................30
Hyperosmolairnon-ketotischhyperglycemischcoma........................................................................31
Lactaatacidose.........................................................................................................................................31
Diabetesmellitus-chronischemicrovasculairecomplicaties................................................................32
Retinopathie.............................................................................................................................................37
Nefropathie...............................................................................................................................................39
Neuropathie..............................................................................................................................................43
Erectieledysfunctie..................................................................................................................................49
Diabetesmellitus-chronischemacrovasculairecomplicaties...............................................................51
Hartafwijkingen.........................................................................................................................................51
Coronairischemischhartlijden(CIHL)................................................................................................51
Hartfalen.............................................................................................................................................51
Afwijkingenvandevaten.........................................................................................................................53
Arteriëlehypertensie..........................................................................................................................53
Diabetischevoet.................................................................................................................................54
Afwijkingenvandehuid...........................................................................................................................55
Afwijkingenvandetanden.......................................................................................................................55
Infecties....................................................................................................................................................55
Diabetesmellitus-behandelingDM2-oraleantidiabetica(OAD)..........................................................56
Richtlijnen.................................................................................................................................................56
1.Levensstijl............................................................................................................................................56
2.Farmacologisch....................................................................................................................................57
Diabetesmellitus-behandelingDM2-injectables...................................................................................65
Incretines..................................................................................................................................................65
Newagents..............................................................................................................................................68
Insulines...................................................................................................................................................69
Diabetesmellitus-behandelingDM1.........................................................................................................73
Insuline.....................................................................................................................................................73
Bolusinsuline...........................................................................................................................................75
Basalinsuline...........................................................................................................................................76
Pompen....................................................................................................................................................77
Zelfmonitoring..........................................................................................................................................78
Flashmonitoring.................................................................................................................................78
Continuousglucosemonitoring(CGM)..............................................................................................79
Deartificiëlepancreas........................................................................................................................79
Diabetesmellitus-workshopinsulineregimens......................................................................................81
Insulineinitiation.......................................................................................................................................81
Insulineintensification..............................................................................................................................82
1
, iabetesmellitus-workshopOAD&GLP1RA.........................................................................................87
D
Diabetesmellitus-diabetischevoet..........................................................................................................90
Schildklier-hyperthyroïdie.......................................................................................................................100
Schildklierfunctietesten..........................................................................................................................100
Hyperthyroïdie........................................................................................................................................101
Graves-Basedow..............................................................................................................................103
Toxischschildklieradenoom.............................................................................................................108
Toxischemultinodulairegoiter..........................................................................................................108
Thyroïditis(infectieuzedestructie)....................................................................................................109
Jodium-geïnduceerdehyperthyroïdie...............................................................................................110
Iatrogenehyperthyroïdie...................................................................................................................111
Thyroïdstorm....................................................................................................................................111
Schildklier-hypothyroïdie........................................................................................................................112
Hypothyroïdie.........................................................................................................................................112
Hashimotothyroïditits=chronischautoimmunethyroïditis..............................................................114
Myxoedeemcoma............................................................................................................................115
Thyroïditis(infectieuzedestructie)....................................................................................................115
Overigevormen................................................................................................................................116
Schildklier-goiter,nodule&kanker........................................................................................................117
Euthyroïdegoiter....................................................................................................................................117
Solitairenodule......................................................................................................................................123
Schildklier-schildkliercarcinoom............................................................................................................126
Parathyroïden-hypercalciëmie................................................................................................................134
Etiologievanhypercalciëmie..................................................................................................................136
1.Hyperparathyroïdie.......................................................................................................................136
2.Hypercalcemietgvmaligniteit.......................................................................................................138
3.Granulomateuzeaandoeningen...................................................................................................138
4.Medicatie......................................................................................................................................138
