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ENDOCRINE Flashcards

1
Q

ANTIDIURETIC HORMONES

DIABETES INSIPIDUS

EXCESS DILUTE URINE=?

A

EXTREME THIRST

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2
Q

NORMAL PERSON? ADH, hypothalamus

A

Hypothalamus produces vasporessin (ADH)->stored in pituitary gland
ADH released when water in the body becomes too low
ADH retains water in the body by reducing amount of water lost through the kidneys

Therefore, more CONCENTRATED urine

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3
Q

DIABETES INSIPIDUS?

A

Reduced production of ADH
Kidneys do NOT retain much water, so too much water passed from body
Causing extreme thirst/polyuria

Therefore, more DILUTE urine

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4
Q

2 TYPES OF DIABETS INSIPIDUS?

A

PITUITARY (CRANIAL)- lack of ADH production

NEPHROGENIC (PARTIAL)- NO response to ADH

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5
Q

DIABETES INSIPIDUS

PITUITARY (CRANIAL) TREATMENT?

A

VASOPRESSIN/DESMOPRESSIN

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6
Q

DIABETES INSIPIDUS

NEPRHOGENIC (PARTIAL) TREATMENT?

A

THIAZIDE-DIURETIC (paradoxical effect)

HOW DOES THIS WORK? UNDERSTANDING!

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7
Q

DESMOPRESSIN x3 FEATUERS?

A

More potent+longer duration of action than vasopressin

No vasoconstrictor effect->avoid bp conditions?

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8
Q

DESMOPRESSIN- SIDE-EFFECTS?

A

Hyponatraemia

Nausea

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9
Q

INAPPROPRIATE ADH SECRETION

Hyponatraemia explained?

A

Increased ADH-> body stores too much water-> dilutes the salt conc. in the blood-> hyponatraemia

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10
Q

HYPONATRAEMIA TREATMENT? FDT

A

FLUID RESTRICTION
DEMECLOCYCLINE (blocks renal tubular effect of ADH)
TOLVAPTAN (vasopressin antagonist)

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11
Q

Why do we AVOID rapid correction of hyponatraemia w/ Tolvaptan?

A

Causes osmotic demyelination-> serious neurological events

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12
Q

CORTICOSTEROIDS

2 TYPES?

A

MINERALCORTICOIDS

GLUCOCORTICOIDS

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13
Q

x2 FEATURES OF MINERALCORTICOID STEROIDS? Bottle of water

A

HIGH FLUID retention

LOW anti-inflammatory effect

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14
Q

MINERALCORTICOID STEROID ACTIVITY? high to low

A

FLUDROCORTISONE

HYDROCORTISONE

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15
Q

FLUDROCORTISONE ALSO USED TO TREAT?

A

POSTURAL HYPOTENSION

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16
Q

MINERALCORTICOID SIDE-EFFECTS?

A

Oedema
Hypertension-> soidum+water retention
Potassium loss-> hypokalaemia
Calcium loss-> hypocalcaemia

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17
Q

Mineralocorticoid actions are negligible with the high potency…? GBD

A

GLUCOCORTICOIDS
BETAMETHASONE
DEXAMETHASONE

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18
Q

X2 FEATURES OF GLUCORTICOID STEROIDS?

A

HIGH ANTI-INFLAMMATORY EFFECT

LOW FLUID RETENTION

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19
Q

HIGHEST GLUCOCORTICOID STEROID ACTIVITY?

A

DEXAMETHASONE/BETAMETHASONE

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20
Q

GLUCOCORTCOID SIDE-EFFECTS? DOAG

A

DIABETES
OSTEROPOROSIS-> fractures
AVASCULAR NECROSIS OF FEMORAL HEAD+ MUSCLE WASTING
GASTRIC ULCERATION+PERFORATION

Clopi+Lans, NOT Omep

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21
Q

CORTICOSTEROID SIDE-EFFECTS? MHRA

A

CENTRAL SEROUS CHORIORETINOPATHY->report blurred vision/other visual disturbances

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22
Q

CORTICOSTEROID PSYCHIATRIC REACTIONS?

A

INSOMNIA, IRRITABILITY, MOOD CHANGE, ETC

SEEK ADVICE+STOP TEATMENT

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23
Q

STEROID EMERGENCY CARD? For patients with…

A 
ADRENAL INSUFFICIENCY
STEROID DEPENDENCE (risk of adrenal crisis)
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24
Q

CORTCOISTEROID SIDE-EFFECTS

ADRENAL SUPPRESSION?

A

Prolonged use can lead to adrenal atrophy (years)

DON’T STOP ABRUPTLY (acute adrenal insufficiency/hypotension/death)

Significant illness/trauma/surgery-> temporary increase in corticosteroid dose OR temporary reintroduction if already stopped

