BNF - Chapter 6 - Endocrine system - (Part 1) Flashcards

Question

Does dexamethasone and betamethasone have a great or little mineralocorticoid action?

Answer 1

Dexamethasone and betamethasone have little if any mineralocorticoid action and their long duration of action makes them particularly suitable for suppressing corticotropin secretion in congenital adrenal hyperplasia

Answer 2

When given at night

Answer 3

For 24 hours

Answer 4

for conditions where water retention would be a disadvantage.

Answer 5

No because it is unlikely to be of benefit and may even be harmful.

Answer 6

It is a retinal disorder that has been linked to the systemic use of corticosteroids Patients should be advised to report any blurred vision or other visual disturbances with corticosteroid treatment given by any route

Answer 7

``` hypertension sodium retention water retention potassium loss calcium loss ```

Answer 8

Mineralocorticoid side effects are most marked with fludrocortisone, but are significant with hydrocortisone, corticotropin, and tetracosactide. Mineralocorticoid actions are negligible with the high potency glucocorticoids, betamethasone and dexamethasone, and occur only slightly with methylprednisolone, prednisolone, and triamcinolone.

Answer 9

diabetes osteoporosis, which is a danger, particularly in the elderly, as it can result in osteoporotic fractures for example of the hip or vertebrae in addition high doses are associated with avascular necrosis of the femoral head muscle wasting (proximal myopathy) can also occur corticosteroid therapy is also weakly linked with peptic ulceration and perforation psychiatric reactions may also occur

Answer 10

When given as a single dose in the morning

Answer 11

the total dose for two days can sometimes be taken as a single dose on alternate days; alternate-day administration has not been very successful in the management of asthma.

Answer 12

A patient-held Steroid Emergency Card has been developed for patients with adrenal insufficiency and steroid dependence who are at risk of adrenal crisis.

Answer 13

It aims to support healthcare staff with the early recognition of patients at risk of adrenal crisis and the emergency treatment of adrenal crisis

Answer 14

Hydrocortisone

Answer 15

Glucocorticoid activity with weak mineralocorticoid activity.

Answer 16

Hydrocortisone and the mineralocorticoid fludrocortisone

Answer 17

Via - oral route. by mouth

Answer 18

2 doses - the larger in the morning and the smaller dose in the evening - mimicking the normal diurnal rhythm or cortisol secretion Also given fludrocortisone

Answer 19

Hydrocortisone intravenously

Answer 20

In hypopituitarism, hydrocortisone should be given as in adrenal insufficiency. But since production of aldosterone is also regulated by the renin-angiotensin system a mineralocorticoid is not usually required.

Answer 21

it should be borne in mind that high glucocorticoid activity in itself is of no advantage unless it is accompanied by relatively low mineralocorticoid activity

Answer 22

The mineralocorticoid activity of fludrocortisone acetate is so high that its anti-inflammatory activity is of no clinical relevance.

Answer 23

Hydrocortisone has a relatively high mineralocorticoid activity, and results in fluid retention making it unsuitable.

Answer 24

Predominantly glucocorticoid activity

Answer 25

- Prednisolone

Answer 26

Long duration of action

Answer 27

Betamethasone and dexamethasone also have a long duration of action and this, coupled with their lack of mineralocorticoid action makes them particularly suitable for conditions which require suppression of corticotropin (corticotrophin) secretion (e.g. congenital adrenal hyperplasia).

Answer 28

A high glucocorticoid activity; it is derived from prednisolone

Answer 29

No - it is listed on the Contraindications

Answer 30

Anxiety; behaviour abnormal; cataract subcapsular; cognitive impairment; Cushing's syndrome; electrolyte imbalance; fatigue; fluid retention; gastrointestinal discomfort; headache; healing impaired; hirsutism; hypertension; increased risk of infection; menstrual cycle irregularities; mood altered; nausea; osteoporosis; peptic ulcer; psychotic disorder; skin reactions; sleep disorders; weight increased

Answer 31

Adrenal atrophy

Answer 32

- acute adrenal insufficiency - hypotension - death

Answer 33

A temporary increase in corticosteroid dose, or if already stopped, a temporary reintroduction of corticosteroid treatment.

Answer 34

To infections and severity of infections clinical presentation of infections may also be atypical. Serious infections e.g. septicaemia and tuberculosis may reach an advanced stage before being recognised, and amoebiasis or strongyloidiasis may be activated or exacerbated (exclude before initiating a corticosteroid in those at risk or with suggestive symptoms).

Answer 35

They may also be exacerbated

Answer 36

Unless they have had chickenpox, patients receiving oral or parenteral corticosteroids for purposes other than replacement should be regarded as being at risk of severe chickenpox

Answer 37

Corticosteroids should not be stopped and dosage may need to be increased

Answer 38

Patients taking corticosteroids should be advised to take particular care to avoid exposure to measles and to seek immediate medical advice if exposure occurs. Prophylaxis with intramuscular normal immunoglobulin may be needed.

Answer 39

Psychiatric reactions including euphoria, insomnia, irritability, mood liability, suicidal thoughts, psychotic reactions and behavioural disturbances,

Answer 40

Yes it does When administration is prolonged or repeated during pregnancy, systemic corticosteroids increase the risk of intra-uterine growth restriction; there is no evidence of intra-uterine growth restriction following short-term treatment (e.g. prophylactic treatment for neonatal respiratory distress syndrome). Any adrenal suppression in the neonate following prenatal exposure usually resolves spontaneously after birth and is rarely clinically important.

Answer 41

The height and weight of children receiving prolonged treatment with corticosteroids should be monitored annually; if growth is slowed, referral to a paediatrician should be considered.

Answer 42

received more than 40 mg prednisolone (or equivalent) daily for more than 1 week; been given repeat doses in the evening; received more than 3 weeks’ treatment; recently received repeated courses (particularly if taken for longer than 3 weeks); taken a short course within 1 year of stopping long-term therapy; other possible causes of adrenal suppression.

Answer 43

Systemic corticosteroids may be stopped abruptly in those whose disease is unlikely to relapse and who have received treatment for 3 weeks or less and who are not included in the patient groups described above

Answer 44

Equivalent to prednisolone 7.5mg daily

Answer 45

Gradual withdrawal of systemic corticosteroids should be considered in those whose disease is unlikely to relapse and have: received more than 40 mg prednisolone (or equivalent) daily for more than 1 week or 2 mg/kg daily for 1 week or 1 mg/kg daily for 1 month; been given repeat doses in the evening; received more than 3 weeks’ treatment; recently received repeated courses (particularly if taken for longer than 3 weeks); taken a short course within 1 year of stopping long-term therapy; other possible causes of adrenal suppression.

Answer 46

Prednisolone 2-2.5mg/m2 daily

Answer 47

to support communication of the risks associated with treatment and to record details of the prescriber, drug, dosage, and duration of treatment.

Answer 48

Steroid Emergency Cards should be issued to patients with adrenal insufficiency and steroid dependence for whom missed doses, illness, or surgery puts them at risk of adrenal crisis.

Answer 49

those with primary adrenal insufficiency; those with adrenal insufficiency due to hypopituitarism requiring corticosteroid replacement; those taking corticosteroids at doses equivalent to, or exceeding, prednisolone 5 mg daily for 4 weeks or longer across all routes of administration (oral, topical, inhaled, intranasal, or intra-articular); those taking corticosteroids at doses equivalent to, or exceeding, prednisolone 40 mg daily for longer than 1 week, or repeated short oral courses; those taking a course of oral corticosteroids within 1 year of stopping long-term therapy.

Answer 50

The card includes a management summary for the emergency treatment of adrenal crisis and can be issued by any healthcare professional managing patients with adrenal insufficiency or prescribing steroids.

Answer 51

Equal activity of both

Answer 52

It results from chronic exposure to excess cortisol

Answer 53

Exogenous corticosteroid use is the most common cause.

Answer 54

adrenocorticotrophic hormone (ACTH)-secreting pituitary tumours (Cushing’s disease), cortisol-secreting adrenal tumours, and rarely, ectopic ACTH-secreting tumours

Answer 55

Surgically

Answer 56

Metyrapone

Answer 57

- Ketoconazole

Answer 58

Imidazole derivative which acts a potent inhibitor of cortisol and aldosterone synthesis

Answer 59

The CHMP recommended that the marketing authorisation for oral ketoconazole to treat fungal infections should be suspended. The CHMP concluded that the risk of hepatoxicity associated with oral ketoconazole is greater than the benefit in treating fungal infections.

Answer 60

Used to treat Cushing's syndrome Also can be used to test anterior pituitary function

Answer 61

In replacement therapy, hydrocortisone (cortisol) (a glucocorticoid) and fludrocortisone (aldosterone) (a mineralocorticoid) is used

Answer 62

Since it has a larger margin of safety

Answer 63

cold and flu like symptoms, itching and weight loss

Answer 64

Due to possible growth restrictions

Answer 65

corticosteroids may enhance the anticoagulant effects of warfarin at high-doses At low doses they may reduce the anticoagulant effect of warfarin

Answer 66

- hypertension - sodium retention - potassium loss - water retention - calcium loss Aldosterone is a mineralocorticoid involved in the rennin- angiotensin system – hence increased sodium and decreased potassium and hydrogen ions. HINT - in ACEi / ARBs - angiotensin-renin system is blocked - meaning less aldosterone meaning opposite - potassium retention

Answer 67

include diabetes and osteoporosis; also potentially peptic ulceration. Hydrocortisone is a glucocorticoid, it has anti- inflammatory and immunosuppressive effects (hence ulceration); they increase blood glucose levels (hence diabetes) and mobilise calcium (hence osteoporosis).

Answer 68

Occurs due to a lack of insulin following autoimmune destruction of the pancreatic beta cells.

Answer 69

- reduced insulin release or resistance to insulin or both

Answer 70

By measuring fasting or random blood-glucose levels

Answer 71

• Type 1 diabetics require insulin, Type 2 diabetics can be managed with diet, but may require antidiabetic drugs, insulin or both. Type

Answer 72

By losing weight and increasing physical activity

Answer 73

It is to optimise blood glucose and minimise the risk of long term complications

Answer 74

- Cardiovascular disease - to reduce this risk diabetic patients are also on ramipril, low dose aspirin and simvastatin (R.A.S)

Answer 75

Ramipril + Simvastatin

Answer 76

Diabetes mellitus is a group of metabolic disorders in which persistent hyperglycaemia is caused by deficient insulin secretion or by resistance to the action of insulin

Answer 77

Leads to the abnormalities of carbohydrate, fat and protein metabolism that are characteristic of diabetes mellitus

Answer 78

Type 1 diabetes and Type 2 diabetes are the two most common classifications of diabetes. Other common types of diabetes are gestational diabetes (develops during pregnancy and resolves after delivery, see Diabetes, pregnancy and breast-feeding) and secondary diabetes (may be caused by pancreatic damage, hepatic cirrhosis, or endocrine disease). Treatment with endocrine, antiviral, or antipsychotic drugs may also cause secondary diabetes.

Answer 79

- Insulin With some exceptions for temporary treatment

Answer 80

Carry a glucose meter and blood-glucose strip when driving

Answer 81

- no more than 2 hours before (within 2 hours before driving) - then every 2 hours while driving.

Answer 82

Above 5mmol/L while driving. If blood glucose falls to 5mmol/L or below then a snack should be taken.

Answer 83

A fast-acting carbohydrate is always available in the vehicle

Answer 84

The patient should not drive

Answer 85

the driver should: stop the vehicle in a safe place; switch off the engine, remove keys from the ignition, and move from the driver’s seat; eat or drink a suitable source of sugar; wait until 45 minutes after blood-glucose has returned to normal, before continuing journey.

Answer 86

No and the DVLA must be notified; drivers may resume if a medical report confirms that awareness has been regained.

Answer 87

Alcohol can make the signs of hypoglycaemia less clear, and can cause delayed hypoglycaemia

Answer 88

- should drink alcohol in moderation, and when accompanied by food.

Answer 89

It is used mainly for diagnosis of impaired glucose tolerance - it is not recommended for necessary for routine diagnostic use when severe symptoms of hyperglycaemia are present. In patients who have less severe symptoms and a blood-glucose concentration that does not establish or exclude diabetes (e.g. impaired fasting glycaemia), an oral glucose tolerance test may be required.

Answer 90

To establish the presence of gestational diabetes

Answer 91

An oral glucose tolerance test involves measuring the blood-glucose concentration after fasting, and then 2 hours after drinking a standard anhydrous glucose drink. Anhydrous glucose may alternatively be given as the appropriate amount of Polycal® or as Rapilose® OGTT oral solution.

Answer 92

Glycated haemoglobin (HbA1c) forms when red blood cells are exposed to glucose in the plasma.

Answer 93

The HbA1c test reflects average plasma glucose over the previous 2 to 3 months and provides a good indicator of glycaemic control

Answer 94

Unlike the oral glucose tolerance test, an HbA1c test can be performed at any time of the day and does not require any special preparation such as fasting.

Answer 95

HbA1c values are expressed in mmol of glycated haemoglobin per mol of haemoglobin (mmol/mol), a standardised unit specific for HbA1c created by the International Federation of Clinical Chemistry and Laboratory Medicine (IFCC)

Answer 96