5-7.Andereoorzaken.......................................................................................................................139
Diagnosevanhypercalciëmie................................................................................................................139
Behandelingvanhypercalciëmie...........................................................................................................140
Multipleendocrieneneoplasie(MEN)......................................................................................................143
2types....................................................................................................................................................143
MultipleendocrieneneoplasietypeI(MEN-I)..................................................................................143
MultipleendocrieneneoplasietypeII(MEN-II)................................................................................144
Parathyroïden-hypocalciëmie.................................................................................................................145
Oorzakenvanhypocalciëmie.................................................................................................................145
1.VerstoordvitDmetabolisme........................................................................................................145
2.Hypoparathyroïdie........................................................................................................................146
3.Pseudohypoparathyroïdie............................................................................................................147
4-7.Andereoorzaken.......................................................................................................................147
Symptomenvanhypocalciëmie.............................................................................................................148
Diagnosevanhypocalciëmie.................................................................................................................148
Behandelingvanhypocalciëmie.............................................................................................................149
Adenohypofyse-NFPA&GH-deficiëntie................................................................................................151
Hypofysetumoren...................................................................................................................................151
Hypopituïtarisme....................................................................................................................................154
GH-deficiëntie........................................................................................................................................160
Adenohypofyse-acromegalie&hyperprolactinemie............................................................................162
2
, cromegalie...........................................................................................................................................162
A
Hyperprolactinemie................................................................................................................................168
Neurohypofyse-diabetesinsipidus........................................................................................................173
Diabetesinsipidus..................................................................................................................................173
SyndromeofinappropriateADHsecretie(SIADH)................................................................................177
Bijnieren-Cushing....................................................................................................................................180
Etiologie.................................................................................................................................................180
Epidemiologie.........................................................................................................................................181
Symptomen&kliniek..............................................................................................................................181
Screening...............................................................................................................................................183
1.Atrandomcortisolemie.................................................................................................................183
2.24uvrijecortisolurie(UFC)...........................................................................................................183
3.Overnightdexamethasonesuppressiontest................................................................................184
3.Midnightsalivarycortisol..............................................................................................................184
SyndroomvanCushingvs.pseudo-Cushing(EXTRA)....................................................................184
Aanpak.............................................................................................................................................184
Diagnostiek............................................................................................................................................185
Behandelinghypercorticisme.................................................................................................................186
Bijnieren-Addison....................................................................................................................................188
Bijnierschorsinsufficiëntie.......................................................................................................................188
Bijnieren-primairaldosteronisme,feochromocytoom.........................................................................195
Primairhyperaldosteronisme.................................................................................................................195
Feochromocytoom.................................................................................................................................201
Surrenalehyperandrogenemie...............................................................................................................205
Bijnierincidentaloom...............................................................................................................................209
Hypogonadisme-mannen........................................................................................................................211
Hypogonadisme......................................................................................................................................211
Hypogonadotroophypogonadisme=secundairhypogonadisme..........................................................213
Kallmannsyndrome&isolatedHH...................................................................................................213
Obesitas-gerelateerdhypogonadisme.............................................................................................215
Hypergonadotroophypogonadisme=primairhypogonadisme..............................................................216
Klinefeltersyndrome.........................................................................................................................216
Anorchie...........................................................................................................................................218
Anabolesteroïden............................................................................................................................218
Hypogonadisme-vrouwen.......................................................................................................................219
Etiologie.................................................................................................................................................219
Hypogonadotroofhypogonadisme...................................................................................................220
Hypergonadotroofhypogonadisme..................................................................................................220
Gynaecomastie...........................................................................................................................................222
Gynaecomastie......................................................................................................................................222
Hirsutisme...................................................................................................................................................227
Hirsutisme..............................................................................................................................................227
Virilisatie.................................................................................................................................................228
Etiologievanhirsutisme.........................................................................................................................228
Polycysticovariansyndrome(PCOS)..............................................................................................229