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25
CORTICOSTEROID SIDE-EFFECTS? I->CM
INFECTIONS (immunocompromised, can't clock on) | CHICKEN POX-> passive immunisation w/ varicella-zoster immunoglobin if unimmune (+if taken steroid in past 3 months) | MEASLES-> prophylaxis w/ IM normal immunoglobulin if needed
26
CORTICOSTEROID SIDE-EFFECTS? ICS
INSOMNIA-> take OM (cortisol produced then) CHILDREN-> stunted growth, even w/ inhaled SKIN THINNING-> most common in topical (apply thinly!)
27
CORTICOSTEROID PROLONGED USE SIDE-EFFECT? Manage? Treat?
``` CUSHING'S SYNDROME | Moon face/striae/hirsutism/acne | Manage? w/ Metyrapone Treat? w/ Ketoconazole ```
28
``` CORTICOSTEROID SIDE-EFFECTS ROUND UP C O R T I C O S t E R O I D u S e ```
``` Cushing's Osteroporosis Retardation of growth Thin skin Immunocompromised+Insomnia Chorioretinopathy Oedema (water retention) Striae T? Emotional Rise in BP (Hypertension) Obestity (truncal) Increased hair growth (hirsutism) Diabetes mellitus (hyperglycaemia) u SUPPRESSION (adrenal) Electrolyte imbalance (hypokalaemia ```
29
HOW DO WE MANAGE STEROID SIDE-EFFECTS?
``` LOWEST EFFECTIVE DOSE, MINIMUM PERIOD SINGLE DOSE OM 2 DAYS DOSE? GIVE ON ALTERNATE DAYS SHORT COURSES? INTERMITTENT THERAPY LOCAL>SYSTEMIC e.g. creams, inhalations, eye-drops, enemas ```
30
WHEN DO YOU GRADUALLY WITHDRAW FROM STEROIDS? GIVE ALL?
>40MG PREDNISOLONE FOR >1 WEEK REPEAT EVENING DOSES >3 WEEKS TREATMENT, ANY DOSE RECEIVED RECEIVED REPEATED COURSES/TAKEN SHOURT COURSE WITHIN 1 YEAR OF STOPPING LONG-TERM THERAPY OTHER CAUSES OF ADRENAL SUPPRESSION GIVE ALL? STEROID CARD
31
TOPIC STEROID POTENCIES MILD? MODERATE? POTENT? VERY POTENT?
MILD? Hydrocortisone MODERATE? Clobetasone POTENT? Betamethasone VERY POTENT? Clobetasol
32
WHAT IS ADRENAL INSUFFICIENCY CAUSED BY?
ADDISON'S DISEASE | CONGENITAL ADRENAL HYPERPLASIA
33
ADRENAL INSUFFICIENCY TREATMENT? PRIMARY?
TREAT WITH HYDROCORTISONE PRIMARY? +FLUDROCORTISONE (mineralcorticoid replacement- aldosterone deficiency)
34
ADRENAL INSUFFICIENCY CAN LEAD TO...?
ADRENAL CRISIS
35
SYMPTOMS OF ADRENAL CRISIS? SHAS^2 CD
``` SHAS^2 CD SEVERE DEHYDRATION HYPOVOLAEMIC SHOCK ALTERED CONSCIOUSNESS SEIZURES STROKE CARDIAC ARREST | DEATH ```
36
ADRENAL CRISIS TREATMENT?
hydrocortisone+Rehydration using a crystalloid fluid (e.g. sodium chloride 0.9%). For patients usually on fludrocortisone, high-dose hydrocortisone has sufficient mineralocorticoid effect to cover this
37
DIABETES MELLITUS is...?
PERSISTENT HYPERGLYCAEMIA
38
DIABETES CAN BE CAUSED BY...?
DEFICIENT INSULIN SECRETION (TYPE 10 RESISTANCE TO ACTION OF INSULIN (TYPE 2) PREGNANCY (GESTATIONAL) MEDICATIONS (SECONDARY) e.g. STEROIDS!
39
DIABETES MELLITUS- DRIVING All drivers w/ insulin must notify the DVLA. What is awareness of hypoglycaemia?
The capability of bringing their vehicle to a safe controlled stop
40
GROUP 1 DRIVERS?
ADEQUATE AWARENESS OF HYPOGLYCAEMIA NO MORE THAN 1 EPISODE OF SEVERE HYPOGLYCAEMIA WHILST AWAKE IN THE PRECEDING 12 MONTHS
41
GROUP 2 DRIVERS? (HGV, bus, etc)
FULL AWARENESS OF HYPOGLYCEAMIA MUST REPORT ALL EPISODES, INCLUDING IN SLEEP NO EPISODES OF SEVERE HYPOGLYCAEMIA IN THE PRECEDIG 12 MONTHS MUST USE A BG meter with sufficient memory- store 3 months of readings VUSUAL COMPLICATIONS- holla DVLA+do not drive
42
ADVICE FROM THE DVLA? <5? <4?
Insulin treatment? Carry a GM+BGS Check BGC no >2hrs before driving+/2hours whilst driving B-G should always be>5mmol/L whilst driving <5mmol/L? Lickle snack Ensure supply of FAST-ACTING carb in the whip <5? lickle snack <4? stop the whip wait until 45 minutes after blood-glucose has returned to normal, before continuing journey
43
HYPOGLYCEAMIA WHILST DRIVING?
<4mmol/L SAFELY STOP VEHICLE OFF THE ENGINE, REMOVE KEYS FROM IGNITIONS, MOVE FROM DRIVER'S SEAT EAT/DRINK SUITABLE SOURCE OF SUGAR WAIT TILL 45MINS AFTER B-G BACK TONORMAL DO NOT DRIVE IF HYPOGLYCAEMIA AWARENESS L+NOTIFY DVLA
44
TPYE 1 DIABETES INSULIN DEFICIENCY?
DESTRUCTION OF INSULIN-PRODUCING BETA-CELLS IN THE PANCREATIC ISLETS OF LANGERHANS Most common before adulthood
45
FEATURES OF TYPE 1 DIABETES?
``` HYPERGLYCAEMIA (>11mmol/L) KETOSIS RAPID WEIGHT LOSS BMI<25 AGE<50 FAMILY HISTORY OF AUTOIMMUNE DISEASE ```
46
TYPE 1 DIABETES- BLOOD GLUCOSE MONITORING HOW MANY TIMES?
MONITOR AT LEAST 4 TIMES A DAY (including before each meal+before bed)
47
TYPE 1 DIABETES- BLOOD GLUCOSE MONITORING TARGETS?
5-7 mmol/L on WAKING (fasting) 4-7 mmol/L fasting BG BEFORE meals at other times of the day 5-9 mmol/L 90mins AFTER eating >5 mmol/L when driving
48
TYPE 1 DIABETES- INSULIN REGIMENS HOW MANY TYPES?
MULTIPLE DAILY INJECTION BASAL-BOLUS (1st LINE) BIPHASIC (mixture) CONTINUOUS SC INFUSION (insulin pump)
49
TYPE 1 DIABETES- MULTIPLE DAILY INJECTION BASAL-BOLUS REGIMEN BASAL? AND BOLUS?
``` BASAL (long/intermediate acting) OD or BD AND BOLUS (short/rapid acting) before meals ```
50
BASAL 1st LINE? 2nd LINE?
1st LINE? Insulin detemir BD | 2nd LINE? Insulin glargine OD
51
TYPE 1 DIABETES- BIPHASIC MIXTURES?
SHORT-ACTING mixed with INTERMEDIATE insulin injected 1-3 TIMES A DAY
52
TYPE 1 DIABETES- CONTINOUS SC INFUSION (insulin pump) for..?
Adults who suffer w/ disabling hypoglycaemia/uncontrolled hyperglycaemia
53
WHAT FACTORS INCREASE INSULIN REQUIREMENTS? SIT DOWN BRO!
IST Infection Stress Trauma
54
WHAT FACTORS DECREASE INSULIN REQUIREMENTS? EIRIE
``` EIRIE Exercise Intercurrent illness Reduced food intake Impaired renal function Endocrine disorders (thyroid, coeliac, addison's) ```
55
INSULIN ADMINISTRATION ADVICE?
Inactivated by GI enzymes- so SC Injected into body area with plenty of SC fat: abdomen (fast) outer thighs/buttocks (slow) ``` Rotate injection sites: Lipohypertrophy happens due to repeato injection sites into same suto area Cutaneous amyloidosis (amyloid protein under skin) ```
56
2 TYPES OF SHORT-ACTING INSULIN?
SOLUBLE RAPID-ACTING
57
SHORT-ACTING- SOLUBLE INSULIN EXAMPLE? INJECT? ONSET? DURATION?
EXAMPLE? HUMAN+BOVINE/PORCINE INJECT? 15-30mins BEFORE MEALS ONSET? 30-60mis, peak 1-4hrs DURATION? Up to 9hrs
58
SHORT-ACTING- RAPID-ACTING INSULIN NO LAGing EXAMPLE? INJECT? ONSET? DURATION?
EXAMPLE? Lispror/Aspart/Glulisine INJECT? Immediately before meal ONSET? <15mins (NO LAG!) DURATION? 2-5hrs