``` IFCC-HbA1c (mmol/mol) DCCT-HbA1c (%) 42 6.0 48 6.5 53 7.0 59 7.5 64 8.0 69 8.5 75 9.0 ```

Answer 97

For monitoring glycaemic control in both Type 1 and 2 diabetes and is also now used for the diagnosis of type 2 diabetes

Answer 98

HbA1c should not be used for diagnosis in those with suspected type 1 diabetes, in children, during pregnancy, or in women who are up to two months postpartum. It should also not be used for patients who have: - had symptoms of diabetes for less than 2 months; - a high diabetes risk and are acutely ill; - treatment with medication that may cause hyperglycaemia; - acute pancreatic damage; - end-stage chronic kidney disease; - HIV infection.

Answer 99

with abnormal haemoglobin, anaemia, altered red cell lifespan, or who have had a recent blood transfusion.

Answer 100

microvascular and macrovascular complications and mortality.

Answer 101

Lower HbA1c is associated with a lower risk of long term vascular complications and patients should be supported to aim for an individualised HbA1c target

Answer 102

HbA1c should usually be measured in patients with type 1 diabetes every 3 to 6 months, and more frequently if blood-glucose control is thought to be changing rapidly. Patients with type 2 diabetes should be monitored every 3 to 6 months until HbA1c and medication are stable when monitoring can be reduced to every 6 months.

Answer 103

invalid for patients with disturbed erythrocyte turnover or for patients with a lack of, or abnormal haemoglobin. In these cases, quality-controlled plasma glucose profiles, total glycated haemoglobin estimation (if there is abnormal haemoglobin), or fructosamine estimation can be used.

Answer 104

Laboratory measurement of fructosamine concentration measures the glycated fraction of all plasma proteins over the previous 14 to 21 days but is a less accurate measure of glycaemic control than HbA1c.

Answer 105

Type 1 diabetes describes an absolute insulin deficiency in which there is little or no endogenous insulin secretory capacity due to destruction of insulin-producing beta-cells in the pancreatic islets of Langerhans. This form of the disease has an auto-immune basis in most cases, and it can occur at any age, but most commonly before adulthood.

