Block 34 PPT Flashcards
1
Q
AKI - actions?
A
- Optimise intra-vascular fluid volume - IV fluids
- Optimise Blood Pressure
- Withholding drugs that interfere with renal autoregulation (ACEIs, ARBs)
- Temporary cessation of all drugs that induce hypotension (antihypertensives)
2
Q
DAMN AKI?
A
- (diuretics, ACEi/ ARBs, metformin, NSAIDs)
3
Q
drugs requiring dose reduction or cessation in AKI?
A
- All medications that are metabolized and excreted by the kidneys should be dose adjusted for an assumed eGFR of < 10 mL/min/1.73m2
- fractionated heparins
- opiates
- penicillin-based antibiotics
- sulfonylurea-based hypoglycaemic drugs
- aciclovir
- metformin
4
Q
Drugs interfering w renal perfusion?
A
- ACEi
- ARBs
- NSAIDs
5
Q
drugs requiring close monitoring w renal function?
A
- warfarin
- aminoglycosides - gentamicin, tobramycin
- lithium
6
Q
drugs aggrevating hyperkalaemia?
A
- trimethoprim
- spironolactone
- amiloride
7
Q
CKD prescribing?
A
- The kidneys provide the major route of elimination for water-soluble drugs and water-soluble metabolites
- Loading doses do not usually require any modification
8
Q
side effects of gentamicin?
A
*Damage to the cochlear and vestibular apparatus - loss of balance, tinnitus, loss of hearing.
*May cause renal damage - risk of nephrotoxicity is increased with prolonged treatment.
9
Q
use of gentamicin w ? diuretics increases risk of
A
*Use with ototoxic diuretics, e.g. furosemide, may increase risk of ototoxicity and nephrotoxicity.
10
Q
gentamicin metabolism?
A
- given IV
- hydrophilic - not distrubuted into body fat and minimally disrubted into tissue fluids
- follows first order kinetics - drug is cleared from blood at a rate proportional to its concentration
11
Q
gentamicin is excreted unmodified by the ?
A
- gentamicin is excreted unmodified from the kidneys
- After a dose, level in the blood decays exponentially.
12
Q
Acute kidney injury is often preventable by:
A
- Avoiding nephrotoxic medications where appropriate
- Ensuring adequate fluid intake (including IV fluids if oral intake is inadequate)
- Additional fluids before and after radiocontrast agents
13
Q
Treating AKI involves…
A
- reversing cause and supportive management
- e.g. IV fluids for dehydration/ hypovol
- relive obstruction in post renal - e.g. catheter
14
Q
Other Tx methods in AKI?
A
- Withhold medicationsthat mayworsen the condition(e.g., NSAIDs and ACE inhibitors)
- Withhold/adjust medicationsthat mayaccumulatewith reduced renal function (e.g., metformin and opiates)
- Dialysismay be required in severe cases
15
Q
Why do ACEi need to be stopped in AKI?
A
- ACEi are not nephrotoxic
- they are stopped in AKI as they reduce filtration pressure
- but ACEi have a protective effect on the kidneys long term
16
Q
ACEi are offered to ppts w?
A
HTN, diabetes, CKD to prevent further damage
17
Q
Most common cause of AKI
A
ATN
18
Q
What happens in ATN
A
- Necrosis of renal tubular epithelial cells severely affects the functioning of the kidney.
- In the early stages ATN is reversible if the cause if removed.
19
Q
Causes of ATN?
A
- caused by ischaemia and nephrotoxins: aminoglycosides, radiocontrast agents, lead
20
Q
Features of ATN?
A
- features of AKI: raised urea, creatinine, potassium
- muddy brown casts in the urine
21
Q
AIN?
A
- 25% of drug induced AKI
- drugs: the most common cause, particularly antibiotics
22
Q
Drugs causing AKI?
A
- penicillin
- rifampicin
- NSAIDs
- allopurinol
- furosemide
23
Q
Treating underlying cause of CKD?
A
- Optimising diabetic control
- Optimising hypertension control
- Reducing or avoiding nephrotoxic drugs
- Treating glomerulonephritis (where this is the cause)
24
Q
medications that help slow progression of CKD
A
- ACE inhibitors(orangiotensin II receptor blockers)
- SGLT-2 inhibitors(specificallydapagliflozin)
25
Tx complications of CKD - metabolic acidosis?
* Oral sodium bicarbonate to treat metabolic acidosis
26
Tx of CKD - anaemia
Iron and EPO
27
treating renal bone disease w CKD?
* Vitamin D, low phosphate diet and phosphate binders to treat renal bone disease
28
Reducing risk of comps from CKD?
* Exercise, maintain a healthy weight and avoid smoking
* Atorvastatin 20mg for primary prevention of cardiovascular disease (in all patients with CKD)
29
role of drugs on progression of CKD?
Common nephrotoxic drugs such as certain antibiotics, NSAIDs, contrast agents, and chemotherapeutic agents can accelerate CKD by directly damaging renal cells and exacerbating underlying renal pathology
30
nephrotoxic drugs?
ACE, ARB, calcaeneurin inhibitors, lithium, mesalazine, NSAIDs
31
Tx of UTI?
* Nitrofurantoin - avoid in renal impairment
* Trimethoprin - avoid in pregnancy
* usually 3 days
32
Avoid nitrofurantoin in ?
renal impairment
33
avoid trimethoprim in?
pregnancy
34
Tx of a complicated UTI?
* oral course of fluoroquinolone
35
Severe UTI or urosepsis Mx?
* In the presence of more severe disease (e.g. urosepsis) or patients unable to tolerate oral therapy, broad-spectrum IV antibiotics can be used - iV co-amoxiclav or ceftriaxone can be used for urosepsis or acute severe pyelo
36
uncomplicated pyelonephritis Mx?
* uncomplicated pyelonephritis does not require admission to hospital
* can be treated w a course of oral fluoroquinolone e.g. ciprofloxacin
37
complicated pyelo?
IV co-amox or ceftriaxone
38
Altered physiology in renal function?
* impaired renal function affects various processes like filtration, secretion, reabs and metabolism of drugs
* role of kidneys in eliminating waste and maintaing fluid and electrolyte balance
39
Pharmacokinetic - dist in RI?
