BNF - Chapter 6 - Endocrine system - (Part 2) Flashcards
1
Q
What are oestrogens required for the development of in females?
A
- Female secondary sexual characteristics
they also stimulate myometrial hypertrophy with endometrial hyperplasia.
2
Q
Which have a more appropriate profile for hormone replacement therapy (HRT) - natural oestrogens or synthetic?
A
Natural oestrogens
3
Q
List the natural and synthetic oestrogens?
A
Natural = Estradiol (oestradiol), estrone (oestrone) and estriol (Oestriol)
Synthetic = Ethinylestradiol and mestranol.
4
Q
What activity does tibolone have?
A
- Oestrogenic
- Progestogenic
- and weak androgenic activity
5
Q
If long term oestrogen therapy is required then women with a uterus should be given what else with oestrogen?
A
- A progestogen should normally be added to reduce the risk of cystic hyperplasia of the endometrium (or of endometritic foci in women who have had a hysterectomy) and possible transformation to cancer
6
Q
Are oestrogens recommended for suppression of lactation?
A
No longer used to suppress lactation because of their association with thromboembolism
7
Q
What is HRT (hormone replacement therapy) useful for?
A
Hormone replacement therapy (HRT) with small doses of an oestrogen (together with a progestogen in women with a uterus) is appropriate for alleviating menopausal symptoms such as vaginal atrophy or vasomotor instability.
8
Q
Does oestrogen have a role in diminishing postmenopausal osteoporsis?
A
Yes but other drugs are preferred for osteoporosis
9
Q
What may menopausal atrophic vaginitis respond to?
A
- A short course of a topical vaginal oestrogen preparation used for a few weeks and repeated if necessary
10
Q
What does systemic therapy with an oestrogen help alleviate the symptoms of?
A
- The symptoms of oestrogen deficiency such as vasomotor symptoms
11
Q
What activity does tibolone combine?
A
Tibolone combines oestrogenic and progestogenic activity with weak androgenic activity;
12
Q
Is tibolone given with or without cyclical progestogen?
A
It is given continuously without cyclical progestogen
13
Q
Which drug class is clonidine in?
A
- Alpha receptor agonist
14
Q
What may clonidine be used for in menopausal symptoms?
A
Clonidine hydrochloride may be used to reduce vasomotor symptoms in women who cannot take an oestrogen, but clonidine hydrochloride may cause unacceptable side-effects.
15
Q
What does HRT increase the risk of?
A
HRT increases the risk of venous thromboembolism, stroke, endometrial cancer (reduced by a progestogen), breast cancer, and ovarian cancer;
16
Q
What is the increased risk of coronary heart disease in women who start HRT 10 years after the menopause?
A
there is an increased risk of coronary heart disease in women who start combined HRT more than 10 years after menopause.
17
Q
Do all systemic HRT increase the risk of breast cancer?
A
Yes - All types of systemic (oral or transdermal) HRT treatment increase the risk of breast cancer after 1 year of use.
18
Q
For which HRT preparations is the risk for breast cancer higher?
A
This risk is higher for combined oestrogen-progestogen HRT (particularly for continuous HRT preparations where both oestrogen and progestogen are taken throughout each month) than for oestrogen-only HRT, but is irrespective of the type of oestrogen or progestogen
19
Q
Are vaginal preparations containing low dose of oestrogen to treat local symptoms thought to increase risk of breast cancer?
A
They are not thought to be associated with an effect on breast cancer risk.
20
Q
If a decision is made to stop treatment, in the absence of contraindications, the MHRA recommends how should this be done?
A
- This should be done gradually to minimise recurrence of menopausal symptoms
21
Q
Why may HRT use make it more difficult for radiological detection of breast cancer?
A
can be made more difficult as mammographic density can increase with HRT use especially oestrogen-progestogen combined treatment, but this is not thought to be the case with tibolone.
22
Q
Has tibolone been associated with an increased or decreased risk of breast cancer during treatment?
