1High-yield endocrine associations
| Finding or trigger | Classic association | The exam point |
|---|---|---|
| SGLT2 inhibitor plus fasting, surgery or bowel preparation | Euglycaemic diabetic ketoacidosis | Glucose may be near normal, so check blood ketones (ADS/ADEA/ANZCA/NZSSD alert 2023). |
| Denosumab stopped or a dose delayed | Rebound bone loss, multiple vertebral fractures | If ceasing, a bisphosphonate for at least 12 months (RACGP and Healthy Bones Australia 2024). |
| Hypertension, with or without low potassium | Primary aldosteronism | Screen with the aldosterone-to-renin ratio; most patients are normokalaemic. |
| Mild hypercalcaemia, low urine calcium | Familial hypocalciuric hypercalcaemia (CASR) | Calcium-to-creatinine clearance ratio usually below 0.01; parathyroidectomy does not help. |
| Low sodium, high potassium, hypotension, pigmentation | Primary adrenal insufficiency | Take cortisol and ACTH, then hydrocortisone 100 mg IV at once; never wait for a synacthen test. |
| Sudden headache and visual loss with a pituitary adenoma | Pituitary apoplexy | Hydrocortisone first (acute ACTH deficiency), then urgent MRI and neurosurgical review. |
| Thyrotoxicosis on amiodarone | Type 1 (iodine-induced) or type 2 (destructive thyroiditis) | Type 1: thionamide. Type 2: prednisolone. |
| Immune checkpoint inhibitors | Thyroiditis (anti-PD-1), hypophysitis (ipilimumab) | In hypophysitis, start hydrocortisone before thyroxine. |
| Medullary thyroid cancer | MEN2 (germline RET variant) | Exclude phaeochromocytoma (plasma metanephrines) before thyroid surgery. |
| Hypoglycaemia, high insulin, suppressed C-peptide | Exogenous insulin | Insulinoma and sulfonylureas raise both insulin and C-peptide. |
| Long-term lithium | Hypothyroidism, hyperparathyroidism, AVP resistance | AVP resistance (nephrogenic diabetes insipidus) does not respond to desmopressin. |
2Australia-only high-yield (won't be in UK or US banks)
Overseas banks miss these. The detail is in the Physify courses Diabetes Mellitus, Adrenal Disorders, Bone and Mineral Metabolism, and Diabetes and Endocrine Disorders in Pregnancy.
SGLT2 inhibitors and procedures (ADS/ADEA/ANZCA/NZSSD alert, May 2023). Omit for at least 3 days (the 2 days before and the day itself) for a hospital stay or bowel preparation; for day procedures without bowel preparation, the day only. Restart once eating and drinking normally.
GLP-1 receptor agonists and tirzepatide before sedation (ADS, NACOS, GESA and ANZCA, April 2025). Do not stop them electively: 24 hours of clear fluids, then the standard 6-hour fast.
PBS (October 2026). Semaglutide (Ozempic only) and dulaglutide: Authority Required, type 2 diabetes only. Tirzepatide and liraglutide, both registered in Australia (ADS 2025): not found in the PBS medicine index in October 2026. Dapagliflozin and empagliflozin: type 2 diabetes, chronic heart failure and chronic kidney disease.
Osteoporosis (RACGP and Healthy Bones Australia, 2024). A minimal trauma fracture after 50 is presumptive osteoporosis. Treat a T-score of -2.5 or lower, or -1.5 to -2.5 with FRAX major fracture risk 20% or more (hip 3% or more); very high risk, an anabolic agent first line. PBS: romosozumab and abaloparatide are listed for severe established osteoporosis, first-line and second-line.
Gestational diabetes (ADIPS 2025, MJA). Thresholds rose: 75 g OGTT fasting 5.3 to 6.9, one hour 10.6 or more, two hours 9.0 to 11.0 mmol/L; HbA1c 6.5% or more is overt diabetes in pregnancy. Early OGTT (ideally 10 to 14 weeks) after previous GDM or HbA1c 6.0 to 6.4%; otherwise 24 to 28 weeks.