59
INTERMEDIATE-ACTING INSULIN/BIPHASIC EXAMPLE? ONSET? DURATION?
EXAMPLE? Biphasic isophane/biphasic aspart/biphasic lispro (isophane mixed with SA) ONSET? 1-2hr, peak 3-12hrs DURATION? 11-24hrs
60
``` LONG-ACTING INSULIN DDG EXAMPLE? INJECT? ONSET? DURATION? ```
DDG EXAMPLE? Detemir/Degludec/Glargine INJECT? OD (Detemir= BD) ONSET? 2-4days to reach steady state DURATION? 36hrs
61
TYPE 2 DIABETES is characterised by...?
Insulin resistance, later in life
62
Prediabetic HBA1c?
42-47mmol/mol | Can try prevent diabetes with lifestyle advice
63
Diabetes HbA1c?
48mmol/mol
64
DIABETES TREATMENT- LOW CVD RISK What do you need to assess first?
HbA1c Kidney function Cardiovascular risk ALL INDIIVDUALLY AGREED THRESHOLDS!
65
DIABETES TREATMENT- LOW CVD RISK 1st LINE?
METFORMIN
66
DIABETES TREATMENT- LOW CVD RISK Metformin L, HBA1C> individually agreed threshold?
``` DUAL THERAPY ADD IN... DPP-4i (gliptin) OR Pioglitazone OR SU (Sulphonylurea- glic, glim, tolb) OR SGLT-2i (Flozins) ```
67
DIABETES TREATMENT- LOW CVD RISK DUAL THERAPY L.. HBA1C> individually agreed threshold?
``` TRIPLE THERAPY by... adding/swapping class of anti-diabetic ``` NOTE: DAPAG with PIOG not recommended, OTHER SGLT-2is calm
68
DIABETES TREATMENT- HIGH CVD RISK When is it high risk?
Established atherosclerotic CVD HF QRISK2>10%
69
DIABETES TREATMENT- HIGH CVD RISK 1ST LINE? ONCE TOLERATED? IF NOT TOLERATED?
1ST LINE? METFORMIN ONCE TOLERATED? ADD SLGT-2i IF NOT TOLERATED? ALONE SLGT-2i
70
DIABETES TREATMENT- HIGH CVD RISK HBA1C> individually agreed threshold?
SAME AS DUAL+TRIPLE THERAPY FLASHCARDS!
71
Patient w/ diabetes develops high risk CVD?
Consider SLGT-2i first. EU marketing agency, recent approval for flozins in HF, draining effect. Lotta hype!
72
TREATMENT OF DIABETES- METFORMIN RESISTANCE Patient can't tolerate metformin due to side-effects?
Use MR preparations
73
TREATMENT OF DIABETES- METFORMIN RESISTANCE Patient can't tolerate metformin MR? Treat w/... BUT When high risk of CVD?
Treat w/ DPP-4I/Pioglitazone/SU/SLGLT-2I (SU first choice heeh) BUT When high risk of CVD? SGLT-2i
74
TREATMENT OF DIABETES- METFORMIN RESISTANCE HbA1c above individually agreed threshold& Monotherapy an L? Treat w/...
``` Treat w/... DPP-4i+Piogltiazone OR DPP-4i+SU OR Pioglitazone+SU ```
75
TREATMENT OF DIABETES- METFORMIN RESISTANCE HbA1c STILL not controlled..?
INSULIN THERAPY!
76
METFORMIN (biguanide) | MOA?
Decreases gluconeogenesis+increases peripheral utilisation of glucose mad
77
METFORMIN SIDE-EFFECTS? LGV
LGV Lactic acidosis (avoid if eGFR<30) GI side-effects (increase dose slowly/give MR prep) Can reduce vitamin B12
78
PATIENT ON METFORMIN w/ AKI?
STOP!
79
SULPHONYLUREAS MOA? S for secretion!
STILMULATES insulin secretio
80
SULPHONYLUREAS | MOA?
Stimulates insulin secretion from pancreatic beta cell
81
2 TYPES OF SULPHONYLUREAS?
SHORT-ACTING- GT- gliclazide, tolbutamide, glipizide LONG-ACTING- GG- glibenclamide, glimepiride
82
What is LONG-ACTING sulphonylureas associated with?
Associated with prolonged/sometimes fatal cases of hypoglycaemia AVOID IN ELDERLY
83
SULPHONYLUREAS- SIDE-EFFECTS? AH(R)F, not KHF
``` High risk of hypoglycaemia AVOID in: Acute porphyria (GTGTGTGTGTGTGTGT) Hepatic/Renal FAILURE ```
84
PIOGLITAZONE MOA? P for less peripheral!
Reduces peripheral insulin resistance
85
PIOGLITAZONE AVOID IN...?
Patients with history of HF
86
PIOGLTAZONE There's an increase risk of...? Report what..?
-Bladder cancer review safety+efficacy after 3-6months stop treatment if patient responds inadequately REPORT... Haematuria (blood in urine) Dysuria (painful urination) Urinary urgency
87
PIOGLITAZONE Increase risk of...? continued
BONE FRACTURES LIVER TOXICITY- report N&V, abdominal pain, fatigue & dark urine ``` PIOGLITAZONE IS MOSTLY ASSOCIATED WITH... HF BLADDER CANCER BONE FRACTURES LIVER TOXICITY ```
88
DPP-4i MOA? increases one, decreases the other
Increases insulin secretion+lowers glucagon secretion
89
DPP-4i Can cause..?
Pancreatitis Discontinue if symptoms of acute pancreatitis occur... - persistent, severe abdominal pain
90
DPP-4i EXAMPLES?
``` ALLOGLIPTIN LINAGLIPTIN SAXAGLIPTIN SITAGLIPTIN VILDAGLIPTIN (hepatotoxic) ```
91
SLGT-2iS | MOA?
Inhibits SLGT2 in renal proximal convoluted tubule (more urine, glucose, infection)
92
SGLT-2iS MHRA WARNINGS? DKAKFaGLLA MONITOR RENAL FUNCTION!
DIABETIC KETOACIDOSIS MONITOR KETONES if treatment interruped-> surgery/illness FOURNIER'S GANGRENE CANAGLIFLOZIN only: risk of lower-limb amputation (mainly toes)
93
SGLT-2iS Volume depletion?
Due to lots of urination, loss of water Correct hypovolaemia (reduced volume of circulating blood in body) before starting treatment
94
SGLT-2iS EXAMPLES?
CANAGLIFLOZIN DAPAGLIFLOZIN EMPAGLIFLOZIN
95
GLP-1 AGONIST MOA? GLP-1 receptor
BINDS TO GLP-1 RECEPTOR Increases insulin secretion, suppresses glucagon secretion slows gastric emptying
96
GLP-1 AGONIST EXAMPLES? -tides
DULAGLUTIDE EXENATIDE LIRAGLUTIDE LIXISENATIDE
97
GLP-1 AGONIST SIDE-EFFECTS?
DULAGLUTIDE!!! ACUTE PANCREATITIS- persistent, severe abdominal pain DEHYDRATION- risk, due to GI side-effects, take precautions to avoid fluid depletion?
98
OTHER ANTIDIABETICS ACARBOSE?
Delays digestion+absorption of starch+sucrose | Risk of GI side-effects- reduce dose?
99
OTHER ANTIDIABETICS MEGLITIDES (Nataglinide/Repaglinide)?
Stimulates insulin secretion | Stressed? Change to treatment to insulin to maintain glycaemia control? :/
100
DIABETICS, PANCREATITIS ASSOCIATION? G^2
GLIPTINS GLP-1 AGONIST, -tides-> PERSISTENT, ABDOMINAL SEVERE PAIN
101
ANTIDIABETIC EFFECT ON WEIGHT WEIGHT GAIN? NEUTRAL? WEIGHT LOSS?
WEIGHT GAIN? Pioglitazone+Sulphonylureas+Insulin NEUTRAL? Metformin+DPP-4i WEIGHT LOSS? GLP-1+SGLT-2i
102
DIABETIC COMPLICATIONS CARDIOVASCULAR DISEASE? Diabetes strong rf WHAT DRUG IS CONSIDERED IN ALL TYPE 1 PATIENTS? WHAT DRUG REDUCES CVD RISK?
WHAT DRUG IS CONSIDERED IN ALL TYPE 1 PATIENTS? Low-dose atorvastatin, offer to: 40+years diabetic 10+years nephropathy/other CVD factors WHAT DRUG REDUCES CVD RISK? ACEi, regardless of ethnicity
103
DIABETIC COMPLICATIONS DIABETIC NEPHROPATHY, proteinuria (protein in urine) TREATMENT? WHAT DRUG CAN POTENTIATE HYPOGLYCAEMIA EFFECT OF ANTIDIABETIC DRUGS/INSULIN?