Androgensecretingovariantumor...................................................................................................230
Androgensecretingadrenaltumor...................................................................................................230
Non-classicalcongenitaladrenalhyperplasia(NCAH).....................................................................230
Idiopathischhirsutisme.....................................................................................................................230
3
, valuatievanhirsutisme........................................................................................................................231
E
Behandelingvanhirsutisme...................................................................................................................231
Transgenderzorg........................................................................................................................................234
Dyslipidemie...............................................................................................................................................239
Classificatievanlipiddisorders..............................................................................................................243
Familialehypercholesterolemie(FH)................................................................................................244
Hypertriglyceridemie&Mixedhypercholesterolemie&hypertriglyceridemie(dyslipidemie)............246
Behandelingvanlipiddisorders.............................................................................................................248
Cholesterolverlagendemedicatie...........................................................................................................251
Triglyceridenverlagendemedicatie........................................................................................................256
Fibraten............................................................................................................................................256
Omega3vetzuren(EPA&DHA,Icosapentethyl)............................................................................257
Hypoglycemie.............................................................................................................................................258
Reactievehypoglycemie=pseudohypoglycemie.................................................................................259
Hypoglycemiebijill/medicatedpatients...............................................................................................260
Alcohol-inducedhypoglycemie.........................................................................................................260
Drugs-inducedhypoglycemie...........................................................................................................261
Hypoglycemiebijcriticalillness........................................................................................................261
Hypoglycemiebijhormoondeficiëntie...............................................................................................261
Extrapancreaticneoplasmatageassocieerdmethypoglycemie......................................................261
Hypoglycemiebijseeminglywellindividuals..........................................................................................262
Diagnostischeworkout.....................................................................................................................262
Insulinoma........................................................................................................................................262
Hypoglycemiedoorinsulinesecretatogen........................................................................................264
Hypoglycemiepostgastricbypass...................................................................................................264
Hypoglycemiedooraangeborenstofwisselingsstoornissen.............................................................266
Obesitas......................................................................................................................................................267
Oorzakenvanobesitas..........................................................................................................................272
Non-modifiablecauses.....................................................................................................................272
Modifiablecauses.............................................................................................................................274
Complicatiesvanobesitas.....................................................................................................................276
Evaluatievanobesitas...........................................................................................................................276
Behandelingvanobesitas......................................................................................................................279
Beeldvormingvandebijnieren.................................................................................................................285
Adrenalmasslesions.............................................................................................................................286
Hyperplasie&tumorenvandecortex..............................................................................................286
Adrenalmedullarytumoren..............................................................................................................288
Metastases.......................................................................................................................................290
Beeldvormingvandehypofyse................................................................................................................291
Casussen(zieppt).................................................................................................................................292
Liquorhypotensionsyndrome..........................................................................................................292
Idiopathicintracranialhypertension..................................................................................................292
Pathologie..............................................................................................................................................293
Intrasellairlesions.............................................................................................................................293
Suprasellarlesions...........................................................................................................................294
Pituitarystalklesions........................................................................................................................296
Takehomemessage..............................................................................................................................296
4
,EXAMEN
● 60 min. voorbereiding
● 2 grote vragen
○ 1 theoretisch (pathogenetisch, behandeling, diagnostiek)
○ 1 casus (differentiaal diagnose obv argumenten)
● in het Nederlands (vragen en antwoorden)
● de meest voorkomende aandoeningen zeker kennen (bv. als je al de uitzonderlijke aandoeningen
kent, maar niets over DM dan buis je)
5
,Diabetes mellitus - diagnose
Diabetes mellitus
= metabole ziekte, primair gekenmerkt door hyperglycemie
● oorzaak
○ type 1(10-15%): absoluut insulinetekort
○ type 2(85-90%): relatief gebrek aan insuline met/zonderinsuline-resistentie
● gevolgen
○ stoornissen in het koolhydraatmetabolisme (CHO), eiwit- en vetstofwisseling
○ chronische hyperglycemie → langetermijncomplicaties
■ microvasculair: retinopathie, nefropathie, neuropathie
■ macrovasculair: hart- en vaatziekten
Prevalentie
● toenemende prevalentie in België
○ 8% gediagnosticeerd (waarschijnlijk onderschatting)
○ 7% impaired glucose tolerance (IGT) → indicatie van pre-diabetes
○ bij > 65 jaar: > 20% prevalentie (vnl type 2)
● bijdragende factoren & risicofactoren
○ leeftijd
○ sedentaire levensstijl
■ studie: elke 2u/dag toename in TV-kijken is
geassocieerd met 23% toename van obesitas en
14% toegenomen risico op diabetes
○ BMI > 30 kg/m² (voor Aziaten: > 25 kg/m²)
○ buikomtrek (indirecte indicator om visceraal vet te meten)
○ dieet (uitsluitend groenten, fruit, bessen)
○ roken (niet geïncludeerd in FINDRISC risico-inschatting)
○ familiale voorgeschiedenis
Diabetes risico inschatting
FINDRISC vragenlijst
● factoren
○ leeftijd
○ BMI, buikomtrek
○ lichaamsbeweging
○ dieet
○ bloeddruk (screening voor type 2 diabetes tijdens
zwangerschap)
○ bloedsuikerwaarde
○ familiale voorgeschiedenis, erfelijkheid
● interpretatie
1-6 punten 1/100 kans op DM binnen 10 jaar
7-11 punten 1/25 kans blijf gezond eten en goed bewegen
12-14 punten ⅙ kans ezonde voeding en beweging
g
ga naar huisarts voor nuchtere bloedsuikerbepaling
15-20 punten ⅓ kans a naar huisarts voor nuchtere bloedsuikerbepaling
g
maak dringend werk van gezonde levensstijl (beweging,
groenten, fruit)
21-26 punten ½ kans a naar huisarts voor nuchtere bloedsuikerbepaling
g
maak dringend werk van gezonde levensstijl (beweging,
groenten, fruit)
misschien hebt u al diabetes zonder het te weten?