* Distrubution - changes in protein binding due to uremia can affect dist or highly protein bound drugs
* altered VoD with fluid overload or dehydration
40
pharmacokinetic - metabolism in RI?
* Metabolism: impaired renal function may lead to decreased drug metabolism, resulting in increased drug levels
41
Pharmacokinetic - excretion in RI?
* excretion is most sig affected: decreased clearance, longer half lives, increased drug accumulation, inc risk of toxicity
42
Pharmacodynamic response in RI?
* Increased sensitivity to drugs
* Toxicity risk espec for renally elimiated drugs
* nephrotoxic drugs can exacerbate renal dysfunction
43
Common meds causing harm to patients w impaired renal function?
* Aminoglycosides
* NSAIDs
* radiocontrast agents - e.g. iodinated contrast media
* chemotherapy - cisplatin, methotrexate
* ACEi/ ARB
* lithium
* cyclosporin and tacrolimus
44
principals involved in selecting medicines and designing dosage regimens for patients with impaired renal function.
* assessment of renal function - eGFR and creatinine clearance
* drug dose adjustment
* monitoring
* avoidance of nephrotoxic drugs
45
Where to find info about choosing and adjusting drug dosage in impaired renal function ?
* BNF
* renal drug database
* NICE CKS
46
stress incontinence - lifestyle modifications?
* Avoiding caffeine, diuretics and overfilling of the bladder
* Avoid excessive or restricted fluid intake
* Weight loss (if appropriate)
47
3 management options in SI?
* Supervised pelvic floor exercises for at least three months before considering surgery
* Surgery
* Duloxetine is an SNRI antidepressant used second line where surgery is less preferred
48
SI - pelvic floor exercises?
* pelvic floor exercises used to strengthen the muscles of the pelvic floor
* they increase the tone & improve support for the bladder and bowel
* 8 contractions 3x a day
49
surgical options for SI?
- Tension free vaginal tape
- autologous sling procedures
- colposuspension
- intramural urethral bulking
50
TVT?
* Tension-free vaginal tape (TVT) procedures involve a mesh sling looped under the urethra and up behind the pubic symphysis to the abdominal wall. This supports the urethra, reducing stress incontinence.
51
Autologous sling procedures?
* Autologous sling procedures work similarly to TVT procedures but a strip of fascia from the patient’s abdominal wall is used rather than tape
52
colposuspension?
* Colposuspension involves stitches connecting the anterior vaginal wall and the pubic symphysis, around the urethra, pulling the vaginal wall forwards and adding support to the urethra
53
intramural urethral bulking?
* Intramural urethral bulking involves injections around the urethra to reduce the diameter and add support
54
management of urge incontinence?
- bladder retraining
- anticholinergic
- mirabegron
- invasive procedures
55
first line in UI?
bladder retraining
56
bladder retraining?
* Bladder retraining (gradually increasing the time between voiding) for at least six weeks is first-line
57
UI - anticholinergics?
* Anticholinergic medication, for example, oxybutynin, tolterodine and solifenacin
* Mirabegron is an alternative to anticholinergic medications
58
SE of anticholinergic?
* anticholinergic SEs: dry mouth, dry eyes, urinary retention, constipation, postural hypotension
* can lead to cognitive decline, memory problems and worsening of dementia
59
Invasive options for overactive bladder that has failed to respond to retraining and medical management include:
* Botulinum toxin type A injection into the bladder wall
* Percutaneous sacral nerve stimulation involves implanting a device in the back that stimulates the sacral nerves
* Augmentation cystoplasty involves using bowel tissue to enlarge the bladder
* Urinary diversion involves redirecting urinary flow to a urostomy on the abdomen
60
Mx of mixed incontinence?
* target treatment at the type that appears to most contribute to the symptoms
61
overactive bladder Tx?
* bladder training
* if symptoms persist, consider adding an antimuscarinic like oxybutynin first line
* Mirabegron — if an antimuscarinic drug is contraindicated
62
overactive bladder in a post menopausal woman?
* if the woman is post-menopausal and has vaginal atrophy consider intravaginal oestrogen therapy
63
Overactive bladder - troublesome noctura?
desmopressin
64
OB - secondary care?
* Treatment options in secondary care include injection of botulinum toxin type A into the bladder wall, percutaneous sacral nerve stimulation, augmentation cystoplasty, and urinary diversion.
65
BPH and LUTS drug options?
- alpha blockers
- 5-AR
66
Alpha blockers?
* Alpha-blockers (e.g., tamsulosin) relax smooth muscle, with rapid improvement in symptoms
67
5-AR inhibitors?
* 5-alpha reductase inhibitors (e.g., finasteride) gradually reduce the size of the prostate
68
how do 5-AR inhibitors work?
* 5 alpha reductase converts testosterone to dihydrotestosterone (DHT), which is a more potent androgen hormone. Inhibitors of 5-alpha reductase (i.e. finasteride) reduce DHT in the tissues, including the prostate, leading to a reduction in prostate size.
* It takes up to 6 months of treatment for the effects to result in an improvement in symptoms.
69
surgical options for BPH/ LUTS?
* Transurethral resection of the prostate (TURP)
* Transurethral electrovaporisation of the prostate (TEVAP/TUVP)
* Holmium laser enucleation of the prostate (HoLEP)
* Open prostatectomy via an abdominal or perineal incision
70
conservative measures of LUTS/ BPH?
* pelvic floor muscle training
* bladder training
* prudent fluid intake
* containment products
71
Mx of bladder cancer?
- TURBT
- intravesical chemo
- intravesical BCG
- radical cystectomy
72
TURBT?
* Transurethral resection of bladder tumour (TURBT) may be used for non-muscle-invasive bladder cancer. The involves removing the bladder tumour during a cystoscopy procedure.
73
BC - intravesical chemo?
* Intravesical chemotherapy (chemotherapy given into the bladder through a catheter) is often used after a TURBT procedure to reduce the risk of recurrence.
74
intravesical BCG?
* Intravesical Bacillus Calmette-Guérin (BCG) may be used as a form of immunotherapy. Giving the BCG vaccine (the same one as for tuberculosis) into the bladder is thought to stimulate the immune system, which in turn attacks the bladder tumours.
75
Radical cystectomy ?