Answer 106

- In hyperglycaemia and other metabolic abnormalities

Answer 107

- Hyperglycaemia (random plasma-glucose concentration above 11mmol/L) - ketosis - rapid weight loss - a body max index below 25kg/m2 - age younger than 50 years - and a personal/family history of autoimmune disease (though not all features may be present

Answer 108

- using insulin regimens to achieve as optimum a level of blood glucose control as is feasible while avoiding or reducing the frequency of hypoglycaemic episodes, in order to minimise the risk of long-term microvascular and macrovascular complications

Answer 109

48 mmol/mol (6.5%) or lower in patients with type 1 diabetes

Answer 110

At least four times a day, including before each meal and before bed

Answer 111

a fasting blood-glucose concentration of 5–7 mmol/litre on waking

Answer 112

4–7 mmol/litre before meals at other times of the day

Answer 113

5-9mmol/L at least 90 minutes after

Answer 114

above 5 mmol/litre when driving, as recommended by the Driver and Vehicle Licensing Agency (DVLA)

Answer 115

- insulin replacement

Answer 116

In patients who have a BMI of 25 kg/m2 or above (23 kg/m2 or above for patients of South Asian or related ethnicity) who wish to improve their blood-glucose control while minimising their effective insulin dose, consider metformin hydrochloride [unlicensed indication] as an addition to insulin therapy.

Answer 117

No it is important for both type 1 and type 2 diabetes

Answer 118

Patients with type 1 diabetes should be offered carbohydrate-counting training as part of a structured education programme.

Answer 119

- Multiple daily injection basal-bolus insulin regimens - Mixed (biphasic) regimen - Continuous subcutaneous insulin infusion (insulin pump)

Answer 120

One or more separate daily injections of intermediate-acting insulin or long-acting insulin analogue as the basal insulin; alongside multiple bolus injections of short-acting insulin before meals. This regimen offers flexibility to tailor insulin therapy with the carbohydrate load of each meal.

Answer 121

One, two, or three insulin injections per day of short-acting insulin mixed with intermediate-acting insulin. The insulin preparations may be mixed by the patient at the time of injection, or a premixed product can be used.

Answer 122

A regular or continuous amount of insulin (usually in the form of a rapid-acting insulin analogue or soluble insulin), delivered by a programmable pump and insulin storage reservoir via a subcutaneous needle or cannula

Answer 123

multiple daily injection basal-bolus insulin regimens

Answer 124

- Insulin detemir (Levemir) | Twice daily administration

Answer 125

Insulin Glargine (100units/ml) (Lantus) (Once Daily Administration)

Answer 126

Insulin degludec (Tresiba) (Ultra-long acting_

Answer 127

Insulin degludec (Tresiba) Insulin Glargine (300units/ml) (Touejo)

Answer 128

No they are not

Answer 129

A rapid acting insulin analogue Rather than soluble human insulin or animal insulin (rarely used).

Answer 130

Should be injected before meals - routine use after meals should be discouraged

Answer 131

(Biphasic) a twice-daily mixed insulin regimen should be considered if it is preferred.

Answer 132

a trial of a twice-daily analogue mixed insulin regimen should be considered.

Answer 133

should only be offered to patients who suffer disabling hypoglycaemia while attempting to achieve their target HbA1c concentration, or, who have high HbA1c concentrations (69 mmol/mol [8.5%] or above) with multiple daily injection therapy (including, if appropriate, the use of long-acting insulin analogues) despite a high level of care. Insulin pump therapy should be initiated by a specialist team.

Answer 134

by physical activity, intercurrent illness, reduced food intake, impaired renal function, and in certain endocrine disorders.

Answer 135

Should be assessed annually using the Gold score or the Clarke score.

Answer 136

Below 3mmol/L

Answer 137

Beta blockers reducing warning signs such as tremor

Answer 138

This should be avoided

Answer 139

No they do not confirm this

Answer 140

Insulin is a polypeptide hormone secreted by pancreatic beta-cells. Insulin increases glucose uptake by adipose tissue and muscles, and suppresses hepatic glucose release. The role of insulin is to lower blood-glucose concentrations in order to prevent hyperglycaemia and its associated microvascular, macrovascular and metabolic complications.

Answer 141

(a low and steady secretion of background insulin that controls the glucose continuously released from the liver) and meal-time bolus insulin (secreted in response to glucose absorbed from food and drink).

Answer 142

Three types - human insulin - human insulin analogues - animal insulin

Answer 143

Animal insulins are extracted and purified from animal sources (bovine or porcine insulin)

Answer 144

No longer initiated but still used in patients who do not wish to change to human insulins

Answer 145

Human insulins are produced by recombinant DNA technology and have the same amino acid sequence as endogenous human insulin.

Answer 146

Human insulin analogues are produced in the same way as human insulins, but the insulin is modified to produce a desired kinetic characteristic, such as an extended duration of action or faster absorption and onset of action.

Answer 147

As it is inactivated by gastro-intestinal enzymes and must therefor be given by injection

Answer 148

Into a body area with plenty of subcutaneous fat - usually the abdomen (fastest absorption rate) or outer thighs/buttocks (Slower absorption compared with the abdomen or inner thighs)

Answer 149

Absorption from a limb site can vary considerably (by as much as 20–40%) day-to-day, particularly in children. Local tissue reactions, changes in insulin sensitivity, injection site, blood flow, depth of injection, and the amount of insulin injected can all affect the rate of absorption. Increased blood flow around the injection site due to exercise can also increase insulin absorption.

Answer 150

Lipohypertrophy can occur due to repeatedly injecting into the same small area, and can cause erratic absorption of insulin, and contribute to poor glycaemic control. Patients should be advised not to use affected areas for further injection until the skin has recovered.

Answer 151

By using different injection sites in rotation

Answer 152

- signs of infection - Swelling - Bruising - Lipohypertrophy all before adminstration

Answer 153

- Soluble insulin (human and, bovine or porcine - both rarely used) - Rapid-acting insulin analgoues

Answer 154

- Insulin Aspart - Insulin Glulisine - Insulin Lispro

Answer 155

- usually given subcutaneously but some preparations can be given intravenously and intramuscularly

Answer 156

Rapid onset of action 30-60 minutes A peak action between 1 and 4 hours and a duration of action up to 9 hours

Answer 157

soluble insulin has a short half-life of only a few minutes and its onset of action is instantaneous.

Answer 158

Soluble insulin administered intravenously

Answer 159

Insulin Aspart Insulin Glulisine - Insulin Lispro

Answer 160

Faster onset of action (within 15 minutes) and shorter duration of action (approximately 2-5 hours) than soluble insulin and are usually given subcutaneously

Answer 161

Immediately before meals

Answer 162

No this should be avoided when given during or after meals, they are associated with poorer glucose control, an increased risk of high postprandial-glucose concentration, and subsequent hypoglycaemia.

Answer 163

Isophane insulin

Answer 164

they have an onset of action of approximately 1–2 hours, a maximal effect at 3–12 hours, and a duration of action of 11–24 hours.

Answer 165

With protamine

Answer 166

(biphasic isophane insulin, biphasic insulin aspart, biphasic insulin lispro

Answer 167

subcutaneous injection immediately before a meal.

Answer 168

- Protamine zinc insulin - Insulin Zinc suspension - Insulin detemir (Levemir) - Insulin Glargine (Lantus - 100units/ml) - Insulin degludec (tresiba) - Insulin Glargine (Touejo 300units/ml)

Answer 169

Up to 36 hours

Answer 170

They achieve a steady-state level after 2–4 days to produce a constant level of insulin.

Answer 171

Insulin glargine and insulin degludec are given once daily and insulin detemir is given once or twice daily according to individual requirements.

Answer 172

They are now rarely prescribed

Answer 173

Novarapid | Rapid-acting

Answer 174

Humalog | Rapid-acting

Answer 175

Apidra | Rapid-acting

Answer 176

Novomix30 Humalog Mix25 Humulin M3

Answer 177

Yes - as patient familiarity and ease of use are important

Answer 178

- obesity - Physical inactivity - Raised blood pressure - Dyslipidaemia - a tendency to develop thrombosis

Answer 179

Type 2 diabetes typically develops later in life but is increasingly diagnosed in children, despite previously being considered a disease of adulthood.