DIABETIC NEPHROPATHY, proteinuria (protein in urine) TREATMENT? ACE-i/ARB WHAT DRUG CAN POTENTIATE HYPOGLYCAEMIA EFFECT OF ANTIDIABETIC DRUGS/INSULIN? ACE-i (risk of HYPERkalaemia)
104
DIABETIC COMPLICATIONS DIABETIC NEUROPATHY TREATMENTS PAINFUL PERIPHERAL NEUROPATHY? Diabetic foot? AUTONOMIC NEUROPATHY? NEUROPATHIC POSTURAL HYPOTENSION? GUSTATORY SWEATING? ERECTILE DYSFUNCTION? VISUAL IMPAIRMENT?
PAINFUL PERIPHERAL NEUROPATHY? antidepressants/gabapentin/pregabalin Diabetic foot? treat pain+manage infection AUTONOMIC NEUROPATHY? treat diarrhoea w/ codeine/tetracyclines NEUROPATHIC POSTURAL HYPOTENSION? increase salt intake/fludrocortisone GUSTATORY SWEATING? antimuscarinic- propantheline bromide ERECTILE DYSFUNCTION? Sildenafil VISUAL IMPAIRMENT? Yearly eye tests
105
DIABETEIC KETOACIDOSIS- SEVERE HYPERGLYCAEMIA SYMPTOMS? PTP(B)DLC
``` PTPDLC Polyurea Thirsty Pear drop breath smells (ketones) (B) Deep breathing Lethargic Confusion ``` LUC, DKA or just drunk?
106
DKA- checking blood sugar levels What do you do if... PATIENT DISPLAYS SYMPTOMS OF DKA? BLOOD SUGAR LEVELS >11mol/L?
PATIENT DISPLAYS SYMPTOMS OF DKA? Check blood sugar levels BLOOD SUGAR LEVELS >11mol/L? Check ketone levels
107
DKA- ketone levels 0. 6-1.5mmol? 1. 6-2.9mmol? 3mmol?
0. 6-1.5mmol? slight risk (retest in 2hrs) 1. 6-2.9mmol? increased risk (contact GP) 3mmol? medical emergency
108
DKA- TREATMENT BP<90? Once BP>90? Give... Start IV insulin mixed w/ NaCl, administer at a rate so that ketone conc. falls at? blood glucose conc. falls at?
BP<90? RESTORE VOLUME W/ 500ml IV NaCl 0.9% Once BP>90? GIVE MAINTENANCE IV NaCl 0.9% Start IV soluble human insulin! mixed w/ NaCl, administer at a rate so that...? - ketone conc. falls at 0.5mmol/L/hr - Blood glucose conc/ falls at 3mmol/L/hr
109
DKA- TREATMENT What do you do when blood glucose <14mmol/L? Continue insulin till.. ketone< ph>? When patient is able to eat, give...? Finally, stop treatment...?
What do you do when blood glucose <14mmol/L? Give IV glucose 10% Continue insulin till.. ketone <3 mmol/L & pH>7.3 When patient is able to eat, give fast-acting insulin w/ meal Finally, stop treatment 1hr after food
110
INSULIN DURING SURGERY ELECTIVE (minor w/ good glycaemic control) day before?
ELECTIVE (minor w/ good glycaemic control) day before? Reduce OD long-acting dose by 20%, rest as usual
111
INSULIN DURING SURGERY ELECTIVE (major/poor glycaemia control) DAY BEFORE? ON THE DAY?
DAY BEFORE? Reduce long-acting dose by 20%- rest as usual ON THE DAY? - Reduce long-acting dose by 20%- stop other insulin till patient eating - IV infusion of KCL+Glucose+NaCl - Variable rate IV insulin (soluble human) - Hourly blood glucose measurements for first 12hrs - Give IV glucose 20% if blood glucose dips <6mmol/L
112
INSULIN- POST SURGERY When do you convert back to SC insulin? BASAL-BOLUS REGIMEN?
CONVERT BACK TO SC INSULIN when patient can eat/drink Restart B-B with the first meal- IV insulin infusions carried on till 30-60mins after first meal-time short-acting insulin dose
113
INSULIN- POST SURGERY LONG-ACTING REGIMEN?
Carry on at 80% until patient leaves hospital
114
INSULIN- POST SURGERY BD REGIMEN?
Restart before breakfast/evening meal- IV insulin infusion carried on for 30-60mins after first SC insulin dose
115
SICK DAY RULES SUGAR LEVELS? INSULIN? CARBOHYDRATES? KETONES?
SUGAR LEVELS? Check regularly INSULIN? Carry on taking CARBOHYDRATES? Keep eating+stay hydrated KETONES? Check regularly
116
DIABETES- PREGNANCY/BREASTFEEDING Risks to woman+foetus, risk reduced by effective blood-glucose control
117
DIABETES- PREGNANCY/BREASTFEEDING PLANNING FOR PREGNANCY?
Aim for HbA1c< 48mmol/mol | Take folic acid 5mg
118
FOLIC ACID HIIGH RISK OF NEURAL TUBULE DEFECTS?
diabetes, antiepileptics, previous yute, smoking is just at risk factor, relax 5MG OD BEFORE CONCEPTION+TILL WEEK 12 PREGNANCY SICKLE CELL THROUGHOUT
119
FOLIC ACID LOW RISK OF NEURAL TUBULE DEFECTS?
400MCG OD | BEFORE CONEPTION+TILL WEEK 12 PREGNANCY
120
WOMEN TAKING INSULIN MUST BE AWARE OF..?
HYPOGLYCAEMIA RISK + ALWAYS CARRY FAST-ACTING GLUCOSE
121
DIABETES- PREGNANCY/BREASTFEEDING x3 MEDICATION KEY POINTS?
- Stop all antidiabetics, bar metformin. - 1st line long-acting insulin: isophane insulin* - Statins/ACE-i/ARBs-> discontinue *Good blood glucose control before pregnancy w/ long-acting insulin analogues (detemir/glargine) calm to continue
122
GESTATIONAL DIABETES | Developed during pregnancy, STOP treatment after birth
123
GESTATIONAL DIABETES Fasting BG<7mmol/L?
1. Diet+Exercise. L? 2. Metformin (unlicensed). L? 3. Insulin IF REQUIREMENTS NOT MET IN 1-2 WEEKS!
124
GESTATIONAL DIABETES Fasting BG>7mmol/L?
diet, exercise, insulin and MAYBE metformin no longer glinbeclamide!
125
GESTATIONAL DIABETES Fasting BG 6-6.9mmol/L w/ complications? macrosomia- newborn>>>>> than average hydramnios- >>>>>amniotic fluid build up
Insulin | with/without Metformin
126
HYPOGLYCAEMIA- mmol/L?
<4mmol/L
127
HYPOGLYCAEMIA- SYMPTOMS?
``` SWEATING LETHARGIC DIZZINESS HUNGER TREMOR TINGLING LIPS PALPITATIONS EXTREME MOODS PALE ```
128
HYPOGLYCAEMIA- TREATMENT (conscious+can swallow) with/without symptoms! What 3 things could you give?
FAST-ACTING CARBS: - 4-5 glucose tablets - 3-4 heaped teaspoonfuls of sugar - 150-200mL fruit juice - Repeat/ 15mins for 3 cycles
129
HYPOGLYCAEMIA- TREATMENT (patient unconscious/swallow L) What do you do now?
IV glucagon unresponsive after 10mins? IV glucose
130
Why be careful with b-blockers?
Can mask the effects of hypoglycaemia
131
OSTEOPOROSIS | What is it?
Progressive bone disease- reduction of bone mass+density, causing increased risk of fractures
132
RISK FACTORS FOR OSTEOPOROSIS?
``` POSTMENOPAUSAL WOMEN MEN>50 LONG-TERM ORAL CORTICOSTEROIDS (glucocorticoids) Age increase Vitamin D+Calcium deficiency Lack of exercise Low BMI Smoking+drinking History of fractures Early menopause ```
133
LIFESTYLE CHANGES?
``` Increase exercise Smoking cessation Maintain an ideal BMI Reduce alcohol intake Increase intake of vitamin D+calcium (supplement if need be) ```
134
OSTEOPOROSIS- TREATMENT Review need for medication after how many years?
After 5 years for most meds, 3 years for Zoledronic