* Radical cystectomy involves the removal of the entire bladder. Following removal of the bladder, there are several options for draining urine:
* Urostomy with an ileal conduit (most common)
* Continent urinary diversion
* Neobladder reconstruction
* Ureterosigmoidostomy
76
chemotherapy in BC?
* Chemotherapy like cistplatin and radiotherapy may also be used.
77
RCC first line
* surgery is first line - partial or radical nephrectomy
78
RCC - Where patients are not suitable for surgery, less invasive procedures can be used to treat the cancer:
- arterial embolisation
- perc cryotherapy
- radiofreq ablation
79
arterial embolisation?
cutting off the blood supply to the affected kidney
80
percutaneous cryotherapy?
injecting liquid nitrogen to freeze and kill the tumour cells
81
radiofreq ablation?
* Radiofrequency ablation, putting a needle in the tumour and using an electrical current to kill the tumour cells
82
advanced RCC mx?
TKI and mTOR
83
TKI e.g.
sunitinib
84
mTOR?
* Temsirolimus/ everolimus: inhibitor of the mammalian target of rapamycin (mTOR)
85
Mx of prostate cancer?
* Surveillance or watchful waiting in early prostate cancer
* External beam radiotherapy directed at the prostate
* Brachytherapy
* Hormone therapy
* Surgery
86
EBR key side effect?
* Proctitis is a key side effect
* caused by radiation affecting the rectum
* Proctitis can cause pain, altered bowel habit, rectal bleeding and discharge
87
bracytherapy for PC?
* involves implanting radioactive metal “seeds” into the prostate.
* This delivers continuous, targeted radiotherapy to the prostate.
88
Side effect of bracytherapy?
* can cause cystitis and proctitis, ED, incontinence
* increased risk or bladder or rectal cancer
89
hormone therapy for PC?
* aims to reduce levels of androgens :
* Androgen-receptor blockers such as bicalutamide, Cyproterone acetate
* GnRH agonists such as goserelin (Zoladex) or leuprorelin (Prostap)
* Bilateral orchidectomy to remove the testicles (rarely used)
90
Side effects of hormone therapy for PC?
* Hot flushes
* Sexual dysfunction
* Gynaecomastia
* Fatigue
* Osteoporosis
91
Radical prostatectomy
* removal of entire prostate
* key comps: ED, UI
92
Modifiable RF for ED?
* Smoking cessation
* minimal alcohol intake
* weight loss
93
psychosexual counselling for ED?
* if there's a psychogenic component and if purely organic causes have been ruled out
94
drug classes for ED?
- PDE-5 inhib like slidenafil
- PE-1 analogue - aprostadil
95
PDE-5 inhibitors?
* These drugs arrest PDE-5, allowing for the prolongation of cGMP and subsequent relaxation of penile blood vessels (sildenafil, vardenafil, avanafil).
96
PE-1 analogues?
* Alprostadil
* induces vascular SM relaxation
97
penile prosthesis?
* recommended when previous treatments have failed
* inflatable implants vs semirigid rods
98
new IDA without an underlying cause?
New iron deficiency in an adult without a clear underlying cause (e.g., heavy menstruation or pregnancy) should be investigated further, including a colonoscopy and oesophagogastroduodenoscopy (OGD) for malignancy.
99
Three options for treating IDA?
- Oral iron
- iron infusion
- blood tranfusion
100
Oral iron?
* Oral iron (e.g., ferrous sulphate or ferrous fumarate)
* side effects: constipation and black stools
* need to be taken for 3 months after levels have been corrected
101
iron infusion?
* Iron infusion (e.g., IV CosmoFer)
* rapid boost
* small risk of allergic reactions
* avoided in infections - risk of feeding bacteria
102
iron rich diet?
* Iron-rich diet: this includes dark-green leafy vegetables, meat, iron-fortified bread
103
B12 def Mx?
* IM hydroxocobalamin
* in patients with co-existing folate deficiency, B12 must be replaced first as folate replacement in this setting may precipitate neurological complications (e.g. subacute degeneration of the cord).
104
B12 > B9 replacement because
risk of subacute degeneration of the cord
105
foods rich in b12?
* Eggs.
* Foods which have been fortified with vitamin B12 (for example some soy products, and some breakfast cereals and breads) are good alternative sources to meat, eggs, and dairy products.
* Meat.
* Milk and other dairy products.
* Salmon and cod.
106
Folate def?
* folic acid supplementation
107
sources of folate?
* Asparagus.
* Broccoli.
* Brown rice.
* Brussels sprouts.
* Chickpeas.
* Peas.
108
packed red cells indications?
* Indicated for patients with symptomatic anemia, acute blood loss, or impaired oxygen delivery.
* Major haemorrhage
109
FFP is used for?
* Used to correct coagulation factor deficiencies in patients with bleeding disorders or massive transfusions.
* clinically sig bleeding but without major haemorrhage if they have an coagulation results
110
platelet concentrates are used for?
* Administered to patients with thrombocytopenia or platelet dysfunction to prevent or treat bleeding.
111
cryoprecipitate Ix?
* Contains high concentrations of fibrinogen, factor VIII, and von Willebrand factor, used in cases of hypofibrinogenemia or von Willebrand disease.
112
albumin is used for?
* Used for volume expansion and to maintain colloid osmotic pressure in patients with hypoalbuminemia or hypovolemia.
113
factor concentrayes Ix?
* Specific coagulation factors (e.g., factor VIII for hemophilia A) administered to patients with congenital or acquired clotting factor deficiencies.
114
granulocytes concentrates Ix?
* Utilized in patients with severe neutropenia or neutrophil dysfunction to prevent or treat infections.
115
immunoglobulins Ix?
* Administered for passive immunity in patients with immunodeficiencies or autoimmune disorders.
116
whole blood transfusions?
* Used in specific clinical scenarios, such as massive transfusion protocols or exchange transfusions.
117
Prothrombin complex concentrate is used immediately for?
* offer immediate prothrombin complex concentrate transfusions for the emergency reversal of warfarin AC in ppts w either
* severe bleeding
* or head injury with suspected inracerebral haemorrhage
118
Mx of hypothyroidism?
* levothyroxine: synthetic T4 which is metabolised to T3 in the body
119
Mx of hyperthyroidism - whilst decision on definitive therapy is being made?