6
,risico op ontwikkeling van diabetes bij prediabetes
● IFG / IGT → 5-7% kans op DM binnen het jaar
● IFG + IGT → 10-13% kans op DM binnen het jaar
⇒ prediabetes is een enorme risicofactor voor het ontwikkelen van diabetes
studieover invloed van levensstijl en dieet
● methode: patiënten met prediabetes (IFG of IGT) randomiseren
○ interventie: 30 min. fysieke activiteit elke dag
○ control: sedentaire levensstijl
● resultaat: 60% reductie van diabetesrisico na 6 jaar
Diagnose
diagnostische criteria voor diabetes
● Hb A1C≥ 6.5%
○ Hb A1C(geglyceerd hemoglobine): parameter die degemiddelde suikerspiegel weergeeft
over de afgelopen 3 maanden (levensduur RBC: 120 dagen)
● FPG≥ 126 mg/dl (7.0 mmol/l)
○ FPG = fasting plasma glucose = nuchtere glycemie (na minstens 8 uur vasten)
○ conversiefactor voor mg/dl → mmol/l = 18
● 2-h plasma glucose≥ 200 mg/dl (11.1 mmol/l)
○ gemeten tijdens orale glucose tolerantie test (OGTT)met 75 g anhydrous glucose opgelost
in water
● random plasma glucose≥ 200 mg/dl (11.1 mmol/l) bij een patiënt met klassieke symptomen van
hyperglycemie of hyperglycemische crisis
○ klassieke symptomen: polydipsie, pollakisurie/polyurie, nycturie …
bij afwezigheid van ondubbelzinnige hyperglycemie moeten criteria 1-3 worden bevestigd door herhaalde
⇒
tests
⇒ elke afwijkende glucosespiegel moet gecontroleerd/bevestigd worden op een andere dag om de
diagnose van DM te kunnen stellen (stress-hyperglycemie uitsluiten: infectie, trauma, chirurgie, INZO)
orale glucosetolerantiestest (OGTT)= suikerbelastingstest
● doel: diagnose van diabetes bevestigen
○ prediabetes:β-cellen zijn niet meer in staat om grote hoeveelheden glucose te verwerken
■ 100-125 mg/dl: gestoorde nuchtere glycemie = impaired fasting glucose (IFG)
■ 140-199 mg/dl: gestoorde glucosetolerantie = impaired glucose tolerance (IGT)
○ diabetes mellitus
■ nuchter:≥ 126 mg/dl
■ 2-h plasma glucose:≥ 200 mg/dl
● opmerking: cut-offs liggen lager tijdens de zwangerschap !
● verloop
1. eerste bloedstaal prikken in nuchtere omstandigheden
2. 75 g glucose drinken in 5 minuten
3. om de 30 minuten, gedurende minimum 2 uur, veneuze stalen afnemen
7
, ADA classificatie
type 1 diabetes (10-15%)(= juveniele diabetes)
●
● type 2 diabetes (85-90%)(= ouderdomsdiabetes)
● andere specifieke types
○ endocrinopathie: Cushing (cortisol), acromegalie (groeihormoon), feochromocytoom
(adrenerg), glucagonoma (glucagon)
○ medicatie-geïnduceerd: anti-HIV medicatie (HAART), corticosteroïden, diuretica (thiaziden),
atypische antipsychotica,β-blokkers
○ pancreaspathologie: chronische/recurrente pancreatitis, pancreascarcinoom,
hemochromatosis
○ insuline (receptor) abnormaliteiten: insulinopathie, receptor defect, circulerende antireceptor
antilichamen, genmutaties
○ erfelijk: maturity onset diabetes of the young (MODY)
○ geassocieerde genetische syndromen
■ DIDMOAD syndrome= diabetes insipidus, diabetes mellitus,optic atrophy and
deafness =Wolfram syndrome
■ lipoathrophic diabetes
■ cystic fibrosis
● zwangerschapsdiabetes (10-12% prevalentie)
Zwangerschapsdiabetes (GDM)
= alle vormen van diabetes die tijdens de zwangerschap ontstaan
p
● revalentie: 10-12%
● op latere leeftijd bepalen of patiënt zwangerschapsdiabetes heeft gehad obv gewicht van baby →
macrosomie (> 4 kg)
● pathogenese
○ tijdens zwangerschap: afgenomen insulinegevoeligheid + verminderde insulinesecretie
○ normaal: hyperglycemie verdwijnt onmiddelijk na partus
○ daarna: verhoogd risico op type 2 DM
diagnostiek: two-step approach
● indien FPG < 100 mg/dl + 24 weken zwanger → 50 g glucose challenge test (GCT)
○ indien < 130 mg/dl → geen GDM
○ indien≥ 130 mg/dl → doorverwijzen voor OGTT
● indien FPG 100-125 mg/dl + 24-28 weken zwanger → 75 g OGTT
○ GDM indien fasting≥ 92 mg/dl (↔ 126 mg/dl indien niet zwanger)
○ GDM indien 2-h plasma glucose≥ 153 mg/dl (↔ 200 mg/dl indien niet zwanger)
○ lagere cut-offs omdat tijdens 2e helft van de zwangerschap hoge glucoselevels
transplacentair naar de foetus gaan → activatie van foetale pancreas door hyperglycemie →
inductie van insuline → insuline fungeert als belangrijk groeihormoon → macrosomie
● indien hoogrisico zwangerschap: 75 g OGTT op 20 weken
○ obesitas (BMI ≥ 30 kg/m2)
○ familiaal eerstegraadsverwanten met diabetes mellitus
○ vorige zwangerschap met gestational diabetes
○ geboortegewicht van een vorig kind > 4500 gram, of macrosomie
○ mors in utero bij vorige zwangerschap zonder duidelijke etiologie
○ vorig kind met onverklaarde congenitale afwijking
○ vorige zwangerschap met polyhydramnios
8
Diabetesmellitus-diagnose.........................................................................................................................8
Type1diabetesmellitus...........................................................................................................................11
Type2diabetesmellitus...........................................................................................................................16
Diabetesmellitus-acutecomplicaties......................................................................................................21
Acuteverwikkelingen...............................................................................................................................21
Acutehypoglycemie.................................................................................................................................21
Acutehyperglycemie................................................................................................................................26
Diabetischeketo-acidotischecoma(DKA).........................................................................................26
EuglycemischeketoacidosebijSGLT2-inhibitoren............................................................................30
Hyperosmolairnon-ketotischhyperglycemischcoma........................................................................31
Lactaatacidose.........................................................................................................................................31
Diabetesmellitus-chronischemicrovasculairecomplicaties................................................................32
Retinopathie.............................................................................................................................................37
Nefropathie...............................................................................................................................................39
Neuropathie..............................................................................................................................................43
Erectieledysfunctie..................................................................................................................................49
Diabetesmellitus-chronischemacrovasculairecomplicaties...............................................................51
Hartafwijkingen.........................................................................................................................................51
Coronairischemischhartlijden(CIHL)................................................................................................51
Hartfalen.............................................................................................................................................51
Afwijkingenvandevaten.........................................................................................................................53
Arteriëlehypertensie..........................................................................................................................53
Diabetischevoet.................................................................................................................................54
Afwijkingenvandehuid...........................................................................................................................55
Afwijkingenvandetanden.......................................................................................................................55
Infecties....................................................................................................................................................55
Diabetesmellitus-behandelingDM2-oraleantidiabetica(OAD)..........................................................56
Richtlijnen.................................................................................................................................................56
