Endocrine System Flashcards
(170 cards)
1
Q
Define diabetes insipidus?
A
Large amounts of dilute urine produced which causes extreme thirst
2
Q
State the two drugs used to treat pituitary diabetes insipidus?
A
Vasopressin and desmopressin - to produce slight diuresis in 24 hours to avoid water intoxication
3
Q
Why is desmopressin preferred?
A
Long acting, more potent and has no vasoconstrictor effect
4
Q
What drug is used in the differential diagnosis of diabetes insipidus?
A
Desmopressin
5
Q
What drug is used in partial pituitary diabetes insipidus?
A
Carbamazepine but is unlicensed - sensitises the renal tubules to remaining endogenous vasopressin
6
Q
Which two drugs treat hyponatraemia?
A
Demeclocycline and tolvaptan
7
Q
How does demeclocycline work?
A
Blocks renal tubular effect of ADH
8
Q
How does tolvaptan work?
A
Vasopressin v2-receptor antagonist
9
Q
State a side effect of tolvaptan?
A
Rapid correction of hyponatraemia can cause osmotic demyelination, leading to serious neurological events
10
Q
State a side effect of desmopressin?
A
Hyponatraemic convulsions
11
Q
State one interaction with desmopressin?
A
With TCAS – increases risk of hyponatraemia
12
Q
State one counselling point with desmopressin?
A
Stop taking medicine whilst episode of vomiting / diarrhoea
13
Q
What is osteoporosis?
A
Low bone mass measured by BMD. SEVERE if one or more fragility fractures. Most common in postmenopausal women over 50 years old and patients taking long term corticosteroids.
14
Q
What is the tx of postmenopausal osteoporosis?
A
Oral bisphosphonates are first line due to their broad spec anti-fracture ability.
15
Q
Who should be considered for bone protection tx with oral corticosteroids?
A
Women over 70 or with previous fragility fracture or taking high doses of gluccocorticoids (>7.5mg/day). men aged 70+ with same criteria.
16
Q
When should bisphosphonate tx be reviewed?
A
After 5 years, 3 years with zolendronic acid
17
Q
How do bisphosphonates work?
A
adsorbed onto bone, slowing growth and dissolution, slowing rate of bone turnover
18
Q
What is the MHRA safety alert for bisphosphonates?
A
Femoral fractures associated with bisphosphonate tx. re evaluate after 5 years. report any hip or groin pain during tx. risk of osteonecrosis of the jaw. higher risk in iv doses in cancer patients. osteonecrosis of auditory canal
19
Q
What is the patient/carer advice for bisphosphonates?
A
Severe oesaphageal reactions can occur, advise patients to stop taking the tablets if they develop symptoms of oesaphageal irritation such as dyspepsia, nausea, heartburn. Take dose with plenty of water whilst sitting or standing, on an empty stomach at least 30 minutes before breakfast or any other oral medicines and remain upright for 30 mins post dose.
20
Q
What is the important safety information for denosumab?
A
- atypical fractures in long term tx
- osteonecrosis of the jaw and hypocalcaemia
- dental exam pre start
- inform patients on the risk
- risk of hypocalcaemia increased in renal failure
- plasma calcium monitoring is recommended
21
Q
State a MHRA side effect of corticosteroids use?
A
Central serious chorioretinopathy – retinal disorder. Patients should report any blurred vision or other visual disturbances. Consider referral to opthamologist.
22
Q
What are the mineralocorticoid side effects?
A
Potassium and calcium loss – sodium and water retention – hypertension
23
Q
What are mineral corticosteroids most marked in?
A
Most marked in fludrocortisone
Significant with hydrocortisone, corticotrophin and tetracosacitide
24
Q
What are the glucocorticoid side effects?
A
Diabetes, osteoporosis, muscle wasting, avascular necrosis, peptic ulceration and psychiatric reactions
25
What are glucocorticoids most marked in?
Betamethasone, dexamethasone and Hydrocortisone
26
How can you minimise the side effects of corticosteroids?
- lowest effective dose for the minimum period of time
- suppressive act on cortisol secretion is least when given as a single dose in the morning
- reduce pituatry adrenal suppression by giving combined dose 2 days at a time
-
27
State the conditions a patient can develop after taking prolonged use of corticosteroids?