135
OSTEOPOROSIS- TREATMENT 1st LINE?
ORAL BISPHOSPHONATES (alendronic acid/risedronate sodium)
136
OSTEOPOROSIS- TREATMENT POSTMENOPAUSAL?
POSTMENOPAUSAL? ibandronic acid/denosumab/raloxifene/strontium
137
OSTEOPOROSIS- TREATMENT YOUNGER MENOPAUSAL WOMEN?
USE HRT/TIBOLONE
138
OSTEOPOROSIS- TREATMENT
TERIPARATIDE- used in severe osteoporosis
139
OSTEOPOROSIS TREATMENT MEN?
ZOLENDRONIC ACID DENOSUMAB TERIPARATIDE STRONITUM
140
OSTEOPOROSIS TREATMENT GLUCOCORTICOID-INDUCED?
FIRST LINE ALENDRONIC ACID/RISEDRONATE ZOLEDRONIC ACID DENOSUMAB TERIPARATIDE
141
GLUCOCORTICOID-INDUCED OSTEOPOROSIS Bone-protection treatment, considered in everyone on large dose corticosteroids for how many months?
>3 months
142
GLUCOCORTICOID-INDUCED OSTEOPOROSIS WOMEN- RISK FACTORS?
>/= 70 years Previous fragility fracture Large doses of glucocorticoids (>/= prednisolone 7.5mg OD)
143
GLUCOCORTICOID-INDUCED OSTEOPOROSIS MEN- RISK FACTORS?
>/= 70 years AND either: Previous fragility fracture OR Large doses of glucocorticoids
144
BISPHOSPHONATES- MHRA WARNINGS?
ATYPICAL FEMORAL FRACTURES- thigh/hip/groin pain OSTEONECROSIS OF THE JAW- dental pain/swelling/non-healing sores/discharge OSTEONECROSIS OF THE EXTERNAL AUDTIORY CANAL- report ear pain/discharge/ear infection
145
BISPHOSPHONATES- SIDE-EFFECTS OSEOPHAGEAL REACTIONS, REPORT & STOP? How do you avoid oesophageal reactions?
REPORT & STOP for: oesophageal irritation, dysphagia & heartburn ``` How do you avoid oesophageal reactions? Take w/ FULL GLASS OF WATER SITTING/STANDING EMPTY STOMACH AT LEAST 30MINS BEFORE BREAKFAST SIT UP RIGHT/STAND 30MINS AFTER ``` ALENDRONIC ACID^
146
RISEDRONATE COUNSELLING?
TAKE 30MINS BEFORE BREAKFAST OR LEAVE 2 HOURS BEFORE & AFTER FOOD/DRINK AT OTHER TIME OF DAY
147
SEX HORMONE RESPONSIVE CONDITIONS 2 TYPES OF OESTROGENS?
NATURAL- estradiol, estrone & estriol SYNTHETIC- ethinylestradiol & mestranol
148
PROGESTOGENS? NLD
NORETHISTERONE LEVONORGESTREL DESOGESTREL
149
TIBOLONE ACTIVITY?
OESTROGENIC PROGESTOGENIC WEAKLY ANDROGENIC
150
HORMONE REPLACEMENT THERAPY What menopausal symptoms can oestrogen alleviate?
itching, flushing, burning | can reduce postmenopausal osteoporosis
151
HORMONE REPLACEMENT THERAPY Issue with Clonidine?
Can be used for vasomotor symptoms, BUT | large side-effect profile
152
HORMONE REPLACEMENT THERAPY- RISKS BREAST CANCER?
Increased risk after 1 year Risk higher in combined HRT over oestrogen-only Excess risk persists for >10 years after stopping but risk lowers after stopping
153
HORMONE REPLACEMENT THERAPY- RISKS ENDOMETRIAL CANCER?
Women with uterus- Lower risk in combined HRT than oestrogen-only Tibolone also increases risk
154
HORMONE REPLACEMENT THERAPY- RISKS OVARIAN CANCER?
Small increase which disappears a few years after stopping
155
HORMONE REPLACEMENT THERAPY- RISKS VTE?
Increased risk of DVT with both oestrogen-only & combined HRT Increased risk with prolonged bed rest, obesity, trauma & family history
156
HORMONE REPLACEMENT THERAPY- RISKS STROKE?
Slight increase w/ both oestrogen-only & combined HRT | Tibolone increases risk by x2.2 in first year of treatment
157
HORMONE REPLACEMENT THERAPY- RISKS CORONARY HEART DISEASE?
Increased risk in combined HRT when started >10 years after menopause
158
CHOOSING HRT WOMEN W/ UTERUS?
Oestrogen w/ cyclical progestogen for last 12-14 days of the cycle OR Continuous administration of an oestrogen+progestogen (from day 1) NOTE: Continuous combined+tibolone, avoid in perimenopausal phase(just before menopause)/within 12months of last menstrual period
159
CHOOSING HRT WOMEN WITHOUT UTERUS? WHAT DO YOU DO IF ENDOMETRIOSIS OCCURS?
CONTINUOUS OESTROGEN USE Endometriosis? Add progesterone
160
HRT- SURGERY ELECTIVE When do you stop HRT? When do you reinitiate?
STOP HRT 4-6 WEEKS BEFORE SURGERY | REINITIATE WHEN FULLY MOBILE
161
HRT- SURGERY NON-ELECTIVE?
PROPHYLACTIC HEPARIN | GRADUATED COMPRESSION STOCKINGS
162
REASONS TO STOP HRT?
``` SUDDEN CHEST PAIN/BREATHLESSNESS (pe?) SWELLING/SEVERE PAIN IN CALF (dvt) SEVERE STOMACH PAIN (hepatoxicity) NEUROLOGICAL: prolonged headache, fainting, seizures HEPATITIS/JAUNDICE BP> 160mmHg systolic OR 95mmHg diastolic PROLONGED IMMOBILITY ```
163
THYROID HORMONES- negative feedback loop? High levels of T3+T4->low levels of TSH->inhibits own production
High levels of T3+T4->low levels of TSH->inhibits own production
164
HYPERTHYROIDISM LEVELS?
LOW TSH-> HIGH T3+T4, too much thyroid hormone
165
HYPERTHYROIDISM SYMPTOMS?
``` HYPERACTIVITY INSOMNIA HEAT INTOLERANCE INCREASED APPETITE WEIGHT LOSS DIARRHOEA GOITRE ```
166
HYPERTHYROIDISM- TREATMENT 1st LINE? 2nd LINE?
1st LINE? CARBIMAZOLE 2nd LINE? PROPYLTHIOURACIL
167
HYPERTHYROIDISM CARBIMAZOLE MHRA WARNINGS? CM-NAP
Neutropenia+Agranulocytosis-> sore throat, malaise, fever Congenital Malformations-> use effective contraception Acute Pancreatitis-> report & stop ASAP (severe abdominal pain, GLP-1s & flozins ;) ) Note: B-blockers can be used for symptomatic relief in primary hyperthyroidism
168
HYPERTHYROIDISM PROPYLTHIOURACIL cautioned in..?
Cautioned in liver disorder-> jaundice, dark urine, nausea
169
Note: B-blockers can be used for symptomatic relief in...
PRIMARY HYPERTHYROIDISM
170
HYPERTHYROIDISM- TREATMENT GRAVE'S DISEASE 1st LINE?
RADIOACTIVE IODINE But if remission is likely with anti-thyroids, consider carbimazole Iodine/surgery unsuitable? Consider carbimazole Given as a block & replace regimen in combo w/ levyothyroxine for 12-18 months
171
HYPERTHYROIDISM- TREATMENT PREGNANCY 1st TRIMESTER? 2nd+3rd TRIMESTER?
1st TRIMESTER? Propylthiouracil (>carbimazole's congenital defects) 2nd+3rd TRIMESTER? Carbimazole (>propylthiouracil's hepatotoxicity)
172
HYPOTHYROIDISM LEVELS?
HIGH TSH->LOW T3+T4
173
HYPOTHYROIDISM SYMPTOMS?
``` FATIGUE WEIGHT GAIN CONSTIPATION DEPRESSION DRY SKIN INTOLERANCE TO COLD MENSTRUAL IRREGULARITIES ``` REDUCED METABOLIC ACTIVITY!
174
HYPOTHYROIDISM- TREATMENT 1st LINE?
LEVOTHYROXINE
175
HYPOTHYROIDISM- TREATMENT LEVOTHYROXINE Monitor TSH/? How to take it? Brands?
Monitor TSH/? /3 months till stable, then yearly thereafter How to take it? Take medicine in AM, at least 30mins before brekky/red bull Brands? Some patients can feel symptoms if alternating between brands