* thionamides - carbimazole or propylthiouracil whilst decision on definitive therpay is being made
120
definitie Mx of hyperthyroidism?
* definitive therapy = radioactive iodine, ongoing thionamide therapy or surgery
121
symptomatic treatment of hyperthyroidism?
* BB or CCB can be prescribed to reduce adrenergic symptoms whilst thionamides take effect
122
radioactive iodine therapy?
* taken up by the thyroid causing destruction and reduced thyroid hormone release
123
thionamides?
* carbimazole first line
* teratogenic - especially in T1
124
when is PTU considered?
* Intolerant/allergic to carbimazole
* Pregnant or planning on pregnancy in the next 6 months
* A history of pancreatitis
125
testing before thionamide tx?
* Baseline FBC and LFTs are obtained prior to the commencement of thioamides.
* Neutropenia or severely deranged transaminases are a contraindication to treatment.
126
severe side effects of thionamides?
* Agranulocytosis is a severe side effect associated with both thioamides
127
thyroidectomy?
* may be used as definitive therapy if malignancy is suspected, there is a compressive goitre or RAI/ anti-thyroid medications are unsuitable.
128
hemithyroidectomy?
* Hemithyroidectomy (removal of half the thyroid gland) may be offered to patients with a solitary toxic nodule.
129
complications of thyroidectomy?
hypocalcaemia, recurrent LN injury
130
AP hormones?
- ACTH
- FSH, LH
- gh
131
testing adrenal function in panhypopituitarism - ACTH?
* Tetracosactide (tetracosactrin), an analogue of corticotropin (ACTH), is used to test adrenocortical function
* failure of the plasma cortisol concentration to rise after administration of tetracosactide indicates adrenal insufficiency
132
Replacing gonadotrophin function in panhypopituitarism?
* FSH + LH used in the treatment of infertility in women with proven hypopituitarism or who have not responded to clomifene citrate
133
GH indications?
* In children it is used in Prader-Willi syndrome, Turner syndrome, chronic renal insufficiency, short children considered small for gestational age at birth, and short stature homeobox-containing gene (SHOX) deficiency
* somatropin
134
hypothalamic hormone replacement?
* gonadorelin leads to rapid rise in LH and FSH
* Gonadorelin analogues are indicated in endometriosis and infertility and in breast and prostate cancer.
135
Mx of hyperprolactinaemia?
* bromocriptine used for treatment of galactorrhoea and treatment of prolactinomas
* cabergolline
136
suppression of lactation - if DRA is required,
* if DRA is req, cabergoline is preferred to bromocriptine
137
Mx of hypogonadism?
* Address any reversible factors contributing to hypogonadism, such as lifestyle modifications (weight loss, smoking cessation), treatment of underlying conditions (e.g., obesity, diabetes), or removal of medications causing hypogonadism
* Testosterone replacement therapy
138
when is GH therapy recommended?
* proven growth hormone deficiency
* Turner's syndrome
* Prader-Willi syndrome
* chronic renal insufficiency before puberty
139
GH replacement is given by?
* given by subcutaneous injection
* GH replacement - recombinant human GH before bed - somatotropin
140
drugs in chronic adrenal insufficiency?
* Glucocorticoid replacement - hydrocortisone
* Mineralcorticoid replacement - fludrocostisone
* Androgen replacement - DHEA replacement in women
141
AI - 3 drugs
hydrocortisone, fludorcortisone, DHEA (in women)
142
steroids in CAI?
* ppts given a steroid card, ID tag and emergency letter to alert that they depend on steroids
* Doses are doubled during an acute illness to match the normal steroid response to illness.
143
Addisonian crisis Mx?
* Intensive monitoring if they are acutely unwell
* Parenteral steroids (i.e. IV hydrocortisone)
* IV fluid resuscitation
* Correct hypoglycaemia
* Careful monitoring of electrolytes and fluid balance
144
summary of drugs in addisonian crisis?
- IV hydrocortisone
- IV fluids
145
initial Mx of hypercal?
rehydration w normal saline
146
what can be done in hypercal after the ppt has been rehydrated?
- bisphosphonates
- calcitonin - quicker than bisphosphonates
- steroids in sarcoidosis
147
? are sometimes used in hypercal, paticularly in ppts who can't tolerate aggressive fluids?
* Loop diuretics such as furosemide are sometimes used in hypercalcaemia, particularly in patients who cannot tolerate aggressive fluid rehydration.
148
surgery in hyperclacemia?
* surgery: able to provide a cure in primary hyperparathyroidism. Potential option in tertiary hyperparathyroidism
149
dialysis in hypercal?
reserved for severe, refractory hypercalcaemia.
150
Hypercalcaemia -Mild (< 3 mmol/L) and asymptomatic/mild symptoms:
increase oral fluids and avoid precipitants (e.g. thiazide diuretics, lithium, dehydration).
151
moderate hypercal (3-3.5)?
acute rise requires inpatient admission for intravenous fluids. Chronically raised elevations may not require acute management depending on the aetiology and symptomatology.
152
severe hypercal - 3.5?
all patients require urgent admission to hospital and treatment. Treatment involves aggressive intravenous fluids and consideration of bisphosphonates, particularly if malignancy is suspected.
153
management of an adult patient with hypocalcaemia/vitamin D deficiency/(osteomalacia).
* colecalciferol (vitamin D₃).
154
NICE recommends checking calcium level within a month of the loading regime for osteomalacia:
* Low in calcium deficiency
* High in primary hyperparathyroidism (previously masked by the vitamin D deficiency)
* High in other conditions that cause hypercalcaemia, such as cancer, sarcoidosis or tuberculosis
155
RF for osteopososis?
* address reversible RF - physical activity, maintain healthy weight, stop smoking, reduce alcohol consumption
* address calcium and vitamin D intake
156
bisphosphonates ?
* first line Tx of osteoporosis
* considered in ppts on long term steroids
157
Bisphosphonates have some important side effects:
* Reflux and oesophageal erosions
* Atypical fractures (e.g., atypical femoral fractures)
* Osteonecrosis of the jaw (regular dental checkups are recommended before and during treatment)
* Osteonecrosis of the external auditory canal
158
how should bisphosphonates be taken?