Answer 180

Weight loss Smoking cessation Regular exercise

Answer 181

Metformin hydrochloride has an anti-hyperglycaemic effect, lowering both basal and postprandial blood-glucose concentrations.

Answer 182

It does not stimulate insulin secretion and therefore, when given alone, does not cause hypoglycaemia.

Answer 183

The dose of standard-release metformin hydrochloride should be increased gradually to minimise the risk of gastro-intestinal side effects.

Answer 184

glibenclamide, gliclazide, glimepiride, glipizide, tolbutamide

Answer 185

Yes - t is more likely with long-acting sulfonylureas such as glibenclamide, which have been associated with severe, prolonged and sometimes fatal cases of hypoglycaemia.

Answer 186

Yes they are and it is probably due to increased plasma-insulin concentrations

Answer 187

Nateglinide | Repaglinide

Answer 188

have a rapid onset of action and short duration of activity.

Answer 189

These drugs can be used flexibly around mealtimes and adjusted to fit around individual eating habits which may be beneficial for some patients, but generally are a less preferred option than the sulfonylureas.

Answer 190

Thiazolidinedione

Answer 191

(Gliptins) - Alogliptin - Linagliptin - Sitagliptin - Saxagliptin - Vildagliptin

Answer 192

No - and have less incidence of hypoglycaemia than the sulfonylureas

Answer 193

- Canagliflozin - Dapagliflozin - Empagliflozin

Answer 194

High risk of diabetic ketoacidosis

Answer 195

- Dulaglutide - Exenatide - Liraglutide - Lixisenatide

Answer 196

Should be reserved for combination therapy when other treatment options have failed

Answer 197

- Single oral antidiabetic drug

Answer 198

48 mmol/mol (6.5%)

Answer 199

53mmol/mol (7.0%)

Answer 200

58mmol/mol or (6.5%) higher

Answer 201

- Metformin

Answer 202

Positive effect on weight loss

Answer 203

Reduced risk

Answer 204

Metformin combined with one of the following: - a sulfonylurea (glibenclamide, gliclazide, glimepiride, glipizide, tolbutamide); - Pioglitazone; - a dipeptidylpeptidase-4 inhibitor (linagliptin, saxagliptin, sitagliptin, or vildagliptin); - a sodium glucose co-transporter 2 inhibitor (canagliflozin, dapagliflozin or empagliflozin) only when sulfonylureas are contra-indicated or not tolerated, or if the patient is at significant risk of hypoglycaemia or its consequences.

Answer 205

Short acting

Answer 206

Elderly patients or those with renal impairment are at particular risk of hypoglycaemia; if a sulfonylurea is indicated, a shorter-acting sulfonylurea, such as gliclazide or tolbutamide should be prescribed.

Answer 207

he place in therapy of alogliptin (a dipeptidylpeptidase-4 inhibitor) is not yet known.

Answer 208

treatment should be intensified again, and one of the following triple therapy regimens prescribed: Metformin hydrochloride and a dipeptidylpeptidase-4 inhibitor and a sulfonylurea; - Metformin hydrochloride and pioglitazone and a sulfonylurea; - Metformin hydrochloride and a sulfonylurea and one of the sodium glucose co-transporter 2 inhibitors; - Metformin hydrochloride and pioglitazone and a sodium glucose co-transporter 2 inhibitor (canagliflozin or empagliflozin; note that dapagliflozin is not recommended in a triple therapy regimen with pioglitazone). Alternatively, it may be appropriate to start insulin-based treatment at this stage—see Drug treatment, insulin

Answer 209

a glucagon-like peptide-1 receptor agonist may be prescribed as part of a triple combination regimen with metformin hydrochloride and a sulfonylurea.

Answer 210

These should only be prescribed for patients who have a BMI of 35 kg/m2 or above (adjusted for ethnicity) and who also have specific psychological or medical problems associated with obesity; or for those who have a BMI lower than 35 kg/m2 but for whom insulin therapy would have significant occupational implications or if the weight loss associated with glucagon-like peptide-1 receptor agonists would benefit other significant obesity-related comorbidities

Answer 211

After 6 months, the drug should be reviewed and only continued if there has been a beneficial metabolic response (a reduction of at least 11 mmol/mol [1.0%] in HbA1c and a weight loss of at least 3% of initial body-weight).

Answer 212

initial treatment should be single therapy with: - a sulfonylurea (glibenclamide, gliclazide, glimepiride, glipizide, or tolbutamide) (first choice), or - a dipeptidyl peptidase-4 inhibitor (linagliptin, saxagliptin, sitagliptin, or vildagliptin), or - Pioglitazone.

Answer 213

only if a dipeptidylpeptidase-4 inhibitor would otherwise be prescribed and neither a sulfonylurea nor pioglitazone is appropriate.

Answer 214

because, should an intensification of treatment be required, it is not licensed to be used in any combination other than with metformin hydrochloride As a single therapy is okay but if intensification is required and metformin is contraindicated it would require a complete change of treatment in those patients who have started it due to intolerance or CI to metformin

Answer 215

treatment should be intensified and one of the following dual combinations prescribed: a dipeptidylpeptidase-4 inhibitor and pioglitazone; a dipeptidylpeptidase-4 inhibitor and a sulfonylurea; or Pioglitazone and a sulfonylurea If dual therapy does not provide adequate glucose control, insulin-based treatment should be considered

Answer 216

Metformin hydrochloride should be continued unless it is contra-indicated or not tolerated. Other antidiabetic drugs should be reviewed and stopped if necessary.

