BNF Chapter 6: Endocrine

Question 1

Why is an insulin passport for diabetics important?

Answer 1

Provides accurate identification of their current insulin therapy across healthcare sectors- errors can be severe.

Question 2

Why is it important for patients to rotate insulin injection sites frequently?

Answer 2

Injection of insulin (all types) can lead to deposits of amyloid protein under the skin (cutaneous
amyloidosis) at the injection site which interferes with insulin absorption thus it is important to rotate injection sites.

Question 3

Which safety needles are first-choice when prescribing?

Answer 3

GlucoRx Safety Pen Needle (5mm/30G or 8mm/30G)

Question 4

What are some examples of rapid-acting insulin analogues for meal-times?

Answer 4

Trurapi (insulin aspart)- preferred cost-effective option for new patients

Novorapid (insulin aspart)- an option if pt is already on novorapid, new patients should be consdiered for Trurapi instead

Fiasp (insulin aspart)

Humalog (insulin lispro)

Apidra (insulin glargine)

Question 5

What are some examples of long-acting insulins as basal?

Answer 5

Levemir (insulin detemir)- first-choice for adult type 1 diabetics

Semglee (insulin glargine biosimilar)

Lantus (insulin glargine)- an option for existing stable patients

Toujeo (insulin glargine)

Tresiba (insulin degludec)

Question 6

What is the first-choice meal-time insulin for diabetics, and why?

Answer 6

Trurapi, most cost-effective

Question 7

What is the first choice basal insulin for adult type 1 diabetics?

Answer 7

Levemir

Question 8

Insulin for Type 2 Diabetics

-Pre-mixed human insulin (commonly used twice daily regimen): Biphasic isophane insulin

-Pre-mixed analagues (an option if the patient prefers to inject insulin immediately before a meal):
*Biphasic aspart
*Biphasic lispro

Answer 8

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Question 9

More on Insulin for Type 2 Diabetics

In a meta-analysis, short-acting insulin analogues for type 2 diabetes did not improve HbA1c, hypoglycaemia,or quality of life, compared with conventional human insulin. JAPC has agreed that insulin analogues in type 2 diabetes are overused and should be considered after conventional human insulin.

Human NPH insulin is preferred, however, long acting analogues can be considered as an alternative in type 2 diabetes if:
* the person needs assistance from a carer or healthcare professional to inject insulin and use of detemir or glargine (ensure glargine prescribed as brand name) would reduce the frequency of injections from twice to once daily or
* the person’s lifestyle is restricted by recurrent symptomatic hypoglycaemic episodes or
* the person would otherwise need twice-daily NPH insulin injections in combination with oral glucoselowering drugs.

Question 10

Insulin in Type 1 Diabetics

Guidance recommends patients with type 1 diabetes should usually be offered two insulins that act in different ways:
* a background (also known as a ‘basal’ or ‘long-acting’) insulin ideally injected twice a day (insulin detemir)
AND
* a ‘quick-acting’ (also known as a ‘bolus’ or ‘rapid-acting’) insulin injected before each meal to deal with the rise in blood glucose from eating.

Answer 10

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Question 11

How much of a HbA1c reduction is considered significant in regards to antidiabetic drugs?

Answer 11

5mmol/mol (0.5%)

Question 12

What is the first-line antidiabetic drug, and how should it be initiated?

Answer 12

Metformin 500mg tablets unless CI- start low and go slow. For example, to be taken with meals for example, start metformin at 500mg od with main meal. After 1
week, increase to 500mg bd. Then increase in 500mg steps at weekly intervals to highest dose tolerated or maximum dose reached. Maximum dose in BNF is 2 g/day but doses up to 3 g/day are commonly used in clinical practice.

Question 13

Metformin

-Contributes to weight loss
-Low risk of hypos
-Maximum dose of 2g daily
-Avoid if eGFR <30, and review dose if eGFR <45.
-Side-effects: B12 deficiency, GI upset and lactic acidosis.

Question 14

When is the only time that metformin SR should be used?

Answer 14

For patients who are intolerant of standard release metformin, even after slow dose titration. Try metformin SR before switching to a different antidiabetic drug.

Question 15

At what eGFR and creatinine clearance should metformin be reviewed? When should it be stopped?

Answer 15

Review the dose of metformin if the serum creatinine exceeds 130 micromol/litre
or the estimated glomerular filtration rate (eGFR) is below 45 ml/minute/1.73-m2.

Stop the metformin if the serum creatinine exceeds 150 micromol/litre or the eGFR is below 30
ml/minute/1.73-m2
.