1.Levensstijl............................................................................................................................................56
2.Farmacologisch....................................................................................................................................57
Diabetesmellitus-behandelingDM2-injectables...................................................................................65
Incretines..................................................................................................................................................65
Newagents..............................................................................................................................................68
Insulines...................................................................................................................................................69
Diabetesmellitus-behandelingDM1.........................................................................................................73
Insuline.....................................................................................................................................................73
Bolusinsuline...........................................................................................................................................75
Basalinsuline...........................................................................................................................................76
Pompen....................................................................................................................................................77
Zelfmonitoring..........................................................................................................................................78
Flashmonitoring.................................................................................................................................78
Continuousglucosemonitoring(CGM)..............................................................................................79
Deartificiëlepancreas........................................................................................................................79
Diabetesmellitus-workshopinsulineregimens......................................................................................81
Insulineinitiation.......................................................................................................................................81
Insulineintensification..............................................................................................................................82
1
, iabetesmellitus-workshopOAD&GLP1RA.........................................................................................87
D
Diabetesmellitus-diabetischevoet..........................................................................................................90
Schildklier-hyperthyroïdie.......................................................................................................................100
Schildklierfunctietesten..........................................................................................................................100
Hyperthyroïdie........................................................................................................................................101
Graves-Basedow..............................................................................................................................103
Toxischschildklieradenoom.............................................................................................................108
Toxischemultinodulairegoiter..........................................................................................................108
Thyroïditis(infectieuzedestructie)....................................................................................................109
Jodium-geïnduceerdehyperthyroïdie...............................................................................................110
Iatrogenehyperthyroïdie...................................................................................................................111
Thyroïdstorm....................................................................................................................................111
Schildklier-hypothyroïdie........................................................................................................................112
Hypothyroïdie.........................................................................................................................................112
Hashimotothyroïditits=chronischautoimmunethyroïditis..............................................................114
Myxoedeemcoma............................................................................................................................115
Thyroïditis(infectieuzedestructie)....................................................................................................115
Overigevormen................................................................................................................................116
Schildklier-goiter,nodule&kanker........................................................................................................117
Euthyroïdegoiter....................................................................................................................................117
Solitairenodule......................................................................................................................................123
Schildklier-schildkliercarcinoom............................................................................................................126
Parathyroïden-hypercalciëmie................................................................................................................134
Etiologievanhypercalciëmie..................................................................................................................136
1.Hyperparathyroïdie.......................................................................................................................136
2.Hypercalcemietgvmaligniteit.......................................................................................................138
3.Granulomateuzeaandoeningen...................................................................................................138
4.Medicatie......................................................................................................................................138
5-7.Andereoorzaken.......................................................................................................................139
Diagnosevanhypercalciëmie................................................................................................................139
Behandelingvanhypercalciëmie...........................................................................................................140
Multipleendocrieneneoplasie(MEN)......................................................................................................143
2types....................................................................................................................................................143
MultipleendocrieneneoplasietypeI(MEN-I)..................................................................................143
MultipleendocrieneneoplasietypeII(MEN-II)................................................................................144
Parathyroïden-hypocalciëmie.................................................................................................................145
Oorzakenvanhypocalciëmie.................................................................................................................145
1.VerstoordvitDmetabolisme........................................................................................................145
2.Hypoparathyroïdie........................................................................................................................146
3.Pseudohypoparathyroïdie............................................................................................................147
4-7.Andereoorzaken.......................................................................................................................147
