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MSRA Content > BASIC - ENDOCRINE > Flashcards

BASIC - ENDOCRINE Flashcards

1
Q

Names of rapid acting insulin?

A
  • Insulin Aspart (e.g. Novorapid)
  • Insulin Lispro (Humalog)
  • Insulin glulisine (Apidra)
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2
Q

Names of short-acting insulin?

A
  • Humulin & Novolin Regular
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3
Q

Names of intermediate acting insulin?

A
  • Humulin & Novolin N
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4
Q

Names of long-acting insulin?

A
  • Insulin glargine (Lantus)

- Insulin detemir (Levemir)

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5
Q

Names of pre-mixed insulin?

A
  • Humulin 70/30 & 50/50
  • Novolin 70/30
  • Humalog Mix 75/25
  • Humalog Mix 50/50
  • Novolog Mix 70/30
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6
Q

Indications of insulin?

A

Type 1 & 2 diabetes
IV in DKA and hyperglycaemic hyperosmolar syndrome
Perioperative glycaemic control in selected diabetic patients
Hyperkalaemia

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7
Q

Mechanism of insulin?

A
  • Similar function to endogenous insulin
  • Stimulates glucose uptake into skeletal muscle and fat
  • Increases use of glucose as energy source
  • Stimulates glycogen, lipid and protein synthesis
  • Inhibits gluconeogenesis and ketogenesis
  • Drives K+ into cells – short-term measure
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8
Q

Side effects of insulin?

A

Hypoglycaemia

SC injection – fat hypertrophy

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9
Q

Caution of insulin?

A
  • Insulin clearance reduced in renal impairment (risk of hypoglycaemia)
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10
Q

Interactions of insulin?

A
  • Combining insulin and other OHAs increase risk of hypoglycaemia
  • Corticosteroids increases insulin requirements
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11
Q

How it insulin prescribed?

A
  • Prescribed in units – normal daily requirements are 30-50 units
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12
Q

Symptoms of hypoglycaemia and how to treat?

A
  • Hypoglycaemia, symptoms to watch out for (e.g. dizziness, agitation, nausea, sweating and confusion)
    o Explain that, if hypoglycaemia develops, they should take something sugary (e.g. glucose tablets or a sugary drink) then something starchy
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13
Q

What is Basal bolus regimens?

A

 Combination of 1/2 slow acting insulin before bedtime (glargine) with 3 injections of rapid acting insulin after/before meals (Humalog/Novorapid)
 Can adjust for meals and infections better
 Need to test sugars more, at school inject (psychological)

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14
Q

What is 2/3x day pre-mixed regimen?

A

Not suitable for kids’ normal daily activity

Difficult to control/change insulin dosages

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15
Q

What is continuous SC insulin pump?

A

 Gives basal infusion and bolus when eat
 Needle changed every 2-3 days
 Cannot use in sports, swimming, baths (if disconnected – DKA)

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16
Q

Monitoring of insulin?

A

o Self-monitoring of blood glucose
 At least 4 times a day, before meals and before bed
 Targets – FPG 5-7 on waking, PG 4-7 before meals, PG 5-9 90 mins after eating
o HbA1c monitored regularly (at least annually)
 Aim for HbA1c of 48 mmol/mol or lower
o If IV then serum K+ measured every 4 hours

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17
Q

Names of sulphonylureas?

A

Gliclazide

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18
Q

Indications of sulphonylureas?

A

Type 2 DM (2nd line single agent or in combination)

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19
Q

Mechanism of sulphonylureas?

A
  • Stimulates pancreatic insulin secretion
  • Block ATP-dependent K+ channels in pancreatic B-cell membranes and open voltage-gated Ca2+ channels
  • Only effective in residual pancreatic function
  • Weight gain
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20
Q

Side Effect of sulphonylureas?

A
  • GI upset (nausea, vomiting, diarrhoea, constipation)
  • Hypoglycaemia
  • Cholestatic jaundice
  • Rashes
  • Agranulocytosis
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21
Q

Dose changes in renal and hepatic impairment of sulphonylureas?

A

o Dose reduction in liver and renal impairment

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22
Q

Caution of sulphonylureas?

A

o Malnutrition, elderly and hepatic impairment

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23
Q

Interactions of sulphonylureas?

A
  • Risk of hypoglycaemia with other OHAs and insulin

- Efficacy reduced by prednisolone, thiazide and loop diuretics

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24
Q

Dose of sulphonylureas?

A
  • Oral, SR/MR (different doses)
  • Usually dose 40-80mg OD
  • Long-term treatment so should not be stopped or changed
  • Take with meals
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25
Q

Monitoring of sulphonylureas?

A 
o	HbA1c (target <53mmol/mol)
o	LFTs and U&amp;Es before treatment
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26
Q

Indications of metformin (biguanide)?