Question 16

Type 2 Diabetes Prevention

Clinicians should use their judgement
on whether (and when) to offer metformin to support lifestyle change for people whose HbA1c or fasting plasma glucose blood test results have deteriorated if:
* This has happened despite their participation in intensive lifestyle-change programmes, or they are unable to participate in an intensive lifestyle-change programme, particularly if they have a BMI greater than 35.
* High risk patients are defined as HbA1c of 42-47mmol/mol (6.0-6.4%) or fasting plasma glucose of 5.5-6.9mmol/l
* Dosage recommendation: Start with a low dose (for example, 500 mg once daily) and then increase
gradually as tolerated, to 1500–2000 mg daily. If the person is intolerant of standard metformin consider using modified-release metformin.
* Metformin should be prescribed for 6–12 months initially. Monitor the person’s fasting plasma glucose or HbA1c levels at 3-month intervals and stop the drug if no effect is seen.

Answer 16

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Question 17

What would classify a patient as high-risk of T2 diabetes?

Answer 17

HbA1c of 42-47mmol/mol (6-6.4%) or a fasting plasma glucose of 5.5-6.9mmol/l.

Question 18

What is the metformin dosing recommendation for new type 2 diabetic patients, and how long should metformin be continued?

Answer 18

Dosage recommendation: Start with a low dose (for example, 500 mg once daily) and then increase
gradually as tolerated, to 1500–2000 mg daily. If the person is intolerant of standard metformin consider using modified-release metformin.
* Metformin should be prescribed for 6–12 months initially. Monitor the person’s fasting plasma glucose or HbA1c levels at 3-month intervals and stop the drug if no effect is seen.

Question 19

Which vitamin can metformin cause a defiency of in the body?

Answer 19

Vitamin B

Question 20

What are some risk factors for developing vitamin B deficiency?

Answer 20

-baseline vitamin B12 levels at the lower end of the normal range
-conditions associated with reduced vitamin B12 absorption (such as elderly people and those
with gastrointestinal disorders such as total or partial gastrectomy, Crohn’s disease and other
bowel inflammatory disorders, or autoimmune conditions)
-diets with reduced sources of vitamin B12 (such as strict vegan and some vegetarian diets)
-concomitant medication known to impair vitamin B12 absorption (including proton pump
inhibitors or colchicine)
-genetic predisposition to vitamin B12 deficiency.

Question 21

What are some examples of SGLT2 inhibitors?

Answer 21

Empagliflozin
Canagliflozin
Dapagliflozin

Question 22

SGL2 Inhibitors

-Low hypo risk
-Can benefit weight loss

-Side-effects: DKA, constipation, weight loss, increased infection risk and urinary disorders.
-Risk of ketoacidosis, Fournier’s gangrene and lower-limb amputation (Canagliflozin)

Answer 22

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Question 23

Which SGLT2 Inhibitor is first-line if SGLT2s are required as treatment?

Answer 23

Empagliflozin

Question 24

All SGLT2 Inhibitiors can be used to treat T2 diabetes with CKD, but only empagliflozin is green for type 2 diabetes WITHOUT CKD. In T2 diabetes where there is chronic HF with reduced ejection fraction, which SGLT2 inhibitors are licensed?

Answer 24

Empagliflozin
Dapagliflozin

Question 25

NICE NG28 type 2 diabetes in adults guideline (updated March 2022) recommends: based on the cardiovascular risk assessment for the person with type 2 diabetes: * If they have chronic heart failure or established atherosclerotic cardiovascular disease, offer an SGLT2 inhibitor with proven cardiovascular benefit in addition to metformin. * If they are at high risk of developing cardiovascular disease, consider an SGLT2 inhibitor with proven cardiovascular benefit in addition to metformin.

Answer 25

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Question 26

SGLT2 inhibitors can lead to ketoacidosis. Ketones should be tested for, and then SGLT2 inhibitors should be stopped immediately if DKA is suspected. What are some symptoms of this condition?

Answer 26

Rapid weight loss Nausea/being sick Stomach pain Fast and deep breathing Sleepiness A sweet smell to the breath A sweet or metalic taste in the mouth A different odour to the urine or sweat

Question 27

SGLT2 inhibitor treatment should be interrupted in patients who are hospitalised for major surgical procedures or acute serious medical illnesses and ketone levels measured.

Answer 27

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Question 28

Sulfonylureas -Contributes to weight gain -Moderate hypo risk -Avoid in severe renal impairment, cautioned in mild-moderate -Side-effects: hypoglycaemia, allergic dermatitis, GI upset

Answer 28

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Question 29

What is an example of a sulfonylurea?