Symptomenvanhypocalciëmie.............................................................................................................148
Diagnosevanhypocalciëmie.................................................................................................................148
Behandelingvanhypocalciëmie.............................................................................................................149
Adenohypofyse-NFPA&GH-deficiëntie................................................................................................151
Hypofysetumoren...................................................................................................................................151
Hypopituïtarisme....................................................................................................................................154
GH-deficiëntie........................................................................................................................................160
Adenohypofyse-acromegalie&hyperprolactinemie............................................................................162
2
, cromegalie...........................................................................................................................................162
A
Hyperprolactinemie................................................................................................................................168
Neurohypofyse-diabetesinsipidus........................................................................................................173
Diabetesinsipidus..................................................................................................................................173
SyndromeofinappropriateADHsecretie(SIADH)................................................................................177
Bijnieren-Cushing....................................................................................................................................180
Etiologie.................................................................................................................................................180
Epidemiologie.........................................................................................................................................181
Symptomen&kliniek..............................................................................................................................181
Screening...............................................................................................................................................183
1.Atrandomcortisolemie.................................................................................................................183
2.24uvrijecortisolurie(UFC)...........................................................................................................183
3.Overnightdexamethasonesuppressiontest................................................................................184
3.Midnightsalivarycortisol..............................................................................................................184
SyndroomvanCushingvs.pseudo-Cushing(EXTRA)....................................................................184
Aanpak.............................................................................................................................................184
Diagnostiek............................................................................................................................................185
Behandelinghypercorticisme.................................................................................................................186
Bijnieren-Addison....................................................................................................................................188
Bijnierschorsinsufficiëntie.......................................................................................................................188
Bijnieren-primairaldosteronisme,feochromocytoom.........................................................................195
Primairhyperaldosteronisme.................................................................................................................195
Feochromocytoom.................................................................................................................................201
Surrenalehyperandrogenemie...............................................................................................................205
Bijnierincidentaloom...............................................................................................................................209
Hypogonadisme-mannen........................................................................................................................211
Hypogonadisme......................................................................................................................................211
Hypogonadotroophypogonadisme=secundairhypogonadisme..........................................................213
Kallmannsyndrome&isolatedHH...................................................................................................213
Obesitas-gerelateerdhypogonadisme.............................................................................................215
Hypergonadotroophypogonadisme=primairhypogonadisme..............................................................216
Klinefeltersyndrome.........................................................................................................................216
Anorchie...........................................................................................................................................218
Anabolesteroïden............................................................................................................................218
Hypogonadisme-vrouwen.......................................................................................................................219
Etiologie.................................................................................................................................................219
Hypogonadotroofhypogonadisme...................................................................................................220
Hypergonadotroofhypogonadisme..................................................................................................220
Gynaecomastie...........................................................................................................................................222
Gynaecomastie......................................................................................................................................222
Hirsutisme...................................................................................................................................................227
Hirsutisme..............................................................................................................................................227
Virilisatie.................................................................................................................................................228
Etiologievanhirsutisme.........................................................................................................................228
Polycysticovariansyndrome(PCOS)..............................................................................................229
Androgensecretingovariantumor...................................................................................................230
Androgensecretingadrenaltumor...................................................................................................230
Non-classicalcongenitaladrenalhyperplasia(NCAH).....................................................................230
Idiopathischhirsutisme.....................................................................................................................230
3
, valuatievanhirsutisme........................................................................................................................231
E
Behandelingvanhirsutisme...................................................................................................................231
