BNF Chapter 6: Endocrine Flashcards
Why is an insulin passport for diabetics important?
Provides accurate identification of their current insulin therapy across healthcare sectors- errors can be severe.
Why is it important for patients to rotate insulin injection sites frequently?
Injection of insulin (all types) can lead to deposits of amyloid protein under the skin (cutaneous
amyloidosis) at the injection site which interferes with insulin absorption thus it is important to rotate injection sites.
Which safety needles are first-choice when prescribing?
GlucoRx Safety Pen Needle (5mm/30G or 8mm/30G)
What are some examples of rapid-acting insulin analogues for meal-times?
Trurapi (insulin aspart)- preferred cost-effective option for new patients
Novorapid (insulin aspart)- an option if pt is already on novorapid, new patients should be consdiered for Trurapi instead
Fiasp (insulin aspart)
Humalog (insulin lispro)
Apidra (insulin glargine)
What are some examples of long-acting insulins as basal?
Levemir (insulin detemir)- first-choice for adult type 1 diabetics
Semglee (insulin glargine biosimilar)
Lantus (insulin glargine)- an option for existing stable patients
Toujeo (insulin glargine)
Tresiba (insulin degludec)
What is the first-choice meal-time insulin for diabetics, and why?
Trurapi, most cost-effective
What is the first choice basal insulin for adult type 1 diabetics?
Levemir
Insulin for Type 2 Diabetics
-Pre-mixed human insulin (commonly used twice daily regimen): Biphasic isophane insulin
-Pre-mixed analagues (an option if the patient prefers to inject insulin immediately before a meal):
*Biphasic aspart
*Biphasic lispro
.
More on Insulin for Type 2 Diabetics
In a meta-analysis, short-acting insulin analogues for type 2 diabetes did not improve HbA1c, hypoglycaemia,or quality of life, compared with conventional human insulin. JAPC has agreed that insulin analogues in type 2 diabetes are overused and should be considered after conventional human insulin.
Human NPH insulin is preferred, however, long acting analogues can be considered as an alternative in type 2 diabetes if:
* the person needs assistance from a carer or healthcare professional to inject insulin and use of detemir or glargine (ensure glargine prescribed as brand name) would reduce the frequency of injections from twice to once daily or
* the person’s lifestyle is restricted by recurrent symptomatic hypoglycaemic episodes or
* the person would otherwise need twice-daily NPH insulin injections in combination with oral glucoselowering drugs.
Insulin in Type 1 Diabetics
Guidance recommends patients with type 1 diabetes should usually be offered two insulins that act in different ways:
* a background (also known as a ‘basal’ or ‘long-acting’) insulin ideally injected twice a day (insulin detemir)
AND
* a ‘quick-acting’ (also known as a ‘bolus’ or ‘rapid-acting’) insulin injected before each meal to deal with the rise in blood glucose from eating.
.
How much of a HbA1c reduction is considered significant in regards to antidiabetic drugs?
5mmol/mol (0.5%)
What is the first-line antidiabetic drug, and how should it be initiated?
Metformin 500mg tablets unless CI- start low and go slow. For example, to be taken with meals for example, start metformin at 500mg od with main meal. After 1
week, increase to 500mg bd. Then increase in 500mg steps at weekly intervals to highest dose tolerated or maximum dose reached. Maximum dose in BNF is 2 g/day but doses up to 3 g/day are commonly used in clinical practice.
Metformin
-Contributes to weight loss
-Low risk of hypos
-Maximum dose of 2g daily
-Avoid if eGFR <30, and review dose if eGFR <45.
-Side-effects: B12 deficiency, GI upset and lactic acidosis.
When is the only time that metformin SR should be used?
For patients who are intolerant of standard release metformin, even after slow dose titration. Try metformin SR before switching to a different antidiabetic drug.
At what eGFR and creatinine clearance should metformin be reviewed? When should it be stopped?
Review the dose of metformin if the serum creatinine exceeds 130 micromol/litre
or the estimated glomerular filtration rate (eGFR) is below 45 ml/minute/1.73-m2.
Stop the metformin if the serum creatinine exceeds 150 micromol/litre or the eGFR is below 30
ml/minute/1.73-m2
.
Type 2 Diabetes Prevention
Clinicians should use their judgement
on whether (and when) to offer metformin to support lifestyle change for people whose HbA1c or fasting plasma glucose blood test results have deteriorated if:
* This has happened despite their participation in intensive lifestyle-change programmes, or they are unable to participate in an intensive lifestyle-change programme, particularly if they have a BMI greater than 35.
* High risk patients are defined as HbA1c of 42-47mmol/mol (6.0-6.4%) or fasting plasma glucose of 5.5-6.9mmol/l
* Dosage recommendation: Start with a low dose (for example, 500 mg once daily) and then increase
gradually as tolerated, to 1500–2000 mg daily. If the person is intolerant of standard metformin consider using modified-release metformin.