A
Tibolone has also been associated with an increased risk of breast cancer during treatment, although the extent of risk and its persistence after stopping is currently inconclusive.
23
Q
What does the risk of endometrial cancer depend on?
A
The dose and duration of oestrogen only HRT.
24
Q
To reduce the risk of endometrial cancer with oestrogen HRT - at least how many days per 28-day cycle (in women with a uterus) should the addition of a progestogen cyclically be given?
A
For at least 10 days per 28-day cycle
25
The risk of endometrial cancer in women who have not used HRT increased with what?
Increases with body mass index (BMI)
26
Is the increased risk of endometrial cancer in users of oestrogen only HRT or tibolone more apparent in women who are overweight or not overweight?
More in women who are not over weight
27
Is there an increased risk of endometrial cancer with tibolone use?
Yes
28
Does the risk of ovarian cancer disappear after discontinuing combined HRT or oestrogen only HRT?
yes it does - within few years after stopping
29
Does combined or oestrogen only HRT increase risk of VTE?
Yes - especially in the first year of use
30
Is risk of VTE with non-oral HRT greater or lower?
Although the level of risk of thromboembolism associated with non-oral routes of administration of HRT has not been established, it may be lower for the transdermal route.
31
Does combined HRT or oestrogen only HRT increase the risk of stroke?
Slightly increases the risk of stroke
32
Which HRT does a o women with a uterus usually require?
A woman with a uterus normally requires oestrogen with cyclical progestogen for the last 12 to 14 days of the cycle or a preparation which involves continuous administration of an oestrogen and a progestogen (or one which provides both oestrogenic and progestogenic activity in a single preparation).
33
When are continuous combined preparation or tibolone not suitable?
are not suitable for use in the perimenopause or within 12 months of the last menstrual period;
In other words - can only be used in post-menopausal women
34
What may women using continuous combined preparations of HRT or tibolone experience?
- May bleed irregularly in the early stages of treatment = of bleeding continues endometrial abnormality should be ruled out and consideration given to changing to cyclical HRT
35
Can oestrogen alone be used in women without a uterus
Yes
36
What circumstances in women without a uterus may progestogen still be considered?
n endometriosis, endometrial foci may remain despite hysterectomy and the addition of a progestogen should be considered in these circumstances.
37
Does transdermal administration avoid first-pass metabolism?
yes
38
For patients on HRT - how many weeks may it need to be stopped before surgery?
Major surgery under general anaesthesia, including orthopaedic and vascular leg surgery, is a predisposing factor for venous thromboembolism and it may be prudent to stop HRT 4–6 weeks before surgery;
it should be restarted only after full mobilisation.
39
What about if HRT is continued or if discontinuation is not possible (e.g. in non-elective surgery)?
prophylaxis with unfractionated or low molecular weight heparin and graduated compression hosiery is advised.
40
Hormone replacement therapy should be stopped (pending investigation and treatment), if any of the following occur?
sudden severe chest pain (even if not radiating to left arm);
sudden breathlessness (or cough with blood-stained sputum);
unexplained swelling or severe pain in calf of one leg;
severe stomach pain;
serious neurological effects including unusual severe, prolonged headache especially if first time or getting progressively worse or sudden partial or complete loss of vision or sudden disturbance of hearing or other perceptual disorders or dysphasia or bad fainting attack or collapse or first unexplained epileptic seizure or weakness, motor disturbances, very marked numbness suddenly affecting one side or one part of body;
hepatitis, jaundice, liver enlargement;
blood pressure above systolic 160 mmHg or diastolic 95 mmHg;
prolonged immobility after surgery or leg injury;
detection of a risk factor which contra-indicates treatment.
41
What is ethnylestradiol licensed for?
Ethinylestradiol (ethinyloestradiol) is licensed for short-term treatment of symptoms of oestrogen deficiency, for osteoporosis prophylaxis if other drugs cannot be used and for the treatment of female hypogonadism and menstrual disorders.
It is also used licensed for the palliative treatment of prostate cancer.
42
What role does raloxifene have postmenopause?