Answer 29

Gliclazide

Question 30

What are some examples of DPP-4 inhibitors?

Answer 30

Alogliptan Linagliptan Sitagliptan

Question 31

What is an example of a thiazolidinedione?

Answer 31

Pioglitazone

Question 32

Treatment Pathway for Type 2 Diabetes Step 1 has three options: - In Atherosclerotic CVD: Metformin + SGLT2i -In no CVD or high risk of CVD: Metformin alone -Over 40 with a QRISK >10%/ Under 40 with over 1 CVD risk factor: Metformin and consider SGLT2i. If target not met with these options: Add another drug or switch to alternative

Question 33

Which antidiabetic drug is associated with a small increase in bladder cancer risk?

Answer 33

Puoglitazone

Question 34

How many times a day should type 1 diabetics measure their blood glucose according to NICE?

Answer 34

At least 4 times a day, up to 10 as a maximum

Question 35

Sometimes a type 1 diabetic would be recommended to test their blood glucose levels up to 10 time a day. What things may mean that this is recommended?

Answer 35

Desired target HbA1c level is not achieved, * Frequency of hypoglycaemic episodes increases, * There is a legal requirement to do so (e.g., such as before driving , in line with DVLA guidance) * During periods of illness * Before, during and after sport * When planning pregnancy, during pregnancy and while breastfeeding * If there is a need to know blood glucose levels >4 times a day for other reasons (e.g., impaired awareness of hypoglycaemia, high-risk activities).

Question 36

At what time of day should levothyroxine be taken?

Answer 36

Ideally 30 minutes before breakfast

Question 37

Why should commencing levothyroxine in the elderly, ischaemic heart disease patients or patients with long-standing hypothyroidism be at a low-dose and increased very cautiously?

Answer 37

Angina and arrhythmias can be precipitated by starting treating

Question 38

How long can it take for TSH levels to normalise in patients who had a very high TSH level before starting levothyroxine?

Answer 38

6 months

Question 39

How long can it take to see the full effects of levothyroxine, and why is this the case?

Answer 39

Levothyroxine has a long half-life (7 days)- dose adjustments should be made at 2-3 monthly intervals.

Question 40

Follow-up and Monitoring of Hypothyroidism in Adults Aged 16 and Over: -Primary hypothyroidism: TSH every 3 months until level stabilised within reference range then once a year; Consider FT4 if symptoms persist after starting levothyroxine. -Subclinical hypothyroidism (untreated or stopped levothyroxine treatment): consider measuring TSH and FT4 once a year if they have features suggesting underlying thyroid disease e.g., thyroid surgery or raised level of autoantibodies; otherwise, every 2-3 years.

Answer 40

..

Question 41

What should the target TSH level be in a patient taking levothyroxine that is considering pregnancy?

Answer 41

0.4-2.0

Question 42

For levothyroxine, generic prescribing on the drug remains appropriate for the majority of patients. If a patient reports any symptoms after changing the exact levothyroxine product that they would normally use, consider testing thyroid function- consider prescribing a specific thyroxine product for that patient that they tolerate.

Answer 42

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Question 43

What is an example of an antithyroid (hyperthyroidism) medication?

Answer 43

Carbimazole

Question 44

Carbimazole - Increases the risk of congenital malformation when used in the _ trimester of pregnancy and at doses above 15mg/day. -Risk of acute _- treatment should be stopped immediately and permanently if this issue occurs. -Counsel patients to report signs that suggest infection, especially a sore throat due to increase neutropenia and agranulocytosis risk. -Hyperthyroid patients tend to be more sensitive to oral _. A higher dose of anticoagulant may be required as their hyperthyroidism stabilises.

Answer 44

First Pancreatitis Anticoagulants

Question 45

What are somes examples of drugs that can be used in glucocorticoid therapy?

Answer 45

Prednisolone Dexamethasone Hydrocortisone

Question 46

When should corticosteroids ideally be taken during the day?

Answer 46

In the morning after breakfast.

Question 47

When are hydrocortisone tablets usually taken, and why?

Answer 47

Taken with the three main meals of the day to mimic the normal diurnal rhythm and to avoid insomnia

Question 48

- Steroid warning cards should be carried by those on long term treatment, both replacement and therapeutic. Patients on replacement therapy should be fully educated about the need to increase dosage during intercurrent illness. Abrupt withdrawal of steroids following long term therapy (> 3 weeks) should be avoided. -Prolonged courses of corticosteroids can increase susceptibility to infection and serious infections can go unrecognised. Unless already immune, patients are at risk of severe chickenpox and should avoid close contact with people who have chickenpox or shingles. -Patients on or commencing high dose oral corticosteroid long-term (7.5mg or more per day prednisolone or its equivalent for 3 months or more) should be offered bone protection with bisphosphonate.