176
HYPOTHYROIDISM TREATMENT LIOTHYRONINE?
Rare More rapid+potent (20-25mcg= 100mcg levo) Non-UK brands may not be bioqeuivalent
177
INTERMEDIATE INSULIN EXAMPLES?
ISOPHANE INSULTARD HUMULIN I
178
NOT INTERMEDIATE?
TRESIBA- DEGLUDEC- LONG-ACTING
179
METFORMIN | AVOID IF eGFR is LESS THAN?
30 mL/minute/1.73 m2
180
POTASSIUM LOSS HYPERTENSION WATER RETENTION ?
MINERALCORTICOIDS
181
DIABETES OSTEOPOROSIS PEPTIC ULCERATION ?
GLUCOCORTICOIDS
182
Miss A is 27 years old and has type 1 diabetes. Her PMR shows that she uses NovoRapid (insulin aspart) and Lantus (insulin glargine). Which of the following is/are appropriate if she experiences severe diarrhoea and is unable to eat solid foods? She should
Increase the frequency of blood glucose monitoring, Take oral rehydration therapy
183
FASTING BLOOD GLUCOSE ON WAKING?
5-7
184
DIABETIC MEDICATION CONTRAINDICATED IN HEART FAILURE BLADDER CANCER?
PIOGLITAZONE
185
DIABETIC KETOACIDOSIS RISK?
FLOZINs GLIPTINs (not lina or saxo!) GLP-1 (NOT dulaglutide) Absolute L when insulin abruptly stopped
186
GLICLAZIDE/SULPHONYLUREA ELDERLY?
Elderly Prescription potentially inappropriate (STOPP criteria) if prescribed a long-acting sulfonylurea (e.g. glibenclamide, chlorpropamide, glimepiride) in type 2 diabetes mellitus (risk of prolonged hypoglycaemia).
187
SICK DAY RULES?
Just because the patient is ill and not eating does not mean they should stop injecting their insulin ill/ infection= stress hormones/ steroids released steroids increase blood glucose stay well hydrated to avoid DKA patient should monitor their BG and urine ketones more frequently and be prepared to inject accordingly
188
A trainee pharmacist asks you to go through the different types of studies conducted in research in order to produce reliable evidence. Which of the following studies is most likely to produce reliable results?
o Systematic Reviews
189
Patient, flushing, face, what med?
CCB, amlodipine
190
A 2-month-old boy has been admitted to hospital with suspected bacterial meningitis Which is the most appropriate treatment for this patient?
BENZYL-CEFOTAXIME-CHLORAMPHENICOL
191
SITAGLIPTIN DOSE ADJUSTMENT RENAL?
50mg OD if eGFR 30–45 mL/minute/1.73 m2. 25mg OD if eGFR less than 30 mL/minute/1.73 m2.
192
CUTANEOUS DD LIPOHYERP
193
INSULIN TYPE 1 FIRST LINE?
insulin detemir twice daily and insulin aspart before meals BASAL-BOLUS!
194
chlorhexidine, gingivitis?
taste disturbance
195
METFORMIN PATIENT ADVICE?
risk of lactic acidosis and told to seek immediate medical attention if symptoms such as dyspnoea, muscle cramps, abdominal pain, hypothermia, or asthenia occur.
196
METRONIDAZOLE BV DOSING?
400–500 mg twice daily for 5–7 days, alternatively 2 g for 1 dose
197
DIABETIC CHOC, NOT ENOUGH SUGAR!
198
CO-AMOX HEPATOXIC!
199
monitor insulin more when meal times changed
200
One week after his hospital admission, the patient develops diarrhoea. A stool sample confirms the presence of Clostridium difficile infection. Doctors decide to stop the lansoprazole and review the antibiotic for his infection. Which ONE of this patient͛s medications listed below is MOST likely to require temporary discontinuation in view of his Clostridium difficile infection?
stop ibu he's sick
201
BISPHOSPHONATES COUNSELLING ALENDRONIC ACID? RISEDRONATE?
alen- avoid if crcl<35 rised- avoid if crcl<30
202
type 1 diabetes, high sugars, too much ketones- abdominal pain!
not flatulence? hm
203
VILDGALIPTIN, HEPATOTOXIC!!
204
ABRUPT INSULIN STOP- DKA risk?
ALL THE GLP1s but dulalglutide not contraindicated in ketoacidosis, don't get it twisted!
205
PIOGLITAZONE AVOID IN?
``` BONE FRACTURES LIVER TOXICITY- report N&V, abdominal pain, fatigue & dark urine HF BLADDER CANCER BONE FRACTURES ```
206
HOW OFTEN DO YOU MEASURE HBA1C?
type 1 diabetes- 3 to 6 months, and more frequently if blood-glucose control is thought to be changing rapidly. type 2 diabetes- 3 to 6 months until HbA1c and medication are stable when monitoring can be reduced to every 6 months. STABLE 6 MONTHS
207
what is exenatide?
GLP-1 mate Binds to, and activates, the GLP-1 (glucagon-like peptide-1) receptor to increase insulin secretion, suppresses glucagon secretion, and slows gastric emptying.
208
DIARRHOEA IN HRT?
myna
209
MINERALCORTICOID SIDE-EFFECTS?
``` hypertension sodium retention water retention hypokalaemia hypocalcaemia ```
210
BG TARGET WHILST DRIVING?
>5 AT LEAST
211
Mr rue Licitiy is a new patient at your practice. You are conducting a new patient meds reconciliation and review with the patient. From his previous practice records you note that he is a Type 2 Diabetic, who is stable on Metformin, Gliclazide and Dapagliflozin. You have a look at his previous HbA1cs and can see that it is stable, around 52mmol/mol. How often should Mr Prue Licitiy get his HbA1c checked?
Every 6 months
212
trulicity drug?
dulaglutide
213
cvd DIABETES COMPLICATION?
MACRO!
214
AWARENESS OF HYPOGLYCAEMIA SYMPTOM?
GOLD SCORE
215
MONITORING TSH LEVELS?
/3 months till stable, then yearly thereafter YEARLY ONCE STABLE
216
You are discussing anti-diabetic treatment regimes for type 2 diabetes with a fellow colleague. Your colleague has a question regarding ongoing use of GLP-1 mimetics once initiated in a patient. Which one of the following statements below is an accurate representation of when GLP-1 mimetics should be continued to treat Type 2 diabetes?
Patient has a reduction of at least 3% initial body weight and 1% reduction of Hb1Ac within 6 months
217
GLP1 FACT
If triple therapy with metformin and 2 other oral drugs is not effective, not tolerated or contraindicated, consider triple therapy by switching one drug for a GLP-1 mimetic for adults with type 2 diabetes who: • have a body mass index (BMI) of 35 kg/m2 or higher (adjust accordingly for people from Black, Asian and other minority ethnic groups) and specific psychological or other medical problems associated with obesity or • have a BMI lower than 35 kg/m2 and: – for whom insulin therapy would have significant occupational implications or – weight loss would benefit other significant obesity related comorbidities.
218