Oral bisphosphonates are taken on an empty stomach with a full glass of water. Afterwards, the patient should sit upright for 30 minutes before moving or eating to reduce the risk of reflux and oesophageal erosions.
159
other Tx of osteoporosis?
- denosumab
- romosozumab
- teriparatode
- HRT
- raloxifene
160
denosumab?
monoclonal antibody that targets osteoclasts)
161
romosozumab?
* Romosozumab (a monoclonal antibody that targets sclerostin – a protein in osteocytes that inhibits bone formation)
162
teriparatide?
* Teriparatide (acts as parathyroid hormone)
163
HRT?
used for osteoporosis paricularly in women w early meno
164
Raloxifene?
SERM
165
Hyponatraemia - hypervolaemic cause?
* normal, i.e. isotonic, saline (0.9% NaCl)
* this may sometimes be given as a trial
* if the serum sodium rises this supports a diagnosis of hypovolemic hyponatraemia
* if the serum sodium falls an alternative diagnosis such as SIADH is likely
166
euvolemic hyponatreamia - most common cause?
SIADH
167
Euvolemic hyponatreamia Mx?
* fluid restrict to 500-1000 mL/day
* demeclocycline - ADH inhibitor
* vaptans - vasopressin receptor antagonist
168
hypervolaemic hyponatreamia?
* fluid restrict to 500-1000 mL/day
* consider loop diuretics
* consider vaptans
169
what are vaptans?
* ADH antagonists
* act on V2 receptors, resulting in selective water diuresis, sparing electrolytes
170
vaptans should be avoided in?
should be avoided in ppts who have hypovolaemic hyponatreamia
171
Severe hyponatreamic can result in?
* untreated severe hyponatreamia may result in cerebral oedema which can cause brain herniation
172
acute hyponatreamia management?
* acute hyponatraemia - Hypertonic saline (typically 3% NaCl) is used to correct the sodium level more quickly than would be done in patients with chronic hyponatraemia
173
acute hyponatreamia should be managed in?
high dependency unit (HDU) espec if neurological symptoms are present
174
DI - underlying cause?
The underlying cause should be treated (e.g., stopping lithium). Mild cases may be managed conservatively.
175
Cranial diabetes insipidus Mx?
- desmopressin - synthetic ADH to replace missing ADH
- serum sodium needs to be monitored, as there is a risk of hyponatraemia (low sodium) with desmopressin.
176
Nephrogenic diabetes insipidus management options include:
* Ensuring access to plenty of water
* High-dose desmopressin
* Thiazide diuretics
* NSAIDs
177
urge incont associated w
OBS
178
stress incont due to?
urethral sphincter incompetence.
179
Overflow incontinence with continuous urine leakage from
hypotonic bladder or bladder outlet obstruction producing urinary retention
180
drugs for urinary urgency?
* Muscarinic antagonists: oxybutinin, tolerodine
* B-3 receptor agonists: mirabegron
181
muscarinic blockage side effects?
* BCDU
* dry mouth
* tachy
* constipation
* bludder vision
* urinary retention if there's bladder outflow obst
182
Drug interactions ofr alpha blockers?
* Mostly by pharmacodynamic interaction causing hypotension
* Other hypotensive agents
* CCBs
* Beta – blockers
* ACE Is, ARBs
* PDE 5 inhibitors - Sildenafil & Vardenafil
183
5-AR inhibitors absolute contra-indication?
Exposure of a male fetus to 5α-reductase inhibitors may cause abnormal development of the external genitalia. It is therefore important that pregnant women do not take these drugs and are not exposed to them, e.g. by handling broken or damaged tablets or through semen during unprotected sex with a man taking these drugs.
184
side effects of 5-ARi like finasteride?
* Breast enlargement
* Breast tenderness
* Decreased libido
* Ejaculation disorders
* Impotence
185
BC - cisplatin based chemo?
* Urothelial bladder cancer is most sensitive to cisplatin-based combination chemotherapy
186
platininum based chemo in BC?
* Platinum-based chemotherapy is the preferred initial approach for systemic therapy in patients with metastatic disease.
187
drug interaction of iron salts
* Mostly by reducing absorption
* Levothyroxine
* Bisphosphonates
* Ciprofloxacin
* Tetracyclines
* Calcium and zinc salts
* These medications should therefore be taken at least 2 hours before oral iron.
188
Ooral dose of iron for IDA?
* oral dose of elemental iron for IDA should be 100 to 200mg daily
189
B12 replacement
* If treating a macrocytic anaemia where there may be a suspected Vitamin B12 deficiency (i.e. you don’t know the serum B12 levels are absolutely and categorically normal) – always give vitamin B12 before starting folic acid.
* Risk of subacute combined degeneration of the cord
190
majority of b12 deficiency is caused by?
* The vast majority of vitamin B12 deficiency is due to inability to absorb B12 in the terminal ileum (e.g. lack of intrinsic factor, terminal ileal Crohn’s disease)
191
non pharm management of T2 diabetes?
* lifestyle advice
* dietary changes, exercise and physical activity, alcohol consumption and smoking cessation
* especially for pre diabetes - 42-47mmol
192
Diet for T2D?
* Patients should be encouraged to maintain a healthy balanced diet with plenty of fibre, low-index carbohydrate and controlling the intake of high-fat foods
193
T2D should avoid?
* Alcohol increases weight and may exacerbate or prolong hypoglycaemia induced by antidiabetic medications.
194
step 1 in the management of T2D?
* Standard release metformin
* Aim for HbA1c < 48 mmol/mol, increasing dose as needed
195
monitoring w metformin?
* Monitor renal function, consider modified-release preparations if develop adverse GI effects
196
step 2 in T2D Mx?
* Consider dual antidiabetic therapy if HbA1c rises > 58 mmol/L
* Metformin in combination with a second antidiabetic agent:
* Sulfonylurea (SU)
* Dipeptidyl peptidase-4 inhibitor (DPP-4i)
* Pioglitazone
* Sodium–glucose cotransporter 2 inhibitor (SGLT-2i)
197
HbA1c aim for dual antidiabetic therapy?
less than 53 mmol
198
diabetes management summary?
1) metformin
2) metformin + second agent
3) metformin + 2 agents or insulin based regime
4) metformin, SU, GLP-1, insulin
199
When should triple antidiabtic therapy be considered?