A

Type 2 DM (1st choice) or used in combination with other OHA

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27
Q

Mechanism of metformin?

A
  • Increases sensitivity to insulin
  • Suppresses hepatic glucose production (glycogenolysis and gluconeogenesis), intestinal glucose absorption and increases glucose uptake by skeletal muscles
  • Reduces weight gain (induce weight loss)
  • Excreted unchanged by kidney
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28
Q

Side Effects of metformin?

A
  • GI upset (nausea, vomiting, taste disturbance, diarrhoea)
  • Lactic acidosis
    o In illness, worsened renal impairment, increased lactate production and reduced lactate metabolism
29
Q

Contraindications of metformin?

A

o Severe renal impairment (dose reduction in moderate)

o Withheld in AKI, tissue hypoxia, acute alcohol intoxication

30
Q

Caution of metformin?

A

o Hepatic impairment
o Chronic alcohol overuse
o Other nephrotoxic drugs (NSAIDs, diuretics, ACEi)

31
Q

Interactions of metformin?

A
  • Withheld before and 48 hours after IV contrast media

- Prednisolone, thiazide and loop diuretics elevate blood glucose so oppose actions of metformin

32
Q

Prescription of metformin?

A
  • Oral tablet
  • GI upset started at low dose and increased gradually
  • Commonly 500mg OD with breakfast then increasing 500mg weekly to BDS
  • Swallow tablets whole with glass of water with or after food
33
Q

Monitoring of metformin?
Missed dose rules?

Aims according to HbA1c?

A

o HbA1c target 48mmol/mol
o U&Es before starting treatment, then at least annually
- If miss a dose, take ASAP unless near next dose

If >58 - intensify treatment
If on one OHA not associated with hypos - Aim 48mmol/L
If on drug associated with hypos - Aim 53mmol/L

34
Q

Name of thiazolidinediones?

A

Pioglitazone

35
Q

Indications of thiazolidinediones? (pioglitazone)

A

Type 2 DM (single agent where metformin not tolerated, second or third agent)

36
Q

Mechanism of thiazolidinediones? (pioglitazone)

A
  • Insulin sensitizers
  • Activate nuclear PPARgamma which induces genes to enhance insulin action in skeletal muscle, adipose tissue and liver
  • Increased peripheral glucose uptake and reduced hepatic gluconeogenesis
  • Weight gain
37
Q

Side effects of thiazolidinediones? (pioglitazone)

A
  • GI upset, Anaemia, Dizziness, headache, disturbed vision
  • Oedema and cardiac failure
  • Bladder cancer
  • Bone fractures
38
Q

Contraindications of thiazolidinediones? (pioglitazone)

A
  • Heart failure
  • CVD
  • Bladder cancer or macroscopic haematuria
39
Q

Caution of thiazolidinediones? (pioglitazone)

A
  • Smoking, occupational exposure
  • Elderly
  • Hepatic impairment (metabolised in liver)
40
Q

Interactions of thiazolidinediones? (pioglitazone)

A

Other OHAs increase risk of hypoglycaemia

41
Q

Prescription of thiazolidinediones? (pioglitazone)

A
  • Oral
  • 15-30mg OD with breakfast and can be increased
  • Long-term treatment should not be stopped or changed
  • Taken in morning with glass of water
42
Q

Monitoring of thiazolidinediones? (pioglitazone)

A

o HbA1c before and 3-6 months after commencing

o LFTs before and during treatments

43
Q

Names of thyroid hormones?

A

Levothyroxine, liothyronine

44
Q

Indications of levothyroxine?

A

Levothyroxine, liothyronine

45
Q

Mechanism of levothyroxine?

A
  • Thyroid gland produces thyroxine (T4), which is converted into active triiodothyronine (T3) in target tissues
  • Regulate metabolism and growth
  • Levothyroxine (synthetic T4) is usual treatment. Liothyronine (synthetic T3) acts quick so used in emergency treatment of hypothyroidism
46
Q

Side Effects of levothyroxine?

A
  • Diarrhoea, vomiting, weight loss
  • Palpitations, arrhythmias, angina, flushing
  • Tremor, restlessness, insomnia
  • Menstrual irregularities
47
Q

Contraindications of levothyroxine?

A

o Thyrotoxicosis

o Pregnancy – may require increased dose – specialist care

48
Q

Cautions of levothyroxine?

A

o Coronary artery disease (low dose starting), MI, HF
o Diabetes mellitus (dose of antidiabetic drug may need increasing)
o Hypopituitarism – need corticosteroid therapy before levothyroxine to avoid Addisonian crisis

49
Q

Interactions of levothyroxine?

A
  • GI absorption affected by antacids, calcium or iron salts
    o Separate by at least 4 hours
  • Levothyroxine can change insulin or OHA requirements in diabetes
50
Q

Prescription of levothyroxine?