Answer 48

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Question 49

What are micronised progesterone vaginal capusles used for?

Answer 49

For the prevention of miscarriage

Question 50

Which drug type is first-line for managing benign prostatic hypertrophy?

Answer 50

Alpha blockers

Question 51

What is desmopressin used for?

Answer 51

Central cranial diabetes insipidus (the body loses too much fluid and becomes dehydrated all the time). Also for bedwetting (nocturnal enuresis)

Question 52

Alendronic Acid 70mg - Weekly (first-line) - An oral bisphosphate that is used to prevent bone loss from the body- it treats osteoporosis. - Can cause serious oesophageal reactions, osteonecrosis of the jaw, atypical fractures. - Effervescent formulations should be used only in patients with long-term swallowing difficulties- short-term swallowing difficulties should result in emitting the alendronic acid until the issue is resolved.

Answer 52

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Question 53

Oral Bisphosphonates - Alendronic Acid 70mg (first-line) and Risedronate 35mg (alternative)- both once weekly dosages. -Both should be taken on a morning, on the same day each week and on an empty stomach, at least 30 minutes before eating anything. The tablet should be taken with a full glass of plain water, and the patient should stay fully upright for at least 30 minutes after swallowing the tablet.

Answer 53

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Question 54

What are some important recommendations for patients when it comes to taking oral bisphosphonates?

Answer 54

Alendronic acid and risedronate should be taken whole on arising, on the same day each week on an emptystomach (at least 30 minutes before the first food, beverage or medicinal product of the day) with a full glass (not less than 200ml) of plain water only (not mineral water). Patients should be advised to stay fully upright for at least 30 minutes after swallowing the tablet.

Question 55

When is Ibandronate 50mg labelled as 'green after consultant initiation'?

Answer 55

For use in post-menopausal women with breast cancer

Question 56

What is adrenal insufficiency?

Answer 56

Inadequate production of steroid hormones in the adrenal cortex of the adrenal glands (glucocorticoids and mineralocorticoids)

Question 57

Adrenal Insufficiency -Inadequate production of steroid hormones -Primary, secondary or tertiary. Glucocorticoids (e.g. cortisol) and mineralocorticoids (e.g. aldosterone) are the two main groups of steroid hormones produced by the adrenal cortex; their production is primarily regulated by the hypothalamic-pituitary-adrenal (HPA) axis and renin-angiotensin system, respectively. These hormones affect a number of body systems such as those involved in metabolic activity, water and electrolyte balance, and the body's response to stress. Symptoms include -Fatigue -Gastrointestinal upset -Anorexia -Weight loss -Musculoskeletal symptoms -Salt cravings -Dizziness or syncope due to hypotension.

Answer 57

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Question 58

How can the systemic use of glucocorticoids cause adrenal insufficiency?

Answer 58

If glucocorticoids are stopped or decreased too quickly after prolonged use, endogenous glucocorticoid production may not be sufficient

Question 59

What is adrenal crisis?

Answer 59

Where adrenal insufficiency is not identified and treated. Patients are unable to mount a stress response (e.g. surgery, infection) by increasing glucocorticoid production, so can cause severe dehydration, hypotension, seizures, cardiac arrest etc

Question 60

Management of Adrenal Insufficiency -Physiological glucocorticoid replacement using _ (most similar to cortisol), prednisolone and (rarely) dexamethasone. -Patients with primary adrenal insufficiency usually also require mineralocorticoid replacement with fludrocortisone.

Answer 60

Hydrocortisone

Question 61

What is the most commonly used medication to manage adrenal insufficiency?

Answer 61

Hydrocortisone

Question 62

Glucocorticoid Replacement During Stress -If ill, general rule is that the patient's daily glucocorticoid dose should be doubled. -Trying to maintain cortisol levels are close to normal as possible

Answer 62

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Question 63

Adrenal Crisis Treatment -Medical emergency -Prompt glucocorticoid replacement with hydrocortisone and rehydration using a crystalloid fluid such as sodium chloride 0.9%.

Answer 63

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Question 64

What do androgens cause?

Answer 64

Masculinisation

Question 65

Androgens - Can be used as replacement therapy in castrated adults or those who are hypogonadal due to pituitary or testicular disease - Useless as a treatment for impotence

Answer 65

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Question 66

Anti-Androgens: Cyproterone Acetate -Used in the treatment of hypersexuality and sexual deviation in males -Inhibits spermatogenesis and produces reversible infertility (NOT a contraceptive).

