Endocrine Flashcards
Questions from endocrine chapter
1
Q
How often should insulin-dependent diabetics check their blood glucose levels whilst driving?
A
2 hours before driving and every 2 hours whilst driving. A fast-acting carbohydrate snack should be available inside the cars and levels should be >5
2
Q
‘Alcohol can mask hypos and cause delayed hypos’
True or false?
A
True
Diabetics should only drink with food + in moderation
3
Q
How does metformin work?
A
- Decreases hepatic gluconeogenesis
- Increases peripheral glucose uptake
- Delays intestinal glucose absorption
4
Q
Which oral antidiabetic drug is first line for all patients?
A
Metformin
5
Q
‘Metformin is associated with weight gain’
True or False?
A
False - it has a positive effect on weight loss
6
Q
Can metformin cause hypos?
A
No - causes normoglycaemia not hypoglycaemia. Does not stimulate insulin secretion so does not cause hypos
7
Q
What is the most common side effect of metformin?
A
GI disturbances
8
Q
What are risk factors for lactic acidosis in patients taking metformin?
A
- Heart failure
- Sepsis
- Renal failure (accumulation)
9
Q
What are the monitoring requirements for metformin?
A
- Renal function before treatment and at least annually
- HbA1c
10
Q
‘Lactic acidosis is rare when metformin is used as labelled but can occur in overdose’
True or false?
A
True
11
Q
At what eGFR should metformin be avoided?
A
Less than 30ml/min
12
Q
What is the maximum dose of metformin?
A
2g daily (SPC states 3g)
13
Q
How would you manage a patient with an eGFR of 33ml/min who is on metformin?
A
Reduce dose to 25% and maximum 1 g per day
14
Q
What is the renal dosing for metformin?
A
<30 ml/min - avoid
30-45ml/min - reduce to 25%, max 1g
45-59ml/min - reduce to 25-50%, max 2g
15
Q
Why should metformin be stopped before surgery and when should it be restarted?
A
- General anaesthetic can cause ketoacidosis, suspend morning of surgery
- Restart when renal function returns to baseline
16
Q
How would you manage a patient on metformin who requires an x-ray?
A
Iodinated contrast agents can cause renal failure and lactic acidosis.
Suspend metformin prior to x-ray and restart in 48 hours if renal function returns to baseline
17
Q
Name some sulphonylureas?
A
Gliclazide, glibenclamide, glipizide, glimepiride, tolbutamide
18
Q
How do sulphonylureas work?
A
Stimulate insulin secretion from beta cells in the islets of Langerhans. Only effective if some residual beta cell activity
19
Q
‘Sulphonylureas can cause weight gain’
True or false?
A
True - should not be recommended to overweight/obese patients
20
Q
Name a short-acting sulphonylurea
A
Gliclazide, tolbutamide
21
Q
Name a long-acting sulphonylurea
A
Glibenclamide, chlorpropamide
22
Q
Why are short acting sulphonylureas preferred to long acting ones?
A
Long acting sulphonylureas eg, glibenclamide are associated with severe prolonged/fatal episodes of hypoglycaemia
23
Q
Should sulphonylureas be taken with food?
A
Yes
24
Q
‘Gliclazide can commonly cause hypoglycaemia’
True or false
A
True- all sulphonylureas are associated with hypoglycaemia
25
Which class of antidiabetics are associated with blood disorders and agranulocytosis?
Sulphonylureas
26
Allergic skin reactions may occur in the fist 6-8 weeks of treatment with which antidiabetic class?
Sulphonylureas
27
'Sulphonylureas are principally renally metabolised'
| True or false?
False - they are metabolised in the liver mainly
Should be used with caution in renal impairment due to risk of hypos
Should be avoided in hepatic impairment and can cause hepatic disorders and choleostatic jaundice
28
Name 3 drugs that can interact with sulphonylureas?
- Chloramphenicol
- Miconazole / voriconazole
- Sulphonamides
29
'Blood dyscrasias are a common side effect of sulphonylureas'
True or False
False- they are a rare side effect.
30
Why should gliclazide be used with caution in the elderly?
Sulphonylurea - risk of hypos
31
How does pioglitazone work?
Reduces peripheral insulin resistance
32
What are some common side effects of pioglitazone?
GI upset, weight gain, oedema, hypos, anaemia, visual disturbances, increased infection risk
33
Pioglitazone should be discontinued if signs of liver dysfunction occurs, what are some of the signs?