Consider triple antidiabetic therapy or an insulin-based regimen if HbA1c > 58 mmol/
200
step 3: triple antidiabetic therapy?
* Metformin, DPP-4i and SU
* Metformin, pioglitazone and SU
* Metformin, pioglitazone/SU, and SGLT-2i
201
step 4 in diabetes Mx?
* consider combination treatment with metformin, SU, GLP-1 analogue (if criteria for GLP-1 met)
* insulin
202
Step 1 of D managemenrt when metformin CI?
* DPP-4i or pioglitazone or SU
* Aim for HbA1c < 48 mmol/mol or < 53 mmol/mol if treatment with a SU
203
Step 2 when metformin CI?
* If HbA1c rises > 58 mmol/mol consider a combination of:
* SU and pioglitazone
* SU and DPP-4i or
* Pioglitazone and DPP-4i
204
Step 3 when metformin CI
* consider insulin if >58
205
tX aims in diabetes
* Management with lifestyle modifications only: aim HbA1c < 48 mmol/mol
* Management with lifestyle and a single antidiabetic agent: aim HbA1c < 48 mmol/mol
* Management with a drug associated with hypoglycaemia (e.g. SU): aim HbA1c < 53 mmol/mol
* Management with higher intensification regimes: aim HbA1c < 53 mmol/mol
206
insulin in T2D?
* considered when there is poor glycaemic control despite dual AP therapy
* may not be appropriate when: risk of hypos, concerns relating to licensing for driving gr 2 vehicles, can exacerbate weight loss
207
which type of insulin is offered to T2D?
* patients are offered an intermediate-acting insulin therapy such as NPH in the initial stages.
208
insulin used when hba1c is v high in T2D?
* If glycemic control is particularly bad (e.g. HbA1c > 75 mmol/L) patients may be started on mixed insulin (intermediate and short-acting).
209
long acting insulin in T2D?
* Long-acting insulin is usually reserved for patients where hypoglycaemia is a problem with NPH insulin or the patients rely on carers for help with their injections
210
First line in T2D summar
211
When should SFLT2 inhibioy be given?
* should be given in addition to metformin if:
* high risk of CVD e.g. QRISK >10%
* established cvd
* CHF
* SGLT-2 inhibitors should also be started at any point if a patient develops CVD (e.g. is diagnosed with ischaemic heart disease), a QRISK ≥ 10% or chronic heart failure
212
when SGLT2 and metformin are being used,
* metformin should be established and titrated up before introducing the SGLT-2 inhibitor
213
further Mx of T2D?
214
if SGLT2 required but metformin is CI?
* if the patient has a risk of CVD, established CVD or chronic heart failure:
* SGLT-2 monotherapy
215
If metformin is CI and there is no risk of CVD or HF?
* DPP€‘4 inhibitor or pioglitazone or a sulfonylurea
216
Tx of HTN in diabetes?
* Same as for ppts without T2D
* ACEi first line in whites
* ARB first line in blacks
217
Lipid modification in diabetes?
* atorvasatin if QRISK >10%
218
BG monitoring in T1D?
* At least 4x a day including before each meal and before bedM
219
When is more freq blood glucose monitoring required?
* more frequent monitoring is recommended if frequency of hypoglycaemic episodes increases; during periods of illness; before, during and after sport; when planning pregnancy, during pregnancy and while breastfeeding
220
first line insulin therapy in T1D?
* 1) multiple injection basal bolus regime which involves background long acting insulin and short acting insulin injected 30 mins before carbs
221
# and what doe s it require
insulin pumps?
* Insulin pumps - constant infusion - alt to basal bolus regimes
* pump pushes insulin through a cannula which is replaced every 2-3 days to prevent lipodystophy
222
tethered pumps?
* Tethered pumps are devices with replaceable infusion sets and insulin. They are usually attached to the patient’s belt or around the waist with a tube connecting the pump to the insertion site. The controls for the infusion are on the pump itself.
223
patch insulin pumps?
* Patch pumps sit directly on the skin without any visible tubes. When they run out of insulin, the entire patch pump is disposed of, and a new pump is attached. A separate remote usually controls patch pumps.
224
One, two, or three injections per day insulin regime?
* One, two, or three injections per day regime: traditionally a biphasic regime with the use of both short-acting and intermediate-acting insulin as separate injections or a mixed product.
225
what are the short acting insulins?
* Actrapid and Humulin S are short acting human insulins.
* Humalog, Novorapid and Apidra are short acting analogue insulins.
226
main principles of DKA managements?
- fluid replacement - isotonic saline
- insulin - IV infusion
- glucose - add when less than 14
227
electrolyte abn in DKA?
* correction of electrolyte abn - potassium often falls quickly following treatment with insulin -> hypokalaemia
228
Which type of insulin should be continued in DKA?
long acting continued, short acting stopped
229
DKA - slower infusion in?
* slower infusion for young adults (18-25) -> risk of cerebral oedema
230
DKA resolution is defined as:
* pH >7.3 and
* blood ketones < 0.6 mmol/L and
* bicarbonate > 15.0mmol/L
231
The goals of management of HHS can be summarised as follows:
* 1. Normalise the osmolality (gradually)
* 2. Replace fluid and electrolyte losses
* 3. Normalise blood glucose (gradually)
232
first line in HHS?
fluid replacement - 0.9% NaCl
233
Fluid replacement in HHS?
* The aim of treatment should be to replace approximately 50% of estimated fluid loss within the first 12 hours and the remainder in the following 12 hours
* Fluid replacement alone (without insulin) will gradually lower blood glucose which will reduce osmolality
* rapid changes need to be avoided
234
insulin in HHS?
* sig ketoneaemia -> give insulin otherwise do NOT
235
mechanism of insulin in HHS?
* Because most patients with HHS are insulin sensitive (e.g. it usually occurs in T2DM), administration of insulin can result in a rapid decline of serum glucose and thus osmolarity.
* Insulin treatment prior to adequate fluid replacement may result in cardiovascular collapse as the water moves out of the intravascular space, with a resulting decline in intravascular volume.
* A steep decline in serum osmolarity may also precipitate CPM.
236
Electroyte that needs to be corrected w HHS?
k+
237
Potassium shifts in HHS?