Answer 217

``` human isophane insulin injected once or twice daily, according to requirements; a human isophane insulin in combination with a short-acting insulin, administered either separately or as a pre-mixed (biphasic) human insulin preparation (this may be particularly appropriate if HbA1c is 75 mmol/mol (9.0%) or higher); Insulin detemir or insulin glargine as an alternative to human isophane insulin. This can be preferable if a once daily injection would be beneficial (for example if assistance is required to inject insulin), or if recurrent symptomatic hypoglycaemic episodes are problematic, or if the patient would otherwise need twice-daily human isophane insulin injections in combination with oral glucose-lowering drugs. Also consider switching to insulin detemir or insulin glargine from human isophane insulin if significant hypoglycaemia is problematic, or in patients who cannot use the device needed to inject human isophane insulin; biphasic preparations (pre-mixed) that include a short-acting human analogue insulin (rather than short-acting human soluble insulin) can be preferable for patients who prefer injecting insulin immediately before a meal, or if hypoglycaemia is a problem, or if blood-glucose concentrations rise markedly after meals. ```

Answer 218

- Basal insulin regimen should be initiated and the dose titrated against morning (Fasting) glucose

Answer 219

the need for short-acting insulin before meals (or a biphasic insulin preparation).

Answer 220

It works by decreasing glucogenesis and increasing the body's use of glucose (glucose utilisation)

Answer 221

No - as it does not stimulate insulin release

Answer 222

GI side effects are common - so the dose of standard release regimens should be increased gradually. MR can be offered when standard release is not tolerated

Answer 223

Three times daily with food

Answer 224

they work by modulating insulin release and therefore may cause hypoglycaemia

Answer 225

Taken once daily in the morning with breakfast

Answer 226

Should generally be avoided

Answer 227

• Pioglitazone increases glycogen synthesis and reduces gluconeogenesis. It also increases insulin receptor sensitivity

Answer 228

as it increases appetite it can cause weight gain and is associated with several long-term risks.

Answer 229

Yes a strong risk factor

Answer 230

- ACEi/ ARB | - Lipid-regulating drugs

Answer 231

lood pressure should be reduced to the lowest achievable level to slow the rate of decline of glomerular filtration rate and reduce proteinuria.

Answer 232

Provided there are no contra-indications, all diabetic patients who have confirmed nephropathy with an albumin:creatinine ratio (ACR) of 3 mg/mmol or more should be treated with an ACE inhibitor or an angiotensin-II receptor antagonist, even if the blood pressure is normal

Answer 233

given as monotherapy to reduce the rate of progression of CKD

Answer 234

add on therapy with a sodium glucose co-transporter 2 inhibitor should be offered if the ACR is over 30mg/mmol; for patients with an ACR of 3–30mg/mmol, add on therapy should be considered.

Answer 235

ACE inhibitors can potentiate the hypoglycaemic effect of insulin and oral antidiabetic drug this effect is more likely during the first weeks of combined treatment and in patients with renal impairment.

Answer 236

However, acute painful diabetic neuropathy can occur in patients with type 1 diabetes who have a rapid improvement in blood glucose control.

Answer 237

his is usually self-limiting and simple analgesics (such as paracetamol) along with other measures (such as bed cradles) are recommended as first line treatments. If the response is inadequate, other treatment options for painful diabetic neuropathy should be considered. Simple analgesia may be continued until the effects of additional treatments have been established.

Answer 238

Monotherapy with antidepressant drugs, including tricyclics (such as amitriptyline hydrochloride and imipramine hydrochloride [unlicensed use]), duloxetine, and venlafaxine [unlicensed use] Antiepileptic drugs, such as pregabalin and gabapentin, can also be considered. Opioid analgesics in combination with gabapentin can be considered if pain is not controlled with monotherapy.

Answer 239

- tetracycline (unlicensed) - Codeine Phosphate as the best alternative other antidiarrhoeal preparations can also be tried.

Answer 240

with an antimuscarinic such as propantheline bromide; side-effects are common.

Answer 241

Yes - Optimal diabetic and blood pressure control should be maintained to prevent onset and progression of diabetic eye disease

Answer 242

Higher mortality than DKA

Answer 243

discontinuation of or inadequate insulin therapy, acute illness such as myocardial infarction and pancreatitis, new onset of diabetes, or stress (e.g. trauma, surgery);

Answer 244

these include inadequate insulin or oral antidiabetic therapy, acute illness in a patient with known diabetes, or stress.

Answer 245

Rapidly (within hours) and mainly occurs in individuals with type 1 diabetes with around a third of cases occurring in those with type 2 diabetes

Answer 246

Unlike DKA, HHS can take days to develop and consequently the dehydration and metabolic disturbances are more severe at presentation.

Answer 247

HHS typically occurs in the elderly, but can also occur in younger adults and adolescents, often as the initial presentation of type 2 diabetes.

Answer 248

- Hyperglycaemia (blood glucose above 11mmol/L or known diabetes mellitus) - ketonaemia (capillary or blood ketone above 3 mmol/L or significant ketonuria of 2+ or more) - acidosis (bicarbonate less than 15 mmol/L and/or venous pH less than 7.3).

Answer 249

- Dehydration due to polydipsia (thirst) and polyuria (excessive urination) - Weight loss - Excessive tiredness - Nausea and vomiting - Abdominal pain - Kussmaul respiration (rapid and deep respiration) - Acetone breath (fruity smelling) - Reduced consciousness

Answer 250

occurs in people with type 2 diabetes who experience very high blood glucose levels (often over 40mmol/l). It can develop over a course of weeks through a combination of illness (e.g.infection) and dehydration.

Answer 251

- hypovolaemia (abnormally low extracellular fluid in the body) - marked hyperglycaemia (blood glucose above 30 mmol/L without significant hyperketonaemia or acidosis) - hyperosmolality (osmolality above 320 mosmol/kg)

Answer 252

- Dehydration due to polyuria and polydipsia - Weakness - Weight loss - Tachycardia - Dry mucous membranes - Poor skin turgor - Hypotension - Acute cognitive impairment - in severe cases can lead to shock

Answer 253

- restore circulatory volume (fluid replacement) - Correct electrolyte imbalance (electrolyte replacement) - correct hyperglycaemia - Clear ketones - supress ketogenesis

Answer 254

- correct fluid and electrolyte loss, hyperosmolarity and hyperglycaemia

Answer 255

the replacement of fluid and electrolytes and the administration of insulin

Answer 256

Within 24 hours

Answer 257

- IV fluid replacement - Followed by IV insulin (Soluble) (Patients who normally take long acting insulin should continue their usual dose(s) throughout treatment) - Potassium replacement and glucose administration may also be required to prevent subsequent hypokalaemia and hypoglycaemia depending on potassium levels and blood glucose concentrations, respectively.

Answer 258

The initial drug management of HHS involves intravenous fluid replacement, followed by intravenous insulin. For patients with significant ketonaemia or ketonuria, insulin can be started earlier. Potassium should be replaced or omitted as required.

Answer 259

Type 1 diabetes

Answer 260

Normally occurs in Type 1 diabetics. As no insulin is produced, fat is broken down (as no insulin is present to stop this occurring) causing ketone production. This type of hyperglycaemia occurs very quickly (>20mM), ketones irritate the vomiting centre and vomiting will potassium levels. If insulin is given, any potassium remaining in the blood will be taken up into cells worsening hypokalaemia

Answer 261

* We have to rehydrate the patient without giving glucose, so initial management involves giving 0.9% saline (sodium chloride) by I.V. infusion. * Potassium levels need to be replenished which is achieved by giving Potassium Chloride fluid * Next, we give an I.V. insulin infusion to reduce blood glucose levels and the production of ketone bodies. Soluble insulin should be diluted and mixed thoroughly with the 0.9% saline. Blood glucose should fall by atleast 3mmol/litre/hour * Once blood glucose concentration falls below 14mmol/litre… glucose 10% should be given by I.V. infusion in addition to 0.9% saline infusion to prevent hypoglycaemia. * The insulin infusion should be continued until the blood ketone concentration is <0.3mmol/litre, blood pH above 7.3 and the patient is able to eat and drink. Ideally give SC fast-acting insulin and a meal and stop the insulin infusion 1 hour later.

Answer 262

All patients should have emergency treatment for hypoglycaemia written on their drug chart on admission.

Answer 263