Raloxifene hydrochloride is licensed for the treatment and prevention of postmenopausal osteoporosis; unlike hormone replacement therapy, raloxifene hydrochloride does not reduce menopausal vasomotor symptoms.
43
What drug treatment may endometriosis respond to?
t may respond to a progestogen, e.g. norethisterone, administered on a continuous basis. Danazol and gonadorelin analogues are also licensed for endometriosis.
44
Oral progestogens have also been used for severe dysmenorrhoea - what if contraception is also required e.g. younger women?
The the best choice is a combined oral contraceptive
45
What progesterone effect does Ulipristal acetate have?
Ulipristal acetate is a progesterone receptor modulator with a partial progesterone antagonist effect
46
What are the use of ulipristal acetate?
Intermittent ulipristal acetate can be used to treat moderate to severe symptoms of uterine fibroids in premenopausal women where surgery and uterine artery embolisation are unsuitable, or have failed. Ulipristal acetate is also used as a hormonal emergency contraceptive.
47
What is vaginal atrophy?
Thinning + Drying of the vaginal walls due to less oestrogen
48
What is endometriosis?
Endometriosis is the growth of endometrial-like tissue outside the uterus.
49
Which age does endometriosis affect?
Women of reproductive age, although the exact cause is unknown, it is an oestrogen dependent condition and is associated with menstruation
50
What symptoms is associated with endometriosis?
- pelvic pain, painful periods and subfertility
Women with endometriosis report pain, which can be frequent, chronic and severe, as well as tiredness, more sick days, and a significant physical, sexual, psychological and social impact
51
Endometriosis is an important cause of what?
Endometriosis is an important cause of subfertility and this can also have a significant effect on quality of life.
52
Do every women with endometriosis show symptoms?
No - so it is is difficult to know how common the disease is in the population
53
How do most drug treatments for endometriosis work?
By suppressing ovarian function and are contraceptive
54
What does surgical treatment aim to remove?
Aims to remove or destroy endometriotic lesions
55
What is the first-line management of endometriosis-related pain?
A short trial (such as 3 months) of paracetamol or an NSAID alone or in combination
56
Which hormonal treatment should be offered to women with suspected, confirmed or recurrent endometriosis?
Combined oral contraceptive or progestogen
57
What can hormonal treatment for endometriosis reduce?
Reduce pain and has no permanent negative effect on subsequent fertility
58
For endometriosis what should women be asked about to guide surgical decision making?
Women with suspected or confirmed endometriosis should be asked about their symptoms, preferences and priorities with respect to pain and fertility, to guide surgical decision-making.
59
When should gonadotropin-releasing hormones be given?
For deep endometriosis involving the bowel, bladder or ureter, gonadotropin-releasing hormones given for 3 months before surgery should be considered
60
Can women with endometriosis who are trying to conceive be offered hormonal treatment?
No - should not be offered hormonal treatment, because it does not improve spontaneous pregnancy rates.
61
What is heavy menstrual bleeding also known as?
- Menorrhagia
62
how much blood loss or more is considered as menorrhagia?
Excessive menstrual blood loss of 80ml or more, and/or for a duration of more than 7 days, which results in the need to change menstrual products every 1-2 hours.
Heavy menstrual bleeding occurs regularly every 24-35 days
63
For menorrhagia what should the choice of drug be guided by?
By the presence or absence of fibroids (including size, number and location), polyps, endometrial pathology or adenomyosis, other symptoms (such as pressure or pain), co-morbidities and patient preference
64
In females with heavy menstrual bleeding and unidentified pathology, fibroids less than 3 cm in diameter causing no distortion of the uterine cavity, or suspected or diagnosed adenomyosis, what is first line treatment option?
- A levonorgestrel-releasing intrauterine system
65
What should patients be advised when going on a levonorgestrel intrauterine device?
irregular menstrual bleeding can occur particularly during the first months of use and that the full benefit of treatment may take at least 6 months.
