Endorcine Flashcards
(218 cards)
1
Q
What is used to treat diabetes insipidus?
A
Vasopressin
2
Q
What is desmopressin used for?
A
Nocturnal enuresis
Used to test fibrinolytic response
Used to treat mild-moderate haemophilia and VWD (a life-long bleeding disorder in which blood does not clot properly)
3
Q
How do you treat hyponatraemia resulting from inappropriate secretion of antidiuretic hormone?
A
If fluid restriction alone does not restore sodium concentration or is not tolerable
- Treat with demeclocycline
- 2nd line: Tolvaptan
4
Q
What would happen if rapid correction of hyponatraemia occurs during tolvaptan therapy?
A
Could cause osmotic demyelination leading to serious neurological events
- slowly monitor serum sodium concentration and balance fluid
5
Q
Which drugs increase the secretion of vasopressin?
A
Tricyclic antidepressants = increases risk of hyponatraemia
6
Q
What counselling is given for the treatment of nocturnal enuresis with desmopressin?
A
Hyponatraemic convulsions - avoid fluid overload (including during swimming) and stop taking drug during episodes of vomiting and diarrhoea until fluid balance normal
7
Q
What is the risk associated with desmopressin and vasopressin in pregnancy?
A
oxytocic
8
Q
How do you take tolvaptan?
A
Morning dose 30 minutes before food and second dose can be taken with or without food
9
Q
What are the risk factors associated with osteoporosis?
A
Post-menopausal women
Men over 50
Patients taking long-term corticosteroids
10
Q
What vitamins should patients with osteoporosis aim to increase?
A
Intake of calcium and vitamin D
11
Q
How do you treat postmenopausal osteoporosis?
A
1st line: alendronic acid (10mg OD or 70mg weekly) or risedronate (5mg OD or 35mg weekly) due to broad spectrum of anti-fracture efficacy
Alternative - ibandronic acid
If intolerant of oral bisphosphonates = consider parenteral bisphosphonates or denosumab
More alternatives: raloxifene, strontium
HRT - restricted to younger postmenopausal women due to risk of adverse effects such as CVD and cancer
- Another option in younger women is tibolone
12
Q
What is used in menopausal women at severe risk of osteoporosis at high risk of fractures?
A
Teriparatide
Romosozumab - who have previously experienced a fragility fracture and are at imminent risk of another (within 24 months)
13
Q
Who should be considered for bone-protection treatment for patients who have glucocorticoid-induced osteoporosis?
A
Women:
- aged ≥ 70 OR
- had previous fragility fracture OR
- taking large doses of glucocorticoids (prednisolone ≥ 7.5mg daily or equivalent)
Men:
- aged ≥ 70 with a previous fragility fracture OR
- taking large doses of glucocorticoids
All men and women taking large doses of glucocorticoids (≥ 7.5mg daily prednisolone or equivalent) for 3 months or longer
14
Q
What is the treatment for bone protection?
A
1st line: alendronic acid/ risedronate
If intolerant to oral bisphosphonates or unsuitable
- zoledronic acid
- denosumab
- teriparatide
15
Q
How do you treat osteoporosis in men?
A
1st line: alendronic acid (10mg OD) or risedronate (35mg weekly)
2nd line: zoledronic acid or denosumab
3rd line: teriparatide or strontium
16
Q
How long is the duration of biphosphonate treatment?
A
Reviewed after 5 years with alendronic acid, risedronate and ibandronic acid
Reviewed after 3 years with zoledronic acid
Continuation beyond this period recommended for patients over 70, have a history of previous hip or vertebral fractures, had 1 or more fragility fractures during treatment, or who are taking long-term glucocorticoid therapy
17
Q
What are the MHRA warnings for biphosphonates?
A
- Atypical femoral fractures: report any thigh, hip or groin pain during treatment
- Osteonecrosis of the jaw: (most potent bisphosphonates = zoledronic acid) get regular dental check-ups and good oral hygiene
- Osteonecrosis of the auditory canal: report any ear pain, discharge from the ear or an ear infection during treatment
18
Q
What are the common side effects of alendronic acid?
A
GI disorders
Joint swelling
Vertigo
Skin reactions
19
Q
When should you avoid alendronic acid in renal impairment?
A
If CrCl less than 35ml/min
20
Q
What is the caution for strontium?
A
Risk factors for CVD - assess every 6-12 months during treatment
Risk factors for VTE - discontinue in patients who become immobile
21
Q
What are the MHRA warnings associated with denosumab?
A
- atypical femoral fractures
- osteonecrosis of the jaw
- osteonecrosis of the auditory canal
- rebound hypercalcemia up to 9 months after discontinuation of treatment for giant cell tumour of bone
- vertebral fractures after stopping (up to 18 months) or delaying ongoing treatment (60mg)
- do not use in under 18 due to severe risk of hypercalaemis
22
Q
What corticosteroid is used for postural hypotension in autonomic neuropathy?
A
Fludrocortisone - mineralcorticoid activity
23
Q
What corticosteroids are used for congenital adrenal hyperplasia?
A
Dexamethasone and betamethasone - glucocorticoid activity (long-acting)
24
Q
What corticosteroid do you use to test for Cushing’s syndrome?
