Endocrine Flashcards
(191 cards)
1
Q
Effects of mineralocorticoids?
A
Fluid and Na+ retention
2
Q
Effects of glucocorticoids?
A
Anti inflammatory
3
Q
Most potent mineralocorticoids?
A
Fludrocortisone (most potent)
Hydrocortisone (significant)
4
Q
Most potent glucocorticoids?
A
Dexamethasone (highest potency)
Betamethasone (highest potency)
Prednisolone (significant)
5
Q
Does hydrocortisone have mineralocorticoids or glucocorticoid activity?
A
Both, higher mineralocorticoid activity but still significant glucocorticoid activity
6
Q
When would a mineralocorticoid be preferred?
A
Neuropathic postural hypotension
Septic shock
7
Q
When would a glucocorticoid be preferred?
A
When fluid retention is considered a disadvantage e.g. in HF PTs
8
Q
Which condition should be particularly avoided with steroid treatment?
A
Chicken pox or shingles
9
Q
What should be done if a patient taking steroids or up to 3 months after taking steroids, contracts Chicken pox or shingles?
A
Require passive immunisation with the varicella-zoster vaccine
10
Q
When does a steroid need to be stopped gradually rather than abruptly?
A
> 3 weeks use
7 days of >40mg dose
11
Q
What is adrenal suppression?
A
Condition where the adrenal cortex stops making corticosteroids
12
Q
Symptoms of adrenal suppression?
A
Opposite to aching bosoms
Fatigue, anorexia, N&V, hyponatraemia, hypotension, hyperkalaemia, hypoglycaemia, itchiness and weight loss
13
Q
What are the sick day rules with steroid use?
A
Dose needs to be increased to mimic normal cortisol levels
Vomiting once = retake dose
Persistent vomiting = go to the hospital
14
Q
Side effects of corticosteroids?
A
“ACHING BOSOM”
A = adrenal suppression
C = Cushing’s syndrome / cataracts
H = hyperglycaemia / hyperlipidaemia
I = infections / insomnia
N = nervous system - psychiatric reactions
G = glaucoma / GI ulcers
B = (mineralocorticoid SEs) increased BP / oedema / hypokalaemia
O = osteoporosis
S = skin thinning
O = obesity
M = muscle wasting
15
Q
MHRA alert for buccal corticosteroids?
A
Not to be used for adrenal insufficiency in children
16
Q
MHRA alert for hydrocortisone?
A
Adrenal insufficiency caused in children when switching from tablets to granules
17
Q
MHRA alert about methyl prednisolone injections?
A
Contains lactulose so caution with allergies
18
Q
What is Addison’s disease?
A
Adrenal insufficiency caused by damage to the adrenal gland
19
Q
How is adrenal insufficiency treated?
A
2 doses of hydrocortisone (larger OM to mimic cortisol levels) + fludrocortisone
20
Q
What is hypopituitarism?
A
When the pituitary glands do not stimulate hormone secretion (including in the adrenal glands)
21
Q
Symptoms of adrenal crisis?
A
Low BP
Dizziness
Fever
N, V & D
Tiredness
Confusion
Aching muscles and joints
Stomach pains
22
Q
Treatment of adrenal crisis?
A
IV hydrocortisone
23
Q
Sick day rules for PTs with adrenal insufficiency?
A
Fever / infection requiring antibiotics = double hydrocortisone dose and switch to SA preparation
Persistent vomiting or diarrhoea = switch to IV/IM hydrocortisone and go to hospital if persistent
24
Q
What is diabetes insipidus?
A
Low antidiuretic hormone (ADH)
25
What are the 2 types of diabetes insipidus?
Cranial and nephrogenic
26
What is cranial diabetes insipidus?
Hypothalamus/pituitary gland doesn’t make enough ADH
27
What is the treatment of cranial diabetes insipidus?
Desmopressin
28
What is nephrogenic diabetes insipidus?
Kidneys no longer respond to ADH
29
Treatment of nephrogenic diabetes insipidus?
Thiazide diuretics as these can help retain water
30
Side effects of desmopressin?
Hyponatraemia - can lead to convulsions so should be used in caution in epilepsy
Oedema - caution in HF, HTN, migraine
31
What is the main drug interaction for desmopressin?
TCAs which also increase ADH secretion
32
Mechanism of action of desmopressin?
Makes urine more concentrated which decreases the number of times you need to go
33
What is SIADH?
“Syndrome of inappropriate ADH secretion”
Too much ADH secretion
34
Electrolyte disturbance caused by SIADH?