66
What are the other options for menorrhagia is levonorgestrel releasing intrauterine system is unsuitable?
either tranexamic acid, an NSAID, a combined hormonal contraceptive, or a cyclical oral progestogen should be considered
67
Why may progestogen only contraceptives be helpful in menorrhagia?
They may supress menstruation and be beneficial to females with heavy menstrual bleeding
68
What type of treatment is recommended in patients actively trying to conceive?
A non-hormonal treatment
69
What about females with fibroids of 3cm or more in diameter?
- Referral to a specialist should be considered
70
What are the treatment options for females with menorrhagia and fibroids of 3cm or more in diameter after specialist referral?
Treatment options include tranexamic acid, an NSAID, a levonorgestrel-releasing intrauterine system, a combined hormonal contraceptive, a cyclical oral progestogen, ulipristal acetate, uterine artery embolisation, or surgery.
71
When can intermittent ulipristal acetate be given?
Intermittent ulipristal acetate can be offered to treat moderate to severe symptoms of uterine fibroids in premenopausal women where surgery and uterine artery embolisation are unsuitable, or have failed.
72
Which treatment should be considered if uterine fibroids are causing an enlarged or distorted uterus?
Treatment with a gonadotrophin-releasing hormone analogue before hysterectomy and myomectomy should be considered
73
What are the indications of raloxefine?
60mg once daily for treatment and prevention of postmenopausal osteoporosis
60mg once daily for 5 years for breast cancer (chemotherapy) in postmenopausal women at moderate to high risk
74
Is raloxifene use for chemoprevention of breast cancer a licence use in UK?
Not licensed in the UK but it is for chemoprevention in the USA
75
Does HRT provide contraception?
No it does not
76
A women is still considered fertile for how long after her last symptom if this was before 50 years old?
For 2 years after her last menstrual period if she is under 50 years
77
A women is still considered fertile for how long after her last symptom if this was after 50 years old?
For 1 year is she is over 50 years - from her last menstrual period
78
Measurement of what can help to determine fertility?
Measurement of follicle stimulating hormone
79
What is the directions for adminstration for HRT patches?
Manufacturer advises patch should be removed after 3–4 days (or once a week in case of 7-day patch) and replaced with fresh patch on slightly different site; recommended sites: clean, dry, unbroken areas of skin on trunk below waistline; not to be applied on or near breasts or under waistband. If patch falls off in bath allow skin to cool before applying new patch.
80
What prescribing information should be noted for tibolone?
Unsuitable for use in the premenopause (unless being treated with gonadotrophin-releasing hormone analogue) and as (or with) an oral contraceptive.
Also unsuitable for use within 12 months of last menstrual period (may cause irregular bleeding).
If transferring from cyclical HRT, start at end of regimen; if transferring from continuous-combined HRT, start at any time.
81
What is the indication of clomifene Citrate?
Female infertility due to ovulatory dysfunction
82
What is the drug action of clomifene Citrate?
Anti-oestrogen which induces gonadotrophin release by occupying oestrogen receptors in the hypothalamus, thereby interfering with feedback mechanisms; chronic gonadotrophin is sometimes used as an adjunct
83
Manufacturer advises clomifene should not normally be used for longer than how many cycles?
6 cycles (possible increased risk of ovarian cancer).
84
What do androgens cause?
| Masculinisation or feminisation?
Masculinisation
85
What does castrated mean?
Removal of the testicles
86
Androgens may be used as replacement therapy in which patients?
- Castrated adults and in those who are hypogonadal due to either pituitary or testicular disease
87
In normal male what do androgens inhibit?
They inhibit pituitary gonadotrophin secretion and depress spermatogenesis
Androgens also have an anabolic action which led to the development of anabolic steroids.
88
Are androgens useful in the treatment of impotence and impaired spermatogenesis?
Androgens are useless as a treatment of impotence and impaired spermatogenesis unless there is associated hypogonadism;
they should not be given until the hypogonadism has been properly investigated. Treatment should be under expert supervision.
89
When androgens are given to patients with hypopituitarism what can they lead to?