can be managed during the operative period by adjustment of their usual insulin regimen, which should be adjusted depending on the type of insulin usually prescribed, following detailed local protocols (which should also include intravenous fluid management, monitoring and control of electrolytes and avoidance of hyperchloraemic metabolic acidosis).

Answer 264

the patient’s usual insulin should be given as normal, other than once daily long-acting insulin analogues, which should be given at a dose reduced by 20 %.

Answer 265

will usually require a variable rate intravenous insulin infusion (continued until the patient is eating/drinking and stabilised on their previous glucose-lowering medication).

Answer 266

on the day before surgery, once daily long-acting insulin analogues should be given at 80 % of the usual dose; otherwise the patient’s usual insulin should be given as normal; On the day of surgery and throughout the intra-operative period, once daily long-acting insulin analogues should be continued at 80 % of the usual dose; all other insulin should be stopped until the patient is eating and drinking again after surgery;

Answer 267

Soluble human insulin

Answer 268

hould not begin until the patient can eat and drink without nausea or vomiting.

Answer 269

Once the patient’s previous insulin regimen is re-started, the usual insulin dose may require adjustment, as insulin requirements can change due to post-operative stress, infection or altered food intake.

Answer 270

when the first postoperative meal-time insulin dose is due (e.g. with breakfast or lunch); doses may need adjustment due to postoperative stress, infection or altered food intake.

Answer 271

Yes - The variable rate intravenous insulin infusion and intravenous fluids should be continued until 30–60 minutes after the first meal-time short-acting insulin dose.

Answer 272

Yes - hould be restarted before breakfast or an evening meal (not at any other time). The variable rate intravenous insulin infusion should be maintained for 30–60 minutes after the first subcutaneous insulin dose has been given.

Answer 273

blood-glucose, blood or urinary ketone concentration, serum electrolytes and serum bicarbonate checked before surgery. If ketones are high or bicarbonate is low, blood gases should also be checked. If ketoacidosis is present, recommendations for diabetes ketoacidosis should be followed immediately, and surgery delayed if possible. If there is no acidosis, intravenous fluids and an insulin infusion should be started and managed as for major elective surgery (above)

Answer 274

acarbose, meglitinides, sulfonylureas, pioglitazone, dipeptidyl peptidase-4 inhibitors (gliptins) and sodium glucose co-transporter 2 inhibitors should be stopped once the insulin infusion is commenced and not restarted until the patient is eating and drinking normally

Answer 275

Yes - can be continued as normal during the insulin infusion.

Answer 276

Pioglitazone, dipeptidylpeptidase-4 inhibitors (gliptins) and glucagon-like peptide-1 receptor agonists can be taken as normal during the whole peri-operative period.

Answer 277

should be omitted on the day of surgery and not restarted until the patient is stable; their use during periods of dehydration and acute illness is associated with an increased risk of developing diabetic ketoacidosis.

Answer 278

Sulfonylureas are associated with hypoglycaemia in the fasted state and therefore should always be omitted on the day of surgery until the patient is eating and drinking again. Capillary blood-glucose should be checked hourly. If hyperglycaemia occurs, an appropriate dose of subcutaneous rapid-acting insulin may be given. A second dose may be given 2 hours later, and a variable rate intravenous insulin infusion considered if hyperglycaemia persists.

Answer 279

renal impairment may lead to accumulation and lactic acidosis during surgery.

Answer 280

If only one meal will be missed during surgery, and the patient has an eGFR greater than 60 mL/minute/1.73m2 and a low risk of acute kidney injury (and the procedure does not involve administration of contrast media), it may be possible to continue metformin hydrochloride throughout the peri-operative period—just the lunchtime dose should be omitted if the usual dose is prescribed three times a day. If the patient will miss more than one meal or there is significant risk of the patient developing acute kidney injury, metformin hydrochloride should be stopped when the pre-operative fast begins. A variable rate intravenous insulin infusion should be started if the metformin hydrochloride dose is more than once daily. Otherwise insulin should only be started if blood-glucose concentration is greater than 12 mmol/litre on two consecutive occasions. Metformin should not be recommenced until the patient is eating and drinking again, and normal renal function has been assured.

Answer 281

There is no need to stop metformin hydrochloride after contrast medium in patients missing only one meal or who have an eGFR greater than 60 mL/minute/1.73m2. If contrast medium is to be used, and eGFR is less than 60 mL/minute/1.73m2, metformin should be omitted on the day of the procedure and for the following 48 hours.

Answer 282

-During periods of dehydration, stress, surgery, trauma, acute medical illness or any other catabolic state, and should be used with caution during these times

Answer 283

increased risks to the woman (such as pre-eclampsia and rapidly worsening retinopathy), and to the developing fetus, compared with pregnancy in non-diabetic women

Answer 284

48mmol/mol (6.5%) if possible without causing problematic hypoglycaemia.

Answer 285

- Folic acid at the dose for women who are at high-risk of neural tube defect

Answer 286

All oral antidiabetic drugs should be discontinued before pregnancy (except metformin) and substituted with insulin therapy

Answer 287

Metformin hydrochloride can be continued immediately after birth and during breast-feeding for those with pre-existing Type 2 diabetes. All other antidiabetic drugs should be avoided while breast-feeding.

Answer 288

Isophane insulin however in women who have good blood-glucose control before pregnancy with the long-acting insulin analogues (insulin detemir or insulin glargine), it may be appropriate to continue using them throughout pregnancy.

Answer 289

Continuous subcutaneous insulin infusion (insulin pump therapy) may be appropriate for pregnant women who have difficulty achieving glycaemic control with multiple daily injections of insulin without significant disabling hypoglycaemia.

Answer 290

All women treated with insulin during pregnancy should be aware of the risks of hypoglycaemia, particularly in the first trimester, and should be advised to always carry a fast-acting form of glucose, such as dextrose tablets or a glucose-containing drink. Pregnant women with Type 1 diabetes should also be prescribed glucagon for use if needed.

Answer 291

first attempt a change in diet and exercise alone in order to reduce blood-glucose.

Answer 292

If blood-glucose targets are not met within 1 to 2 weeks, metformin hydrochloride may be prescribed [unlicensed use].

Answer 293

- Insulin and may also be added to treatment if metformin is not effective alone

Answer 294

should be treated with insulin immediately, with or without metformin hydrochloride, in addition to a change in diet and exercise.

Answer 295

hould be considered for immediate insulin treatment, with or without metformin hydrochloride.

Answer 296

No - Women with gestational diabetes should discontinue hypoglycaemic treatment immediately after giving birth.

Answer 297

Delays the digestion and absorption of starch and sucrose; it has small but significant effect in lowering blood glucose

Answer 298

Less than 25ml/min/1.73m2

Answer 299

Biguanides

Answer 300

Less than 30ml/min/1.73m2

Answer 301

- dyspnoea, muscle cramps, abdominal pain, hypothermia or asthenia (weakness; lack of energy and strength)

Answer 302

Usual dose is 25mg once daily if eGFR 30-50ml/min/1.73m2 then reduce to 12.5mg daily If eGFR less than 30ml/min.1.73m2 then reduce dose to 6.25mg daily

Answer 303

Yes - vipdomet

Answer 304

Yes - no dose adjustments required

Answer 305

Jentadueto

Answer 306

Sitagliptin with metformin

Answer 307

Dulaglutide is a long acting glucagon-like-receptor 1 agonist that augments glucose dependent insulin secretion and delays gastric emptying

Answer 308

Slowly and gradually as rapid withdrawal of insulin has been linked to serious and life-threatening cases of diabetic ketoacidosis

Answer 309

In the fridge 2-8degrees celsius Once in use, may be stored unrefrigerated for up to 14 days at a temperature not above 30degree.

Answer 310

If a dose is missed, it should be administered as soon as possible only if there are at least 3 days until the next schedule dose; if less than 3 days remain before the next schedule dose, the missed dose should not be taken and the next dose should be taken at the normal time

Answer 311

Victoza | Saxenda

Answer 312

GLP-1 agonist

Answer 313

Reversibly inhibit sodium-glucose co-transporter 2 in the renal proximal convoluted tubule to reduce glucose reabsorption and increase urinary glucose excretion

Answer 314