Answer 66

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Question 67

Dutasteride and Finasteride -Alternatives to alpha-blockers in men with significantly enlarged prostates. -Finasteride can also be used alongside doxazosin for managing benign prostatic hyperplasia. -Low strength finasteride can treat male-pattern baldness in men

Question 68

What is cholestasis?

Answer 68

The impairment of bile formation and/or bile flow, which may clinically present with fatigue, pruritis, dark urine, pale stools and, in its most overt form, jaundice and signs of fat soluble vitamin deficiencies

Question 69

What drug is first-line for treating pruritis associated with cholestasis?

Answer 69

Colestyramine- forms an insoluble complex in the intestine with bile acids and other compounds, which reduces serum bile levels and therefore the deposition of bile acids in dermal tissues too.

Question 70

What is first-line for treating pruritis in intrahepatic cholestasis in pregnancy?

Answer 70

Ursodeoxycholic acid

Question 71

What are some side-effects of mineralocorticoids?

Answer 71

-Hypertension -Sodium retention -Water retention -Potassium loss -Calcium loss

Question 72

What are some glucocorticoid side-effects?

Answer 72

-Diabetes -Osteoporosis -Muscle wasting -Psychiatric reactions -Peptic ulceration

Question 73

What are some glucocorticoid side-effects?

Answer 73

-Diabetes -Osteoporosis -Muscle wasting -Psychiatric reactions -Peptic ulceration

Question 74

What is primary hyperparathyroidism, and what usually causes it?

Answer 74

A disorder of the parathyroid glands- most commonly caused by a non-cancerous tumour in one of the glands. Causes excess secretion of parathyroid hormones, which leads to hypercalcaemia, hypophosphataemia and hypercalciuria.

Question 75

What are the main symptoms associated with hyperparathyroidism?

Answer 75

They are as a result of hypercalcaemia: increased thirst, increased urine output, constipation, fatigue and memory impairment.

Question 76

Treatment of Hyperparathyroidism -Parathyroidectomy surgery is the recommended first-line treatment -Cinacalcet may be considered as a drug treatment if surgery is unsuccessful

Question 77

What is hyperthyroidism?

Answer 77

Results from the excessive production and secretion of thyroid hormones leading to thyrotoxicosis (an excess of circulating thyroid hormones)

Question 78

What are the symptoms of hyperthyroidism?

Answer 78

Hyperactivity, disturbed sleep, fatigue, palpitations, anxiety, heat intolerance, increased appetitewith unintentional weight loss and diarrhoea.

Question 79

Difference Between Hyperthyroidism and Primary Hyperthyroidism Primary refers to when the condition arises from the thyroid gland rather than due to a pituitary or hypothalmic disorder. Mainly causes by Grave's disease.

Answer 79

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Question 80

What drug is first-line treatment for hyperthyroidism?

Answer 80

Carbimazole

Question 81

What causes hypothyroidism?

Answer 81

The underproduction and secretion of thyroid hormones

Question 82

What are some symptoms of hypothyroidism?

Answer 82

Fatigue Weight gain Constipation Depression Dry skin

Question 83

What is primary hypothyroidism?

Answer 83

When the condition arises from the tyroid gland and may be caused by iodine deficiency, autoimmune disease, radiotherapy, surgery or drugs?

Question 84

What is the first-line treatment of hypothyroidism?

Answer 84

Levothyroxine

Question 85

What is primary biliary cholangitis?

Answer 85

A chronic cholestatic disease which develops due to progressive destruction of small and intermediate bile ducts within the liver, subsequently evolving to fibrosis and cirrhosis. Treated with ursodeoxycholic acid

Question 86

Hormone Replacement Therapy -A small dose of oestrogen + progesterone alleviates menopausal symptoms such as vaginal atrophy or vasomotor instability. -Increases VTE risk, stroke, endometrial cancer, breast cancer and ovarian cancer. -Only prescribe to relieve menopause symptoms that are significantly affecting quality of life.

Answer 86

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Question 87

Reasons to Stop HRT -Severe chest pain -Sudden breathlessness -Unexplained swelling or severe pain in calf of one leg -Severe stomach pain -Neurological effects -Hepatitis, jaundice, liver enlargement -BP above 160/95 (either or)

Question 88

What is the target HbA1c for patients with type 1 diabetes, and T2 diabetes controlled by diet and lifestyle alone?