Can lead to normal sexual development and potency but not fertility
90
What if fertility is desired?
If fertility is desired, the usual treatment is with gonadotrophins or pulsatile gonadotrophin-releasing hormone which will stimulate spermatogenesis as well as androgen production.
91
What formulations and drug is preferred for replacement therapy?
Intramuscular depot preparations of testosterone esters are preferred for replacement therapy.
92
Which testosterones are available?
Testosterone enantate, propionate or undecanoate, or alternatively Sustanon®, which consists of a mixture of testosterone esters and has a longer duration of action, may be used.
93
Name an anti-androgen?
Cyproterone Acetate
94
What is Cyproterone Acetate used for?
Cyproterone acetate is an anti-androgen used in the treatment of severe hypersexuality and sexual deviation in the male
95
How does Cyproterone Acetate work?
It inhibits spermatogenesis and produces reversible infertility (but is not a male contraceptive); abnormal sperm forms are produced. Fully informed consent is recommended and an initial spermatogram.
96
What has been associated with Cyproterone acetate in animal studies?
Hepatic Tumours
97
What are some other uses of Cyproterone acetate?
Cyproterone acetate is also licensed for use alone in patients with metastatic prostate cancer refractory to gonadorelin analogue therapy, and has been used as an adjunct in prostatic cancer and in the treatment of acne and hirsutism in women.
98
What are alternatives to alpha-blockers particularly in men with a significantly enlarged prostrate?
Dutasteride and finasteride
99
What is finasteride also licensed for use with doxazosin?
- The management of benign prostatic hyperplasia
100
A low strength of finasteride can be used to treat?
A low strength of finasteride is licensed for treating male-pattern baldness in men.
101
Do anabolic steroids have androgenic activity?
Anabolic steroids have some androgenic activity but they cause less virilisation than androgens in women.
102
What is verillisation?
Development of male physical characteristics (e.g. body hair, deep voice)
103
What may anabolic steroids be used in?
In the treatment of some aplastic anaemias
104
What are the contraindications of androgens?
- breast cancer in males
- history of live tumours
- hypercalcaemia
- Prostate cancer
105
What indication may you see testosterone be used in women?
Low sexual desire in postmenopausal women (administered on expert advice) (not a licensed indication)
106
When used for low sexual desire in post menopausal women what are the side effects?
Long terms effects of testosterone in this patient group are largely unknown, but side-effects can include growth of unwanted hair, frontal balding and deepening of the voice
107
Does Cyptoterone agonise or antagonise male sex hormone?
It is a male sex hormone antagonist
used for hyper sexuality and sexual deviation in males
Also prevention of tumour flare with initial gonadorelin analogue therapy
108
Cyproterone has been associated with what (MHRA warning)?
increased risk of meningioma (single and multiple), mainly at doses of 25mg/day and higher
Meningioma = a tumor that arises from the meninges — the membranes that surround the brain and spinal cord.
109
What is thyrotropin alfa?
It is a recombinant human thyroid stimulating hormone (rhTSH)
110
What is hyperthyroidism?
Hyperthyroidism results from the excessive production and secretion of thyroid hormones leading to thyrotoxicosis (an excess of circulating thyroid hormones)
111
What are the signs and symptoms of hyperthyroidism?
- Goitre
- Hyperactivity
- Disturbed sleep
- Fatigue
- Palpitations
- Anxiety
- heat intolerance
- Increased appetite
- Unintentional weight loss
- Diarrhoea
112
What are the complications of hyperthyroidism?
- Graves' orbitopathy
- Thyroid storm (thyrotoxic crisis)
- Pregnancy complications
- reduced bone mineral density
- Heart failure
- AF
113
What are the risk factors of hyperthyroidism?
- smoking
- a family history of thyroid disease
- Co-existent autoimmune conditions
- Low iodine intake
114
What does primary hyperthyroidism refer to?
refers to when the condition arises from the thyroid gland rather than due to a pituitary or hypothalamic disorder.
115
What is primary hyperthyroidism mainly caused by?
Grave's disease
116
What is Grave's disease?