Increased risk of infections
Increased risk of chicken pox
Increased risk of measles
Increased risk of psychiatric reactions Glaucoma, cataracts
Purple stretch marks
Growth restriction in children Hypertension
diabetes
High doses cause Cushing syndrome – moon face, strae, acne
28
What is adrenal insufficiency?
Inadequate production of steroid hormones in the adrenal cortex. symptoms are mild and non-specific. Can be caused from systemic corticosteroid use. If stopped or decreased too quickly after prolonged use.
29
What are the symptoms of adrenal crisis?
Severe dehydration, hypotension, stroke, seizures, cardiac arrest
30
Who needs a steroid emergency card?
Patients with adrenal insufficiency and steroid dependance at risk of adrenal crisis
31
What is the management of adrenal insufficiency?
Physiological gluccocorticoid replacement with hydrocortisone, presnisolone or dexamethasone. With primary adrenal insufficiency, may need fludrocortisone.
32
Discuss gluccocorticoid replacement during stress
Prevent adrenal crisis during stress. Sick day rules should be followed, daily dose doubled. If on long acting hydrocortisone, switch to short acting. If severe illness eg vomitting, then give iv steroids.
33
Discuss the tx of adrenal crisis
Medical emergency. Hydrocortisone and rehydration using nacl.
34
What should be monitored in children on long term steroids
Height and weight
35
How should steroids be withdrawn?
Gradual withdrawal if:
- received >40mg prednisolone daily for more than one week
- been given repeat doses at night
- received more than 3 weeks tx
- recently received repeated courses
- taken a short course within one year of stopping therapy
36
What is Cushing’s syndrome?
Too much cortisol in body
37
What are symptoms of cushing’s syndrome?
Increased fat on chest and tummy
Build-up of fat on neck
Red, puffy, rounded moon face,
Purple stretch marks Low libido
38
Which two drugs are used in cushing’s syndrome?
Ketoconazole and metyrapone
39
State the symptoms of adrenal insufficiency?
Fatigue, anorexia, vomiting, hypotension, hypoglycaemia, hyponatraemia, hyperkalaemia
40
State advice for ketoconazole?
Know signs of liver toxicity
Nausea, vomiting, jaundice, abdominal pain, dark urine, anorexia
can increase warfarin conc in blood
can cause adrenal insufficiency
41
State DVLA advice for patients taking insulin:
Check blood glucose no more than 2 hours before driving and every 2 hours while driving Blood glucose should always be above 5mmol/L
If it falls to 5 or below, a snack should be taken
If it falls below 4 mmol/L the driver should stop driving.
Have a sugary drink or snack + wait 45 mins before continuing the journey
42
What can mask symptoms of hypoglycaemia:
Alcohol
43
What is pre diabetic:
42-47 mmol (6%)
44
What is defined as having diabetes:
Over 48 mmol (6.5%)
45
Who is hba1c not suitable for?
type 1 diabetes, children, during pregnancy, women post partum.
46
What are the typical features of type 1 diabetes?
- hyperglycaemia
- ketosis
- rapid weight loss
-low bmi
-younger than 50
47
What is the target hba1c in t1dm
48mmol or lower
48
Discuss blood glucose monitoring in t1dm
Measured at least four times a day, before each meal and before bed
49
What is the target fbg for t1dm
5-7mmol/l
50
What is the target pre prandial bg in t1dm?
4-7mmol/L
51
What is the target post prandial bg reading for t1dm?
5-9mmol/l 90 minutes after eating
52
Discuss multiple daily dosing basal-bolus insulin injections
one or more separate injections of intermediate acting or long acting as basal, alongside multiple bolus injections of short acting insulin before meals. Helps tailor according to carb content of meals
53
Discuss the mixed biphasic insulin regimen
One - three injections per day of short acting mixed with intermediate acting insulin
54
Discuss insulin pumps
Regular/continuous amount of insulin delivered by a programmable pump
55
What is the first line insulin regimen for type 1 diabetes?
multiple daily dosing, basal-bolus injections
56
Which basal insulins are given only once daily?
Insulin glargine
insulin degludec if concerns of nocturnal hypo
57
What can blunt hypoglycaemic awareness?
beta blockers, reducing warning signs such as tremor
58
Discuss the administration of insulin
Inactivated by gi enzymes, so given by injection. Injected into an area with plenty of subcutaneous fat
59
What can occur if insulin is routinely injected at the same site?