- rapid weight loss, nausea or vomiting, abdominal pain, fast and deep breathing, sleepiness, a sweet smell to the breath, a sweet or metallic taste in the mouth, or a different odour to urine or sweat)

Answer 315

Volume depletion - especially in the elderly correct hypovolaemia before starting treatment

Answer 316

Caution if under 60ml/min/1.73m2 Avoid if under 30ml/min/1.73m2

Answer 317

Postural hypotension | Dizziness

Answer 318

Fournier's gangrane - if suspected - stop treatment - seek medical attention

Answer 319

It is no longer recommended in the treatment of type 1 diabetes (Previous BNF notes say - high risk of diabetic ketoacidosis in type 1 diabetes)

Answer 320

Gliclazide Glimepiride Glipizide Tolbutamide

Answer 321

Reduces peripheral insulin resistance, leading to reduction of blood-glucose concentration

Answer 322

No it should not be used in patients with heart failure or a history of heart failure

Answer 323

- Bladder cancer Should not be used in patients with active bladder cancer or with a past history of bladder cancer or in those who have univestigated macroscopic haematuria. Risk of bladder cancer with pioglitazone increases with age

Answer 324

3-6 months

Answer 325

- Haematuria - dysuria - Urinary urgency

Answer 326

Adults - 4-7mmol/L before meals and less than 9mmol/L after meals Children - 4-8mmolL before meals and less than 10mmol/L after meals

Answer 327

who are treated with insulin; who are treated with oral hypoglycaemic drugs e.g. sulfonylureas, to provide information on hypoglycaemia; to monitor changes in blood-glucose concentration resulting from changes in lifestyle or medication, and during intercurrent illness; to ensure safe blood-glucose concentration during activities, including driving.

Answer 328

Glucose interstitial fluid detection sensors

Answer 329

Less than 4mmol/L

Answer 330

who is acutely unwell, drowsy, unconscious, unable to co-operate, or presenting with aggressive behaviour or seizures.

Answer 331

a small carbohydrate snack such as a slice of bread or a normal meal, if due.

Answer 332

should be treated with a fast-acting carbohydrate by mouth.

Answer 333

Lift® glucose liquid (previously Glucojuice®), glucose tablets, glucose 40% gels (e.g. Glucogel®, Dextrogel®, or Rapilose®), pure fruit juice, and sugar (sucrose) dissolved in an appropriate volume of water. Oral glucose formulations are preferred as absorption occurs more quickly.

Answer 334

Not effective for patients taking acarbose which prevents the breakdown of sucrose to glucose

Answer 335

As they have lower sugar content and their high fat content may delay stomach emptying

Answer 336

repeat treatment after 15 minutes, up to a maximum of 3 treatments in total.

Answer 337

a snack providing a long-acting carbohydrate should be given to prevent blood glucose from falling again (e.g. two biscuits, one slice of bread, 200–300 mL of milk (not soya or other forms of 'alternative' milk, e.g. almond or coconut), or a normal carbohydrate-containing meal if due) Insulin should not be omitted if due, but the dose regimen may need review.

Answer 338

should be treated with intramuscular glucagon or glucose 10% intravenous infusion

Answer 339

Thiamine supplementation

Answer 340

Glucagon is a polypeptide hormone produced by the alpha cells of the islets of Langerhans, which increases blood-glucose concentration by mobilising glycogen stored in the liver.

Answer 341

he manufacturer advises that it is ineffective in patients whose liver glycogen is depleted, therefore should not be used in anyone who has fasted for a prolonged period or has adrenal insufficiency, chronic hypoglycaemia, or alcohol-induced hypoglycaemia.

Answer 342

Glucagon may also be less effective in patients taking a sulfonylurea; in these cases, intravenous glucose will be required.

Answer 343

In an emergency, if the patient has a decreased level of consciousness caused by hypoglycaemia, intramuscular glucagon can be given by a family member or friend who has been shown how to use it. If glucagon is not effective after 10 minutes, glucose 10% intravenous infusion should be given.

Answer 344

Patients who are unconscious, having seizures, or who are very aggressive, should have any intravenous insulin stopped, and be treated initially with glucagon. If glucagon is unsuitable, or there is no response after 10 minutes, glucose 10% intravenous infusion, or alternatively glucose 20% intravenous infusion should be given

Answer 345

No - Glucose 50% intravenous infusion is not recommended as it is hypertonic, thus increases the risk of extravasation injury, and is viscous, making administration difficult.

Answer 346

A larger portion of long acting carbohydrate Glucose 10% intravenous infusion should be given to patients who are nil by mouth.

Answer 347

Up to 24-36 hours following the last dose, especially if there is concurrent renal impairment

Answer 348

At least 24-48 hours

Answer 349

1 unit = 1mg

Answer 350

Severe pancreatitis has been reported rarely, discontinue permanently if diagnosed

Answer 351

When taken with insulin, especially in patients with predisposing factors. Patients should be closely monitored for signs of heart failure, and treatment stopped if any cardiac deterioration occurs. It should not be used in patients with heart failure or with a history of heart failure.

Answer 352

No - liver toxicity - rare reports of liver dysfunction, discontinue if jaundice occurs.

Answer 353

It is a progressive bone disease characterised by low bone mass measured by bone mineral density (BMD), and microarchitectural deterioration of bone tissue

Answer 354

Increased risk of fragility fractures (fractures resulting from low-level trauma)

Answer 355

If there have been one or more fragility fractures

Answer 356

- Postmenopausal women - men over 50 years - in patients taking long-term oral corticosteroids (glucocorticoids)

Answer 357

- increasing age - Vitamin D deficiency - Low calcium intake - Lack of physical activity - Low body mass index (BMI) - Cigarette smoking - Excess alcohol intake - Parental history of hip fractures - a previous fracture at a site characteristic of osteoporotic fractures - Early menopause

Answer 358

- increase level of physical activity - Stop smoking - maintain a normal BMI level (between 20-25kg/m2) - Reduce their alcohol intake - ensure adequate intake of calcium and Vitamin D

Answer 359

Calcium should preferably be obtained through increasing dietary intake; supplements may be used if necessary

Answer 360

A daily dietary supplement of vitamin D may be considered for those at increased risk of deficiency.

Answer 361

Elderly patients, especially those who are housebound or live in residential or nursing homes, are at high risk of vitamin D deficiency and may benefit from calcium and vitamin D treatment Elderly patients also have an increased risk of falls

Answer 362

- Alendronic acid and risedronate are considered first line due to their broad spectrum of anti-fracture efficacy

Answer 363

Reduce occurrence of vertebral, non-vertebral and hip fractures.

Answer 364

Ibandronic acid

Answer 365

Yes for those who are intolerant to oral bisphosphonate, or in whom they are unsuitable, with raloxifene hydrochloride or strontium ranelate as additional alternative options.

Answer 366

Hormone replacement therapy (HRT) may also be considered as an additional alternative option, but its use is generally restricted to younger postmenopausal women with menopausal symptoms who are at high risk of fractures. This is due to the risk of adverse effects such as cardiovascular disease and cancer in older postmenopausal women and women on long-term HRT therapy.

Answer 367

- Tibolone

Answer 368

Teriparatide is reserved for postmenopausal women with severe osteoporosis at very high risk of fractures, particularly vertebral fractures

Answer 369

postmenopausal women with severe osteoporosis who have previously experienced a fragility fracture and are at imminent risk of another (within 24 months).

Answer 370

- Teriparatide | - Romosozumab

Answer 371

With bone loss and increased risk of fractures

Answer 372

he greatest rate of bone loss occurs early after initiation of glucocorticoids and increases with the dose and duration of therapy.

Answer 373

Bone-protection treatment should be started at the onset of glucocorticoid treatment in patients who are at high risk of a fracture.

Answer 374

Women aged ≥70 years, OR with a previous fragility fracture, OR who are taking large doses of glucocorticoids (prednisolone ≥7.5 mg daily or equivalent) should be considered for bone-protection treatment. Men aged ≥70 years with a previous fragility fracture, OR who are taking large doses of glucocorticoids, should also be considered for treatment. For some premenopausal women and younger men (particularly those with a previous history of fracture or who are receiving large doses of glucocorticoids), bone-protection treatment may be appropriate. SIGN (2021) recommends that bone-protection treatment should be considered in all men and women taking large doses of glucocorticoids (prednisolone ≥7.5 mg daily or equivalent) for 3 months or longer.

Answer 375