Sick-day rules (Endocrine Society of Australia sick-day plan, Hormones Australia, reviewed 2023). Fever 37.5 to 38.5 C: double the glucocorticoid dose for at least 2 days; above 38.5 C or diarrhoea: triple it for at least 3 days, until well. Vomiting or persistent diarrhoea: hydrocortisone 100 mg IM or subcutaneously, which patients or family can give, then to an emergency department.
3Sample questions (Physify format)
1. A 31 year old woman has a 75 g two-hour pregnancy oral glucose tolerance test at 26 weeks' gestation: fasting 5.2 mmol/L, one hour 9.8 mmol/L, two hours 8.7 mmol/L. Her first-trimester HbA1c was 5.4% (36 mmol/mol). Under the ADIPS 2025 consensus, what is the correct interpretation?
- A. Gestational diabetes on the fasting value
- B. Gestational diabetes on the two-hour value
- C. Overt diabetes in pregnancy
- D. No gestational diabetes on these results
- E. Repeat the test at 32 weeks before deciding
Answer: D
D. Correct. ADIPS 2025 raised the thresholds to fasting 5.3, one hour 10.6 and two hours 9.0 mmol/L; every value here is below them.
A. Fasting 5.2 mmol/L met the 2014 threshold of 5.1 but is below the 2025 threshold of 5.3 mmol/L.
B. Two hours 8.7 mmol/L met the 2014 threshold of 8.5 but is below the 2025 threshold of 9.0 mmol/L.
C. Overt diabetes needs fasting 7.0 or more, two hours 11.1 or more, or HbA1c 6.5% or more.
E. The test is interpretable as it stands; repeating it adds nothing without a new clinical concern.
2. A 58 year old man with type 2 diabetes takes metformin and empagliflozin. He is booked for an elective laparoscopic cholecystectomy with a planned two-night stay. Under the ADS/ADEA/ANZCA/NZSSD periprocedural alert (May 2023), what advice about empagliflozin is correct?
- A. Continue it, including a dose on the morning of surgery
- B. Omit it on the day of surgery only, then restart that evening
- C. Omit it for the two days before surgery and on the day itself
- D. Stop it two weeks before surgery and start basal insulin
- E. Continue it and check blood ketones hourly during the operation
Answer: C
C. Correct. For surgery needing one or more days in hospital, omit for at least 3 days (the 2 days before and the day of the procedure); restart once eating and drinking normally.
A. A dose on the day of surgery leaves him exposed to periprocedural euglycaemic DKA; the alert says omit it.
B. Day-only omission is for day procedures without bowel preparation, and restarting waits for normal eating and drinking.
D. Two weeks is longer than needed and insulin is not routinely required; other glucose-lowering drugs can be increased.
E. Ketone monitoring does not replace omission; it is the fallback when the drug has not been stopped.
3. A 71 year old woman has had denosumab every six months for five years for postmenopausal osteoporosis. Her hip T-score is now -2.1 and she has had no fractures. She wishes to stop it. Under the 2024 RACGP and Healthy Bones Australia guideline, what is the most appropriate plan?
- A. Stop it and repeat a DXA scan in two years
- B. Stop it and give a bisphosphonate for at least 12 months
- C. Extend the dosing interval to once every 12 months
- D. Stop it and continue calcium and vitamin D supplements alone
- E. Stop it and start raloxifene to protect the spine
Answer: B
B. Correct. Denosumab should not be interrupted; if it is ceased, the guideline advises a bisphosphonate for a minimum of 12 months to prevent rebound bone loss.
A. Stopping without follow-on therapy risks rebound bone loss and multiple vertebral fractures.
C. Lengthening the interval lets the effect wear off and brings on the same rebound; doses are six-monthly.
D. Calcium and vitamin D alone do not prevent the rebound after denosumab.
E. The follow-on therapy the guideline names is a bisphosphonate, not a SERM.