An autoimmune disorder mediated by antibodies that stimulate the thyroid-stimulating hormone (TSH) receptor
117
What are other causes of primary hyperthyroidism?
Other causes include toxic nodular goitre (autonomously functioning thyroid nodules that secrete excess thyroid hormone), or drug-induced thyrotoxicosis.
118
Is primary hyperthyroidism more common in male or females?
It is more common in females than males
119
What can primary hyperthyroidism be classified as?
- Overt or
- subclinical
Both of which may or may not be symptomatic
120
What is overt hyperthyroidism characterised by?
TSH levels below the reference range
- Free thyroxine (FT4) above reference range
- Free Tri-iodthyronine (FT3) above reference range
121
What is sub-clinical hyperthyroidism characterised by?
TSH is supressed
FT4 and FT3 are within the reference range
122
Does thyrotoxicosis only occur due to hyperthyroidism?
No - Thyrotoxicosis can also occur without hyperthyroidism; this is usually transient, and can occur due to excess intake of levothyroxine or over-the-counter supplements containing thyroid hormone, or thyroiditis.
123
What are the wrong non-drug treatment of hyperthyroidism?
- Radioactive iodine
| - Surgery (such as total thyroidectomy or hemithyrodectomy)
124
What should patients with symptoms of thyroid storm be treated as?
- A medical emergency
125
If a pituitary or hypothalamic disorder is suspected for hyperthyroidism then what must you do?
Refer to an endocrinologist
126
What should you explain to patients and their family or carers about symptoms of hyperthyroidism?
Some patients may feel well even when their thyroid function tests are outside the reference range;
Even when they have no symptoms, treatment may be advised to reduce the risk of long-term complications;
Symptoms may lag behind treatment changes for several weeks to months.
127
You can consider anti-thyroid drugs alongside supportive treatment for patients with hyperthyroidism awaiting specialist assessment with what?
Such as beta blockers
128
What is the recommended choice of anti-thyroid drug for hyperthyroidism?
- Carbimazole and the risk of acute pancreatitis
129
Which drug is considered in those in whom carbimazole is unsuitable?
- Propylthiouracil
130
For Grave's disease what is the first line definitive treatment?
Under specialist care, radioactive iodine is recommended as first-line definitive treatment unless it is unsuitable or remission is likely to be achieved with antithyroid drugs
131
What about in those with Graves disease in whom an antithyroid drug is likely to achieve remission (such as in mild and uncomplicated cases)?
A choice of either carbimazole or radioactive iodine should be offered
132
For Grave's disease - which anti-thyroid drug should be used if radioactive iodine and surgery are unsuitable?
- Carbimazole should be offered first
133
When Carbimazole is used for Grave's disease how long is it used for and what is this regimen called?
Offer carbimazole as a 12–18 month course using either a block and replace regimen (combination of fixed high-dose carbimazole with levothyroxine sodium), or a titration regimen (dose based on thyroid function tests), and review the need for further treatment.
134
If patients have persistent or relapsed hyperthyroidism despite anti-thyroid drug treatment then what should you consider?
- consider radioactive iodine or surgery
135
Who would you consider propylthiouracil in?
for patients who experience side-effects to carbimazole, are pregnant or are trying to conceive within the following 6 months, or have a history of pancreatitis
136
What should you do if agranulocytosis develops during anti-thyroid treatment?
Stop and do not restart treatment
137
What is recommended first line for toxic nodular goitre?
radioactive iodine is recommended as first-line definitive treatment for patients with hyperthyroidism secondary to multiple nodules
138
For treatment of toxic nodular goitre what if first line radio active iodine is unsuitable?
offer total thyroidectomy or life-long antithyroid drugs if radioactive iodine is unsuitable.
139
For which toxic nodular goitre is surgery an option for?
For patients with hyperthyroidism secondary to a single nodule and not due to multiple nodules
140
When using carbimazole for life long anti-thyroid treatment of toxic nodular goitre - which regimen is used?
