CH6: ENDO CLINICAL Flashcards
what is diabetes insipidus & its symptoms
- large amounts of diluted urine produced
- excessive thirst
symptoms
- polyuria
- polydipsia
Types of diabetes insipidus
- Cranial diabetes insipidus = not enough ADH (vasopressin) is produced by the hypothalamus
- Nephrogenic diabetes insipidus = kidney’s do not respond to ADH
diagnosis of cranial diabetes insipidus
producing concentrated urine after IM/intranasal desmopressin
treatment for cranial diabetes insipidus
desmopressin/vasopressin and restriction of fluid intake
treatment of partial pituitary diabetes insipidus
- carbamazepine (UL) - sensitise the renal tubules to the vasopressin
- thiazides can be used (indapamide)
diagnosis of nephrogenic diabetes insipidus
failure to produce concentrated urine after IM/intranasal desmopressin
treatment of nephrogenic diabetes insipidus
thiazide diuretics = to reduce urine output
what is hyponatraemic convulsions & how can we minimise its risk
- too much ADH secretions are produced
- minimise risk
-> fluid-intake restriction
-> stopping desmopressin during D/V = until the fluid balance is restored
-> avoiding any meds that increase vasopressin secretions = paracetamol, nicotine and tricyclics
elderly risk of hyponatraemic convulsions, what monitoring parameters to take?
monitor
- initial Na baseline
- then regular monitoring of serum Na levels
- STOP if Na levels are below baseline
can pregnant women taken desmopressin?
yes, but not in their 3rd trimester, as it increases the risk of pre-eclampsia
if pt has hyponatraemia or increased in ADH concentration and is not corrected by fluid restriction, what treatment would you suggest?
ADH antagonists (tolvaptan, demeclocycline)
aim is to block the renal tubular effect of ADH
what is adrenal cortex
secretes cortisol (glucocorticoid & some mineralocorticoid activity)
AND aldosterone (mineralocorticoid activity)
High mineralocorticoid activity what does this mean & give a drug example
High mineralocorticoid activity = MORE fluid retention
e.g. fludrocortisone
High glucocorticoid activity what does this mean & give a drug example
High glucocorticoid activity = high anti-inflammatory effect = LOW fluid retention
example; dexamethasone, betamethasone
name a corticosteroid drug that is appropriate for heart failure?
dexamethasone & betamethasone
- as it does NOT cause fluid retention
what are the monitoring parameters for all corticosteroids
- Lipid
- Blood pressure
- Serum potassium
- Bone mineral density
- Blood glucose
- Eye examination
- Body weight and height in children
What is the MHRA alert for methylprednisolone use
- to avoid use in pts allergic to cow’s milk
- reported symptoms of bronchospasm and anaphylaxis
how to avoid abrupt withdrawal of corticosteriods
issue steriod cards
- prolonged treatment > 3 weeks at any dose
- > 40mg of prednisolone or equivalent dose > 1 week
- repeat doses in the evening
- recent repeat rx
- short courses with 1 year of stopping long term steriod
- if pt has nay other cause of adrenal suppression
what are the causes of adrenal insufficiency
- addison’s disease
- congenital adrenal hyperplasia
name 3 conditions that adrenal replacement therapy
- Addison’s disease
- Cushing syndrome
- Hypopituitarism
what is addison’s disease & its treatment
- low cortisol & low aldosterone levels
treatment
- hydrocortisone + fludrocortisone (PO)
- large dose = AM and small dose = PM ; to mimic the biologic rhythms
what is hypopituitarism
pituitary gland does not respond to the hormone secretion due to the LOW cortisol levels.
treatment
- IV hydrocortisone
- Replacement for necessary hormones;
what is hypopituitarism
the pituitary gland does not respond to the hormone secretion due to the LOW cortisol levels.
treatment
- IV hydrocortisone
- Replacement for necessary hormones; growth hormones, sex hormones and thyroid hormones
symptoms of cushing’s syndrome
- moon face
- red/purple striae (stretch marks)
- bruising
- buffalo hump
- muscle wasting/thin extremities
- weight & obesity
- skin and bone thinning
- menstrual changes
- low libido
- hirsutism (excessive hair growth)
- osteoporosis
- growth suppression in children
what is cushing syndrome and its causes
excessive cortisol levels caused by
- tumour
- prolonged use of glucocorticoid drug treatments
treatment of cushing’s syndrome if it is caused by a tumour
cortisol inhibiting drugs;
1. Ketoconazole
2. Metyrapone
treatment of Cushing’s syndrome if it is caused by excessive use of glucocorticoid drug treatments
- reduce dose
- withdraw treatment - gradually
what are the risk factors for osteoporosis
- smoking
- 65+ (over 50 for male)
- low body weight
- lack of exercise
- menopause (if early)
- excess alcohol
- family history
- long-term use of corticosteroids (oral)
- vitamin D/ Ca deficiency
non-pharmacological advice to minimise the risk of osteoporosis if pt has risk factors
- vitamin D/Ca2+ supplements
- increase exercise & diet
- reduce the dose of corticosteroids and maintain the shortest course
what are the different types of osteoporosis
- corticosteriod induced osteoporosis
- menopausal-induced osteoporosis
- male osteoporosis
first-line treatment for corticosteroid-induced osteoporosis
Oral bisphosphonates (alendronic acid or risedronate)
second-line treatment for corticosteroid-induced osteoporosis
zoledronic acid (IV), denosumab, teriparatide
first-line treatment for post menopausal-induced osteoporosis
Oral bisphosphonates (alendronic acid or risedronate)
second-line treatment for post-menopausal-induced osteoporosis
ibradronic acid
strontium
denosumab
raloxifene
IV bisphosphonate
severe treatment for post-menopausal-induced osteoporosis
teriparatide
add-on therapy for post-menopausal-induced osteoporosis
HRT
Tibolone (for younger menopausal women)
when should you review use of bisphosphonates
after 5 years
3 years for zoledronic acid
for corticosteroid-induced osteoporosis when would you consider starting prophylaxis? (in women)
start prophylaxis when starting corticosteroid treatment
(women)
- >70y/o +
- previous fragility fracture
- large doses of glucocorticoid >7.5mg of prednisolone
for corticosteroid-induced osteoporosis when would you consider starting prophylaxis? (in males)
start prophylaxis when starting corticosteroid treatment
(male)
- >70y/o +
- previous fragility fracture
- large doses of glucocorticoid >7.5mg of prednisolone
for corticosteroid-induced osteoporosis what other incident would you consider starting prophylaxis?