Answer 88

48 mmol/mol (6.5%) or lower

Question 89

What is the target HbA1c for patients with type 1 diabetes, and T2 diabetes controlled by diet and lifestyle alone?

Answer 89

48 mmol/mol (6.5%) or lower

Question 90

Aims of Treatment with Type 1 Diabetes -HbA1c of 48mmol/mol (6.5%) or lower -CGM should be offered to support patients Aims: - 5-7 mmol/litre fasting-glucose when waking -4-7 mmol/litre before meals -5-9 mmol/litre 90 mins after food -At least 5 mmol/litre when driving

Answer 90

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Question 91

Type 1 Diabetes Insulin Regimens First-line choice= Multiple daily injection basal-bolus: One or more separate daily injections of intermediate or long-acting insulin as the basal, alongisde multiple bolus injections of short-acting insulin before meals. Mixed (biphasic) regimen: one, two or three injections per day of short-acting mxed with intermediate-acting. Continuous subcutaneous insulin infusion (pump)

Question 92

Management Options of Type 2 Diabetes -Weight loss, healthy diet, smoking cessation and regular exercise Drugs: -Metformin- no association with weight gain or hypoglycaemia when used alone -Sulfonylureas such as gliclazide, glipizide and tolbutamide- associated with moderate weright gain and hypoglycaemia. -Pioglitazone -Dipeptidylpeptidase-4 (DDP-4) inhibitors such as alogliptan, linagliptan and sitagliptan: no association with weight gain and have less incidence of hypoglycaemia than sulfonylureas. -SGLT2 inhibitors: canagliflozin, dapagliflozin, empagliflozin- can promote weight loss. Risk of diabetic ketoacidosis.

Answer 92

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Question 93

Initial Treatment of Type 2 Diabetes -Metformin is first-line: gradually increase the dose (only offer modified release metformin to patients experiencing GI side-effects with standard treatment). -Patients with chronic HF or atherosclerotic CV disease should be offered an SGLT2 inhibitor in addition to metformin. Initiate metformin first, and add in the SGLT2 inhibitor once metformin is tolerated. If metformin is not tolerated, use a SGLT2 inhibitor alone.

Answer 93

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Question 94

Further Type 2 Diabetes Treatment Options -Add SGLT2 inhibitor to any patient who develops chronic HF or atherosclerotic disease at any point during treatment, or patients at a high risk for developing. -If metformin does not control HbA1c sufficiently or is not tolerated in patients NOT at a high CVD risk, add a DDP-4 inhibitor, or pioglitazone or a sulfonylurea. SGLT2 inhibitor may be considered too. -Consider triple therapy if dual therapy unsuccessful: add in either DDP-4 inhibitor or pioglitazone or sulfonylurea. -Insulin therapy is another option if dual therapy is unsuccessful (can continue metformin but stop other antidiabetic drugs). -GLP-1 agonists (Semaglutide, dulaglutide etc) can be used in triple therapy if previous triple therapy unsuccessful; remove one of the diabetic drugs and add this instead. Usually given as injections daily or weekly.

Answer 94

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Question 95

What are some examples of rapid-acting insulins?

Answer 95

Regular insulin Insulin lispro Insulin aspart Insulin glulisine

Question 96

What are some examples of intermediate-acting insulins?

Answer 96

Isophane insulin Insulin zinc

Question 97

What are some examples of long-acting insulins?

Answer 97

Insulin glargine Insulin detemir

Question 98

At what eGFR would CKD be classed as kidney failure?

Answer 98

Less than 15 ml/min/1.73m2

Question 99

What eGFR is classed as normal in a typical adult?

Answer 99

90 or higher

Question 100

Which formula is recommended for estimating GFR in MOST patients with renal impairment?

Answer 100

CKD-EPI

Question 101

Which formula is the preferred method for estimating GFR in elderly patients, or patients at extremes of muscle mass with renal impairment?

Answer 101

Cockroft and Gault ((140-age) x weight x constant) / Serum creatinine Constant= 1.23 for men and 1.04 for women

Question 102

How do you calculate someones ideal body weight?