A
overnight dexamethasone suppression test
25
What is the MHRA warning for corticosteroids?
Rare risk of central serous chorioretinopathy with local and systemic administration - report blurred vision or visual changes
26
What are the side effects of mineralocorticoids?
Hypertension
Sodium retention
Water retention
Potassium loss
Calcium loss
These are most marked with fludrocortisone but also significant with hydrocortisone, corticotropin, and tetracosactide
27
What are the side effects of glucocorticoids?
Diabetes
Osteoporosis - danger in elderly
High doses associated with avascular necrosis of femoral head
Muscle wasting (proximal myopathy)
Weakly linked with peptic ulceration and perforation
Psychiatric reactions
28
What are the symptoms of adrenal insufficiency?
Fatigue
GI upset
Anorexia
Weight loss
Salt cravings
Dizziness/ syncope due to hypotension
Musculoskeletal symptoms
29
What are the symptoms of adrenal crisis?
Severe dehydration
Hypotension
Hypovolemic shock
Altered consciousness
Seizures
Stroke
Cardiac arrest - if left untreated
30
How do you treat adrenal insufficiency?
Physiological glucocorticoid replacement - mainly with hydrocortisone, prednisolone and rarely dexamethasone
Patients with primary adrenal insufficiency may also require mineralocorticoid replacement with fludrocortisone due to aldosterone deficiency
31
What should you advise patients with adrenal insufficiency to do during times of stress?
Double the dose of glucocorticoid
32
What are the sick day rules for glucocorticoids?
if unwell with moderate intercurrent illness (fever or infection requiring antibiotics) - double the dose
Patients with adrenal insufficiency on long-acting hydrocortisone should be switched to short-acting, more readily absorbed preparations during illness
During severe illness (vomiting and GI viral illness) - IM/IV hydrocortisone should be given
33
How do you manage adrenal crisis?
Prompt glucocorticoid replacement - hydrocortisone
Rehydration - using crystalloid fluid (sodium chloride 0.9%)
34
What are the MHRA warnings for corticosteroids?
- rare risk of central serous chorioretinopathy with local and systemic administration
- steroid emergency card
- paediatric steroid card for children with adrenal insufficiency
35
What is an important side effect to be aware of with high doses of corticosteroids?
Psychiatric reactions
36
What symptoms are associated with steroid withdrawal?
Fever
Myalgia
Arthralgia
Rhinitis
Conjunctivitis
Painful itchy skin nodules
Weight loss
37
When should gradual steroid withdrawal be considered?
- More than 40mg of prednisolone for more than 1 week
- Repeat doses in the evening
- Treatment more than 3 weeks
- Recent repeat courses
- Taken short-course within 1 year of stopping long-term therapy
38
Which steroid is associated with Stevens-Johnson syndrome?
Betamethasone
Other side effects of betamethasone:
- oedema
- hiccups
- myocardial rupture: following recent MI
39
Which steroid can cause hyperglycaemia?
Dexamethasone
40
Which steroid increases blood pressure and conjunctivitis?
Fludrocortisone
41
Which steroid has a common side effect of depressed mood?
Methylprednisolone
42
Which drugs are used to manage Cushing's syndrome?
Metyrapone
Ketoconazole - for endogenous cushings syndrome
43
What is the safety warning associated with ketoconazole?
Administration of oral ketoconazole to treat fungal infections should be suspended - risk associated with hepatotoxicity is greater than the benefit
- oral ketoconazole for treatment of Cushing's syndrome not affected by this warning
44
What should the minimum blood glucose concentration be while driving?
At least 5mmol/L
If 5mmol/L or below - have a snack
Driver treated with insulin should always ensure a fast-acting carb is in the vehicle
45
When should a driver with diabetes not drive?
When blood glucose is less than 4 mmol/L or there are warning signs of a hypo
- stop vehicle and wait 45 minutes for blood glucose to return to normal
46
If a diabetic patient is not taking insulin, what other drugs would you need to monitor blood glucose levels for when driving?
Sulfonylureas and meglitinides ('glinide')
47
what causes delayed hypoglycaemia or makes the symptoms of hypoglycaemia less clear?
Alcohol
48
What are the typical features of T1DM?
Blood glucose concentrations of above 11mmol/L
Ketosis
Rapid weight loss
BMI of less than 25kg/m2
Age younger than 50
Personal/ family history of autoimmune disease
49
What is the target fasting blood glucose concentration on waking?
5-7mmol/L
50
What is the target blood glucose concentration before meals?
4-7mmol/L
51
What is the target blood glucose concentration at least 90 minutes after eating?
5-9mmol/L
52
For a patient with T1DM, when would you consider metformin as add-on therapy?
When they have a BMI of 25kg/m2 or above (23kg/m2 or above for south asian and related ethnicities) who wish to improve their blood glucose control while minimising their effective insulin dose
53
What is a multiple daily injection basal-bolus insulin regimen?
One or more separate daily injections of intermediate-acting insulin or long-acting insulin analogue
Alongside multiple bolus injections of short-acting insulin BEFORE meals
54
What is a mixed (biphasic) regimen?