The oral bisphosphonates alendronic acid or risedronate sodium are first-line treatment options. Zoledronic acid, denosumab or teriparatide are alternative options in patients intolerant of oral bisphosphonates or in whom they are unsuitable.

Answer 376

The oral bisphosphonates alendronic acid or risedronate sodium are recommended as first-line treatments for osteoporosis in men. Zoledronic acid or denosumab are alternatives in men who are intolerant of oral bisphosphonates or in whom they are unsuitable; teriparatide or strontium ranelate are additional alternative options.

Answer 377

Men having androgen deprivation therapy for prostate cancer have an increased fracture risk. Fracture risk assessment should be considered when starting this therapy. A bisphosphonate can be offered to men with confirmed osteoporosis; denosumab may be considered as an alternative if bisphosphonates are unsuitable or not tolerated.

Answer 378

After 5 years of treatment

Answer 379

After 3 years

Answer 380

Bisphosphonates are adsorbed onto hydroxyapatite crystals in bone, slowing both their rate of growth and dissolution, and therefore reducing the rate of bone turnover.

Answer 381

Femoral fractures Discontinuation of bisphosphonate treatment in patients suspected to have an atypical femoral fracture should be considered after an assessment of the benefits and risks of continued treatment.

Answer 382

Patients should be advised to report any thigh, hip, or groin pain during treatment with a bisphosphonate.

Answer 383

The risk of osteonecrosis of the jaw is substantially greater for patients receiving intravenous bisphosphonates in the treatment of cancer

Answer 384

Risk factors for developing osteonecrosis of the jaw that should be considered are: potency of bisphosphonate (highest for zoledronate), route of administration, cumulative dose, duration and type of malignant disease, concomitant treatment, smoking, comorbid conditions, and history of dental disease.

Answer 385

osteonecrosis of the external auditory canal Benign idiopathic osteonecrosis of the external auditory canal has been reported very rarely with bisphosphonate treatment, mainly in patients receiving long-term therapy (2 years or longer). The possibility of osteonecrosis of the external auditory canal should be considered in patients receiving bisphosphonates who present with ear symptoms, including chronic ear infections, or suspected cholesteatoma.

Answer 386

steroid use, chemotherapy, infection, an ear operation, or cotton-bud use.

Answer 387

Patients should be advised to report any ear pain, discharge from the ear, or an ear infection during treatment with a bisphosphonate.

Answer 388

Atypical femoral fractures - Patients should be advised to report any thigh, hip, or groin pain during treatment with a bisphosphonate. Osteonecrosis of the jaw - During bisphosphonate treatment patients should maintain good oral hygiene, receive routine dental check-ups, and report any oral symptoms. Osteonecrosis of the external auditory canal- Patients should be advised to report any ear pain, discharge from ear or an ear infection during treatment with a bisphosphonate.

Answer 389

No should be avoided

Answer 390

Oesophageal rections Patients should stop treatment and seek medical attention if they develop oesophageal irritation, dysphagia or worsening heartburn

Answer 391

Men - 10mg daily Women - 10mg daily/ alternatively 70mg once weekly

Answer 392

with a full glass of water whilst sitting or standing. It should be taken atleast 30 minutes before breakfast and other medicines and the patient should remain upright for a further 30 minutes after taking.

Answer 393

Less than 35ml/min/1.73m2

Answer 394

Monthly - 150mg once a month Alternatively (by IV) 3mg every 3 months to be administered over 15-30 seconds

Answer 395

5mg daily/ alternatively 35mg weekly

Answer 396

No - IV only

Answer 397

Calcium regulating drug (parathyroid hormones and analogues)

Answer 398

It is a human monoclonal antibody that inhibits osteoclast formation, function and survival, thereby decreasing bone resorption

Answer 399

60mg every 6 months (supplement with calcium and vitamin D, to be adminstered into the thigh, abdomen or upper arm.

Answer 400

Yes - long term use 2.5 or more years Also osteonecrosis of the jaw and external auditory canal

Answer 401

Becuase it is associated with causing hypocalcaemia - the risk increases with the degree of renal impairment

Answer 402

- before each dose - within two weeks after the intial dose in patients with risk factors for hypocalcaemia (e.g. severe renal impairment, creatinine clearance less than 30ml/min) - if suspected symptoms of hypocalcaemia occur

Answer 403

- muscle spasms - twitches - cramps - numbness or tingling in the fingers, toes or around the mouth

Answer 404

Hypocalcaemia

Answer 405

Ensure effective contraception in women of child bearing potential, during treatment and for at least 5 months after stopping treatment

Answer 406

Within 1 month of scheduled date

Answer 407

Bromocriptine is used for the treatment of galactorrhoea, and for the treatment of prolactinomas (when it reduces both plasma prolactin concentration and tumour size).

Answer 408

- Inhibits the release of growth hormone and is sometimes used in the treatment of acromegaly, but somatostatin analogues (such as octreotide) are more effective

Answer 409

- Cabergoline

Answer 410

No - they are not recommended for routine suppression (or for the relief of symptoms of postpartum pain and engorgement) that can be adequately treated with simple analgesics and breast support.

Answer 411

Cabergoline

Answer 412

It is a non-ergot dopamine D2 agonist

Answer 413

Hyperprolactinaemia

Answer 414

Cetrorelix and ganirelix are luteinising hormone releasing hormone antagonists, which inhibit the release of gonadotrophins (luteinising hormone and follicle stimulating hormone) They are used in the treatment of infertility by assisted reproductive techniques.

Answer 415

are used in the treatment of endometriosis, precocious puberty, infertility, male hypersexuality with severe sexual deviation, anaemia due to uterine fibroids (together with iron supplementation), breast cancer, prostate cancer and before intra-uterine surgery

Answer 416

Use of leuprorelin acetate and triptorelin for 3 to 4 months before surgery reduces the uterine volume, fibroid size and associated bleeding.

Answer 417

Once any serious underlying cause for breast pain has been ruled out, most women will respond to reassurance and reduction in dietary fat; withdrawal of an oral contraceptive or of hormone replacement therapy may help to resolve the pain.

Answer 418

Mild, non-cyclical breast pain is treated with simple analgesics; moderate to severe pain, cyclical pain or symptoms that persist for longer than 6 months may require specific drug treatment.

Answer 419

Danazol is licensed for the relief of severe pain and tenderness in benign fibrocystic breast disease which has not responded to other treatment.

Answer 420

Treatment for breast pain should be reviewed after 6 months and continued if necessary. Symptoms recur in about 50% of women within 2 years of withdrawal of therapy but may be less severe.

Answer 421

- Buserelin - Goserelin - Leuprorelin Acetate - Nafarelin - Triptorelin

Answer 422

Tetracosactide (tetracosactrin), an analogue of corticotropin (ACTH), is used to test adrenocortical function Failure of the plasma cortisol concentration to rise after administration of tetracosactide indicates adrenal insufficiency

Answer 423

Follicle-stimulating hormone (FSH) and luteinising hormone (LH) together, or follicle-stimulating hormone alone (as in follitropin), are used in the treatment of infertility in women with proven hypopituitarism or who have not responded to clomifene citrate, or in superovulation treatment for assisted conception (such as in vitro fertilisation).

Answer 424

Growth hormone is used to treat deficiency of the hormone in children and in adults.

Answer 425

In children it is used in Prader-Willi syndrome, Turner syndrome, chronic renal insufficiency, short children considered small for gestational age at birth, and short stature homeobox-containing gene (SHOX) deficiency

Answer 426

Growth hormone of human origin (HGH; somatotrophin) has been replaced by a growth hormone of human sequence, somatropin, produced using recombinant DNA technology.

Answer 427

Gonadorelin when injected intravenously in normal subjects leads to a rapid rise in plasma concentrations of both luteinising hormone (LH) and follicle-stimulating hormone (FSH). It has not proved to be very helpful, however, in distinguishing hypothalamic from pituitary lesions. Gonadorelin analogues are indicated in endometriosis and infertility and in breast and prostate cancer.

Answer 428

Assessment of pituitary function

Answer 429

Acromegaly is a hormonal disorder that develops when your pituitary gland produces too much growth hormone during adulthood. When you have too much growth hormone, your bones increase in size. In childhood, this leads to increased height and is called gigantism. But in adulthood, a change in height doesn't occur

Answer 430

- Pegvisomant

Answer 431

Somatropin

BNF - Chapter 6 - Endocrine system - (Part 1) Flashcards

(473 cards)