Transgenderzorg........................................................................................................................................234
Dyslipidemie...............................................................................................................................................239
Classificatievanlipiddisorders..............................................................................................................243
Familialehypercholesterolemie(FH)................................................................................................244
Hypertriglyceridemie&Mixedhypercholesterolemie&hypertriglyceridemie(dyslipidemie)............246
Behandelingvanlipiddisorders.............................................................................................................248
Cholesterolverlagendemedicatie...........................................................................................................251
Triglyceridenverlagendemedicatie........................................................................................................256
Fibraten............................................................................................................................................256
Omega3vetzuren(EPA&DHA,Icosapentethyl)............................................................................257
Hypoglycemie.............................................................................................................................................258
Reactievehypoglycemie=pseudohypoglycemie.................................................................................259
Hypoglycemiebijill/medicatedpatients...............................................................................................260
Alcohol-inducedhypoglycemie.........................................................................................................260
Drugs-inducedhypoglycemie...........................................................................................................261
Hypoglycemiebijcriticalillness........................................................................................................261
Hypoglycemiebijhormoondeficiëntie...............................................................................................261
Extrapancreaticneoplasmatageassocieerdmethypoglycemie......................................................261
Hypoglycemiebijseeminglywellindividuals..........................................................................................262
Diagnostischeworkout.....................................................................................................................262
Insulinoma........................................................................................................................................262
Hypoglycemiedoorinsulinesecretatogen........................................................................................264
Hypoglycemiepostgastricbypass...................................................................................................264
Hypoglycemiedooraangeborenstofwisselingsstoornissen.............................................................266
Obesitas......................................................................................................................................................267
Oorzakenvanobesitas..........................................................................................................................272
Non-modifiablecauses.....................................................................................................................272
Modifiablecauses.............................................................................................................................274
Complicatiesvanobesitas.....................................................................................................................276
Evaluatievanobesitas...........................................................................................................................276
Behandelingvanobesitas......................................................................................................................279
Beeldvormingvandebijnieren.................................................................................................................285
Adrenalmasslesions.............................................................................................................................286
Hyperplasie&tumorenvandecortex..............................................................................................286
Adrenalmedullarytumoren..............................................................................................................288
Metastases.......................................................................................................................................290
Beeldvormingvandehypofyse................................................................................................................291
Casussen(zieppt).................................................................................................................................292
Liquorhypotensionsyndrome..........................................................................................................292
Idiopathicintracranialhypertension..................................................................................................292
Pathologie..............................................................................................................................................293
Intrasellairlesions.............................................................................................................................293
Suprasellarlesions...........................................................................................................................294
Pituitarystalklesions........................................................................................................................296
Takehomemessage..............................................................................................................................296
4
,EXAMEN
● 60 min. voorbereiding
● 2 grote vragen
○ 1 theoretisch (pathogenetisch, behandeling, diagnostiek)
○ 1 casus (differentiaal diagnose obv argumenten)
● in het Nederlands (vragen en antwoorden)
● de meest voorkomende aandoeningen zeker kennen (bv. als je al de uitzonderlijke aandoeningen
kent, maar niets over DM dan buis je)
5
,Diabetes mellitus - diagnose
Diabetes mellitus
= metabole ziekte, primair gekenmerkt door hyperglycemie
● oorzaak
○ type 1(10-15%): absoluut insulinetekort
○ type 2(85-90%): relatief gebrek aan insuline met/zonderinsuline-resistentie
● gevolgen
○ stoornissen in het koolhydraatmetabolisme (CHO), eiwit- en vetstofwisseling
○ chronische hyperglycemie → langetermijncomplicaties
■ microvasculair: retinopathie, nefropathie, neuropathie
■ macrovasculair: hart- en vaatziekten
Prevalentie
● toenemende prevalentie in België
○ 8% gediagnosticeerd (waarschijnlijk onderschatting)
○ 7% impaired glucose tolerance (IGT) → indicatie van pre-diabetes
○ bij > 65 jaar: > 20% prevalentie (vnl type 2)
● bijdragende factoren & risicofactoren
○ leeftijd
○ sedentaire levensstijl
■ studie: elke 2u/dag toename in TV-kijken is
geassocieerd met 23% toename van obesitas en
14% toegenomen risico op diabetes
○ BMI > 30 kg/m² (voor Aziaten: > 25 kg/m²)
○ buikomtrek (indirecte indicator om visceraal vet te meten)
○ dieet (uitsluitend groenten, fruit, bessen)
○ roken (niet geïncludeerd in FINDRISC risico-inschatting)
○ familiale voorgeschiedenis
Diabetes risico inschatting
FINDRISC vragenlijst
● factoren
○ leeftijd
○ BMI, buikomtrek
○ lichaamsbeweging
○ dieet
○ bloeddruk (screening voor type 2 diabetes tijdens
zwangerschap)
○ bloedsuikerwaarde
○ familiale voorgeschiedenis, erfelijkheid
● interpretatie
1-6 punten 1/100 kans op DM binnen 10 jaar
7-11 punten 1/25 kans blijf gezond eten en goed bewegen
12-14 punten ⅙ kans ezonde voeding en beweging
g
ga naar huisarts voor nuchtere bloedsuikerbepaling
15-20 punten ⅓ kans a naar huisarts voor nuchtere bloedsuikerbepaling
g
maak dringend werk van gezonde levensstijl (beweging,
groenten, fruit)
21-26 punten ½ kans a naar huisarts voor nuchtere bloedsuikerbepaling
g
maak dringend werk van gezonde levensstijl (beweging,
groenten, fruit)
misschien hebt u al diabetes zonder het te weten?