1-3 insulin injections per day of short-acting insulin mixed with intermediate-acting insulin
It may be mixed by the patient or a pre-mixed product can be used
Must always be taken 30 minutes before a meal
Not recommended for adults newly diagnosed with T1DM
55
What type of insulin is used for continuous subcutaneous insulin infusion?
Rapid-acting analogue or soluble insulin
56
What is the first line recommended insulin regimen?
Basal-bolus regimen
Long-acting insulin = twice daily insulin detemir
- alternative: once daily insulin glargine
Nocturnal hypoglycaemia concern = once daily insulin degludec (ultra-long acting)
57
Which insulin would you consider if the patient experiences nocturnal hypoglycaemia?
Once daily insulin degludec
58
What insulin would you consider if a patient requires help administering from a carer or HCP?
Once daily ultra-long acting insulin
- insulin degludec
- insulin glargine (300 units/ml)
59
What insulin is recommended as the mealtime insulin replacement?
Rapid-acting insulin analogue (rather than soluble human insulin or animal insulin)
Administered BEFORE meals
60
Who should the insulin pumps be offered to?
- Patients who suffer disabling hypoglycaemia while attempting to achieve target HbA1c
- Have high HbA1c levels: 69mmol/mol (8.5%) with multiple daily injection therapy
- children under 12 where multiple injection regimen is impractical
61
How do you test a patient's awareness of hypoglycaemia?
The Gold score or the Clarke score
62
What class of drugs masks the symptoms of hypoglycaemia?
Beta blockers - by reducing warning signs such as a tremor
63
How do you restore the warning signs of hypoglycaemia?
By minimising episodes of hypoglycaemia
64
Why is insulin given subcutaneously and not orally?
Gastrointestinal enzymes inactivate insulin
65
What risk is associated with insulin injections in one site?
Lipohypertrophy - can causes erratic absorptions of insulin
66
Which insulins are soluble insulins?
Soluble insulins are short-acting insulins
Soluble insulins include: human and bovine or porcine
67
Which insulins are rapid-acting insulins?
Rapid-acting insulins are short-acting insulins
Rapid-acting insulins include:
- insulins aspart
- insulin glulisine
- insulin lispro
LAG - there is not lag with rapid-acting insulins
onset of action = 15 minutes
duration of action = 2-5 hours
68
Which insulin can be injected subcutaneously, IV and IM?
Soluble insulin
S/C: rapid onset of action (30-60 mins), peak action between 1-4 hours and duration of action of 9 hours
IV: short half-life (few minutes) but onset of action instantaneous --> used in diabetic emergencies e.g. diabetic ketoacidosis and peri-operatively
69
Which short-acting insulin is more advantageous?
Rapid-acting insulin is more advantageous than soluble insulin
- improved glucose control
- reduce HbA1c
- reduction in incidence of hypoglycaemia episodes including nocturnal
70
Name an intermediate-acting insulin
Isophane insulin
onset of action 1-2 hours
maximal effects: 3-12 hours
duration of action: 11-24 hours
71
How is intermediate-acting insulin used?
It can be used given OD, BD in basal-bolus regimen with separate short-acting mealtime insulins
OR
It can be mixed with short-acting insulin for biphasic regimens (administered before meals)
Also comes are pre-mixed
- biphasic isophane insulin
- biphasic insulin aspart
- biphasic insulin lispro
72
Name the long-acting insulins
- protamine zinc insulin
- insulin zinc suspension
- insulin determir (OD/BD)
- insulin glargine (OD)
- insulin degludec (OD)
duration of action: up to 36 hours
achieve steady-state level: after 2-4 days
73
What is the blood glucose targets in patients managing their T2DM with lifestyle changes and or with one antidiabetic drug not associated with hypoglycaemia?
48 mmol/mol (6.5%)
74
What is the target blood glucose level in T2DM on an antidiabetic associated with hypoglycaemia?
53 mmol/mol (7%)
75
What is the blood glucose target for patients with T2DM on 2 antidiabetic drugs?
53 mmol/mol (7%)
76
Which anti-diabetic non-insulin drug causes hypoglycaemia?
sulfonylureas
More associated with long-acting sulfonylureas e.g. glimepiride
77
Which anti-diabetic non-insulin drugs is associated with weight gain?
sulfonylureas
Pioglitazone
78
Which anti-diabetic drugs promote weight loss?
SGLT2s
GLP-1s "tide"
79
Which anti-diabetic drug has benefits when used in HF?
SGLT2s
80
Which anti-diabetic drug has renal benefit?
SLGT2s
81
Which anti-diabetic drug poses a risk of diabetic ketoacidosis?
SGLT2s
82
What is used in rescue therapy for patients who become symptomatically hyperglycaemia?
Insulin or Sulfonylureas
83
What is the initial treatment for T2DM?