Increased fluid retention causing reduced concentrations of Na+ therefore causing hyponatraemia
35
1st line treatment of SIADH?
Fluid retention
36
2nd line treatment of SIADH?
Demeclocycline - blocks renal effects of ADH
Or tolvaptan - ADH antagonist
37
Why can’t hyponatraemia be corrected rapidly?
Can cause osmotic demyelination of neurones causing serious CNS effects
38
What is Cushing’s syndrome?
Condition where cortisol levels are too high
39
What are the distinguishing symptoms of Cushing’s syndrome?
Fat deposits on the face and back of the neck causing a moon face and buffalo hump
40
Treatment of Cushing’s caused by steroid use?
Reduce/review dose
41
Treatment of Cushing’s caused by tumours?
Surgery / Ketoconazole (cortisol inhibiting drug reserved for only this purpose due to SEs)
42
Ketoconazole side effects?
Report signs of liver disorder E.g. vomiting, abdomen pain and jaundice
Can also cause adrenal insufficiency
43
What are the diabetes sick day rules?
“SICK”
S = sugar - check blood glucose every 3-4H until normal including ON
I = insulin - never stop
C = carbs - maintain normal meal pattern and replace meals with high carb drinks if necessary. Drink 3L of fluid a day. Seek medical help for persistent N&V
K = ketones - check blood and urine ketones every 3-4 hours. Seek medical help if urine ketones > 2 or blood ketones > 3
44
Symptoms of diabetes?
Polyuria, polydipsia (thirst), polyphagia (hunger), poor wound healing, fatigue, weight loss, blurred vision
45
Pre-diabetes levels?
5.7 - 6.4
46
Diabetes levels?
6.5 +
(48mmol/L)
47
Treatment of type 1 diabetes?
Insulins
48
Treatment of type 2 diabetes?
Diet and lifestyle advice
Anti diabetic drugs
Insulin
49
Different types of diabetic complications?
Microvascular
Macrovascular
Diabetic foot
50
Types of microvascular complications in diabetes and treatment?
Retinopathy - treat hypertension
Nephropathy - treat hypertension, low dose ACE/ARB to treat protein urea
Peripheral neuropathy- treat neuropathic pain using analgesics/ TCAs and anti-epileptics
51
Types of macrovascular complications in diabetes?
CVD = Stroke, heart attack and atherosclerosis
52
Prevention of macrovascualr complications?
CVD prevention with low dose high intensity statin E.g. atorvastatin 20mg or low-dose aspirin for secondary prevention
53
When is a low dose statin given to a diabetic patient for primary prevention of CVD?
Over 40, type 1 > 10 years, type 2 > 20 years, target organ damage, QRISK > 10%
54
What is diabetic ketoacidosis?
When blood glucose levels are too high
55
Symptoms of diabetic ketoacidosis?
Pear drop breath
Polyuria
Abdominal pain
Dehydration and excessive thirst
Ketonuria
Anorexia
Difficulty breathing
56
Treatment of ketoacidosis?
Soluble (human) insulin + fluids + electrolytes E.g. potassium (only if the patient is urinating) until ketones < 0.3mmol/L
57
Do you continue LA insulin while undergoing treatment for ketoacidosis?
Yes
58
Which area of the body has the fastest absorption rates for insulin?
The abdomen
59
Is it safe to miss meals or do strenuous exercise before injecting insulin?
No
60
Which insulins are considered a bolus insulin?
Short acting and rapid acting
These mimic prandial insulin released after a meal
61
Which insulins are considered basal insulins?
Long and intermediate acting insulins
Mimics insulin secretion throughout the day
62
Can beta blockers be given in diabetes? And why?
No, because they mask symptoms of hypoglycaemia
63
Examples of short acting (soluble) insulins?
Human / animal
64
What routes can SA insulin be given?
SC / IM
IV in emergencies / surgery
65
When should SA insulins be injected?
15-30mins before food
Max 30mins to avoid hypos
66
Examples of rapid acting insulins?
“LAG”
Lispro, Aspart, Glulisine
67
What routes can RA insulin be given?
SC or IV in emergencies
68
When should RA insulins be injected?
Just before food
(Can be after but not recommended due to poor glycemic control)
69
Example of intermediate acting insulin?
Isophane
70
Which route can isophane never be given?
IV due to risk of VTE
71
Caution with isophane?
Contains protamine which can cause allergic reactions
72
How often is isophane injected?