* Patients with HHS are potassium deplete but less acidotic than those with DKA so potassium shifts are less pronounced
* Hyperkalaemia can be present with acute kidney injury
* Patients on diuretics may be profoundly hypokalaemic
238
Management of hypoglycaemia in the community (for example, diabetes mellitus patients who inject insulin):
* Initially, oral glucose 10-20g should be given in liquid form or sugar lumps.
* Alternatively, a propriety quick-acting carbohydrate may be given: GlucoGel or Dextrogel
* A 'HypoKit' may be prescribed which contains a syringe and vial of glucagon for IM or SC injection at home
239
Management of hypoglycaemia in hosp
* If the patient is alert, a quick-acting carbohydrate may be given .
* If the patient is unconscious or unable to swallow, subcutaneous or intramuscular injection glucagon may be given.
* Alternatively, intravenous 20% glucose solution may be given through a large vein
240
# Insulin
perioperative care in diabetics - day surgery
* day surgery may only need reduction in insulin dose or omission/continuation of oral drug
* Use of variable rate insulin infusion + Glucose
* Transition back to usual diabetes regimen
241
Elective surgery - minor procedures in patients w good glycaemic control
* HbA1c less than 69 who are undergoing minor procedures can usually be managed by adjusting their insulin regimen
* On the day before the surgery, the patient’s 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 %.
242
Elective surgery—major procedures or poor glycaemic control?
* major procedures (longer fasting period of more than one missed meal) or poor diabetes control -> variable rate IV insulin infusion
* continued until the patient is eating/drinking and stabilised on their previous glucose-lowering medication
243
insulin use in major procedures or poor fglycaemic control?
* long acting insulin should be given at 80% of the normal dose the day before and day of, all other insulin should be stopped until their eating and drinking again
244
major procedures/ poor glycaemic control - on the day of surgery give?
* on the day of surgery, start IV infusion of KCl - To prevent hypoglycaemia, this infusion must not be stopped while the insulin infusion is running
* variable rate IV infusion of insulin in sodium chloride should be gviven at intiial infusion
245
Which diabetes meds can be taken as normal during the whole periop period?
* Pioglitazone, gliptins, GLP-1 analogues can be taken as normal during the whole perioperative period
246
what should be omitted on the day of surgery?
* SGLT-2 inhibitors should be omitted on the day of surgery - their use during periods of dehydration and acute illness is associated with an increased risk of developing diabetic ketoacidosis.
247
which drug is associated w hypo in the fasted state and needs to be omitted the day of surgery?
* sulfonylureas - associated w hypo in the fasted state and so should always be omitted the day of surgery until eating and drinking
248
which drug can be cont unless the patient cwill miss more than1 meal?
* Metformin - can be continued less the patient will miss more than one meal or sig risk of AKI -> lactic acidosis
249
SGLT2 inhibitors are associated w ?
inc risk of developing DKA during dehydration, stress, surgery. trauma, acute ilness or other catabolic states
250
diabetes drugs and surgery summary table
251
Sick day rules - type 1?
* patient cannot stop insulin due to risk of DKA
* more freq glucose monitoring
* maintain normal meal pattern or replace meals w carb drinks
* 3L of fluid to prevent dehydration
252
sick day in type 2 duabetcs?
* advise the patient to temporarily stop some oral hypoglycaemics during an acute illness
* medication may be restarted once the person is feeling better and eating and drinking for 24-48 hours
253
sick day - metformin?
* metformin: stop treatment if there is a risk of dehydration, to reduce the risk of lactic acidosis
254
Diabetes sick day - sulfonylureas?
increase the risk of hypoglycaemia
255
diabetes sick day rules - SGLT2 INHIB?
* SGLT-2 inhibitors: check for ketones and stop treatment if acutely unwell and/or at risk of dehydration, due to the risk of euglycaemic DKA
256
Diabetes sick day rules - GLP-1 agonists?
* GLP-1 receptor agonists: stop treatment if there is a risk of dehydration, to reduce the risk of AKI
257
Diabetes sick day - insulin?
* if on insulin therapy, do not stop treatment
* monitor blood glucose more frequently as necessary
258
rapid acting insulin?
* Novorapid, humalog, apidra
* dec risk of hypoglycaemia
259
short acting insulin?
* soluble
* actrapid, humulin S
* slower onset and longer duration
260
Insulin - multiple daily injections?
*Most T1DM
261
Biphasic insulin twice daily?
*T2DM
*T1DM incapable of using MDI
262
# When is it used
long acting once daily insulin?
*T2DM usually with oral drugs
263
Continuous subcutaneous insulin infusion (CSII)
*T1DM
264
DAFNE?
DAFNE stands for Dose Adjustment for Normal Eating. It's an educational program for people with type 1 diabetes aimed at helping them better manage their condition through understanding the effects of food, insulin, and exercise on blood sugar levels. DAFNE teaches individuals how to adjust their insulin doses based on factors like carbohydrate intake, physical activity, and blood glucose levels to achieve better control over their diabetes
265
Summary of diabetes meds
266
summary of further insulin Tx ?
267
metformin and renal activity?
* 100% renal clearance - can't use in RI
* decreases gluconeogesis and increases peripheral insulin sensitivity
268
sulfonylreas SE?
* weight gain
* GI side effects
* can cause hypoglycaemia!!
269
pioglitazone (thiazolindinediones)?
* weight gain
* edema
* heart failure - espc when given w insulin
* Small bone fractures (esp women)
* Small increased risk of bladder cancer
270
Pioglitazone and insulin ->
HF
271
ddp4 inhib SE?
* No hypoglycaemia as monotherapy
* Weight neutral
* Low potency
272
Which DDP4 inhibitors need dose adjustemtn for renal impairment?
* Sitagliptin and saxagliptin need dose adjustment for renal impairment
273
which DDP4i doesnt need dose adjustemnt for RI?
* Linagliptin no need for renal dose adjustment
274
SGLT2 impact on weight?
* No hypoglycaemia as monotherapy
* Weight neutral (may aid weight loss)
* Good glucose lowering effect
275
side effects of SGLT2i?
* Urinary infections + candidiasis
* Hypovolaemia (uncommon)
276
rare SE of SGLT2i?