1st line: standard release metformin - increase dose gradually to minimise risk of GI side effects (offer MR metformin if experiencing GI side effects)
if patient has chronic HF, or established atherosclerotic CVD (or at high risk of developing CVD) - offer SGLT2 as well
-> initiate as soon as tolerability to metformin established
2nd line: (monotherapy of metformin +) DPP4/ piogloitazone/ sulfonylureas
-> use SLGT2 instead of sulfonylureas if contraindicated or not tolerated or pt at significant risk of hypo's
(after dual therapy, can consider insulin)
3rd line: (triple therapy) options:
-> metformin + sulfonylureas + SGLT2 (canagliflozin, empagliflozin/ dapagliflozine)
-> metformin + pioglitazone + canagliflozin/empagliflozin
-> metformin + DPP4 + ertugliflozin (if sulfonylureas or pioglitazone inappropriate)
84
What is the treatment option for T2DM if triple therapy ineffective?
Consider GLP-1 as part of triple therapy by swapping it with one of the other drugs
-> only consider in patients with BMI 35kg/m2 or above AND who have specific psychological or medical problems associated with obesity
-> OR have BMI <35kg/m2 and whom insulin therapy would have significant occupational implications
-> OR if weight loss associated with GLP-1 would benefit other obesity-related co-morbidities
85
Which sulfonylureas are short-acting and may be considered for elderly patients/ patients with renal imapirment?
Gliclazide or tolbutamide
86
Which class of drugs have proven CVD benefit?
GLP-1 - consider in patients with established cardiovascular disease
87
What are the conditions after starting a GLP-1?
Review after 6 months of starting
-> continue only if there has been at least 11 mmol/mol (1%) reduction in HbA1c AND weight loss of at least 3% of initial weight
88
What is the non-metformin T2DM regimen?
1st line: SGLT2 with proven cardiovascular benefit for this with chronic HD or established atherosclerotic CVD or high risk of developing CVD
All other patients: consider DPP4/ Pioglitazone/ sulfonylureas as 1st line - if not appropriate then SLGT2
2nd line: dual therapy
3rd line: insulin
89
What are the insulin regimen options for T2DM?
Option 1: human isophane OD/BD
Option 2: human isophane + short-acting insulin - separately or biphasic (may be particularly appropriate if HbA1c 77 mmol/mol (9%) or higher)
Option 3: Insulin detemir/ glargine OD (Especially if assistance is required during administration) + short-acting insulin
(consider switching to detemir/ glargine from human isophane if significant hypoglycaemia)
Option 3: biphasic preparations including short-acting human analogue insulin
90
When would you need to treat diabetic nephropathy?
if the patient has:
- confirmed diabetic nephropathy
- has an albumin-creatinine ratio (ACR) of 3mg/mmol or more
91
How do you treat diabetic nephropathy?
ACEi/ARB even if BP normal
in patients with CKD and proteinuria - give ACE/ARB as monotherapy to reduce rate of progression of CKD
in patients with T2DM and CKD already on ACE/ARB - add-on therapy of SGLT2 if ACR >30mg/mmol (if between 3-30 then consider)
92
Which drug potentiates hypoglycaemic effect of insulin and oral anti-diabetic drugs?
ACEi - more likely during first weeks of combined therapy and in patients with renal impairment
93
What simple measures can help acute diabetic neuropathy?
Analgesia - paracetamol
Bed cradles - helps air circulation to keep feed drug
94
What monotherapy treatment should be considered for diabetic neuropathy?
Tricyclics (amitriptyline/ imipramine), duloxetine, or venlafaxine for painful diabetic neuropathy
Can also consider pregabalin or gabapentin
If not controlled with monotherapy - opioid analgesic + gabapentin
95
How do you manage diabetic diarrhoea in autonomic neuropathy?
Tetracyclines or codeine
96
How do you treat gastroparesis?
Erythromycin (especially if given IV)
Refer patient is suspect differential diagnosis or patient has persistent to severe vomiting
97
How do you treat neuropathic postural hypotension?
Increase salt intake
Use of minercorticoid e.g. fludrocortisone may help by increasing plasma volume
-> however, uncomfortable oedema is a common side effect
-> can be used in combination with flurbiprofen and ephedrine
98
How do you treat gustatory sweating?
antimuscarinic
-> propantheline but side effects are common
99
How do you treat neuropathic oedema?
ephedrine
100
What is the main precipitating factor for DKA and HHS?
Infection
101
What are the precipitating factors for DKA?
Discontinuation or inadequate insulin therapy
Acute illness such as MI and pancreatitis
New onset of diabetes
Stress (trauma or surgery)
Infection
Corticosteroids
102
What are the precipitating factors for HHS?
Inadequate insulin or oral diabetic therapy
Acute illness in patient with known diabetes
Stress
103
What type of diabetes is DKA most likely to occur in?
T1DM (only a third occurring in T2DM)
104
What is the onset of DKA and HHS?
DKA occurs rapidly within hours
HHS can take days to develop = dehydration and metabolic disturbances more severe
105
What are the characteristics of a DKA?
Hyperglycaemia - HbA1c above 11 mmol/L
Ketonaemia - capillary/blood ketone above 3 mmol/L or significant ketonuria of 2+ or more
Acidosis - bicarbonate less than 15 mmol/L and or venous pH less than 7.3
106
What are the signs of DKA?
Dehydration due to polydipsia and polyuria
Weight loss
Excessive tiredness
N/V
Abdominal pain
Kussmaul respiration (rapid and deep respirations)
107
What are the characteristics of HHS?