taking large doses of glucocorticoid >3 months
treatment for bone metastases in breast ca/severe hypercalcemia in malignancy
- pamidronate (IV)
- zolendronic acid (IV)
very potent
potential doses for risedronate for the prevention/treatment of osteoporosis
5mg OD
35mg once WEEKLY
potential doses for alendronic acid for the prevention/treatment of osteoporosis
10mg OD
70mg once WEEKLY
HRT for post-menopause
tibolone
HRT for peri- and post-menopause
oestrogen
what is HRT used for
- oestrogen-only or combined HRT (oestrogen + progestogen
- given to alleviate symptoms of post-menopause = vaginal atrophy, reduce risk of osteoporosis and vasomotor instability
MHRA alert of HRT
- only to be used to alleviate post-menopausal symptoms if it is affecting the patient’s quality of life.
- use the lowest effective dose and at the shortest duration
- use of HRT = increased risk of breast cancer, advice to attend regular breast routines
symptoms & treatments for menopause
- Vaginal dryness/atrophy = topical oestrogen (cream, vaginal tabs/rings)
- Vasomotor symptoms (hot flushes/ night sweats) = systemic oestrogen (tabs/patches = increases risk of SE)
treatment option you would recommend to a pt with the uterus and unable to respond?
clonidine (lots of SE)
side effects/ risk of breast cancer from use of HRT
- increased risk after 1 year of use & prolonged use
- increased risk in combined HRT compared to oestrogen only
- risk continues after 10 years of stopping
side effects/ risk of ovarian cancer from use of HRT
- small risk, however, risk reduces after a few years of stopping
side effects/ risk of endometriosis cancer from use of HRT
- a reduced risk with progestogen
- women w/ uterus = reduced risk with combined HRT compared to oestrogen only
side effects/ risk of coronary heart disease (CHD) from the use of HRT
- if using combined HRT > 10 years after starting menopause
side effects/ risk of stroke from the use of HRT
- slight increase with both oestrogen only and combined HRT
CI/ cautions of combined HRT
- peri-menopausal phase = <12 months since last menstrual
- Risk of cancer
- liver disease
- prolonged immobility
- women with risk factors for VTE
- hypertension above 160 mmHg
- CHD
HRT treatment for women with a uterus
- oestrogen + cyclical progestogen for the last 12-14 days of the cycle
- continuous administration of oestrogen + progestogen
AVOID if in peri-menopausal phase
HRT treatment for women without a uterus
- continuous oestrogen-only use
- if endometriosis occurs - consider addition of progestogen
when to stop & restart HRT during elective surgery
4-6 weeks
restart when fully mobile
when to stop & restart HRT during non-elective surgery
- start anticoagulant prophylaxis (heparins)
and compressive stockings
what contraceptives to use in patients under 50 y/o
combined contraceptive
what contraceptives to use in patients over 50 y/o
barrier methods
when to stop the use of HRT
• Prolonged immobility = increased risk of VTE
• Severe abdominal pain
• VTE/ PE
- Chest pain, SOB, bloody cough
- Swelling/ severe pain of one calf
• Stroke/ neurological
- Unusual severe prolonged headache
- Loss of vision, hearing disturbance
- Dysphasia
- Seizures
- Collapse, motor disturbance, numbness
• Liver dysfunction
- Hepatitis, jaundice…
- Severe stomach pain
• Blood pressure
- Systolic > 160mmHg or diastolic >95mmHg
treatment for menorrhagia
• oral progesterone can be used but tranexamic acid more effective
• mefenamic acid also used for heavy/ irregular periods
treatment for miscarriage prevention
• vaginal micronized progesterone (UL) until 16 weeks gestation
• offered if the following:
- vaginal bleeding in women with confirmed IUD pregnancy
- previous miscarriage
• Aspirin 75mg and low dose prophylactic LMWH can decrease fetal loss risk with antiphospholipid antibody syndrome + recurrent miscarriage
what is hyperthyroidism & what the hormones regulate
- excess production/secretion of thyroid hormones
- regulates; metabolic rate, heart rate, digestive function, muscle control and brain development
primary hyperthyroidism
- thyroid issue: caused by grave’s disease, an autoimmune disease that attacks the thyroid gland = overactive production of thyroid hormone
symptoms of hyperthyroidism
- fatigue
- goitre
- heat intolerance
- palpitation
- hyperactivity
- anxiety
- increased appetite
- weight loss
- diarrhoea
complications of hyperactivity
- pregnancy complication
- atrial fib
- grave’s disease
- heart disease
- thyrotoxic crisis
- reduced bone density
risk factors of hyperthyroidism
- FH
- Smoking
- Autoimmune disease
- Low iodine
what are the lab test markers for hyperthyroidism
HIGH T3/T4
LOW TSH
what is the non-pharmacological treatment?
- radioactive iodine (CI in pregnancy) or
- surgery (have iodine for 10-14 days before surgery)
1st line treatment for hyperthyroidism
carbimazole
2nd line treatment for hyperthyroidism
propylthyiouracil
add-on therapy for hyperthyroidism
beta blockers - for heart rate
when would you consider to use GLP 1 agonists (as per NICE guidelines)
used as 3rd option once 2 drugs have been tried if BMI over 35 OR metformin <35 but where insulin would affect occupation OR if weight loss would benefit obesity comorbidities
name the anti-diabetic drugs that cause pancreatitis as a SE
DPP4I and GLP-1
name the anti-diabetic drugs that cause weight GAIN as a SE
SU, pioglitazone, meglitinides
name the anti-diabetic drugs that cause weight LOSS as a SE
GLP-1, SGLT-2I, acarbose
name the anti-diabetic drugs that cause HYPOglycemia as a SE
SU, meglitinides
name the anti-diabetic drugs that increase risk of DKA as a SE
SGLT-2I, metformin, meglitinides
name the anti-diabetic drugs that should be avoided in renal impairment
Metformin, SGLT-2I, some DPP-4I (not linagliptin), long-acting SU, acarbose, meglitinides
Briefly state the basal-bolus insulin regime
- 1st line for T1DM: good w/ flexible meal time, common SE: hypoglycaemia, requires often blood glucose testing.