* Metformin should be prescribed for 6–12 months initially. Monitor the person’s fasting plasma glucose or HbA1c levels at 3-month intervals and stop the drug if no effect is seen.
.
What would classify a patient as high-risk of T2 diabetes?
HbA1c of 42-47mmol/mol (6-6.4%) or a fasting plasma glucose of 5.5-6.9mmol/l.
What is the metformin dosing recommendation for new type 2 diabetic patients, and how long should metformin be continued?
Dosage recommendation: Start with a low dose (for example, 500 mg once daily) and then increase
gradually as tolerated, to 1500–2000 mg daily. If the person is intolerant of standard metformin consider using modified-release metformin.
* Metformin should be prescribed for 6–12 months initially. Monitor the person’s fasting plasma glucose or HbA1c levels at 3-month intervals and stop the drug if no effect is seen.
Which vitamin can metformin cause a defiency of in the body?
Vitamin B
What are some risk factors for developing vitamin B deficiency?
-baseline vitamin B12 levels at the lower end of the normal range
-conditions associated with reduced vitamin B12 absorption (such as elderly people and those
with gastrointestinal disorders such as total or partial gastrectomy, Crohn’s disease and other
bowel inflammatory disorders, or autoimmune conditions)
-diets with reduced sources of vitamin B12 (such as strict vegan and some vegetarian diets)
-concomitant medication known to impair vitamin B12 absorption (including proton pump
inhibitors or colchicine)
-genetic predisposition to vitamin B12 deficiency.
What are some examples of SGLT2 inhibitors?
Empagliflozin
Canagliflozin
Dapagliflozin
SGL2 Inhibitors
-Low hypo risk
-Can benefit weight loss
-Side-effects: DKA, constipation, weight loss, increased infection risk and urinary disorders.
-Risk of ketoacidosis, Fournier’s gangrene and lower-limb amputation (Canagliflozin)
.
Which SGLT2 Inhibitor is first-line if SGLT2s are required as treatment?
Empagliflozin
All SGLT2 Inhibitiors can be used to treat T2 diabetes with CKD, but only empagliflozin is green for type 2 diabetes WITHOUT CKD. In T2 diabetes where there is chronic HF with reduced ejection fraction, which SGLT2 inhibitors are licensed?
Empagliflozin
Dapagliflozin
NICE NG28 type 2 diabetes in adults guideline (updated March 2022) recommends: based on the
cardiovascular risk assessment for the person with type 2 diabetes:
* If they have chronic heart failure or established atherosclerotic cardiovascular disease, offer an SGLT2 inhibitor with proven cardiovascular benefit in addition to metformin.
* If they are at high risk of developing cardiovascular disease, consider an SGLT2 inhibitor with proven cardiovascular benefit in addition to metformin.
.
SGLT2 inhibitors can lead to ketoacidosis. Ketones should be tested for, and then SGLT2 inhibitors should be stopped immediately if DKA is suspected. What are some symptoms of this condition?
Rapid weight loss
Nausea/being sick
Stomach pain
Fast and deep breathing
Sleepiness
A sweet smell to the breath
A sweet or metalic taste in the mouth
A different odour to the urine or sweat
SGLT2 inhibitor treatment should be interrupted in patients who are hospitalised for major surgical
procedures or acute serious medical illnesses and ketone levels measured.
.
Sulfonylureas
-Contributes to weight gain
-Moderate hypo risk
-Avoid in severe renal impairment, cautioned in mild-moderate
-Side-effects: hypoglycaemia, allergic dermatitis, GI upset
.
What is an example of a sulfonylurea?
Gliclazide
What are some examples of DPP-4 inhibitors?
Alogliptan
Linagliptan
Sitagliptan
What is an example of a thiazolidinedione?
Pioglitazone
Treatment Pathway for Type 2 Diabetes
Step 1 has three options:
- In Atherosclerotic CVD: Metformin + SGLT2i
-In no CVD or high risk of CVD: Metformin alone
-Over 40 with a QRISK >10%/ Under 40 with over 1 CVD risk factor: Metformin and consider SGLT2i.
If target not met with these options: Add another drug or switch to alternative
Which antidiabetic drug is associated with a small increase in bladder cancer risk?
Puoglitazone
How many times a day should type 1 diabetics measure their blood glucose according to NICE?
At least 4 times a day, up to 10 as a maximum
Sometimes a type 1 diabetic would be recommended to test their blood glucose levels up to 10 time a day. What things may mean that this is recommended?
Desired target HbA1c level is not achieved,
* Frequency of hypoglycaemic episodes increases,
* There is a legal requirement to do so (e.g., such as before driving , in line with DVLA guidance)
* During periods of illness
* Before, during and after sport
* When planning pregnancy, during pregnancy and while breastfeeding
* If there is a need to know blood glucose levels >4 times a day for other reasons (e.g., impaired awareness
of hypoglycaemia, high-risk activities).