Consider treatment with a titration regimen of carbimazole when offering life-long antithyroid drugs.
141
Can propylthiouracil be used for toxic nodular goitre?
Consider propylthiouracil for patients who experience side-effects to carbimazole, are pregnant or are trying to conceive within the following 6 months, or have a history of pancreatitis.
142
What reading is considered as subclinical hypertension?
For patients who have 2 TSH readings lower than 0.1 mIU/litre at least 3 months apart and evidence of thyroid disease or symptoms of thyrotoxicosis, consider seeking specialist advice.
143
For patients with subclinical hyperthyroidism - how often should you consider measuring TSH levels?
Every 6 months
144
What is the treatment for thyrotoxicosis without hyperthyroidism?
Transient thyrotoxicosis without hyperthyroidism usually only needs supportive treatment (for example, beta-blockers).
145
Females who have recently received radioactive iodine should be advised to avoid becoming pregnant for at least how many months after treatment?
At least 6 months after treatment
146
Is the blocking-replacement regimen suitable to use during pregnancy?
Not suitable
147
Which beta blocker is used for the rapid relief of thyrotoxic symptoms and can be used in conjunction with the drugs mentioned for hyperthyroidism treatment?
- Propranolol
148
Can radioactive iodine be used in pregnant women?
No
149
What is carbimazole linked with (what can it cause)?
Linked with neutropenia and agranulocytosis
Also acute pancreatitis
150
What signs should patients taking carbimazole look out for?
Signs of sore throat and infection
| WBC count should be carried out if there is suspected infection
151
Is rash and itching common with carbimazole?
Rashes + itching are a common s.e. of antithyroid drugs – continue treatment and consider antihistamine
152
For blocking replacement therapy - higher doses of carbimzole are given - what doses are given?
40-60mg daily - therapy usually given for 18 months
153
When switching from carbimazole to propylthiouracil what is the dose conversion?
carbimazole 1mg is considered to be equivalent to propylthiouracil 10mg but dose may need to be adjusted according to response
154
If acute pancreatitis occurs with carbimazole use then what should you do?
It should be stopped permanently
155
Can carbimazole be used in patients with a history of acute prancreatitis?
No
156
Is contraception required when taking carbimazole?
Yes the MHRA advies women of child bearing age to use effective contraception during treatment
157
Patients on carbimazole should warn doctor of which symptoms?
- sore throat
- mouth ulcers
- bruising
- fever
- malaise
- or non-specific illness
158
What is iodide with iodine (Lugol's Solution) used for?
Thyrotoxicosis
159
Hypothyroidism is a result of.......?
Results from the under production and secretion of thyroid hormones
160
What are the signs and symptoms of hypothyroidism?
- Fatigue
- Weight gain
- constipation
- menstrual irregularities
- depression
- Dry skin
- intolerance to the cold
Reduced body and scalp hair
161
What are the complications of hypothyroidism?
dyslipidaemia, coronary heart disease, heart failure, impaired fertility, pregnancy complications, impaired concentration and/or memory, and rarely myxoedema coma (which is a life-threatening medical emergency).
162
What does primary hypothyroidism refer to?
refers to when the condition arises from the thyroid gland
163
What may primary hypothyroidism be caused by?
by iodine deficiency, autoimmune disease (such as Hashimoto’s thyroiditis), radiotherapy, surgery or drugs, rather than due to a pituitary or hypothalamic disorder (secondary hypothyroidism)
164
Is primary hypothyroidism more common in females or males?
Primary hypothyroidism is more common in females than males
165
Similarly to hyperthyroidism, what can hypothyroidism be classified into?
Either overt or subclinical
166
What is Overt hypothyroidism characterised by?
TSH levels above the reference range
Free thyroxine (FT4) levels below the reference range
167
What is subclincial hypothyroidism characterised by?
TSH levels are above the reference range
FT4 and free tri-iodothyronine (FT3) levels are within the reference range
168
In pregnancy what is hypothyroidism defined as?