REGIMEN
1. Long-acting/intermediate acting
- Determir (Levemir) BD or
- Glargine (Lantus) OD (if detemir is CI/ pt prefer OD-dosing)
- Degludec (Tresiba) OD (if above CI/ pt needs ultra cover as carer administrating or concern for nocturnal hypoglycaemia)
- Short-acting/ rapid-acting (bolus, before a meal or just after meal time)
- Offer insulin analogues rather than soluble/ animal insulins)
- Humalog I, apart (Novorapid, fisas) or glulisine
Briefly state the non-basal-bolus insulin regime
- not recommended for newly diagnosed T1DM
- Mixed regimen (Biphasic: short/soluble acting insulin with intermediate insulin)
- e.g. Novomix 50, Humalog Mix 50
- dosing OD/BD or TDS - OD-dosing regimen (add-on therapy for T2DM not recommended for T1DM)
- Intermediate or long-acting insulins
- Basal-only regimen OR
- Bolus only regimen OR
- Insulin pump; for T1DM pts only who;
> children under 12 y/o
> HbA1c level of >69 mmol/mol (8.5%)
> suffering from disability hypoglycaemia
given alongside bolus injections
when do we INCREASE insulin doses?
- Infection
- Surgery Trauma
- Stress
- Pregnancy (2nd and 3rd trimester)
when do we REDUCE insulin doses?
- Exercise
- Impaired renal function
- Illnesses
- Reduced food intake
- Some endocrine disorders; coeliac disease, thyroid
Briefly state the T2DM insulin treatment
- Isophane (Humulin I) intermediate insulin as OD/BD dosing
- Isophane + short-acting insulin
- OD dosing (long-acting) if a carer is needed to administer or have recurrent hypoglycaemia episodes
Name the drug class that is commonly used in treating diabetic-induced blood pressure
- treat if BP>140/90 mmHg
- ACE inhibitors
State the macrovascular complications associated with diabetics pts
- CVD
- Primary prevention is required if;
1. Pt is T1DM over the age of 40 or had 10 years of this disease
2. T2DM with QRISK score >10%
then should be initiated Atorvastatin 20 mg
Name microvascular diabetes-associated complications
- Nephropathy (affecting kidneys)
- Neuropathy (affecting the neurons)
- Retinopathy (affecting the eyes)
Nephropathy diabetes-associated complications
1st line treatment of T2DM w/ diabetes nephropathy
- ACEi/ARBs provide a reno-protective effect
- To be used in pts who have normal BP but with proteinuria/ microalbuminuria to start ACEi/ARBs
- to stop or withhold ACEi/ARBs if pts is AKI but to cont. if pt is CKD.
- Nephropathy increases hypoglycaemia effects of antidiabetic drugs/insulin
Briefly state the treatment options for pain due to diabetic neuropathy
- TCAs (amitriptyline, nortriptyline or imipramine)
- Antidepressants in painful peripheral neuropathy (duloxetine or venlafaxine)
- Anti-epileptics (gabapentin or pregabalin)
- Opioid analgesic: Morphine/ oxycodone under specialist
Briefly state the treatment options for diabetic autonomic neuropathy
- Diarrhoea - codeine or tetracycline (UL)
- Erectile dysfunction - sildenafil
- Gastroparesis (slow digestion)- erythromycin (UL)
Briefly state the treatment options for diabetic gustatory neuropathy
- Sweating or secretions …
- Propantheline bromide
Briefly state the treatment options for diabetic postural hypotension
- Fludrocortisone (UL) = may cause oedema as a SE
- Ephedrine/Flurbiprofen (+ fludrocortisone) to reduce oedema
- Midodrine (UL)
Briefly state the treatment options for diabetic retinopathy
- Caused by high BP and high blood glucose levels
- Treat hypertension > 130/80 mmHg
- Maintain target HbA1c level of 7% (53 mmol/mol)
- Annual eye tests
briefly state the treatment options for MILD diabetic foot infection
- It is a local infection with erythema of 0.5-2 cm
- PO: 1st line: Flucloxacillin 500mg (1g QDS for 7 days)
- Pen allergy:
> Clarithromycin 500mg BD for 7 days
> Doxycycline 200mg for 1st day then 100mg OD for 7 days
> Erythromycin 500mg QDS for 7 days (if pregnant)
briefly state the treatment options for Moderate to Severe diabetic foot infection
- Mod = > 2cm of erythema and deep abscess
- Sev = > 2 cm of erythema and systemic inflammation
PO/IV
1st line: Flucloxacillin (or co-trimoxazole if pen allergy with or without
- Gentamicin +/or Metronidazole
OR
Co-amoxiclav with or without Gentamicin
OR
Ceftriaxone with Metronidazole
if Pseudomonas aeruginosa is suspected/ confirmed for pt’s diabetic foot infection (mod-severe), what are the treatment options?
- Piptaz 4.5g TDS IV OR
- Clindamycin with Ciprofloxacin +/or Gentamicin
if MRSA is suspected/ confirmed for pt’s diabetic foot infection (mod-severe), what are the treatment options?
- Vancomycin OR
- Teicoplanin OR
- Linezolid (if above are CI)
what blood glucose level is considered to be hypoglycaemia
less than 4 mmol/L
explain the effect of alcohol on hypoglycaemia
- mask the signs of hypoglycaemia
- delay hypoglycaemia
- advise to drink in moderation & with food
name the drugs that can MASK hypoglycaemia
Beta-blockers
name the drugs that CAUSE hypoglycaemia
- ACEi/ ARBs potentiate the hypoglycaemic effect of insulin and oral anti-diabetic drugs especially in the 1st few weeks and in renal impairment
- Sulfonylureas (SU) -> Glibenclamide which is a long-acting SU, prolongs hypo-
- SU-> Gliclazide
name the drugs that BLOCK hypoglycaemic effect
- corticosteroids
- oral contraceptives
- loop/thiazide diuretics
state the assessment carried out for impaired awareness hypoglycaemia
- annual assessment using the gold and Clarke score
- impaired awareness if blood glucose is less than 3 mmol/L = severe hypo- risk
what are the symptoms of hypoglycaemia?