Lipohypertrophy, which can cause erratic absorption of insulins. Rotate injection sites and check areas for swelling routinely.
60
Discuss and give examples of short acting insulins
Short duration and rapid onset of action, replicate insulin produced in response to meals. Insulin aspart, insulin glulisine and insulin lispro.
61
Which branded insulins are short acting?
fiasp novorapid (aspart), glulisine, humalog (lispro)
62
What is adminstered in diabetic emergencies?
Soluble insulin
63
Discuss intermediate acting insulins
Mimic endogenous basal insulin
64
What are examples of intermediate insulin?
Biphasic (humulin m3), isophane (humulin I, insulatard), biphasic aspart (novomix), biphasic lispro (humalog), degludec (tresiba), insulin degludec with liraglutide, glargine (lantus, asbasgular, semglee, toujeo)
65
What are examples of intermediate insulin?
Biphasic (humulin m3), isophane (humulin I, insulatard), biphasic aspart (novomix), biphasic lispro (humalog)
66
What are examples of long acting insulin?
Degludec (tresiba), glargine (abasgular, lantus, semglee, toujeo)
67
Discuss the use of metformin in t2dm
Anti hyperglycaemic effect, lowering both basal and post-prandial bg conc, does not stimulate insulin secretion, and therefore does not cause hypo. Given gradually to prevent gi side effects, then offer mr if not tolerated
68
Disucss the use of sulfonylureas
Can cause hypos, gliblencamide in particular as long acting. Associated with modest weight gain
69
What is the target hba1c in patients with a drug with risk of hypo/on two or more antidiabetic drugs
53 mmol/l
70
All sulphonylureas cause hypoglycaemia but which one is associated with severe, prolonged fatal cases:
Glibenclamide
71
State one common side effect of sulphonylurea:
Modest weight gain
72
State DPP4:
Gliptins
Less incidence of hypoglycaemia and no weight gain
73
State SGL2:
Flozins
Canagliflozin and empaglifozin can be beneficial in patients with diabetes + established heaert disease
Flozins are at an increased risk of diabetic ketoacidosis
74
Which GLP1 agonist is has proven cardiovascular benefit in patients with diabetes and established CVD:
Liraglutide
75
Which antidiabetic medicine can be used for polycystic ovary syndrome:
Metformin – can improve weight gain, acne, hirsutism, regulation of menstrual cycle. 500mg once daily
76
State target hba1c conc when diabetes is managed by diet and lifestyle alone:
48 mmol – 6.5%
77
State target hba1c conc if a single sulphonyurea is used OR two or antidiabetic drugs used:
53 mmol – 7.0%
78
State initial treatment of diabetes:
1. Metformin (dose should be increased gradually to minimise risks of GI effects. If GI effects noticed then give M/R metformin
2. Metformin + sulphonylurea OR pioglitazone OR DPP4 or SGLT2
3. Metformin + sulphonylurea + DPP4 or Metformin + sulphonylurea + pioglitazone
79
State tx for diabetes in chronic heart failure or established cvd/ qrisk score of 2+
metformin, then once tolerability confirmed offer sglt2 inhibitor (flozin)
80
Which sulphonlyurea is indicated in elderly patients or those with renal impairment:
Short acting sulphonylurea – gliclazide / tolbutamide
81
Triple therapy with metformin + sulphonlyurea + GLP1A:
Only prescribed with BMI over 35 kg/m2
82
GLP1A:
After 6 months, drug should only be continued if 11mmol/ 1% in HBA1C and 3% of weight loss of initial body weight
83
State treatment of diabetic nephropathy:
ACE or ARB. Blood pressure should be reduced to lowest achievable level to slow the decline in glomerular filtration rate and reduce proteinuria. ACE inhibitors can potentiate the hypo effects of insulin, usually in first few weeks of tx and in renal impairment
84
State treatment of painful diabetic peripheral neuropathy:
1. Amitriptyline, imipramine, duloxetine, venlafaxine
2. Pregabalin, gabapentin
85
State treatment of diabetic diarrhoea in patients with autonomic neuropathy:
1. Tetracycline
2. Codeine
(erythromycin IV given for gastroparesis)
86
State treatment of postural hypotension:
Midodrine
87
State treatment of neuropathic postural hypotension:
Increased salt intake + fludrocortisone
88
State treatment of gustatory sweating:
Propantheline bromide
89
State treatment of neuropathic oedema
Ephedrine
90
Symptoms of Diabetic ketoacidosis:
Rapid weight loss, nausea, vomiting, sweet metallic taste, different odour in sweat and urine, Confusion, tired, fast breathing, breathe smells fruity, thirsty
91
State treatment of DKA:
1. Soluble insulin IV mixed with sodium chloride 0.9%
92
Which drug to use in pregnancy:
1. Metformin
all other drugs should be discontinued and substituted with insulin
93
State insulin treatments in pregnancy:
Isophane insulin – first choice for long acting Or insulin detemir / glargine
Continuous S/C insulin infusion
94
Define gestational diabetes:
Women with gestational diabetes who have a fasting plasma glucose below 7mmol/litre at diagnosis should first attempt a change in diet and exercise
alone. If blood-glucose targets are not met within 1-2 weeks, metformin is prescribed. If metformin is not effective or contraindicated, then insulin is prescribed
95
How do you treat pregnant patient if fasting plasma glucose is above 7mmol/litre:
Treat with insulin immediately, with or without metformin
96
How do you treat pregnant patient if fasting plasma glucose is between 6 and 6.9 mmol/litre alongside complications such as macrosomia or hydramnios:
Treat with insulin immediately, with or without metformin
97
State treatment of gestational diabetes:
1. Metformin
2. Insulin if metformin C/I
98
How does metformin work:
Decreases gluconeogenesis and by increasing peripheral utilisation of glucose
99
State common side effects of metformin:
Diarrhoea, taste altered, vitamin b12 cyanocobalamin deficiency, abdominal pain, appetite decreased, lactic acidosis, skin reactions
100
State symptoms of lactic acidosis:
Dyspnoea, muscle cramps, abdominal pain, hypothermia, asthenia, hypothermia
Most common with metformin
101
State which egfr to avoid metformin in:
30 ml and under
102
How do DPP4’s work:
Inhibits DPP4 to increase insulin secretion and lower glucagon secretion
103
Which DPP4 does not require a dosage change:
Linagliptin
Can also cause pancreatitis – severe abdominal pain – discontinue
104
Which DPP4 has a side effect of increased risk of infection:
Alogliptin
Saxagliptin
105
Patient is taking vildagliptin, state patient carer advice:
Pancreatitis = severe abdominal pain
Liver toxicity = nausea, vomiting, dark urine, fatigue, abdominal pain
106
State side effects of gliptins, dpp4:
Nausea, vomiting, diarrhoea, dyspepsia, gord, pancreatitis
107
How does GLP1A work:
Augments glucose dependent insulin secretion and slows gastric emptying, Supresses glucagon secretion
108
State handling and storage requirements for dulaglutide:
Fridge 2-8 degrees. Once opened – can stay unrefrigerated for up to 14 days less than 30 degrees
109
What is the mhra alert for glp1 inhibitors
Can cause life threatening dka after adjusting insulin dosages.