Hypovolaemia marked with hyperglycaemia (blood glucose above 30 mmol/L without significant hyperketonaemia or acidosis
Hyperosmolality - above 320 mosmol/kg
108
What are the signs of HHS?
Dehydration due to polyuria and polydipsia
Weakness
Weight loss
Tachycardia
Dry mucous membranes
Poor skin turgor
Hypotension
Acute cognitive impairment
Shock - in severe cases
109
How do you treat a DKA?
- IV fluid replacement
- IV soluble insulin - pt's normally taking long-acting insulin should continue their usual dose throughout treatment
- Potassium replacement and glucose administration to prevent subsequent hypokalaemia and hypoglycaemia
110
How do you treat HHS?
- IV fluid replacement
- IV insulin: can be given earlier with significant ketonaemia or ketonuria
- Potassium should be replaced or omitted
111
What is the course of action with insulin (good glycaemic control - less than 69 mmol/mol) in minor elective surgical procedure?
Day before surgery - usual insulin should be given as normal
OTHER THAN once daily long-acting insulin analogues which should be given at a dose reduced by 20%
112
What is the course of action with insulin in patients undergoing major procedure or poor glycaemic control in elective surgery?
Variable rate intravenous insulin infusion - continued until patient eating or drinking normally and stabilised on their previous glucose-lowering medication
Aim is to achieve a glucose concentration of 6-10 mmol/L but up to 12 mmol/L by infusing a constanr rate of glucose-containing fluid + infusing insulin at variable rate
113
What is the course of action with insulin the day before a patient undergoes major procedure or poor glycaemic control in elective surgery?
Once daily long-acting insulin analogues should be given at 80% usual dose - otherwise usual insulin dose
114
What is the course of action with insulin on the day of surgery and throughout the intra-operative period in patients undergoing major procedure or poor glycaemic control in elective surgery?
Once daily long-acting insulin analogues should be given at 80% usual dose
All other insulins should be stopped until the patient is eating and drinking again after surgery
115
What is the course of action with insulin on the day of surgery in patients undergoing major procedure or poor glycaemic control in elective surgery?
Start IV substrate infusion of potassium chloride with glucose and sodium chloride - must not be stopped while the insulin infusion if running
116
What is the treatment with glucose in patients undergoing major procedures of have poor glycaemic control in elective surgery?
IV glucose 20% should be given if blood glucose drops below 6 mmol/L
- check hourly to prevent drop below 4 mmol/L
If blood glucose drops below 4 mmol/L IV glucose 20% should be adjusted
- checked every 15 minutes until above 6 mmol/L then hourly
If blood glucose rises above 12 mmol/L - check ketones and consider other signs of DKA
117
How do you convert back to previous subcutaneous basal-bolus regimen after surgery?
Restarted when first post-op meal-time insulin dose is due (breakfast/lunch)
- adjust dose due to post-of stress/ infection/ altered food intake
- Variable rate IV insulin infusion and IV fluids should continue until 30-60 minutes after first meal-time short-acting insulin dose
- If patient previously on long-acting insulin analogue: this should be continued throughout operative period at 80% normal dose until discharge
118
How do you convert back to previous subcutaneous twice daily mixed insulin regimen after surgery?
Restart before breakfast or an evening meal - variable rate IV insulin infusion should be maintained for 30-60 minutes after first s/c insulin dose has been given
119
What is the course of action for diabetic patients in emergency surgeries?
Check for DKA
If ketoacidosis present - DKA treatment should be followed and delay surgery if possible
If no ketoacidosis - IV fluids and insulin should be started
120
What is the course of action for patient on anti-diabetic who require insulin during surgery?
Acarbose, meglitinides, sulfonylureas, pioglitazone, DPP4's, and SGLT2's should be stopped when insulin is commenced and not restarted until patient is eating and drinking normally
121
Which class of anti-diabetic drugs can be continued during insulin infusion in surgery?
GLP1's can be continued as normal during insulin infusion
122
Which antidiabetic drugs can be taken as normal during peri-operative period?
DPP4s
GLP1s
pioglitazone
123
Which class of antidiabetic drugs must be stopped on the day of surgery and not restarted until patient is stable?
SGLT2
- their use during periods of dehydration and acute illness are associated with DKA
Sulfonylureas - associated with hypoglycaemia
124
What is the procedure with metformin and surgery?
Metformin is renally excreted - renal imapirment may lead to accumulation and lactic acidosis
If only one meal is missed for surgery and pt has eGFR greater than 60ml/min and has low risk of AKI - may be possible to continue metformin during perio-op period and just omit lunch time dose if TDS metformin OTHERWISE stop when pre-op fast begins
Variable rate IV insulin infusion should be started if metformin dose more than OD OTHERWISE should only be started if blood glucose more than 12 mmol/L on 2 consecutive occasions
125
Should you stop metformin if contrast medium is used for surgery?
No need to stop metformin after contrast medium if only missing one meal or have eGFR more than 60ml/min
If contrast medium used and pt eGFR less than 60ml/min - omit metformin on day of procedure and the following 48 hours
126
What are the risks associated with diabetes in pregnancy?
pre-eclampsia and rapidly worsening retinopathy
127
What drug are women with pre-existing diabetes recommended to take if planning to conceive?