- Hunger
- Blurred vision
- Palpitations
- Dizziness
- Tingling lips
- Clamping/ sweating, chills
- Shaking
- Irritability
- Irrational behaviour
- Coma
- Pale skin
- Difficulty concentrating
- Drowsiness
- Slurred speech
state the treatment for MILD hypoglycaemia
- Classified as when blood glucose levels are > 4 mmol/L
- Small carbohydrate snack/meal
state the treatment for MODERATE hypoglycaemia
- classified as when blood glucose levels are < 4mmol/L if pt is with or w/out hypo-symptoms, but conscious and able to swallow.
Fast-acting carbohydrates by mouth (Glucose liquid, tabs, glucose 40% gel, pure fresh fruit/ 3-4 teaspoons of sugar dissolved in water)
If necessary, repeat after 15 mins (3x max)
Avoid sugar in acarbose
Avoid orange juice in low K+ diet in CKD
Avoid chocolate
When blood glucose >4 mmol/L give a long acting high carbohydrate meal, do not omit insulin if due, but r/v dose with doctor
state the treatment for SEVERE hypoglycaemia
Classified when hypo- is not responsive to treatments of MILD & MOD for over 30-45 mins = severe hypo-
IM Glucagon (to be avoided: pts w/ prolonged fasting, adrenal insufficiency, alcohol-induced, chronic hypo-, taking sulfonylureas)
OR
Glucose 10% infusion (can also be given if IM glucagon is not responsive within 10 mins)
treatment for alchol-induced hypoglycaemia
Thiamine supplements to avoid Wernicke’s encephalopathy
treatment for EMERGENCY hypoglycaemia
Classified when pt is unconscious, seizures and aggression
Stop IV insulin and start IM/SC glucagon if not responsive within 10 mins/not suitable initiate IV Glucose 10% or 20%.
Once recovered and blood glucose > 4 mmol/L = give long-acting carbs e.g. biscuits or a slice of bread
If given IV Glucose, monitor blood glucose levels every 15 mins until >3mmol/L then restart IV insulin but the dose is to be reviewed – do not omit if due.
SU/ LA insulin-induced hypoglycaemia
- may last up to 24-36 hours
- monitor blood glucose levels for at least 24 - 36 hours
what drugs cause hyperglycaemia
- bendroflumethiazide
- prednisolone
diabetic ketoacidosis (DKA)
- When the body runs out of insulin
- Management = replacing fluids and insulin
Saline/fluids + Insulin + KCL (unless anuria – kidney unable to produce urine) - Severe case of hyperglycaemia, where blood glucose >11mmol/L
symptoms of DKA
- Polyuria
- Thirst
- Unconsciousness
- Ketone breathing
- Fast breathing
- Confusion
causes of DKA
- Stress
- Illness
- Infection
treatment for DKA
- If systolic pressure <90mmHg give 500ml NaCl 0.9% infusion over 10-15minutes (repeat if remains low)
- If systolic pressure >90mmHg give NaCl 0.9% at a suitable rate
- Include KCl in fluid unless patient has anuria (lack of urination)
- Begin IV insulin infusion: soluble insulin diluted in 0.9% NaCl at 1unit/ml at 0.1unit/kg/hr
- Monitor blood ketones and glucose hourly, adjust insulin accordingly
- Blood ketone should fall by at least 0.5mmol/l/hr
- blood glucose should fall by 3mmol/l/hr - Administer glucose 10% IV once blood glucose <14mmol/l + NaCl 0.9% infusion
- Continue insulin infusion until blood ketone <0.3mmol/l and blood pH >7.3 and patient can eat and drink
- When patient can eat – give fast acting insulin with meal
- Stop treatment 1 hour after food
treatment for DKA
- If systolic pressure <90mmHg give 500ml NaCl 0.9% infusion over 10-15minutes (repeat if remains low)
- If systolic pressure >90mmHg give NaCl 0.9% at a suitable rate
- Include KCl in fluid unless patient has anuria (lack of urination)
- Begin IV insulin infusion: soluble insulin diluted in 0.9% NaCl at 1unit/ml at 0.1unit/kg/hr
- Monitor blood ketones and glucose hourly, adjust insulin accordingly
- Blood ketone should fall by at least 0.5mmol/l/hr
- blood glucose should fall by 3mmol/l/hr - Administer glucose 10% IV once blood glucose <14mmol/l + NaCl 0.9% infusion
- Continue insulin infusion until blood ketone <0.3mmol/l and blood pH >7.3 and patient can eat and drink
- When patient can eat – give fast acting insulin with a meal
- Stop treatment 1 hour after food
Describe what HONK state is; its characterisation & its management
- HONK; Hyperosmolar non-ketotic state
- Characterised by; blood glucose levels > 30 mmol/L and hypovolaemia
- Management; similar to DKA but at a slower Insulin infusion rates and rehydration
state the types of diabetic pts who should inform DVLA for driving
- All diabetic patients who are taking INSULIN must inform DVLA unless temporary treatment
- If taking oral anti-diabetic drugs that can cause hypoglycaemic risk e.g. SU or meglitinides
- Suffering from complications associated diabetes such as retinopathy
- All diabetes patients who are driving lorry/bus/coach
DVLA recommendations for diabetic pts
• Avoid hypoglycaemia when driving
• Always carry glucose meter and blood glucose strips when driving
• Check blood glucose every 2 hours while driving (more frequent if high risk of hypo e.g., after exercise/ altered meal routine) and no less than 2 hours before driving
• Always keep fast-acting carbohydrate in the vehicle
• Blood glucose should always be >5mmol/l while driving
- Take a snack if falls below this
• Do NOT drive if blood glucose <4mmol/l or warning signs of hypoglycaemia
- If already driving, stop in a safe place and switch off engine – move from driver’s seat
- Eat/ drink a suitable source of sugar
- Wait until 45 minutes after blood glucose returned to normal then continue journey
Drivers who are diabetic must not drive if:
• hypoglycaemia awareness has been lost- notify DVLA
• Can drive again if medical report confirms that awareness has been regained
• 2 episodes of severe hypoglycaemic events in 12 months
- or 1 if lorry/ bus/ coach driver (even if hypoglycaemia in sleep)
- must have full awareness and use blood glucose meter with 3 months readings
briefly explain the sliding scale for diabetic pts day before & day of surgery MINOR surgery (elective)
- Must have a good glycaemic control = HbA1c level must be <8.5%, 65 mmol/mol.