A

o Oral initially 50-100 micrograms OD, adjusted in 25-50 microgram steps every 3-4 weeks to response
o Maintenance of 100-200 micrograms OD, taken >30 minutes before breakfast or coffee/tea
o If elderly or cardiac disease – initial 25 micrograms daily and adjust dose to maintenance of 50-200 micrograms

51
Q

Monitoring of levothyroxine?

A

o Review patient monthly, dose changes guided by symptoms
o TFTs at 3 months after starting or a dose change
o Stable patients have annual review and TFTs

52
Q

Indications of carbimazole?

A
  • Hyperthyroidism
53
Q

MEchanism of carbimazole?

A
  • Thyroid gland produces thyroxine (T4), which is converted into active triiodothyronine (T3) in target tissues
  • Regulate metabolism and growth
  • Carbimazole reduces the amount of hormone released by thyroid
  • Does not affect thyroxine already made and stored so takes 4-8 weeks to work
54
Q

Side Effects of carbimazole?

A
  • Nausea, vomiting, stomach upset
  • Headache, muscle and joint pain
  • Skin rash and itching
  • Taste disturbances
  • Bone marrow suppression
    o Neutropenia and agranulocytosis
     Report infective symptoms (sore throat), perform WBC if clinical evidence of infection
     Stop promptly if neutropenia
55
Q

Contraindications of carbimazole?

A

o Pregnancy – use contraception when on therapy (congenital malformations, especially first trimester)
o Severe blood disorders
o Severe liver disease
o Acute pancreatitis

56
Q

Interactions of carbimazole?

A
  • Risk of myelosuppression with other medication that causes this
  • Warfarin enhances anticoagulant effects – additional monitoring needed
57
Q

Prescription of carbimazole?

A

o 15-40mg OD continue until patient euthyroid, usually after 4-8 weeks
o Reduce dose gradually, therapy usually given for 12-18 months

58
Q

Monitoring of carbimazole?

A

o Before treatment – FBC and LFT

o During treatment – TFTs every 4-6 weeks for first few months, then every 3 months

59
Q

Patient communication of carbimazole?

A

o Report any infective signs (sore throat, mouth ulcers, bruising, fever, malaise)
o Advise against pregnancy on medication – use effective contraception

60
Q

Names of glucocorticoids?

A

Prednisolone, hydrocortisone, dexamethasone

61
Q

Indications of glucocorticoids?

A

Allergic or inflammatory disorders (anaphylaxis, eczema, asthma, COPD)
Severe croup
Autoimmune disease (IBD, ITP, inflammatory arthritis)
Cancer treatment
Myasthenia Gravis, Polymyalgia rheumatica, GCA, Lupus
Proctitis
Joint injections
Adrenal insufficiency/Hypopituitarism

62
Q

MEchanism of glucocorticoids?

A
  • Bind to cytosolic glucocorticoid receptors which upregulate anti-inflammatory genes and downregulate pro-inflammatory genes (cytokines, TNFa)
  • Suppression of circulating monocytes and eosinophils
  • Metabolic effects
    o Increased gluconeogenesis
    o Increased catabolism
  • Mineralocorticoid effects
    o Stimulate Na and water retention and K excretion
63
Q

Side Effects of glucocorticoids?

A 
Immunosuppression
Diabetes mellitus
Insomnia, psychosis and suicidal ideas
Osteoporosis
Metabolic
o	Proximal muscle weakness, skin thinning with easy bruising and gastritis
Mineralocorticoid
o	Hypertension, hypokalaemia and oedema
Prolonged
o	Adrenal atrophy leading to Addisonian crisis if withdrawn suddenly
64
Q

Cautions of glucocorticoids?

A
  • Infection
  • Children (suppress growth)
  • Hepatic or Renal impairment
65
Q

Interactions of glucocorticoids?

A

Risk of peptic ulceration – NSAIDs
Hypokalaemia – B2-agonists, theophylline, loop and thiazide diuretics
Affected by CYP450 enzymes

66
Q

Prescription of glucocorticoids?

A

o Can be given orally, IM, IV
o OD, taken in the morning to mimic natural circadian rhythm
o Consider use of bisphosphonates and PPIs if long-term and risk

67
Q

Monitoring of glucocorticoids?

A

o For children – height and weight monitored annually – refer to paediatrician if slow
o Prolonged treatment – HbA1c or DEXA scan

68
Q

Cessation of glucocorticoids?

A

o Abrupt withdrawal can lead to adrenal insufficiency

o Gradual withdrawal used if treatment >3 weeks, received >40mg, repeated evening doses

69
Q

Patient communication in glucocorticoids?

A

o Should feel better in 1-2 days
o Do not stop immediately
o Steroid card to carry round at all times
o If ill, double usual dose

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