You are reviewing a clinic letter from the consultant endocrinologist for Mr P 29-years-old. The consultant has recommended initiating a “block and replace” treatment regimen to help treat his hyperthyroidism. Usually how long would you expect this “block and replace” regimen to be given?
18 months, thought it was 12-18?
219
AKI likely presentation? Mad word
Oliguria Oliguria is the production of abnormally small amounts of urine. It is one of the symptoms of AKI alongside oedema (legs, ankles and around the eyes), fatigue, shortness of breath, confusion, nausea, seizures, chest pain or pressure and coma (severe)
220
Mr H has a diagnosis of Type 2 diabetes from a few months ago. He has been finding it very difficult to control his glucose levels. The doctor has decided to start him on a new antidiabetic drug. Mr H is a bus driver and is concerned that this new medication will affect his ability to drive. When counselling Mr H, you tell him that he can drive but should be wary of hypoglycaemia and should try and avoid it. Which of the following medications has Mr H most likely been started on?
Glipizide is a sulfonylurea and they are known to cause hypoglycaemia. They act mainly by augmenting insulin secretion and consequently are effective only when some residual pancreatic beta-cell activity is present
221
Mrs N is a 52year old woman who is suffering from the symptoms of menopause. She also has asthma and hyperthyroidism. She is on the following medication: ● Carbimazole 5mg OD ● Alendronic acid 70mg weekly ● Adcal D3, TWO tablets TWICE daily ● Salbutamol 100mcg, TWO puffs when required ● Seretide 125 evohaler, TWO puffs BD Mrs N presents at the pharmacy with symptoms of heartburn and difficulty swallowing. Which one of Mrs S’ medications is the most likely cause of her symptoms?
ALENDRONIC ACID Severe oesophageal reactions are a side effect of oral bisphosphonates. Severe Oesophageal reactions (oesophagitis, oesophageal ulcers, oesophageal stricture and oesophageal erosions) have been reported; patients should be advised to stop taking the tablets and to seek medical attention if they develop symptoms of oesophageal irritation such as dysphagia, new or worsening heartburn, pain on swallowing or retrosternal pain.
222
diabetic neuropathy | foot infection?
refer to foot protection service, not gp
223
ciprofloxacin+ibuprofen? IV meropenem L too
reduces seizure threshold!!
224
A patient has suspected unstable angina and a glyceryl trinitrate spray is ineffective. Manage?
ASPIRIN 300MG P
225
ORLISTAT+LEVOTHYROXINE?
THYROID, INTERACTION, CHECK Signs of meningitis. 1st line is benzylpenicillin but unsuitable due to penicillin allergy. Cefotaxime can be used as no history of immediate anaphylactic reaction to penicillins. See a doctor first
226
WHAT DRUG RISK OF LOWER LIMB AMPUTATION?
CANAGLIFLOZIN!
227
INSULIN PEN
228
METFORMIN, LESS B12, AVOID IF CRCL IS
30ml/min
229
SULPHONYLUREAS should be avoided in?
Hepatic and renal failure
230
PIOGLITAZONE avoid in?
HF bladder cancer bone fractures liver toxicity
231
DPPis Pancreatitis? Hepatotoxic?
DPPis ``` Pancreatitis? Alogliptin Linagliptin Sitagliptin Saxagliptin Vildagliptin ``` Hepatotoxic? Vildagliptin
232
SGLT2s monitor renal function?
CANAGLIFLOZIN- 'LLA' ;) DAPAGLIFLOZIN EMPAGLIFLOZIN
233
GLP-1 AGONIST PANCREATITIS?
DULAGLUTIDE EXENATIDE LIRAGLUTIDE LIXISENATIDE
234
SC INSULIN REGIMEN, SURGERY, doesn't require?
IV infusion continued 1hr later?
235
SIDE-EFFECTS OF INSULIN?
WEIGHT GAIN OEDEMA (reabsorption of soidum, water, etc) LIPODYSTROPHY- body storing fat, SKIN REACTIONS NOT WEIGHT LOSS (hypertrophy- lump of fat tissue under skin, repeated injection)
236
Patient w/ lipodystrophy/cutaneous amyloidosis?
NO NEED TO REFER | Just rotate injection sites
237
gluconeogenesis?
the production of glucose
238
DRUG TO PRESCRIBE BY BRAND?
NIFEDIPINE MR
239
medication hyperglycaemia risk?
thiazide, bendro
240
Novorapid advice?
Generally taken before a meal. Taken immediately before a meal due to risk of hypo, onset of action is <15mins!
241
NOVORAPID ADMINISTRATION?
Rapid acting, immediately at/before but also after eating, wow
242
ultra rapid acting insulin?
Fiasp, right at meal, woi
243
15mins before meal insulin?
``` short-acting insulins bovine porcine insuman rapid humulin s actrapid ```
244
``` INSULATARD? LYUMJEV? TOUJEO? TRESIBA? ACTRAPID? ```
``` INSULATARD? isophane, intermediate LYUMJEV? lispro, rapid-acting TOUJEO? glargine, long-acting TRESIBA? degludec, long-acting ACTRAPID? short-acting ```
245
RAPID-ACTING INSULINS?
LISPRO- HUMALOG ASPART- NOVORAPID GLULISINE- APIDRA
246
SHORT-ACTING INSULINS? SOLUBLE/NEUTRAL
``` ACTRAPID HUMULIN S INSUMAN RAPID BOVINE NEUTRAL PORCINE NEUTRAL ```
247
INTERMEDIATE-ACTING INSULINS? ISOPHANE
``` BOVINE ISOPHANE PORCINE ISOPHANE INSULATARD HUMULIN I INSUMAN BASAL ```
248
LONG-ACTING INSULINS?
DETEMIR- LEVEMIR DEGLUDEC- TRESIBA GLARGINE- LANTUS
249
BIPHASIC INSULINS- BIPHASIC INSULIN ASPART?
NOVOMIX 30
250
WHAT IS USED TO TREAT ADDISON'S DISEASE/ADRENAL INSUFFICIENCY?
HYDROCORTISONE... PRIMARY+FLUDROCORTISONE
251
SIDE-EFFECTS OF CORTICOSTEROID USE?
DIABETES OSTEOPOROSIS WEIGHT GAIN MUSCLE WASTAGE NOT ADDISON'S DISEASE, IT TREATS IT!
252
FIASP?
insulin aspart+nicotinamide- vitamin b3
253
BIPHASIC INSULINS- BIPHASIC INSULIN LISPRO?
HUMALOG MIX25 | HUMALOG MIX50
254
BIPHASIC INSULINS- BIPHASIC ISOPHANE?
HUMULIN M3 INSUMAN COMB 15 INSUMAN COMB 25 INSUMAN COMB 50
255
An 82-year-old patient has been newly diagnosed with type 2 diabetes mellitus. Their past medical history includes atrial fibrillation, previous bladder cancer and hypertension. Recent blood results show an eGFR of 25 mL/min. Which Of the following would be the most appropriate initial drug therapy for this patient? A. Dapagliflozin B. Glibenclamide C. Metformin D. Pioglitazone E. Sitagliptin
Dapagliflozin- consider additional antidiabetic if egfr <45 Sitagliptin- 25mg OD egfr<30
256
HRT RISKS?
BREAST CANCER NOT? OSTEOPOROSIS
257
METFORMIN MAX./DAY?
2G
258