Day before surgery
- Continue normal insulin dose unless on long-acting insulins = dose to be reduced by 20%.
- Oral antidiabetic meds to be adjusted or continued rather than switching to IV insulin/fluids if only 1 missed meal for minor surgery. Metformin can be continued if the patient has a low risk of AKI and no contrast media is needed (if pt is fasted= omit the dose).
Pt’s who are NOT fasting
- Continue regular anti-diabetic meds as usual for surgery unless on SGLT2i or Sulfonylureas – to be stopped on the day of surgery
- Resume SGLT2i/ Sulfonylureas when pts are stable and able to drink/eat, stable renal function = metformin
briefly explain the sliding scale for diabetic pts before and day of MAJOR surgery/poor glycaemic control
- Switch to variable rate IV insulin infusion – continue after surgery until patient can eat/drink
- Stop any oral antidiabetic med unless taking GLP-1 agonist= can continue
- Target HbA1c level = 6-10 mmol/L (up to 12 mmol/L is acceptable)
Day BEFORE surgery
- OD long acting insulin analogues to be given at 80% of usual dose
- Other insulins can be given at usual dose.
Day OF surgery
- Continue OD long acting insulin analogues to be given at 80% of usual dose
- Stop other insulins until pt is eating/drinking after surgery
- Start KCL infusion with glucose + NaCl with variable rate IV insulin infusion in 0.9% NaCl.
- Monitor glucose hourly for the first 12 hours
- If glucose drops to <6 mmol/L we start IV Glucose 20%
- If glucose drops to <4 mmol/L, adjust glucose dose, monitor glucose levels every 15 minutes until goes up to 6 mmol/L
- If glucose >12 mmol/L, check ketones levels & signs of DKA.
what monitoring parameters and management for a pt who is diabetic undergoing emergency surgery
- Check ketone levels/ electrolytes and pH
- Delay surgery if acidosis/ DKA
- Administer IV insulin and fluids as major surgery rules
Advice in sliding scale for intercurrent illnesses
- Temporarily may need to stop/withhold oral antidiabetic medication and replace with insulin
- This could be in cases such as IM, coma, severe infection, trauma etc
- SGLT2-I are associated with DKA in periods with stress/trauma –use in caution nd stop if hospitalised
if pt is at increased risk of hyperglycaemia what measure would you take to control this?
control with SICK
Sugar= increase blood glucose monitoring
Insulin = do not stop taking insulin even if not eating
Carbs = maintain carbs and hydrate
Ketones= check ketones every 2-4 hours – may need to take extra fast-acting insulin
what are the drugs to stop temporarily in case of hyperglycemia
SADMAN
SGLT2 inhibitors
ACE inhibitors
Diuretics
Metformin = dehydration can lead to lactic acidosis
ARBs
NSAIDs
*the rest risk of dehydration that cal lead to AKI
What is graves disease & the 1st line treatment for graves
Graves disease = autoimmune disease where the immune system attacks the thyroid gland causing it to be overactive.
1st line: radioactive iodine
• Unless not suitable or antithyroid drugs would be successful (carbimazole)
2nd line treatment for graves disease
2nd line: carbimazole if iodine or thyroid not suitable
- Block and replace regimen OR
- Titrating regimen
3rd line treatment for graves disease
3rd line: propylthiouracil if:
- Unable to tolerate carbimazole (SE)
- Pregnant/ trying to conceive within 6 months
- History of acute pancreatitis
briefly explain what the ‘block and replace regimen’ and ‘titration regimen’ mean?
BLOCK AND REPLACE
• Fixed high dose anti-thyroid drug (approx. 18 months) + levothyroxine (approx. 6-12 months)
• Avoid in pregnancy
TITRATION
• antithyroid dose based on thyroid tests
• for toxic nodular goitre
what would you offer if a pt is experiencing persistent/ relapsing hyperthyroidism (despite drug treatment)
• Offer radioactive iodine or surgery
State the 1st and 2nd line treatment for toxic nodular goitre
1st line: radioactive iodine
2nd line: thyroidectomy / long life antithyroid drugs (titrating regimen)
- If carbimazole unsuitable -> propylthiouracil
management for subclinical hyperthyroidism
• Patients with thyroid disease or thyrotoxicosis + 2 low TSH levels 3 months apart
• Untreated subclinical hyperthyroidism: monitor TSH every 6 months
treatment for hyperthyroidism in pts who are pregnant
• Avoid radioactive iodine and carbimazole
• Avoid block and replace regimen; high dose of antithyroid drug crosses placenta
• May need a higher dose of levothyroxine when pregnant
• 1st trimester: propylthiouracil
• 2nd + 3rd trimester: carbimazole (as propylthiouracil can cause hepatotoxicity)
what is thyrotoxicosis
Thyrotoxicosis is a condition that happens when you have too much thyroid hormone in your body.
symptoms of thyrotoxicosis
• HR> 140bpm+ increased pulse
• Tachycardia, arrythmia
• Heat intolerance > 41oC
• Diarrhoea, N/V, dehydration
• Seizures, delirium, confusion, psychosis
treatment of thyrotoxicosis
Anti-thyroid drug + hydrocortisone + radioactive sodium iodide solution
Propranolol for rapid symptom relief
what is hypothyroidism
• Underproduction/ secretion of thyroid hormones
what are the symptoms of hypothyroidism
• Fatigue
• Weight gain
• Constipation
• bradycardia
• Menstrual irregularities
• Depression
• Dry skin
• Intolerance to cold
• Reduced hair
complications associated to hypothyroidism
• Dyslipidaemia
• CHD
• Heart failure
• Impaired fertility
• Pregnancy complication
• Impaired concentration
• Myxoedema coma (rare)
what are the lab test markers for hypothyroidism
HIGH TSH
LOW T3/T4
Primary hypothyroidism (what is the thyroid gland issue?)