6
,risico op ontwikkeling van diabetes bij prediabetes
● IFG / IGT → 5-7% kans op DM binnen het jaar
● IFG + IGT → 10-13% kans op DM binnen het jaar
⇒ prediabetes is een enorme risicofactor voor het ontwikkelen van diabetes
studieover invloed van levensstijl en dieet
● methode: patiënten met prediabetes (IFG of IGT) randomiseren
○ interventie: 30 min. fysieke activiteit elke dag
○ control: sedentaire levensstijl
● resultaat: 60% reductie van diabetesrisico na 6 jaar
Diagnose
diagnostische criteria voor diabetes
● Hb A1C≥ 6.5%
○ Hb A1C(geglyceerd hemoglobine): parameter die degemiddelde suikerspiegel weergeeft
over de afgelopen 3 maanden (levensduur RBC: 120 dagen)
● FPG≥ 126 mg/dl (7.0 mmol/l)
○ FPG = fasting plasma glucose = nuchtere glycemie (na minstens 8 uur vasten)
○ conversiefactor voor mg/dl → mmol/l = 18
● 2-h plasma glucose≥ 200 mg/dl (11.1 mmol/l)
○ gemeten tijdens orale glucose tolerantie test (OGTT)met 75 g anhydrous glucose opgelost
in water
● random plasma glucose≥ 200 mg/dl (11.1 mmol/l) bij een patiënt met klassieke symptomen van
hyperglycemie of hyperglycemische crisis
○ klassieke symptomen: polydipsie, pollakisurie/polyurie, nycturie …
bij afwezigheid van ondubbelzinnige hyperglycemie moeten criteria 1-3 worden bevestigd door herhaalde
⇒
tests
⇒ elke afwijkende glucosespiegel moet gecontroleerd/bevestigd worden op een andere dag om de
diagnose van DM te kunnen stellen (stress-hyperglycemie uitsluiten: infectie, trauma, chirurgie, INZO)
orale glucosetolerantiestest (OGTT)= suikerbelastingstest
● doel: diagnose van diabetes bevestigen
○ prediabetes:β-cellen zijn niet meer in staat om grote hoeveelheden glucose te verwerken
■ 100-125 mg/dl: gestoorde nuchtere glycemie = impaired fasting glucose (IFG)
■ 140-199 mg/dl: gestoorde glucosetolerantie = impaired glucose tolerance (IGT)
○ diabetes mellitus
■ nuchter:≥ 126 mg/dl
■ 2-h plasma glucose:≥ 200 mg/dl
● opmerking: cut-offs liggen lager tijdens de zwangerschap !
● verloop
1. eerste bloedstaal prikken in nuchtere omstandigheden
2. 75 g glucose drinken in 5 minuten
3. om de 30 minuten, gedurende minimum 2 uur, veneuze stalen afnemen
7
, ADA classificatie
type 1 diabetes (10-15%)(= juveniele diabetes)
●
● type 2 diabetes (85-90%)(= ouderdomsdiabetes)
● andere specifieke types
○ endocrinopathie: Cushing (cortisol), acromegalie (groeihormoon), feochromocytoom
(adrenerg), glucagonoma (glucagon)
○ medicatie-geïnduceerd: anti-HIV medicatie (HAART), corticosteroïden, diuretica (thiaziden),
atypische antipsychotica,β-blokkers
○ pancreaspathologie: chronische/recurrente pancreatitis, pancreascarcinoom,
hemochromatosis
○ insuline (receptor) abnormaliteiten: insulinopathie, receptor defect, circulerende antireceptor
antilichamen, genmutaties
○ erfelijk: maturity onset diabetes of the young (MODY)
○ geassocieerde genetische syndromen
■ DIDMOAD syndrome= diabetes insipidus, diabetes mellitus,optic atrophy and
deafness =Wolfram syndrome
■ lipoathrophic diabetes
■ cystic fibrosis
● zwangerschapsdiabetes (10-12% prevalentie)
Zwangerschapsdiabetes (GDM)
= alle vormen van diabetes die tijdens de zwangerschap ontstaan
p
● revalentie: 10-12%
● op latere leeftijd bepalen of patiënt zwangerschapsdiabetes heeft gehad obv gewicht van baby →
macrosomie (> 4 kg)
● pathogenese
○ tijdens zwangerschap: afgenomen insulinegevoeligheid + verminderde insulinesecretie
○ normaal: hyperglycemie verdwijnt onmiddelijk na partus
○ daarna: verhoogd risico op type 2 DM
diagnostiek: two-step approach
● indien FPG < 100 mg/dl + 24 weken zwanger → 50 g glucose challenge test (GCT)
○ indien < 130 mg/dl → geen GDM
○ indien≥ 130 mg/dl → doorverwijzen voor OGTT
● indien FPG 100-125 mg/dl + 24-28 weken zwanger → 75 g OGTT
○ GDM indien fasting≥ 92 mg/dl (↔ 126 mg/dl indien niet zwanger)
○ GDM indien 2-h plasma glucose≥ 153 mg/dl (↔ 200 mg/dl indien niet zwanger)
○ lagere cut-offs omdat tijdens 2e helft van de zwangerschap hoge glucoselevels
transplacentair naar de foetus gaan → activatie van foetale pancreas door hyperglycemie →
inductie van insuline → insuline fungeert als belangrijk groeihormoon → macrosomie
● indien hoogrisico zwangerschap: 75 g OGTT op 20 weken
○ obesitas (BMI ≥ 30 kg/m2)
○ familiaal eerstegraadsverwanten met diabetes mellitus
○ vorige zwangerschap met gestational diabetes
○ geboortegewicht van een vorig kind > 4500 gram, of macrosomie
○ mors in utero bij vorige zwangerschap zonder duidelijke etiologie
○ vorig kind met onverklaarde congenitale afwijking
○ vorige zwangerschap met polyhydramnios
8