BD
73
Onset and duration of isophane?
Onset = 1-2 hours
Duration = 11-24 hours
74
Examples of long acting insulins?
“DDG (David DeGea is long)”
Detemir, degludec (OD/BD), glargine (brand specific)
75
Onset of LA insulins?
2-4 hours
76
Which LA insulin should be prescribed by brand?
Glargine
77
What are the three types of insulin regimens for type 1 diabetes?
1. Multiple injections AKA basal-bolus
2. Biphasic injections
3. Subcutaneous infusion
78
What is a multiple injection regiment?
SA/RA before meals + intermediate or LA OD/BD
E.g. RA + detemir BD
79
What is a biphasic injection regiment?
SA/RA mixed with isophane (typically 30:70)
80
How often is biphasic regimens injected?
BD before meals
Match carb intake to dose
81
When are biphasic regimens contraindicated?
In inter current illness due to changing insulin requirements
82
What is a subcutaneous insulin infusion regimen?
SA/RA continuously through the day via an insulin pump
83
When can a SC insulin infusion regimen be used?
In severely poor control or children < 12 (must be trialled on MIR once they turn 12)
84
Which insulin regimens are used in T2DM?
Biphasic or MIR
85
What should be done to the dose of insulin when undergoing a minor surgery?
Adjust dose
86
What anti diabetic medications should be stopped when undergoing minor surgery?
SGLT - risk of ketoacidosis
SU - risk of hypo
Metformin - risk of renal impairment
87
What anti diabetic medications should be stopped when undergoing major surgery?
All of them
88
What should be done to the dose of insulin when undergoing a major surgery?
Stop all insulins except LA (give 80% dose) and start sliding scale soluble human insulin until patient is eating and drinking and established on normal meds.
89
What are the mechanisms of action of anti diabetic medications?
All hypoglycaemics except metformin and pioglitazone which increase insulin sensitivity
90
1st line anti diabetic drug?
Metformin
(Also used in poly cystic ovary syndrome - PCOS)
91
What are the main side effects of metformin?
GI disturbances - take with food or switch to MR
Lactic acidosis
Low vit b12
Taste disturbances
92
Symptoms of lactic acidosis?
Dyspnoea, cramps, abdominal pain, hypothermia, asthenia (muscle weakness)
93
Contraindications of metformin?
renal impairment <30 eGFR
AKI
Tissue hypoxia - e.g. acute HF, respiratory failure, MI or liver dysfunction
94
When is triple therapy an option in T2DM?
When dual therapy including metformin is not effective. Cannot be given without metformin
95
When is a GLP1 switched in during triple therapy?
When normal triple therapy is in effective and the patient has a BMI>35 or having occupational implications with insulin.
96
When can an SGLT2 be added to treatment?
At any stage if a PT has a QRISK > 10%
97
Examples of sulphonylureas?
LA = Glimepiride
SA = gliclizide, Tolbutamide
98
Which SU is used in renal impairment or in the elderly?
Gliclazide
99
Side effects of SUs?
Hypoglycaemia - treated in hospital with glucose
HypoNa+
Weight gain
Jaundice
Allergic dermatitis
100
Main interaction with sulphonylureas?
ACE/ARB = increased risk of hypo
101
Side effects of pioglitazone?
Heart failure (particularly with insulins)
Bladder cancer (CI in uninvestigated haematuria)
Hepatotoxicity
Vision impairment
Weight gain
102
Example of an SGLT2?
“Flozins”
Canagliflozin, Empagliflozin, Dapagliflozin
103
Which SGLT2s are beneficial in CVD?
Canagliflozin and empagliflozin
104
Side effects of SGLT2s?
Atypical ketoacidosis (HbA1c only slightly rises)
Volume depletion - hydrate and report dizziness and postural hypotension
Increased glucose secretion which also leads to increased risk of infections
Fournier’s gangrene - report severely painful, red and swollen genitals with fever and malaise
Weight loss
105
Which SGLT2 should not be used in T1DM?
Dapagliflozin
106
Which SGLT2 increases risk of lower limb amputation?
Canagliflozin
- report ulcers and skin colour change
107
Examples of DPP4 inhibitors?
“Gliptins”
Linagliptin
Sitagliptin
Vidagliptin
108
Which DPP4 can be given in renal impairment?
Linagliptin
109
Side effects of DPP4s?
Pancreatitis - report persistent, severe abdominal pain
Vidagliptin can cause hepatotoxicity
110
Examples of GLP1s?