Folic acid
Should aim for HbA1c of less than 48 mmol/mol without problematic hypo's to reduce risk of congenital malformations
128
Which is the only antidiabetic drug that does not need to be discontinued before pregnancy or as soon as unplanned pregnancy identified?
Metformin
May be used as an adjunct or alternative to insulin in preconception period and during pregnancy if benefits outweigh risks
Can also be continued immediately after birth and during breast-feeding
129
What is the first line insulin regimen in pregnancy?
Rapid-acting: aspart or lispro
Long-acting: isophane
- however in women with good glycaemic control before pregnancy with long-acting insulin e.g. glargine or detemir then these can continue
130
What should pregnant women with T1DM be prescribed along with insulin?
Glucagon
131
What should women with pre-existing diabetes who are treated with insulin during pregnancy do after birth?
They are at increased risk of hypoglycaemia in the postnatal period and should reduce their insulin immediately after birth
132
What other drugs should be discontinued or switched to pregnancy-friendly drugs to avoid diabetic complications?
ACE/ARB - alternative
Statins should not be used - discontinue before planned pregnancy
133
What is the treatment for gestational diabetes?
Fasting plasma glucose <7 mmol/L at diagnosis - diet and exercise
- if blood glucose targets not met within 1-2 weeks: prescribe metformin
- of metformin contraindicated: prescribe insulin or add-on if metformin not sufficient
If fasting plasma glucose >7 mmol/L at diagnosis - treat with insulin immediately with or without metformin + diet and exercise
If fasting blood glucose between 6-6.9 mmol/L alongside complications e.g. macrosomia and hydramnios - immediate insulin with or without metformin
Discontinue hypoglycaemic treatment straight after birth
134
What is the MHRA warning for metformin?
Reduces vitamin B12 levels
135
What is the MHRA warning for GLP-1s?
Reports of DKA when concomitant insulin was rapidly discontinued
136
What are the MHRA warnings for SGLT2s?
- Reports of DKA when concomitant insulin was rapidly reduced or discontinued
- Monitor ketones in blood during treatment disruptions
- Reports of fournier's gangrene
137
What is the MHRA warning for canagliflozin?
Increased risk of lower-limb amputation - mainly toes
STOP IF PATIENT HAS FOOT ULCERATIONS
138
What is the MHRA warning for forxiga?
Forxiga 5mg should not longer be used in T1DM
139
What are the MHRA warnings for pioglitazone?
- cardiovascular safety - incidence of heart failure increased especially in patients with predisposing factors
- Risk of bladder cancer
140
What is the course of action if a patient has a blood glucose of less than 4mmol/L with or without symptoms but is conscious and able to swallow?
Treat with fast-acting carbohydrates
- Lift glucose liquid
- glucose tablets
- glucose 40% gels (e.g. glucogel, dextrogell or rapilose)
- Pure fruit juice
- sugar (sucrose) dissolved in appropriate volume of water
Oral glucose formulations are preferable as they are absorbed faster
141
What type of diabetic patients should you avoid orange juice in?
Patients following a low potassium diet due to CKD
142
What should be avoided in a hypoglycaemic patient taking acarbose?
Sugar dissolved in water - prevents the breakdown of sucrose to glucose
143
Which foods should be avoided in hypoglycaemia events?
Chocolate and biscuits as they have a lower sugar content and their higher fat content may delay stomach emptying
144
How many times should you attempt to treat hypoglycaemic event in community?
3 times with 15 minute intervals
Once patient has reached a blood glucose concentration of above 4 mmol/L = give a long-acting carbohydrate to prevent blood glucose from falling again
145
What snacks are considered a long-acting carbohydrtae?
- 2 biscuits
- one slice of bread
- 200-300ml of milk (not alternative milks)
- normal carbohydrate-containing meal if due
146
What do you do if hypoglycaemia below 4 mmol/L does not increase after 3 treatments and 30-45 minutes has passed?
Treat with IM glucagon of glucose 10% IV infusion
147
What should you do if a diabetic patient who is an alcoholic requires glucagon IM or glucose IV?
Give thiamine supplements with or following treatment to reduce risk of Wernicke's encephalopathy
148
Who should glucagon be avoided in?
pt who has fasted for a prolonged period of time and patients with have adrenal insufficiency, chronic hypoglycaemia or alcohol-induced hypoglycaemia
Also less effective in patients taking sulfonylureas
In these cases IV glucose will be needed
149
What to do in the event hypoglycaemia causes unconsciousness?
- stop any IV insulin
- treat initiallly with glucagon
- if unsuitable or no response after 10 minutes, give IV 10% or 20% glucose
150
What are the long-acting carbohydrate amounts for a patient who received glucagon?
They require larger portions:
- 4 biscuits
- 2 slices of bread
- 400-600ml of milk
- normal carbohydrate containing meal if dur
151
How do you treat galactorrhoea and prolactinomas?
Bromocriptine
2nd line: cabergoline
152
What is used to treat endometriosis and severe pain and tenderness in benign fibrocystic breast disease?
Danazol
Tamoxifen - adjunct in treatment of mastalgia
Reviewed after 6 months
153
What should be given to patients who require long-term oestrogen therapy?