Metformin is available in a selection of strengths and formulations. Which Of the following is NOT an appropriate dose of metformin? A. Metformin 500mg tablets. ONE tablet taken each day with breakfast for at least one week for an adult newly diagnosed with type 2 diabetes B. Glugophage SR 1000mg tablets. TWO tablets taken daily with evening meal for an adult male with type 2 diabetes C. Metformin 500mg tablets. TWO tablets taken with breakfast and TWO with evening meal for an adult female with polycystic Ovary Syndrome D. Metformin hydrochloride 100mg/ml oral solution sugar free. ONE 5ml spoonful taken three times a day for a 13-year-old child with type 2 diabetes E. Metformin 500mg tablets. TWO tablets taken three times a day for a 29-year-Old pregnant woman with gestational diabetes
E- too much relax
259
A diabetic patient is having his insulin regime reviewed with his diabetic nurse. He is prescribed an insulin he has never used before. He presents in your pharmacy with a prescription for Insulin lispro. Which Of the following products is correct? A. Lantus B. Levemir C. Novorapid D. Apidra E. Humalog
Humalog- insulin lispro
260
A patient has a review at the diabetes clinic and a decision is made to begin a basal insulin regime. Due to his current social situation, it is decided that the prescribed insulin should be chosen in order that the carer can remind the patient to administer the insulin once daily around breakfast time. Which of the below insulins would be the most appropriate to prescribe? A. Apidra (insulin glulisine) B. Humulin S (soluble insulin) C. Humalog (insulin lispro) D. Novomix 30 (biphasic insulin aspart) E. Tresiba (insulin degludec)
Tresiba, insulin degludec
261
Mr R, aged 76, is diagnosed with type 2 diabetes and osteoarthritis and has been prescribed the medicines listed below. He lives alone but has a carer visit twice a day to help around the house. Mr R's carer visits your pharmacy to ask for advice. She tells you he is suffering from "sickness and diarrhoea and hasn't been able to keep anything down". You are worried about these symptoms and decide to advise the patient to withhold one of his regular medications. Which one of the following would it be most appropriate for Mr R to withhold? A. Atorvastatin B. Codeine C. Lantus Solostar (insulin glargine) D. Metformin E. Paracetamol
D, METFORMIN SICK DAYS SADMAN, stop, come on
262
``` The diabetes clinic counsels Mr R regarding recognising the symptoms of hypoglycaemia and diabetic ketoacidosis. Which one of the following is least likely to be a symptom of hypoglycaemia? A. Blurred vision B. Bradycardia C. Mood changes D. Sweating E. Tremor ```
NOT BRADYCARDIA
263
After a recent HbA1c test, a diabetes nurse decides to prescribe canagliflozin for Mr R. He comes into the pharmacy two weeks later, with conjunctivitis in one of his eyes and wonders if his new rnedication may increase the risk of eye infections. Which is the most appropriate response? A. Canagliflozin is a black triangle drug and all adverse effects should be reported via the Yellow Card Scheme B. Eye infections are not a known side effect of canagliflozin. Mr R could treat his conjunctivitis with chloramphenicol eye drops C. Eye infections are a known side effect of canagliflozin. Mr R should continue taking the canagliflozin but if the eye infections become recurrent, he could return to his diabetes nurse for an alternative D. Eye infections are a known side effect of canagliflozin. Mr R should continue taking the canagliflozin and see his GP E. Eye infections are a known side effect of canagliflozin. Mr R should stop taking the canagliflozin and see his GP
B, unknown, chloramphenicol myna
264
side-effects of glucocorticoids?
``` growth retardation hypertension hyperglycaemia osteoporosis weight gain ``` not hypoglycaemia,silly, read Q, eliminate and execute
265
STEROID WITHDRAWAL, KEY TERM more than PREDNISOLONE 40MG OR EQUIVALENT AND....?
MORE THAN 40MG OD FOR MORE THAN A WEEK, SO 7 DAYS IS FINE, key details
266
267
268
A drug, hypocalcaemia risk?
Denosumab MHRA/CHM advice: Denosumab: minimising the risk of osteonecrosis of the jaw; monitoring for hypocalcaemia
269
HYPOGLYCAEMIA YOU ARE TACHYCARDIC
270
271
Driving 45 mins after?
Blood glucose level is normal, NOT after eating
272
273
Informing DVLA, gestational?
Need insulin for >3 months after birth
274
Acne, lowest photosensitivitiy risk? highest?
Lowest- Minocycline Highest- Doxy/Oxy
275
276
hba1c monitoring?
3-6 months type 2 stable, 6 months 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.
277
osteoporosis+prednisolone L
osteoporosis+prednisolone L
278
SITALGLIPTIN INTERSTITIAL LUGN DISEASE? OK
279
HBA1C TARGETS?
48 IF NO hypoyglycaemia drugs | 53 IF HYPOYGLYCAEMIA DRUGS
280
Mr H, a 45-year old patient at your community pharmacy, brings in a new prescription for linagliptin 5 mg tablets once daily. You notice that he was previously prescribed sitagliptin 100 mg tablets once daily, which he had been taking for 2 years. Mr H has type 2 diabetes mellitus which is currently well controlled. Mr H's only Other regular medication is ibuprofen 400 mg tds for back pain. Which of the following is the most likely reason for the switch to linagliptin?
The patient's renal function has deteriorated and so linagliptin is more appropriate
281
A diabetic patient is having his insulin regime reviewed with his diabetic nurse. He is prescribed an insulin he has never used before. He presents in your pharmacy with a prescription for Insulin lispro. Which Of the following products is correct?
HUMALOG LISPRO!!! NOVORAPID ASPART!!!! GLULISINE APIDRA!!
282
FLOZIN, REDUCED RENAL?
CONSIDER ADDITIONAL DRUG GLIPTIN BEST
283
BRADYCARDIA NOT A SYMPTOM OF?
HYPOYGLYCAEMIA!
284
SUGAR HYPO?
DISSOLVED IN WATER!
285
Mr. AJ is a 19-year-old newly diagnosed with type-1 diabetes. Which of the following is recommended as first-line therapy?
BASAL-BOLUS FIRST LINE! BD INSULIN DETEMIR INSULIN DEGLUDEC- nocturnal hypoglycaemia DEGLUDEC/GLARGINE- once daily, carer/ etc
286
levothyroxine dose?
25mcg before food
287
Anaemia can exacerbate heart failure!!
288
WHAT IS NOT RECOMMENDED IN TRIPLE THERAPY?
DAPAGLIFLOZIN+PIOGLITAZONE
289
In type 1 diabetes, aim for a clinic blood pressure of 135/85 mmHg or less unless the adult with type 1 diabetes has albuminuria or 2 or more features of metabolic syndrome, in which case it should be 130/80 mmHg or less

GPhC BNF (48 decks)

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