Answer 102

Ideal BW in kg= constant + 0.91 (height- 152.4) Constant: 50 for men, 45.5 for women

Question 103

Examples of Hepatotoxic Drugs - Antibiotics: flucloxacillin, erythromycin, trimethoprim, co-amoxiclav, rifampicin -NSAIDs -Antidepressants (paroxetine) -Anticonvulsants (phenytoin, carbamazepine and valproic acid)

Question 104

Adults with Hyperthyroidism -Offer anti-thyroid drugs to people waiting for radioactive iodine -Consider anti-thyroid drugs with supportive treatment while awaiting specialist assessment Radioactive Iodine: -Offer for _ disease and toxic nodules, unless pregnant, fathering a child within 6 months, thyroid eye disease. Anti-thyroid Drugs: -Offer for Graves' if likely to achieve remission or other treatments are unsuitable. -Offer for toxic single or multiple nodules if other treatments unsuitable. Surgery (Thyroidectomy): -Offer for Graves' if compression or malignancy suspected or if other treatments unsuitable -Offer for toxic multiple or single nodule, if radioactive iodine is unsuitable.

Answer 104

Graves'

Question 105

Radioactive Iodine in Adults with Hyperthyroidism -Offer for Graves', toxic multiple modules or toxic single nodules as an alternative to surgery. -Should measure TSH, FT4 and FT3 every _ weeks for first six months until TSH is normal. -If patient has hyperthyroid still, consider anti-thyroid drug until 6 months and then more if TSH not normal -If hypothyroid- levothyroxine -Euthyroid- measure TSH at 9 and 12 months.

Answer 105

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Question 106

Anti-Thyroid Drugs for Hyperthyroidism -Offer for Graves' (12-18 month course) if likely to achieve remission or if other treatments unsuitable. -Toxic single or multiple nodules if other treatments unsuitable (life-long course) -Consider radioactive iodine or surgery for Graves' with persistent or relapsed hyperthyroidism. Measure TSH, FT4 and FT3 every 6 weeks until TSH is normal, then do TSH every _ months- no need to monitor FBC or liver function unless clinical concern. After stopping anti-thyroid drugs, consider measuring TSH within 8 weeks, then every 3 months for a year, then once a year.

Answer 106

3

Question 107

Surgery (Thyroidectomy) for Hyperthyroidism -Offer for Graves' if compression or malignancy suspected, or if other treatments unsuitable. -Toxic multiple (total thyroidectomy) or single nodule (hemithyroidectomy) if radioactive iodine unsuitable. Offer _ after total thyroidectomy- consider measuring TSH and FT4 at 2 and 6 months after hemithyrodectomy, then yearly.

Answer 107

Levothyroxine

Question 108

After a hemithyroidectomy, what should be done? What about after a total thyroidectomy?

Answer 108

Total= offer levothyroxine Hemi= measure TSH and FT4 at 2 and 6 months, then yearly.

Question 109

When should radioactive iodine be offered to adults with hyperthyroidism?

Answer 109

-Graves' and toxic multiple nodules -Toxic single nodules as an alternative to surgery

Question 110

What are some CVD risk factors?

Answer 110

-Hypertension -Dyslipidaemia -Smoking -Obesity -Family history in a first-degree relative of CVD

Question 111

What does established atherosclerotic CVD include?

Answer 111

Coronary heart disease Acute coronary syndrome Previous MI Stable angina Prior coronary or other revascularisation Cerebrovascular disease (Ischaemic stroke and TIA) Peripheral arterial diease

Question 112

Which thyroid-related drug are patients taking it told to report any signs of infection, especially a sore throat? Why?

Answer 112

Carbimazole Sign of agranulocytosis.

Question 113

Which alpha glucosidase inhibitor is used to treat diabetes that is not controlled by diet, or any other anti-diabetic drugs?

Answer 113

Acarbose

Question 114

Which group of anti-diabetic drugs should not be used in the elderly?

Answer 114

Sulfonylureas

Question 115

Process of Thyroid Hormones Being Released -Hypothalamus releases TRH (thyrotropin releasing hormone), which acts on the pituitary gland. -The pituitary gland releases TSH (thyroid-stimulating hormone), which acts on the thyroid gland. -The thyroid gland then releases T3 and T4 hormones (thyroid hormones).

Answer 115

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Question 116

What is the process of thyroid hormones being produced in the body?

Answer 116

-Hypothalamus releases TRH (thyrotropin releasing hormone), which acts on the pituitary gland. -The pituitary gland releases TSH (thyroid-stimulating hormone), which acts on the thyroid gland. -The thyroid gland then releases T3 and T4 hormones.

Question 117

If a patient was expected to have hyperthyroidism, what would you expect the levels of thyroid hormones to look like in the blood? And why?

Answer 117

Low TSH levels (normal is 4.5-5.0)- this is because there is plenty of thyroid in the body, so there is no need for more thyroid hormones to be produced. High T4 or T3 levels- high levels of ciruclating hormones.

Question 118

Which two drugs are the most common cause of drug-induced hyperthyroidism?