Progesterone to reduce the risk of cystic hyperplasia of the endometrium and possible transformation of cancer
Should be given for at least 10 of the 28 day treatment
154
Why are oestrogen's no longer used to suppress lactation?
Due to their association to thromboembolism
155
What can be given for menopausal atrophic vaginitis?
Topical vaginal oestrogen for a few weeks and repeat if necessary
156
What should be given to a patient experiencing vasomotor symptoms and cannot take oestrogen?
Clonidine
157
What are the risks associated with HRT?
- venous thromboembolism in first year of use
- stroke
- endometrial cancer (reduced by progesterone)
- breast cancer (higher risk in combined HRT): excess risk persists for more than 10 years after stopping treatment
- ovarian cancer
- coronary heart disease in women who start combined HRT more than 10 years after menopause
158
What is the HRT treatment recommendation for a women WITH a uterus?
Oestrogen with cyclical progesterone for the last 12-14 days of their cycle
Continuous combined preparations or tibolone are NOT suitable for use in perimenopause or within 12 months of last menstural period
159
What is the HRT treatment recommendation for a women WITHOUT a uterus?
oestrogen only for continuous use
- addition of progesterone should be considered in those who still have endometrial foci
160
Do you need to stop HRT before surgery?
Stop 4-6 weeks before surgery due to the risk VTE - restart only after full mobilisation
If discontinuation not possible - prophylaxis with unfractioned heparin or LMWH and graduated compression hosiery is advised
161
What are the reasons to stop HRT?
- sudden severe chest pain (even if not radiating)
- sudden breathlessness (or cough with blood-stained sputum)
- unexplained swelling or severe pain calf of one leg
- severe stomach pain
- serious neurological effects e.g. severe unusual prolonged headache, complete loss of vision, sudden disturbance of hearing , dysphagia or bad fainting attacks, first unexplained epileptic seizure or weakness, motor disturbances or marked sudden numbness affecting one side or body part
- hepatitis, jaundice, liver enlargement
- BP above 160 systolic or 95 diastolic
162
What is used for menopausal osteoporosis?
Raloxifene
163
What is the treatment for endometriosis?
1st line: short trial (3months) of paracetamol/ NSAID alone or in combination
2nd line: hormone treatment with combined oral contraception or progesterone
164
What are the symptoms of hyperthyroidism?
- goitre
- hyperactivity
- disturbed sleep
- fatigue
- palpitations
- anxiety
- heat intolerance
- increased appetite with unintentional weight loss
- diarrhoea
165
What are the complications of hyperthyroidism?
- graves' orbitopathy (swelling of the tissue in the eye)
- thyroid storm
- pregnancy complications
- reduced bone mineral density
- HF and AF
166
What are the risk factors of hyperthyroidism?
- smoking
- family history
- co-existent autoimmune conditions
- low iodine intake
167
What is primary hyperthyroidism?
Refers to when the condition arises from the thyroid gland rather than due to a pituitary or hypothalamic disorder - mainly caused by Grave's disease
168
What is the non-drug treatment for hyperthyroidism?
Radioactive iodine or surgery in the management of grave's disease or nodular goitre
169
How do you treat primary hyperthyroidism?
1st line: carbimazole with propylthiouracil
170
How do you treat Grave's disease?
1st line: radioactive iodine
If antithyroid likely to achieve remission:
1st line: Carbimazole 12-18 month course using either:
- a block and replace regimen = combination of carbimazole + levothyroxine
- or a titration regimen dose based on thyroid function
if persistent or relapsed hyperthyroidism - radioactive iodine
Consider propylthiouracil for patients who experience side effects with carbimazole, are pregnant or trying to conceive within the following 6 months or have a history of pancreatitis
171
When should you stop treatment with Grave's disease?
if agranulocytitosis develops while on antithyroid treatment
172
What is the treatment for toxic nodular goitre?
1st line: radioactive iodine
if unsuitable, offer thyroidectomy or life-long antithyroid drugs
2nd line: treatment with titration regimen of carbimazole
173
How long after radioactive iodine should you avoid pregnancy?
6 months after treatment
174
What is the MHRA warning for carbimazole?
- neutropenia and agranulocytosis
- increased risk congenital malformations: strengthened advice on contraception (especially in 1st trimester)
- risk of acute pancreatitis
175
What is the counselling advice with carbimazole?
Warn patients or carers to tell doctor immediately if sore throat, mouth ulcers, bruising, fever, malaise, or non-specific illness develops
176
What is the counselling advice with propylthiouracil?
Recognise symptoms of liver disorder - anorexia,N/V, fatigue, abdominal pain, jaundice, dark urine, or pruritus develop
177
What are the symptoms of hypothyroidism?
- fatigue
- weight gain
- constipation
- menstrual irregularities
- depression
- dry skin
- intolerance to cold
- reduced body and scalp hair
178
What are the complications of hypothyroidism?
- dyslipidaemia
- coronary heart disease
- heart failure
- impaired fertility
- pregnancy complications
- impaired concentration or memory
- rarely myxoedema coma
179
Which autoimmune disease can cause hypothyroidism?
Hashimoto's thyroiditis
180
How do you treat overt hypothyroidism?