110
Which GLP1A can cause severe pancreatitis including haemorrhagic or necrotising pancreatitis:
Exenatide
But all GLP1A can cause acute pancreatitis
111
State conception advice for patients taking exenatide:
Women should use effective contraception during treatment and for 12 weeks after discontinuation
112
Which drug do you have to counsel patient potential risk of dehydration:
Liraglutide
113
Which drug has an increased risk of cholelithiasis and cholecystitis and increased HR:
Liraglutide
114
How does SGLT2 work:
Reversibly inhibits sodium glucose co-transporter 2 in the renal proximal convoluted tubule to reduce glucose reabsorption and increase urinary glucose excretion
115
Patient is taking canagliflozin and rifampicin, what do you advise dr:
Increase canagliflozin dose to 300 mg
116
State MHRA warning with SGLT2 flozins:
Fatal cases of DKA
- Increases lower limb amputation (mianly toes)
- Stop if patient develops skin ulcer, osteomyelitis or gangrene
- Fournier’s gangrene – severe pain, tenderness, erythema, swelling in genital or perianal area
+ fever, necrotising fasciitis
117
State patient carer advice for DPP4:
Told about symptoms of DKA
Canagliflozin has extra one = report symptoms of volume depletion and postural hypotension and dizziness
With Empagliflozin and Ertugliflozin = Correct hypovolaemia
118
State common symptoms of DPP4:
Balanoposthitis, hypoglycaemia, increased risk of infection, thirst, urinary disorders
119
State treatment of DPP4 in renal impairment:
Avoid initiation if egfr below 60ml
Avoid if below 45ml
120
State cautions of sulphonylureas:
Can encourage weight gain, G6PD deficiency, elderly (long-acting ones)
121
State common side effects of sulphonylureas:
Abdominal pain, diarrhoea, nausea, hypoglycaemia Jaundice may occur it is common side effect
122
State max dose for gliclazide:
320 mg
Can cause angioedema, dyspepsia, anaemia, hyponatraemia Safe in elderly and renal impairment
123
State max dose for glimepiride:
6 mg
124
Which sulphonylurea is considered safe in acute porphyrias:
Glipizide
Max 20 mg daily
125
State max dose for tolbutamide:
2mg
Safe in elderly and renal impairment
126
How does pioglitazone work:
Reduces peripheral insulin resistance Max dose is 45 mg
127
State MHRA warning with pioglitazone:
Not be used in patients with heart failure or history of heart failure
- Increased risk of bladder cancer
- Report promptly any haematuria, dysuria, urinary urgency during treatment
- (not MHRA but increased risk of bone fractures in women)
128
State common side effects of pioglitazone:
Bone fracture, increased risk of infection, weight gain, numbness, visual issues Monitor liver function before and annually
Liver toxicity = dark urine, nausea, vomiting, severe abdominal pain, fatigue
129
State risk factors of osteoporosis:
Age
Low bmi
Cigarette smoking
Excess alcohol intake
Lack of physical activity Vitamin D deficiency
Family history of hip fractures Low Ca levels
130
State side effects of alendronic acid:
GI, vertigo, severe oesophageal reactions (seek medical attention if they develop oesophageal irritation, dysphagia, pain or swallowing or retrosternal pain,
new or worsening heartburn
131
Which bisphosphonate has highest risk for developing osteonecrosis of jaw:
Zoledronate
132
State monitoring requirements for ibandronic acid:
Calcium, phosphate and magnesium
133
State MHRA warning with denosumab:
- Atypical femoral features
- Report any new or unusual thigh, hip, groin pain
- Risk of osteonecrosis of jaw and risk of hypocalcaemia
- Report any mobility, pain, swelling, sores, discharge
- Osteonecrosis of external auditory canal reported
- Ear pain, ear infection, discharge
- Hypercalcaemia reported up-to 9 months after discontinuation
134
State symptoms of hypocalcaemia
Muscle spasms, twitches, cramps, numbness, tingling in fingers, toes or around mouth
135
What is the important safety information for insulin?
Unit/units should not be abbreviated
insulin should not be withdrawn from an isnulin pen then administered via syringe
136
What is the tx for hypoglycaemia
- small carb snack
- less than 4 and can swallow: fast acting carb by mouth eg glucojel
- unconsciousness = emergency, treat with glucagon and then a long acting carb asap
137
State use of bromocriptine:
Galactorrhoea and for treatment of prolactinomas
138
What is most effective treatment of acromegaly:
Octreotide (somatostatin analogue) Bromocriptine too
139
What is quinagolide:
Non-ergot dopamine D2 agonist
Monitor BP
Excessive daytime sleepiness and sudden onset of sleep can occur with dopamine-receptor agonists
140
State treatment of endometriosis and for relief of severe pain and tenderness in benign fibrocystic breast disease:
Danazol
141
What are oestrogens necessary for :
Development of female secondary characteristics
142
State the natural oestrogens:
Estradiol
Oestradiol
Oesterone
Estriol
143
State features of tibolone:
Oestrogenic, progestogenic and weak androgenic activity
144
What drug can be used to reduce vasomotor symptoms in patients with menopause:
Clonidine for facial flushing
145
Discuss the risks with HRT
All HRT medication (including tibolone) increases risk of breast cancer within 1-2 years of initiating treatment. This risk disappears after 5 years of stopping.