Dark urine, jaundice, fatigue, severe GI upset
34
What is the dose for Pioglitazone?
15-45mg per day taken with or without food
35
Can pioglitazone affect blood pressure?
It may lower blood pressure and improve lipid metabolism
36
What are the 2 MHRA warnings surrounding pioglitazone?
1. Cardiovascular safety, risk of HF when used with insulin
| 2. Risk of bladder cancer
37
Pioglitazone should be monitored for signs of heart failure and it should be discontinued if there is deterioration in cardiac status, what are some signs of this?
Shortness of breath, oedema, fatigue, irregular heartbeat
38
What are some contra-indications for pioglitazone?
- Heart failure
- Previous/active bladder cancer
- Uninvestigated macroscopic haematuria
39
Why should pioglitazone be used with caution in the elderly?
Increased risk of heart failure and bladder cancer
40
'Pioglitazone can increase risk of bone fractures'
| True or false?
True, particularly in women
41
What can increase your risk of bladder cancer?
Smoking, age, previous exposure to agents such as radiation
42
How should pioglitazone be monitored?
Review efficacy after 3-6 months and stop if no response.
| Monitor LFTs and cardiac status
43
Which symptoms should patients taking pioglitazone be counselled to report as they may be signs of bladder cancer?
Haematuria, dysuria or urinary urgency
44
'Pioglitazone requires a dose adjustment in renal insufficiency'
True or false?
False -it is mainly hepatically cleared
45
Name some DPP-4 inhibitors?
Sitagliptin, saxagliptin, linagliptin, alogliptin, vildagliptin
46
How do DPP-4 inhibitors work?
Inhibits DPP-4 enzyme that breaks down incretins. Incretins trigger insulin secretion and reduce glucagon secretion
47
Which is the only DPP-4 inhibitor NOT licensed as monotherapy?
Alogliptin
| The rest can all be used as monotherapy
48
'Gliptins are more likely to cause hypos than sulphonylureas'
True or false?
False - gliptins can cause hypos but this has less incidence than with sulphonylureas
49
How would you manage a patient taking sitagliptin who presents with severe abdo pain and vomiting?
Potentially pancreatitis, discontinue treatment
50
Name some side effects of DPP-4 inhibitors?
Headache, GI upset, URTI, periperal oedema
51
Which is the only DPP-4 inhibitor that does NOT require a dose reduction in renal impairment?
Linagliptin - always 5mg OD
| The rest should all be reduced
52
Can gliptins cause liver toxicity?
Yes- should be discontinued if symptoms of liver dysfunction occur
Dark urine, jaundice, fatigue, severe GI upset
53
Name some SGLT-2 inhibitors?
Canagliflozin, dapagliflozin, empagliflozin
54
How do SGLT-2 inhibitors work?
Inhibit sodium-glucose co-transporter 2 (SGLT2) in the renal proximal convoluted tubule to reduce glucose reabsorption and increase urinary glucose excretion
55
Why are UTIs common with SGLT2 use?
More glucose excreted in urine = more infections
56
Do SGLT2 inhibitors have to be taken with food?
No, taken once a day with or without food
57
What are some common side effects of SGLT2 inhibitors?
Constipation, thirst, polyuria, nausea, UTIs, hypos
58
Which class of anti-diabetics are associated with hypovolaemia?
SGLT2 inhibitors
Correct prior to treatment and look for signs such as dizziness or postural hypotension.
Risk higher in elderly, pts on anti-hypertensives, cardiovascular disease and GI illness
59
What MHRA warning is in place for all SGLT2 inhibitors?
Risk of diabetic ketoacidosis - potentiall life-threatening DKAs
60
What are the symptoms of DKA which patients takign SGLT2 inhibitors should be counselled to recognise?
N+V, rapid weight loss, abdo pain, fast/deep breathing, fruity smelling breath/urine, sweet taste in mouth
61
Which MHRA warning is in place for canagliflozin?
Increased risk of lower limb amputation (mainly toes)
| Patients should practice foot care, stay hydrated and report any ulceration, discolouration or new pain
62
Which monitoring is needed for canagliflozin following the MHRA warning?
Should be stopped if pt develops a significant lower limb complication
Patient should be monitored for risk factors for amputation eg, previous amputations/peripheral vascular disease
63
What is the min eGFR for initiation of an SGLT2 inhibitor?
60ml/min
Do not initiate if eGFR below this.