1st line: levothyroxine
Monitor levels every 3 months until within range then yearly
181
How do you treat subclinical hypothyroidism?
If patient has TSH level of more than 10mIU/L or higher on 2 separate occasions 3 months apart - consider levothyroxine
For symptomatic patients under 64 with TSH level above reference range but lower than 20mIU/L on 2 separate occasions 3 months apart = consider trial of levothyroxine for 6 months.
182
How do you manage pregnancy and hypothyroidism?
For those planning pregnancy but TFTs not within range - advise delaying conception until stabilised on levothyroxine
183
What is the MHRA warning for levothyroxine?
Experiencing symptoms with different levothyroxine products - TFT should be considered
- consider consistently prescribing one brand
- if symptoms or poor control of thyroid function persist despite adhering to specific tablet = consider levothyroxine in oral solution formulation
184
What is the impact of amiodarone on the endocrine system?
Can cause amiodarone-induced hypothyroidism because it contains iodine
Continue amiodarone and start levothyroxine 25mcg - perform TFTs every 6 months
185
What is considered as microvascular complications of diabetes?
Retinopathy - loss of vision
Neuropathy - sensory loss, damage to limbs, impotence in men, gastroparesis, sweating
Nephropathy - renal impairment
186
What are considered the macrovascular complications of diabetes?
Ischaemic heart disease - MI
peripheral vascular disease - decreased blood flow to extremities = causing pain, cramps and slow healing
Cerebrovascular disease - stroke
187
Which HRT would you give to a female without a uterus?
Oestrogen only preparations:
- natural oestrogens: estrone, estradiol, estriol
- synthetic; ethinylestradiol, mestranol
188
Which HRT would you give a female with a uterus?
Combined preparations (oestrogen and progesterone)
- add progesterone to reduce endometrial cancer risk
- unsuitable if perimenopausal or <12 months after last period as can cause irregular periods
189
Which HRT has weak androgenic activity?
Tibolone - combined HRT
190
How would you treat vaginal atrophy?
Topical oestrogens
191
How do you treat vasomotor symptoms of menopause?
Systemic oestrogens - tablets and patches
If contraindicated - give clonidine (causes vasodilations)
This can also be given in women with history of breast cancer and experiencing hot flushes
192
What is the risk associated with clomifene?
There is a risk of multiple pregnancy’s
(Used to treat infertility)
193
What is the risk when you give an SGLT2 with ramipril?
Risk of volume depletion especially with ramipril which lowers BP and causes postural hypotension
194
What is strontium contraindicated in?
Men
195
Which sulfonylureas are long acting?
Gilbenclamide
Glimepiride
Chlorpropamide
Avoided in elderly - higher risk of hypo
196
Which sulfonylureas are short-acting?
Gliclazide
Tolbutamide
Lower hypo risk - use in elderly/ renal impairment
197
Which is a side effect of long term steroids?
Psychiatric reactions
198
What are the adverse effects of corticosteroids?
Adrenal suppression
Cushings syndrome, cataracts
Hyperglycaemia, hyperlipidaemia
Infections, insomnia
Nervous system - psychiatric reactions
Glaucoma, GI ulcers
BP increase
Osteoporosis
Skin thinning
Obesity
Muscle wasting
199
What is the adverse effect of bromocriptine?
Fibrotic reactions
200
How should evorel conti patches be applied?
Apply one patch on a clean, dry, unbroken area of the skin on the trunk below waistline twice a week
201
How should estradiol gel be applied?
Apply gel once daily to an area around 1-2x the size of your hand
202
What medication for osteoporosis is taken once a month?
Ibandronic acid 150mg
203
What is the eGFR limit for metformin?
30ml/min
204
Which antidiabetic is associated with fluid retention?
Pioglitazone - avoid in hypertensive patients with CKD as could impact their hypertension and lead to further renal insufficiencies
205
Which class of drugs cause immunosuppression and increase susceptibility to infection?
Corticosteroids
206
What side-effects of hydrocortisone is caused by its mineralocorticoid activity?
Hypertension
207
Which antidiabetic is cautioned in elderly?
Sulfonylureas due to prolonged risk of hypoglycaemia
208
Which dose of dexamethasone impact glucose metabolism?
6mg/day for 10 days
209
Which corticosteroid has equally mineralcorticoid and glucocortcoid activity?
Hydrocortisone
210
Which antidiabetic can cause acute pancreatitis?
sitagliptin - stop if pt experiencing severe or persistent abdominal pain
211
How is acarbose administered?
tablets should be chewed with first mouthful of food or swallowed whole with a little liquid immediately before food
212
What is the risk associated with naproxen and prednisolone?
Increased risk of bleeds
213
What is the risk associated with digoxin and prednisolone?
Hypokalaemia
214
What kind of toxicity can occur with pioglitazone?
Liver toxicity
215
Which antidiabetic does not need dose adjustments in renal impairment?
linagliptin
216
What is used for both hypothyroidism and hyperthyroidism?
Levothyroxine
217
What is given for adjunct therapy for treatment of side effects of hyperthyroidism?
Metoprolol
218
How often do you need blood tests for carbimazole?
Every 6 weeks until stable then every 3 months