- Small increased risk of ovarian cancer
- Slightly increases risk of stroke
- Tibolone increases risk of stroke about 2.2 time from first year of treatment
- Increased risk of CVD
146
Patient is undergoing general anaesthesia, orthopaedic surgery, vascular leg surgery and is taking HRT what do you advise:
Stop taking HRT 4-6 weeks before surgery
If It can’t be stopped add in unfractionated or low molecular weight heparin
147
State the reasons to stop COC / HRT?
- Sudden severe chest pain
- Sudden breathlessness (or cough with blood-stained sputum)
- Unexplained swelling or severe pain in calf of one leg
- Severe stomach pain
- Severe prolonged headache / complete loss of vision / sudden disturbance of hearing /
dysphasia / bad fainting / first seizure / marked numbness
- Hepatitis / jaundice / liver enlargement
- 160 mmHg / 95 mmHg
148
How is type of HRT chosen?
Uterus usually produces oestrogen for last 12-14 days of cycle.
149
Define endometriosis:
Growth of endometrial-like tissue outside the uterus
Women report pain, which can be frequent or chronic and severe, tiredness, more sick days and impacts sexually and psychologically
150
State treatment of endometriosis:
1. Paracetamol AND/OR NSAID for first 3 months
2. COC or progestogen only pill
Such as: Nexplanon, depot-provera or sayana press
151
Describe menorrhagia:
Excessive menstrual blood loss of 80 ml or more for duration of more than 7 days
152
State the treatment of menorrhagia:
1. Levonorgestrel releasing intra uterine system (LNG – CIUD)
2. Tranexamic acid / NSAID
3. COC, Cyclical progestogen
153
State some serious side effects with tibolone and when to withdraw treatment:
Vaginal bleeding – investigate for endometrial cancer if bleeding continues 6 months Abnormal LFTs
Cholestatic jaundice, Thromboembolic disease
Which drug is used for treatment of severe hypersexuality and sexual deviation in males: Cyproterone acetate
154
A low strength of this medication can be used for treating male-pattern baldness in men:
Finasteride
155
State a common side effect of testosterone:
Hypertriglycerideamia
156
State lab results for hyperthyroidism:
High T3,T4
Low TSH
Malaise, fever, agitation, polyuria, thirst, diarrhoea, increased sweating, heat intolerance, anxiety, reduced libido
157
State treatment of hyperthyroidism:
1. Carbimazole
2. Propylthiouracil
158
What is blocking-replacement therapy:
Carbimazole + levothyroxine given for 18 months
159
State treatment of thyrotoxicosis (thyroid storm):
IV fluids
Propranolol + hydrocortisone + iodine + carbimazole/propylthiouracil
160
Which two beta-blockers can be used for treating rapid relief of thyrotoxic symptoms:
Propranolol / nadolol
161
State treatment of hyperthyroidism in pregnancy:
1. Propylthiouracil in FIRST trimester (as carbimazole associated with congenital defects, aplasia cutis of neonate)
2. Carbimazole in SECOND trimester (as propylthiouracil can cause risk of hepatotoxicity
162
State patient carer advice with carbimazole:
Sore throat / mouth ulcer / bruising / fever / fever / son-specific illness / blood disorder – stop medicine
Female should use effective contraception during treatment
Signs of low neutropoenia / type of low WBC = stop
163
State MHRA warning with carbimazole:
STOP if symptoms of acute pancreatitis occur
164
State MHRA warning with carbimazole:
STOP if symptoms of acute pancreatitis occur
165
State patient carer advice for propylthiouracil:
Nausea, vomiting, fatigue, abdominal pain, jaundice, dark urine, pruritus – monitor for hepatotoxicity and then stop medicine if develops
Discontinue if significant liver enzymes develop
166
State use of propylthiouracil in pregnancy:
Used in first trimester
High doses can cause foetal goitre and hypothyroidism
167
State symptoms of hypothyroidism:
Fatigue, Cold intolerance, Weight gain, myalgia, dry skin, hair loss, changes to hair and skin, deepening of voice goitre, depression
168
State lab results for hypothyroidism:
High TSH
Low T3, T4
169
State treatment of hypothyroidism:
1. Levothyroxine
2. Liothyronine sodium
170
What is the patient/carer advice for levothyroxine?
Taken 30-60 mins before breakfast, or any caffeine containing liquids or any other meds.
increased in 25 mcg increments every 4 weeks
initial dosage in cv disorders - metabolism increased too quick then reduce dose or withold for 1-2 days then restart at a lower dose.