Answer 118

Amiodarone (main one) Lithium

Question 119

What are some potential complications of hyperthyroidism if left untreated?

Answer 119

Increased risk of AF, and therefore an increased stroke risk Thyrotoxic crisis.

Question 120

DPP-4 Inhibitors Potential interactions: -Beta-blockers can mask hypoglycaemia -Sulfonylureas when used alongside DPP-4 inhibitors can increase hypoglycaemia risk. -Digoxin+sitagliptan can increase risk of digoxin toxicity Potential side-effects: -GI upset -Acute pancreatitits (rare but serious) -Headache/dizziness, tremor -Hepatitis (very rare)

Answer 120

.

Question 121

Insulin Given by SC injection; IV soluble insulin is given in emergencies such as ketoacidosis. -Ketoacidosis treatment may also require sodium chloride IV fluid replacement, and potassium chloride is given in the infusion to prevent hypokalaemia from the insulin.

Answer 121

/

Question 122

Corticosteroid Summary -Main indications: replacement therapy for _ disease, acute adrenal insufficiency, hypopituitarism, anti-inflammatory treatment, immunosuppression. -Prolonged use increases susceptibility to _ -Prolonged use can also lead to adrenal suppression, psychiatric reactions and growth restriction in children. -Until one year after stopping, patients must mention that have taken steroids. -Withdrawal must be gradual if taken repeatedly, especially if for longer than _ months. Also if pt has had more than 3 weeks treatment.

Answer 122

Addison's Infection 3

Question 123

Alcohol should be avoided with which antidiabetic drug?

Answer 123

Chlorpropamide ( can cause facial flushing)

Question 124

Sulphonylureas Can be used in non-overweight T2 diabetic patients. Short-acting: Gliclazide and Tolbutamide Long-acting: Chlorpropamide and glivenclamide. Increased risk of hypoglycaemia, should avoid in elderly.

Answer 124

.

Question 125

Warfarin metabolism is unaffected by thyroid status. True or False?

Answer 125

False Warfarin metabolism IS affected by thyroid status

Question 126

Which antidiabetic drug increases fracture risk?

Answer 126

Gliclazide (sulfonylureas). Pioglitazone also does.

Question 127

Which antidiabetic drug increases the risk of UTIs and thrush?

Answer 127

SGLT2

Question 128

Which antidiabetic drug category should be stopped if pancreatitis is suspected?

Answer 128

DPP-4 inhibitors.

Question 129

HbA1C targets in T2DM -Lifestyle managed: 48 mmol/mol (6.5%) -Lifestyle+Metformin: 48 mmol/mol (6.5%) -Management including any drug that can cause hypoglycaemia, e.g. sulfonylurea: 53 mmol/mol (7.0%)

Question 130

Which vitamin do patients with renal impairment need to receive in its hydroxylated form?

Answer 130

Vitamin D

Question 131

What are some risk factors for developing gout?

Answer 131

Alcohol Hypertension Diuretics Obesity CHD Diabetes CKD High cholesterol Heart failure Being male Eating meat/seafood

Question 132

Gradual withdrawal of prednisolone should be considered if a patient has been taking what dose, and for how long?

Answer 132

More than 40mg a day for one week

Question 133

How does metformin work?

Answer 133

Inhibits mitochondrial respiratory chain in the liver- enhances insulin sensitivity, lowers cAMP and therefor reduces the expression of gluconeogenic enzymes.

Question 134

How do sulfonylureas work?

Answer 134

Directly stimulate the release of insulin from pancreatic beta cells- they are only useful in patients with some beta cell function.

Question 135

How do DPP-4 Inhibitors work?

Answer 135

They block the action of DPP-4, which is an enzyme that destroys the hormone 'incretin'. Incretin helps the body produce more insulin and recues the amount of glucose being produced by the liver.

Question 136

How do GLP-1 inhibitors work?

Answer 136

Stimulate glucose-dependent insulin release from pancreatic islets

Question 137

How do SGLT2 inhibitors work?

Answer 137

They reduce renal tubular glucose reabsorption- reduces blood glucose levels.

Question 138

How does pioglitazone work?

Answer 138

Selectively stimulates a nuclear receptor- modulates the transcription of the genes involved in the control of glucose and lip metabolism.

Question 139

Diagnosing Gestational Diabetes -A fasting BG of 5.6 mmol/litre or above OR -a 2-hour BG of 7.8 mmol/litre or above If pt has a fasting BG of below 7, offer a trial of diet and exercise changes. If pt has a fasting BG above 7, offer immediate treatment with _, with or without metformin AND also offer lifestyle changes,.

Answer 139

Insulin