• Thyroid gland issue- may be caused by iodine deficiency, Hasimotos thyroiditis (autoimmune disease), radiotherapy, surgery or drugs
• More common in females
State the 2 classifications of primary hypothyroidism
OVERT
• High TSH
• Low T3/T4
SUBCLINICAL
• High TSH
• Normal T3/T4
1st line treatment of hypothyroidism
Levothyroxine
• If symptoms persist even if TSH levels normal, adjust dose without causing TSH suppression/ thyrotoxicosis
• If TSH levels very high prior to treatment, may take up to 6 months to return to normal
A 28-year-old woman is started on tamoxifen for locally advanced oestrogen-receptor positive breast cancer.
What is the most appropriate advice to give her regarding potential side effects?
A. It can stimulate milk production from her breasts
B. It causes infertility
C. It is safe to take during pregnancy
D. There is an increased risk of cancer of the lining of the womb
E. There is an increased risk of ovarian cancer
D There is an increased risk of cancer of the lining of the womb.
Tamoxifen is a sex hormone antagonist, which can lead to endometrial changes including a small risk of endometrial cancer, but not ovarian cancer. Patients should be advised to report vaginal bleeding to their doctor.
A 45-year-old man with type 2 diabetes is taking metformin.
What is the main means by which metformin lowers blood glucose concentration?
A. Increased pancreatic insulin secretion
B. Increased peripheral insulin sensitivity
C. Increased urinary glucose excretion
D. Reduced hepatic glucose output
E. Reduced intestinal glucose absorption
D Reduced hepatic glucose output.
The main mechanism by which metformin lowers blood glucose is through a reduction in hepatic glucose output (from gluconeogenesis). It may also improve peripheral insulin sensitivity (and therefore glucose uptake) but this is probably less important to its glucose-lowering effect.
An 84-year-old woman has started taking anastrozole, after being found to have advanced breast cancer.
What best describes the mechanism of action of anastrozole?
A. 5α-reductase inhibition
B. Aromatase inhibition
C. Inhibition of ergosterol synthesis
D. Luteinising hormone (LH)/follicle-stimulating hormone (FSH) suppression
E. Selective oestrogen receptor modulation
B Aromatase inhibition. Anastrozole is a sex hormone antagonist.
It acts by inhibiting aromatase, which prevents the peripheral conversion of androstendedione to oestradione. This reduces the amount of oestradione that can be converted to oestradiol (the active form of oestrogen). Reducing oestradiol decreases the amount able to bind oestrogen-receptor positive breast cancers, reducing tumour growth. Tamoxifen is another example of a sex hormone antagonist used in breast cancer treatment, but it acts as a selective oestrogen receptor modulator.
A 72-year-old woman is admitted with a suspected pulmonary embolism (PE) and requires a computerised tomography (CT) pulmonary angiogram with contrast. She is taking alendronic acid, atorvastatin, diltiazem, metformin and ramipril.
What drug should be withheld now and for 48 hours after the procedure?
A. Alendronic acid
B. Atorvastatin
C. Diltiazem
D. Metformin
E. Ramipril
D
Metformin must be withheld before and for 48 hours after injection of IV contrast media (e.g. for computerised tomography [CT] scans, coronary angiography) when there is an increased risk of renal impairment because of contrast nephropathy. This can lead to metformin accumulation and lactic acidosis.
A 50-year-old man presents to review the results of recent blood tests. He has a past medical history of type 2 diabetes and hypertension. He takes metformin 1 g twice daily and ramipril 10 mg daily.
Investigations: Creatinine 148 µmol/L (60–110), estimated glomerular filtration (eGFR) 44 mL/min/1.73 m2 (>60)
What complication is more likely if metformin is taken in the context of renal impairment?
A. Diabetic ketoacidosis
B. Hypersensitivity reaction
C. Lactic acidosis
D. Megaloblastic anaemia
E. Respiratory alkalosis
C. Lactic acidosis.
Due to overdose or renal impairment, since metformin is eliminated by the kidneys, metformin may be a contributory factor.
Metformin does not cause respiratory alkalosis or diabetic ketoacidosis.
Metformin may interfere with vitamin B12 absorption and therefore cause or contribute to megaloblastic anaemia, but renal failure is unlikely to modulate this effect significantly.
A 34-year-old woman has started taking tamoxifen following a mastectomy for locally advanced oestrogen-receptor positive breast cancer. Her past medical history includes anxiety, hay fever and schizophrenia. Her current medications are codeine, fluoxetine, loratadine, propranolol and risperidone.
What drug is most likely to reduce the efficacy of tamoxifen?
A. Codeine
B. Fluoxetine
C. Loratadine
D. Propranolol
E. Risperidone
B. Fluoxetine.
Tamoxifen is a sex hormone antagonist. It is a prodrug that requires activation by a cytochrome P450 (CYP) enzyme, CYP2D6. CYP2D6 is also involved in the metabolism of other drugs, including codeine (also a prodrug, which is metabolised by CYP2D6 to morphine), loratadine, propranolol and risperidone. Fluoxetine, a selective serotonin reuptake inhibitor (SSRI), is a potent inhibitor of CYP2D6. For the prodrugs tamoxifen and codeine, inhibition of CYP2D6 results in lower plasma levels of active metabolites. This can result in reduced efficacy. For drugs that are inactivated by CYP2D6, such as propranolol (a β-blocker), risperidone (a second-generation antipsychotic) and loratadine (an antihistamine), the interaction may increase the risk of adverse effects.
A 25-year-old woman presents to her GP to request a combined oral contractive pill. She has a past medical history of epilepsy, which is well controlled on lamotrigine 200 mg daily and levetiracetam 1 g 12-hrly. After appropriate assessment and counselling, a preparation containing ethinylestradiol 30 micrograms and levonorgestrel 150 micrograms per tablet (Microgynon 30®) is prescribed.
What modification, if any, is most likely to be needed to her antiepileptic treatment?
A. Decrease levetiracetam dosage
B. Decrease lamotrigine dosage
C. Increase levetiracetam dosage
D. Increase lamotrigine dosage
E. No changes required to antiepileptic therapy
D. Increase lamotrigine dosage
Lamotrigine is metabolised by glucuronidation. Other drugs, including oestrogens such as ethinylestradiol, can induce more rapid lamotrigine glucuronidation. This reduces lamotrigine concentrations and may lead to a loss of seizure control. If contraception with a systemic oestrogen is considered appropriate (alternative contraception, e.g. with an intrauterine device, may be preferable), a pre-emptive increase to the dosage of lamotrigine should be considered. This may be supported by plasma lamotrigine concentration measurement.