“Tide”
Exenatide
Lixisenatide
Dulaglutide
111
When should GLPs be injected?
Before food
112
Which GLP1s do not need to be kept in the fridge?
Lixisenatide
Exenatide
113
What route are GLP1s given?
SC
114
Side effects of GLP1s?
GI disturbances and decreased gastric emptying
Pancreatitis
DKA when insulin stopped
Weight loss
115
Which GLP1s increase risk of infections?
“The Ls”
Liraglutide
Lixisenatide
116
What is acarbose?
Last line treatment for diabetes which decreases sucrose absorption
117
Side effects of acarbose?
Flatulance - improves with time, antacids won’t help
Diarrhoea- reduce dose or withdraw
118
Patient counselling for acarbose?
Chew with 1st mouthful of food
Carry glucose not sucrose for hypo
119
Side effects of Meglitinide “glinides”?
Hypoglycaemia
Diarrhoea
120
Counselling for meglitinides?
Take 30mins before main meal
121
What blood glucose range is considered hypoglycaemic?
<4mmol/L
122
Symptoms of hypoglycaemia?
Palpitations
Tingling lips
Pale/clammy skin
123
Should a patient take their next insulin dose if they are experiencing hypoglycaemia?
Yes but it must be reviewed
124
What should be done if blood glucose is >4 in hypoglycaemia?
Give a long acting carb snack
125
What should be done if blood glucose is <4 in hypoglycaemia?
15-20g of fast acting sugar, repeat after 15mins (max 3 times)
+ Give a long acting carb
126
How is gestational diabetes diagnosed?
Oral glucose tolerance test
127
What is the 1st line treatment is gestational diabetes when the PTs fasting blood glucose < 7mmol/L?
Diet and exercise
128
What is the 2nd line treatment is gestational diabetes when the PTs fasting blood glucose < 7mmol/L?
When blood glucose levels not met in 1-2 weeks give Metformin / insulin
129
What is the 1st line treatment is gestational diabetes when the PTs fasting blood glucose > 7mmol/L?
Insulin +/- Metformin
130
Which diabetic medications are safe in breastfeeding and pregnancy?
Metformin and insulin
131
When should treatment of gestational diabetes be stopped?
At term
132
What is the blood glucose target in pre-existing diabetes in pregnancy?
< 6.5% (48mmol)
133
What is the treatment of pre-existing diabetes in pregnancy?
RA insulin + isophane
Doses increase during pregnancy but must be decreased straight after birth
134
What is the blood glucose target in type 1 diabetes?
< 6.5% (48mmol)
135
What is the blood glucose target for type 2 diabetics controlled with diet or monotherapy?
< 6.5% (48mmol)
136
What is the blood glucose target for type 2 diabetics controlled with monotherapy with a hypoglycaemic drug or combo therapy?
< 7% (53mmol)
137
When does diabetic treatment need to be stepped up?
When blood glucose >7.5% (58mmol)
138
Which anti diabetic medications can cause weight gain?
Pioglitazone
Sulphonylureas
139
Which anti diabetic medications can cause weight loss?
“The GLs”
SGLT2
GLP1
140
Which anti diabetic medications can cause pancreatitis?
“The ones with P (except pioglitazone)”
DPP4
GLP1
141
Which anti diabetic medications are cardio protective?
SGLTs - Canagliflozin and empagliflozin
142
Risk factors for osteoporosis?
Menopause
50+ men
Prolonged steroid use
Elderly
Low BMI
Smoking
Diabetes
Rheumatoid arthritis
Low vit D/C levels
143
First line treatment of osteoporosis?
Bisphosphonates e.g. alendeonic acid, risendronate, Ibadronic (IV or PO), Zolendronic acid (IV, most potent)
Also used for prophylaxis in LT glucocorticoid Tx
144
What dose of glucocorticoids are considered a high risk for osteoporosis?
7.5mg + of prednisolone
145
What is the alternative option for menopausal women at high risk of osteoporosis?
HRT if < 60 years old and has menopausal symptoms
146
Which bisphosphonates can be given for 5 years before needing to be reviewed?
Alendronic acid and risendronate
147
Alendronic acid counselling?
Take 30mins before food
Swallow whole with plenty of water while sitting upright or standing
Stand or sit upright for another 30mins
148
Alendronic acid dose?
10mg OD (can give 70mg once weekly for women)
149
MHRA alerts for bisphosphonates?
Atypical femoral fractures
Osteonecrosis of the jaw
Osteonecrosis of the external auditory canal
150
Risedronate dose?