At what time of day should levothyroxine be taken?
Ideally 30 minutes before breakfast
Why should commencing levothyroxine in the elderly, ischaemic heart disease patients or patients with long-standing hypothyroidism be at a low-dose and increased very cautiously?
Angina and arrhythmias can be precipitated by starting treating
How long can it take for TSH levels to normalise in patients who had a very high TSH level before starting levothyroxine?
6 months
How long can it take to see the full effects of levothyroxine, and why is this the case?
Levothyroxine has a long half-life (7 days)- dose adjustments should be made at 2-3 monthly intervals.
Follow-up and Monitoring of Hypothyroidism in Adults Aged 16 and Over:
-Primary hypothyroidism: TSH every 3 months until level stabilised within reference range then once a year; Consider FT4 if symptoms persist after starting levothyroxine.
-Subclinical hypothyroidism (untreated or stopped levothyroxine treatment): consider measuring TSH and FT4 once a year if they have features suggesting underlying thyroid disease e.g., thyroid surgery or raised level of autoantibodies; otherwise, every 2-3 years.
..
What should the target TSH level be in a patient taking levothyroxine that is considering pregnancy?
0.4-2.0
For levothyroxine, generic prescribing on the drug remains appropriate for the majority of patients. If a patient reports any symptoms after changing the exact levothyroxine product that they would normally use, consider testing thyroid function- consider prescribing a specific thyroxine product for that patient that they tolerate.
.
What is an example of an antithyroid (hyperthyroidism) medication?
Carbimazole
Carbimazole
- Increases the risk of congenital malformation when used in the _ trimester of pregnancy and at doses above 15mg/day.
-Risk of acute _- treatment should be stopped immediately and permanently if this issue occurs.
-Counsel patients to report signs that suggest infection, especially a sore throat due to increase neutropenia and agranulocytosis risk.
-Hyperthyroid patients tend to be more sensitive to oral _. A higher dose of anticoagulant may be required as their hyperthyroidism stabilises.
First
Pancreatitis
Anticoagulants
What are somes examples of drugs that can be used in glucocorticoid therapy?
Prednisolone
Dexamethasone
Hydrocortisone
When should corticosteroids ideally be taken during the day?
In the morning after breakfast.
When are hydrocortisone tablets usually taken, and why?
Taken with the three main meals of the day to mimic the normal diurnal rhythm and to avoid insomnia
- Steroid warning cards should be carried by those on long term treatment, both replacement and
therapeutic. Patients on replacement therapy should be fully educated about the need to increase dosage
during intercurrent illness. Abrupt withdrawal of steroids following long term therapy (> 3 weeks) should
be avoided.
-Prolonged courses of corticosteroids can increase susceptibility to infection and serious infections can go
unrecognised. Unless already immune, patients are at risk of severe chickenpox and should avoid close
contact with people who have chickenpox or shingles.
-Patients on or commencing high dose oral corticosteroid long-term (7.5mg or more per day prednisolone or its equivalent for 3 months or more) should be offered bone protection with bisphosphonate.
.
What are micronised progesterone vaginal capusles used for?
For the prevention of miscarriage
Which drug type is first-line for managing benign prostatic hypertrophy?
Alpha blockers
What is desmopressin used for?
Central cranial diabetes insipidus (the body loses too much fluid and becomes dehydrated all the time). Also for bedwetting (nocturnal enuresis)
Alendronic Acid 70mg - Weekly (first-line)
- An oral bisphosphate that is used to prevent bone loss from the body- it treats osteoporosis.
- Can cause serious oesophageal reactions, osteonecrosis of the jaw, atypical fractures.
- Effervescent formulations should be used only in patients with long-term swallowing difficulties- short-term swallowing difficulties should result in emitting the alendronic acid until the issue is resolved.
.
Oral Bisphosphonates
- Alendronic Acid 70mg (first-line) and Risedronate 35mg (alternative)- both once weekly dosages.
-Both should be taken on a morning, on the same day each week and on an empty stomach, at least 30 minutes before eating anything. The tablet should be taken with a full glass of plain water, and the patient should stay fully upright for at least 30 minutes after swallowing the tablet.
.
What are some important recommendations for patients when it comes to taking oral bisphosphonates?
Alendronic acid and risedronate should be taken whole on arising, on the same day each week on an emptystomach (at least 30 minutes before the first food, beverage or medicinal product of the day) with a full glass (not less than 200ml) of plain water only (not mineral water). Patients should be advised to stay fully upright for at least 30 minutes after swallowing the tablet.
When is Ibandronate 50mg labelled as ‘green after consultant initiation’?
For use in post-menopausal women with breast cancer