In pregnancy, it is defined as overt based on elevated TSH levels (using trimester-specific reference ranges) regardless of FT4 levels.
169
What is the first line treatment for hypothyroidism?
Offer levothyroxine sodium as first line and aim to maintain thyroid-stimulating hormone (TSH) levels within the reference range
If symptoms persist, even after achieving normal TSH levels, consider adjusting the dose to achieve optimal well-being whilst avoiding doses that cause TSH suppression or thyrotoxicosis.
170
For patients whose TSH level was very high before starting treatment or who have had a prolonged period of untreated disease, how long can the TSH level take to return to the reference range?
Can take up to 6 months
171
In overt hypothyroidism how often should you consider measuring TSH levels?
- Every 3 months until a stable level has been achieved, then yearly thereafter
172
Monitoring of thyroxine FT4 should be considered in which patients?
In those who continue to be symptomatic
173
Why is thyroxine (T4) used over monotherapy with liothyronine (T3)?
Due to the uncertainty around the long-term adverse effects and the insufficient evidence of benefit over levothyroxine monotherapy, the use of natural thyroid extract is not recommended.
174
What TSH level readings would indicate treatment in subclinical hypothyrodism?
For patients who have a TSH level of 10 mIU/L or higher on 2 separate occasions 3 months apart, consider levothyroxine sodium.
If symptoms persist, even after achieving normal TSH levels, consider adjusting the dose to achieve optimal well-being whilst avoiding doses that cause TSH suppression or thyrotoxicosis.
175
What about subclinical hypothyroidism for symptomatic patients aged under 65 years with a TSH level above the reference range, but lower than 10 mlU/L on 2 separate occasions 3 months apart, what should be considered?
consider a 6-month trial of levothyroxine sodium. If symptoms do not improve after starting levothyroxine, re-measure TSH and if the level remains elevated, adjust the dose.
176
Should all females with hypothyroidism who are planning a pregnancy or a are pregnancy be referred?
Yes - Refer all females with hypothyroidism who are planning a pregnancy or are pregnant, to an endocrinologist.
177
For patients planning a pregnancy and whose thyroid function tests (TFTs) are not within range what should you advice them?
advise delaying conception until stabilised on levothyroxine sodium treatment.
178
Are TFTs reliable in pregnancy?
TFTs may produce misleading results in pregnancy and trimester-related reference ranges should be used.
As thyroxine requirement may increase during pregnancy
179
When is liothyronine (T3) used?
In severe hypothyroid states where a rapid response is required.
It has a similar action to levothyroxine, but it is more rapidly metabolised and has a more rapid effect.
180
What are the side effects of thyroid hormones?
They are similar to hyperthyroidism:
diarrhoea, arrhythmias, palpitations, tachycardia, sweating, fever and weight loss.
181
What effect do thyroid hormones have on warfarin?
They can enhance the anticoagulation effect of warfarin
182
Why is baseline ECG needed when initiating levothyroxine?
Because changes induced by hypothyroidism can be confused with ischaemia
183
When giving liothyronine if metabolism occurs too rapidly (causing diarrhoea, nervousness, insomnia, tremors etc.) what should you do?
Reduce dose or withhold for 1-2 days and start again at a lower dose
184
What should be noted about brands of liothyronine?
patients switched to a different brand should be monitored as brands without a UK license may not be bioequivalent. If liothyronine is continued long-term, TFTs should be repeated 1-2 months after any change in brand.
185
What counselling advice should be given on administration of levothyroxine?
- should be taken in the morning 30-60 mins before breakfast. caffiene-containing liquids (e.g. coffee, tea) or other medications
186
What is a contraindication of levothyroxine?
Thyrotoxicosis
187
In patients with cardiac disease and being treated with levothyroxine for hypothyrodism - need to be monitored for what?
May be susceptible to faster metabolism - causing hyperthyroidism like symptoms (diarrhoea, nervousness, rapid pulse, insomnia, tremors, and sometimes anginal pain where there is latent myocardial ischaemia).
Reduce dose or withhold for 1-2 days and start again at a lower dose