For patients already on treatment avoid if eGFR <45ml/min
64
Name some GLP receptor agonists?
Liraglutide, Exenatide, albiglutide, dulaglutide
65
How to GLP receptor agonists work?
Bind to glucagon-like receptors and mimic normal incretins. Cause increased insulin secretion and slow gastric emptying
66
How are GLP receptor agonists given?
As a S/C injection usually weekly
67
Name some side effects of GLP receptor agonists?
Weight loss, GI upset, headache, pancreatitis
68
Which GLP receptor agonist can be associated with severe pancreatitis?
Exenatide.
| Can be fatal, seek prompt medical attention if symptoms such as N+V or severe abdo pain develop
69
When should a missed dose of GLP receptor agonist be given?
Usually give missed dose if there are >3 days until next scheduled dose
NEVER give after a meal (one hour before)
Exenatide - leave missed dose
70
How are GLP receptor agonists usually stored?
Fridge
71
What is a contraindication for GLP receptor agonists?
Severe GI disease
72
What is the renal dosing for GLP receptor agonists?
Exentaide avoid <30ml/min (MR <50)
| Liraglutide avoid <30ml/min
73
What is the place in therapy for GLP receptor agonists?
Reserved for combination therapy where other treatment options have failed
74
Name some meglitinides?
Nateglinide, repaglinide
75
How do meglitinides work?
Stimulate insulin secretion, similar to sulphonylureas
76
'Meglitinides have a long duration of action'
| True or false?
False - have a short duration of action and rapid onset
| Should be taken up to TDS 30mins before meals to limit post-meal glucose spikes
77
What are some side effects of meglitinides?
Diarrhoea, hypos, abdo pain, skin reactions
78
What advice should be given to drivers taking meglitinides?
Risk of hypos
79
Meglitinides should be used with caution in which patients?
- Elderly
- Malnourished
- Debilitated
- Contraindicated in ketoacidosis
80
'Meglitinides should be avoided in severe hepatic impairment'
True or false?
True
81
What are the symptoms of hypoglycaemia?
Pale skin, sweating, tremor, tachycardia, confusion, aggression, fits, impaired consciousness
82
How should hypos be treated?
1. oral glucose/sugar followed by carbohydrate snack
2. IV dextrose
3. IM glucagon
83
Which of these would NOT be considered a cause of hypoglycaemia?
- stress
- alcohol
- excessive exercise
- smoking
- delayed meal
Smoking
84
What is the recommended target HbA1c for Type 1 diabetics?
48mmol/mol
85
How often should type 1 diabetics measure their blood glucose per day?
4 times including before meals and before bed
86
What level should blood glucose be for a diabetic who is driving?
5mmol/L
87
What is the 'multiple daily injections basal-bolus regime'?
One or more daily injections of intermediate/long acting insulin with multiple (usually 3) bolus short acting insulins before meals.
Can be tailored to carb load
88
What is the 'mixed/biphasic regime'?
1, 2 or 3 injections per day of short acting insulin mixed with intermediate-acting insulin.
89
Which types of patients may be suitable for an insulin pump (constant subcut infusion)?
Patients with disabling hypos or poorly controlled diabetes with a high HbA1c (>69mmol/mol)
90
Which insuline regime is considered first line treatment and why?
Multiple injection basal-bolus regime
| As this most closely mimics the natural profile of insulin secretion
91
Which insulin is recommended to be used as basal therapy?
Detemir (Levemir) twice daily
| If not tolerated, glargine (Lantus/toujeo/Absalgar) once daily
92
Which insulin therapy is recommended to be used as bolus therapy?
Rapid acting insulin injected before meals
93
Which may INCREASE insulin requirements?
- Stress
- HTN
- Exercise
- Infection
STRESS AND INFECTION
Exercise may decrease insulin requirements
94
Which may DECREASE insulin requirements?
- Fatigue
- Impaired renal function
- Trauma
- Smoking
Impaired renal function
Trauma may increase insulin req.
95
Which class of drugs should never be used in diabetics as they can mask symptoms of a hypo such as tremor?
Beta-blockers
96
Which of these is NOT a sign of hypoglycaemia?
- Sweating
- Aggression
- Rapid heart rate
- Abdominal pain
- Confusion
Abdominal pain
97
Which of these is NOT a sign of DKA?
- Rapid breathing
- Confusion
- Abdominal pain
- Chest pain
- Sweet smelling breath and urine
Chest pain
98
Why do insulins have to be injected?