Mr T SHach has come into your practice for his annual review today. He informs you that over the last few months he has been feeling “Not himself, and things are starting to fall apart”. He says he has been getting really tired even though he isn’t exerting as much as normal, and his muscles are aching. When questioned further he informs you that he has been developing a little tremor and his skin has been feeling a little warm and moist. He has felt as though his appetite has increased, however is losing weight.
Which of the following medicines below may be contributing to these symptoms which Mr T SHach is experiencing?
A. Carbimazole
B. Levothyroxine
C. Digoxin
D. Propylthiouracil
B. Levothyroxine
Mrs Sue Karto 45-years-old has come into the practice for her annual diabetic review. She has had her Hb1Ac checked as part of the routine bloods, and it is found that her Hb1Ac has increased since the last time it was checked 3 months ago. Mrs Sue Karto is currently being treated with Metformin at the maximum dose to try control her diabetes.
What should the Hb1Ac be before you offer an additional antidiabetic agent to help control her diabetes?
A. 46mmol/mol
B. 52mmol/mol
C. 54mmol/mol
D. 58mmol/mol
D. 58mmol/mol
You are undertaking a MUR with Mrs Chloe Trimazol. Upon discussing her medicines, she informs you she has been experiencing recurrent episodes of vaginal thrush.
Which one of the drugs below may be contributing to Mrs Chloe Trimazol recurrent episodes of vaginal thrush?
A. Atorvastatin
B. Metformin
C. Levothyroxine
D. Dapagliflozin
D. Dapagliflozin
When someone’s thyroid level is stabilised how often should you monitor TSH levels?
A. Monthly
B. Every 3 months
C. Every 6 months
D. Yearly
D. Yearly
Mrs H is a 55-year-old woman who suffers from Type 2 Diabetes for which she takes Metformin 500mg THREE times a day. She presents in the pharmacy complaining of painful lesions in her mouth that often bleed when she rubs them. She has had these symptoms for the past 10 days and has noticed that the number of lesions have increased and the pain has become progressively worse. Upon examination, you notice a number of white patches on her tongue.
Which of the following is the most appropriate action for you to take?
A. Advise Mrs H that this is a normal side effect of her medication and that she could use paracetamol to ease the pain
B. Sell her Bonjela oral gel and advise her to apply it to the lesions up to 8 times a day
C. Advise Mrs H that she is suffering from mouth ulcers and using an antibacterial
mouthwash may help
D. Sell her Nystatin oral suspension and advise her to apply 1mL to the lesion FOUR times
a day for 7 days
E. Advise Mrs H to see her GP as her medication may need to be reviewed
E
- Miss O, a 23-year-old lady, has recently been diagnosed with hypothyroidism. She presents at the pharmacy with a prescription for levothyroxine 50mcg daily.
Which of the following is the least appropriate advice to give Miss O taking the levothyroxine tablets?
A. You should not take antacids at the same time as levothyroxine
B. You should wait at least 30 minutes after taking your levothyroxine tablets before you
drink coffee or tea
C. If you are taking iron supplements, you should leave a 2-hour gap between taking iron
and levothyroxine
D. Calcium salts can reduce the absorption of levothyroxine
E. Levothyroxine is best taken in the morning with breakfast
E
BNF monograph - dose to be taken preferably at least 30 minutes before breakfast, caffeine- containing liquids (coffee, tea) or other medication. Under interactions - calcium is predicted to decrease the absorption of levothyroxine.
Mrs N is a 52year old woman who is suffering from the symptoms of menopause. She also has asthma and hyperthyroidism. She is on the following medication:
Carbimazole 5mg OD
Alendronic acid 70mg weekly
Adcal D3, TWO tablets TWICE daily
Salbutamol 100mcg, TWO puffs when required
Seretide 125 evohaler, TWO puffs BD
Mrs N presents at the pharmacy with symptoms of heartburn and difficulty swallowing.
Mrs N presents at the pharmacy with symptoms of heartburn and difficulty swallowing.
Which one of Mrs S’ medications is the most likely cause of her symptoms?
A. Carbimazole
B. Alendronic acid
C. Calcichew D3
D. Salbutamol 100mcg inhaler
E. Seretide 125 Evohaler
B. Alendronic acid
Severe oesophageal reactions are a side effect of oral bisphosphonates. Severe Oesophageal reactions (oesophagitis, oesophageal ulcers, oesophageal stricture and oesophageal erosions) have been reported; patients should be advised to stop taking the tablets and to seek medical attention if they develop symptoms of oesophageal irritation such as dysphagia, new or worsening heartburn, pain on swallowing or retrosternal pain.
You are an independent prescriber running a diabetic clinic. Ms P has recently been diagnosed with gestational diabetes. She has failed to respond adequately to two weeks restriction of energy and carbohydrate intake and an increase in physical activity. Her fasting blood glucose is 6.1 mmol/L.
Which of the following is the most appropriate advice for this patient?
A. Ms P should be initiated on Metformin
B. Ms P should be initiated on insulin
C. Ms P should be initiated on Gliclazide
D. Offer no treatment and refer Ms P to a dietician
E. Offer no treatment and advise Ms P to continue with a healthy diet during pregnancy and
emphasise eating foods with a low glycaemic index.
A. Metformin.
Women with gestational diabetes who have a fasting plasma glucose below 7 mmol/L at diagnosis, should first attempt a change in diet and exercise alone in order to reduce blood- glucose. If blood-glucose targets are not met within 1 to 2 weeks, metformin hydrochloride may be prescribed [unlicensed use]. Insulin may be prescribed if metformin is contraindicated or not acceptable, and may also be added to treatment if metformin is not effective alone.