* DKA (rare)
* Fournier’s gangrene (rare)
277
GLP-1 analogue?
* No hypoglycaemia as monotherapy
* Weight loss
* Good glucose lowering effect
* Injectable
278
glp-1 analogue - side effect?
* GI side effects – N & V
* Risk of pancreatitis
279
GLP-1 analogues should be avoided in?
medullay thyroid Cx
280
DKA treatment summary?
* fluid resus
* treatment of ketosis and hyperglycaemia w insulin infusion
* management of potassium effects
* transition back to usual insulin regime
281
differences of HHS comp too DKA?
* IV fluids before insulin – essential
* No IV insulin until glucose stops falling by 5 mmol/hr using IV fluids
* If IV insulin needed then use low dose (0.5 units/kg/hr)
* Need for thromboprophylaxis
* Look for infection + treat
* Foot care
282
characteristic features of HHS
* hypovolaemia
* marked hyperglycaemia (>30mmol) without sig hyperketoneaemia (<3mmol) or acisdosis (ph >7.3)
* high osmolarity >320
283
hypo - adults who are unconscious and/or having seizures and/or are very aggressive w IV access?
* If IV access available, give 75-100ml of 20% glucose over 15 minutes, (e.g. 300-400ml/hr).
* If IV access available, give 150-200ml of 10% glucose (over 15 minutes, e.g. 600-800ml/hr).
284
hypo - adults who are unconscious and/or having seizures and/or are very aggressive - no IV access?
* If no IV access is available then give 1mg Glucagon IM.
285
graves radioiodine scan results?
* thyroid will have homogenous uptake
* pyramidal lobe visualization supports diagnosis
286
Toxic multinodular goitre radiodione scan?
* herotegnous thyroid appearancr rep a mix of overactive tissues and normal tissue
* high radio-iodine uptake
287
subacute thyroiditis radioidoine scan?
* thyrotoxicosis secondary to leakage of stored hormone from an inflamed gland
* v low uptake of radioiodine
288
toxic nodule radioiodine scan?
* almost always benign
* focal inc uptake w suppression of surrounding tissues
* high uptake
289
Treating hyperprolactinoma - dopamine agonists?
* cabergoline: causes less nausea than bromocriptine, adminstered once or twice a week
* bromocriptine - daily
290
Hypercal summary?
* Bisphosphonates
* Calcitonin
* Corticosteroids (high Vit D, sarcoidosis)
291
Hypercalcaemia >3.5 mmol/L =
EMERGENCY
* IV 0.9% sodium chloride
* IV Zoledronic acid 4mg over 15 min (once fully rehydrated)
292
how do bisphosphonates work?
* inhibit osteoclastic bone resportion
* poorly abs from gut - orally best taken once a week on an empty stomach to avoid binding Ca2+ in food
293
hypocalcaemia?
* PTH def, vitamin D def
* usually treated w vitamin D compounds
294
hypocalcaemia Tx?
* alfacalcidol (1α-hydroxycholecalciferol), calcitriol (1,25-dihydroxyvitamin D3 or 1,25-dihydroxycholecalciferol) – can be used in renal failure
* colecalciferol (vitamin D3), ergocalciferol (vitamin D2) – need a functioning kidney
295
hypomagnesima and hypocalcaemua?
- Severe hypomagnesemia can result in hypocalcemia as magnesium is a co-factor necessary for PTH production in the parathyroid glands.
- correct Mg first
296
comps of Severe hyponatreamia?
* risk of osmotic demylination syndrome
* too rapid rise or fall in serum Na
* limit to no greater than 10mmol change in first day
297
SIADH mX?
* tolvaptan
* decreases binding ot vasopressin at the V2 receptor, decreasing fluid secretion
298
acute hyponatreamia management?
- hypertonic saline - 3% NaCl
299
Acute severe hyperkalaemia Mx?
- defined as K+ >6.5
- urgent IV treatment with calcium chloride or calcium gluconate
300
what else can be used for acute hyperkalaemia?
- IV injection of insulin with 50mL glucose 50%
- salbutamol
301
correcting acidosis w hyperkalaemia?
sodium bicarb (do not give in the same line as calcium salts - risk of precipitation)
302
hyponatraemia symptoms?
* Seizures
* Obtundation
* Respiratory failure
* Nausea & vomiting,
* Headache
* altered mental status
* Asymptomatic especially in chronic hyponatraemia (>48hrs onset)
303
# management
Hyponatreamia - SIADH?
- fluid restruction to 1/L/ day and use of 3% sodium chloride infusion
- or loop diuretic
304
hypernatremia symptoms?
* Lethargy
* Weakness
* Irritability
* Seizures
* Increased thirst
* Spasticity
* Hyperreflexia
* Hyperthermia
* Delirium
* Coma if hypernatremia is acute (< 48 hours) and/or severe
305
management of hypernatreamia?
isotonic saline
306
causes of hypokalaemia?
- loop and thiazide diuretics
- hyperaldosteronism
- GI losss - diarrhoea, vomiting
- hypomag
307
symptoms of hypokalaemia?
* Muscle pain
* Cramps
* Weakness
* Fatigue
* Constipation
* Syncope
* Palpitations
308
K+ of < 2.5
* In <2.5mmol/L - paralysis starting from lower extremities then upwards, respiratory failure, ileus, tetany
309
Hypokalaemia ECG?
- flattened T waves
- ST depression
- U waves
310
Hypokal managament?
- Mild - sando-K oral
- moderate - IV
- severe (life threatening) - iV K+
311
severe hyperkal =
> 6.5
312
drugs causing hyperkal?
- amiloride
- ACE
- heparin
- NSAIDs
- ciclosporin
313
symptoms of hyperkal?
* Weakness
* Fatigue
* Flaccid paralysis
* Depressed/absent reflexes
* bradycardia
314
ecg in hyperkal?
- tall tented T waves
- prolonged PR
- wide QRS
- asystole
315
stabilising the myocardium when potassium is > 6.5?
- IV calcium chloride
- IV calcium gluconate
316
Hyperkal: shifting K intracellularly?
- glucose
- salbutamol
317
hyperkal - removing it from the body?
- sodium zirconium
- calcium resonium
318
what can be used in resistant hyperkal?
haemodialysis
319