They are inactivated by GI enzymes
99
What actions can be taken to avoid lipohypertrophy from injecting insulin?
- Change injection site
| - Inject into areas with lots of subcut fat such as abdomen or inner thighs
100
What type of insulin is 'soluble insulin'
Short acting
101
Name some short acting insulins?
Humulin S, Actrapid, Insuman rapid, Hypurin neutral
102
How should short acting insulins be used?
Should be injected 15-30 minutes before meals
| Onset of action take 30-60 minutes
103
Name some rapid-acting insulins?
Aspart (Novorapid), Lispro (Humalog), Apidra (Glulisine)
104
How should rapid-acting insulins be used?
Should be injected immediately before meals.
| Can be administered after meals but this should be avoided as this is associate with poor control
105
What is the difference between 'short-acting' and 'rapid-acting' insulin?
- Short acting has an onset of action of 30-60 mins and a duration of 5-8 hours
- Rapid acting has an onset of 5-15 mins and a duration of 2-5 hours
- Hypos are less likely with rapid-acting
- Short acting should be given 15-30 mins before meals, rapid acting can be given immediately before/with meals
106
Name some intermediate acting insulins?
Humulin I, Insulatard, Insuman basal, Hypurin isophane
107
How should intermediate-acting insulins be used?
- Usually injected twice a day
- Mimic human basal insulin
- Onset of 2-4 hours, duration of 16 hours
108
Name some long-acting insulins?
Detemir (Levemir), Glargine (Lantus/Abasalgar/Toujeo), Degludec (Tresiba)
109
How do long-acting insulins work?
- Usually injected once a day (levemir is BD)
- Onset after 6 hours, duration of 36hours
- Reach steady state in 2-4 days
110
Name some biphasic insulins?
Novomix 30, Humulin M, Humalog Mix, Insuman Comb
111
How do biphasic insulins work?
Mixture of short and long acting insulins.
Offer dual release insulin profiles from one injection
% of short acting varies from 15-50
Usually used BD before meals
112
What is the MHRA warning associated with insulin?
Insulin should NEVER be withdrawn from pen devices.
| Risk of overdose/death
113
How can ACEis interact with insulins?
ACEis can potentiate the hypoglycaemic effect of insulin and oral anti-diabetic drugs. Increased risk of hypos especially on initiation of treatment
114
What is the 'once daily' insulin regime?
- One intermediate/long acting injection given at breakfast or bedtime
- Often used in combo with oral therapies
- Can be sufficient for elderly T2DM or obese T2DM uncontrolled on max dose of oral therapies
115
What is vasopressin?
Anti-diuretic hormone
| Associated with water regulation in the body
116
What are the symptoms of diabetes insipidus?
Occurs when ADH fails to regulate water levels
Polyuria and polydipsia
Can be caused by pituitary gland or kidneys
117
How is desmopressin dosed?
To give slight diuresis every 24 hours
118
Why is desmopressin contra indicated in hyponatraemia?
Risk of hyponatraemic convulsions
| The risk can be minimised by avoiding fluid overload and stopping desmopressin treatment during vomiting/diarrhoea
119
Which drug does NOT increase secretion of vasopressin (ADH)?
- Nicotine
- Paracetamol
- Senna
- Tricyclic antidepressants
Senna
120
Why should patients taking corticosteroids report any vision changes such as blurring?
MHRA warning - risk of chorioretinopathy with local and systemic corticosteroid treatment.
Refer to opthamologist
121
Which corticosteroid has the highest mineralcorticoid activity?
Fludrocortisone
122
Which is NOT a mineralcorticoid side effect?
- Sodium retention
- Potassium loss
- Calcium loss
- Hypotension
Hypotension
Minercorticoid side effects include HYPER tension
123
Name some glucocorticoid side effects?
- Diabetes
- Osteoporosis
- Muscle wasting
- Peptic ulcer formation
- Weight gain
- Psychiatric reactions
- Cushings syndrome (moon face, acne)
124
Which corticosteroids have high glucocorticoid activity?
Betamthasone and dexamethasone
125
Which is equivalent to 5mg prednisolone?
- 750mg betemethasone
- 0.5mg prednisone
- 4mg methylprednisolone
- 7mcg dexamethasone
4mg methylprednisolone
126
Why are corticosteroids given as a single dose in the morning?