Women = 5mg OD (can give 35mg weekly)
Men = 35mg weekly
151
Risedronate counselling?
Do not have food, drink, calcium products, antacids, iron or minerals 2 hours before or after taking.
Stand or sit upright for 30mins after taking each dose
152
What is menopause?
A decrease in oestrogen levels in ages 45-55
153
What is vaginal atrophy?
Vaginal dryness
154
Treatment of vaginal atrophy?
Topical oestrogens (creams, tablets, rings)
155
What are the vasomotor symptoms of menopause?
Hot flushes and night sweats
156
Treatment of vasomotor symptoms in menopause?
Systemic oestrogens or Tibolone tablets or patches (when the patient has an intact uterus to avoid endometrial cancer)
157
Patient counselling for topical oestrogen patches?
Apply below the waistline as oestrogens can cause breast cancer
158
What is the mechanism of action of tibolone?
Oestrogenic, prostogenic and weak androgenic activity
159
What is HRT?
Oestrogen replacement given continuously
160
What is combined HRT E.g. Tibolone?
The addition of progestogen for women with an intact uterus to help prevent endometrial cancer caused by oestrogens alone
161
Is progestogen given continuously or cyclically?
Either
Cyclically lasts 12-14 days of cycle
Continuous avoids withdrawal bleeding (if bleeding occurs rule out endometrial cancer)
162
When can continuous combined HRT not be given?
Peri-menopausal women or women who have had a period in the last 12 months
163
What could bleeding during continuous combined HRT a sign of?
Endometrial cancer
164
HRT side effects?
Breast, cervical, ovarian cancer
VTE
CVD - CI in angina or MI
165
Reasons to stop HRT?
VTE (including both PE and DVT)?
Stroke?
Liver dysfunction?
BP > 160/90
166
How long before major surgery should HRT be stopped?
4-6 weeks before
167
What can be offered if HRT can not be stopped in time before surgery?
Anticoagulant + stockings
168
Does HRT provide contraception?
No
169
How long after their last period is a woman under 50 fertile for?
2 years
170
How long after their last period is a woman over 50 fertile for?
1 year
171
What form of contraception should a woman on HRT who is under 50 use?
Low oestrogen COC if VTE risk free
172
What form of contraception should a woman on HRT who is over 50 use?
Condoms
173
What is clomifene used for?
Infertility treatment in women
174
Side effects of clomifene?
Ovarian cancer (max use = 6 cycles)
Multiple pregnancies in one go E.g. triplets
175
Symptoms of hyperthyroidism?
Heat intolerance
Weight loss
Tachycardia
Diarrhoea
Bulging eyes
Lump on the front of the neck
176
Lab test results for hyperthyroidism?
Low TSH
High T3
High T4
177
Treatment of hyperthyroidism?
Carbimazole / propylthiouracil
178
Side effects of carbimazole?
Acute pancreatitis
Bone marrow suppression (agranulocytosis and neutropenia) - report signs of infection
Rashes / itching - give antihistamine or switch
Teratogenic
179
Propylthiouracil side effects?
Hepatotoxicity - discontinue if ALT/AST 3x normal range
180
Which thyroid reducing drug should be used during pregnancy?
Propylthiouracil for 1st trimester
Then switch to carbimazole in the 2nd trimester
181
Hypothyroidism symptoms?
Cold intolerance
Weight gain
Constipation
Bradycardia
Depression
Loss of eyebrows
182
Lab test results that suggest hypothyroidism?
High TSH
Low T3
Low T4
183
Which drugs commonly cause hypothyroidism?
Amiodarone (can cause hypo/hyper) and Lithium
184
Treatment of hypothyroidism?
Levothyroxine or Liothyronine
185
Patient counselling for levothyroxine?
Take OM 30mins before food of caffeine contains drinks or medications. If other meds needed before food space out by 2 hours
186
Side effects of levothyroxine?
Increase thyroid levels which in turn increases blood glucose therefore cautioned in diabetes. Also cautioned in CVD due to hyperthyroidism related heart activity.
187
What dose of levothyroxine should be questioned?
>200micrograms
188
Is liothyronine brand specific?
Yes
189
What dose of insulin lantus would be equivalent to insulin toujeo?
Lantus dose = 80% of toujeo dose
190
What is grave’s disease?
Autoimmune disorder causing hyperthyroidism
191
Treatment of grave’s disease?
Radioactive iodine = 1st line