This is where least cortisol suppression occurs
| Suppressive action of glucocorticoids is greater and more prolonged when given at night
127
'Growth restriction can occur in children taking inhaled corticosteroids regularly'
True or false
False
| Growth restriction occurs with systemic glucocorticoid therapy
128
What advice should be given to children under 15 taking inhaled steroids?
Use a large volume spacer device to increase airway deposition and reduce oropharyngeal deposition
129
'Hydrocortisone has high mineralcorticoid activity'
| True or false?
True - causes fluid retention making it unsuitable for long term disease suppression
130
'Prednisolone has predominantly mineralcorticoid activity'
| True or False?
False - it has mainly glucocorticoid activity
131
Name some features of glucocorticoids?
- Affect carbohydrate, fat and protein metabolism
- Have anti-inflammatory, immunosuppressive and anti-proliferative action
- Have vasoconstictive effects
132
Abrupt withdrawal of corticosteroids can lead to acute adrenal insufficiency. What are the signs of this?
Fever, N+V, weight loss, fatigue, headache, muscle weakness, myalgia
- can lead to hypotension and death
133
'Prolonged courses of corticosteroids can lead to increased susceptibility to infections'
True or false?
True - clinical presentations of infections may also be atypical or at an advanced stage
134
Which infectious diseases should patients taking corticosteroids take care to avoid if they are not immune?
Chickenpox, shingles and measles
135
Which psychiatric reactions are associated with corticosteroids?
Insomnia, depression, suicidal thoughts, psychotic reactions, behavioural disturbances
- medical advice should be sought if worrying changes occur (especially depression or suicidal thoughts)
136
Should corticosteroids be used in pregnancy?
Yes, if they are needed the benefits outweigh the risks
As prednisolone crosses the placenta 88% is inactivated
Women should be monitored for fluid retention and steroid cover is needed in labour
137
What are the monitoring requirements for corticosteroids?
- Blood pressure (risk of HTN)
- Blood lipids
- Serum K+ (risk of hypokalaemia)
- Height and weight in children (can slow growth)
- Bone mineral density (osteoporosis)
- Blood glucose (impaired diabetic control)
- Eye exam (retinopathy/cataracts/inc pressure)
- Signs of adrenal suppression
138
In which circumstances should prednisolone be gradually withdrawn?
- Received 40mg/day of more for over a week
- Had repeat evening doses
- Over 3 weeks of treatment
- Recently received repeat courses (esp if over 3 weeks)
- Had a short course within one year of stopping long term treatment
139
Which patient would need a reducing course?
1. Mrs A received 30mg OM of prednisolone for 5 days
2. Miss C, 3 year old weighing 10kg who received 10mg prednisolone/day for 2 weeks
3. Mr K received 20mg of prednisolone for 4 weeks
3. Mr K
As treatment longer than 3 weeks
For children, >2mg/kg/day for over a week
140
'Corticosteroids can enhance the anticoagulation effect of warfarin'
True or false?
True
141
Why should corticosteroids not be given with NSAIDs?
NSAIDs can mask the GI side effects of corticosteroids
Gastroprotection should be considered
142
Which is not a risk factor for osteoporosis?
- Lack of physical activity
- Smoking
- Anaemia
- High alcohol intake
- Vitamin D deficiency
Anaemia
143
How to bisphosphonates work?
They are adsorbed onto bone crystals and reduce the rate of bone turnover
144
What are the 3 MHRA warnings relating to bisphosphonates?
- Reports of atypical femoral fractures
report thigh, groin or hip pain
- Osteonecrosis of the jaw
good oral hygiene and report oral symptoms
- Osteonecrosis of external auditory canal
report any ear pain, discharge or infection
145
At what point should treatment with oral bisphosphonates be reviewed?
After 5 years
| Some evidence to show benefit from bisphosphonate-free period and therapeutic effects last after treatment cessation
146
What is a contra indication for alendronic acid and risedronate sodium?
Hypocalcaemia
| Correct before treatment
147
Why should patients taking alendronic acid report any dysphagia?
Risk of severe oesophageal reactions
148
How should a patient starting alendronic acid be counselled?
- Swallow whole with a full glass of water
- Sit up straight or stand for 30 mins after taking
- Take on an empty stomach 30 mins before any food/drinks/medicines
149
Which is a side effect of Alendronic acid?
- Hypercalcaemia
- Hyperkalaemia
- Hypocalcaemia
- Hypokalaemia
- Hyponatraemia
HYPOCALCAEMIA