Mrs P, a 35-year-old Type 1 diabetic, who has been admitted to hospital whilst visiting the UK from the USA. She uses Humulin R-500 insulin (500 units per 1 mL) from a 20mL vial: 70 units in the morning, 95 units at lunchtime and 35 units at teatime. Mrs P had been self- administering her insulin using her own vial but this ran out 2 days and Mrs P has been unwell. The drug chart indicates that the nursing staff continued to administer the same 0.4mL daily dosing using their ward stock of 10mL vial of Humulin I (100 units per 1 mL). What is the most likely cause of Mrs P’s symptoms?
A. Hypoglycaemia
B. Hyperglycaemia
C. Erratic blood glucose levels due to stress
D. Changes in the effectiveness of Humulin
E. The ward supply of Humulin I is out of date
B
Mrs P has 200 units of Humulin R-500 which is 0.4mL, however she has been having 0.4mL of Humulin I which is 100 units per mL, which equates to 40 units daily. 40 units is much lower than her usual 200 units and therefore is most likely unwell due to hyperglycaemia.
Master A is taken to his doctor by his mother. The whole family has had colds and fevers over the last weeks. Master A has also been feeling sick and complaining of a stomach ache. His mother is worried that he does not appear to have had much of an appetite and looks like he has lost some weight. Also, she is worried that his symptoms do not appear to be improving. She is relieved however that he has been drinking lots as she was advised that he must keep his fluid intake up. However, Master P has wet his bed at night on several occasions. The GP makes a diagnosis of Type 1 diabetes. Blood glucose level is measured at 22mmol/L.
Which one of the following is least likely to be a presenting symptom of Type 1 diabetes?
A. Abdominal pain
B. Enuresis
C. Hypoglycaemia
D. Fatigue
E. Weight loss
C. Hypoglycaemia
Glycated haemoglobin levels (Hb1Ac) is a good indication of glycaemia control over the last 2-3 months. Mr HB is a patient of yours with hypercholesterolaemia and smokes 20 a day. He has an increased risk of peripheral arterial disease.
In those at risk of arterial disease, the aim should be to maintain Hb1Ac concentrations at:
A. 42 mmol/mol
B. 44 mmol/mol
C. 48 mmol/mol
D. 52 mmol/mol
E. 54 mmol/mol
C. 48 mmol/mol
A target Hb1Ac concentration of 48mmol/mol (6.5%) or lower is recommended in patients with type 1 diabetes regardless of peripheral arterial disease.
A patient with type 2 diabetes needs to commence insulin treatment and would like to use an insulin preparation that is injected subcutaneously TWICE daily with meals.
Which of the following is the most suitable insulin preparation for this regimen?
A. Actrapid (soluble insulin)
B. Apidra (insulin glulisine)
C. Humalog Mix25 (biphasic insulin lispro)
D. Lantus (insulin glargine)
E. NovoRapid (insulin aspart)
Humalog Mix25 (biphasic insulin lispro) is a combination of an intermediate acting and rapid acting insulin. This is commonly used for twice daily regimens when basal-bolus regimens are unsuitable/not tolerated.
Mrs O is 70 years old. She was admitted to hospital after falling at home. Upon admission, the ward pharmacist review Mrs O’s current medication and discussed her lifestyle and previous medical history. The pharmacist was concerned about Mrs O’s risk of developing osteoporosis and discussed her case at a multidisciplinary meeting that afternoon.
Which one of the following is not a risk factor for the development of osteoporosis?
A. Cigarette smoking
B. Early menopause
C. Excessive alcohol consumption
D. Family history of osteoporosis
E. Obesity
E - obesity
Osteoporosis occurs most commonly in postmenopausal women and in those taking long-term oral corticosteroids (glucocorticosteroids). Other risk factors for osteoporosis include low body weight, cigarette smoking, excess alcohol intake, lack of physical activity, family history osteoporosis, and early menopause.
Mrs O is taking ethinylestradiol as a means to alleviate her menopausal symptoms, however she is worried about the risks and side effects that come with hormonal replacement therapy. Which ONE of the following adverse effects is NOT a reason to stop her medication?
A. A blood pressure reading of 145/90
B. Unusual, severe, prolonged headache
C. Severe stomach pain
D. Sudden severe chest pain
E. Swelling in the calf of one leg
A
Reasons to stop HRT: sudden severe chest pain; sudden breathlessness (or cough with blood- stained sputum); unexplained swelling or severe pain in calf of one leg; severe stomach pain; serious neurological effects; hepatitis, jaundice, liver enlargement; blood pressure above systolic 160mmHg or diastolic 95mmHg; prolonged immobility after surgery or leg injury; detection of a risk factor which contra-indicates treatment.
A 55-year-old woman has visited the pre-operative assessment clinic as she is due to have a total hip replacement. Her current medication is shown below:
▪ Paracetamol 500mg tablets 2 QDS
▪ Lansoprazole 30mg capsules 1 OD
▪ Clenil Modulite (Beclometasone) 100mcg inhaler 2 puffs BD
▪ Bricanyl Turbohaler (Terbutaline) 500mcg 1 puff QDS PRN
▪ Elleste Duet Conti (Estradiol and Norethisterone) 2mg/1mg tablets 1 OD
She has been advised to stop Elleste Solo tablets 6 weeks prior to surgery. What is the correct rationale?
A. There is an increased risk of bleeding
B. There is an increased risk of cancer
C. There is an increased risk of VTE
D. There is an increased risk of stroke
E. There is an increased risk of heart disease
C
Major surgery under general anaesthesia is a predisposing factor for VTE and it may be prudent to stop HRT 4-6 weeks before surgery; it should be restarted only after full mobilisation. If HRT is continued or if discontinuation is not possible, prophylaxis with unfractionated or for molecular weight heparin and graduated compression hosiery is advised.
Abrupt withdrawal of a corticosteroid after a prolonged period can lead to adrenal insufficiency, hypertension or death. Gradual withdrawal of systemic corticosteroids should be considered in certain circumstances.
Which of the following would require gradual withdrawal of systemic corticosteroids?
A. Mr HA who has been on prednisolone 40 mg OD for 3 days
B. Mrs P who has been on prednisolone 40 mg OD for 5 days
C. Mr D who has been on prednisolone 10 mg OD for 4 weeks
D. Mr E who has been on prednisolone 40 mg OD for 3 days but was on prednisolone 5 mg
OD for 1 year over 2 years ago
E. Mrs F who has been on prednisolone 10 mg OD for 2 weeks
C Mr D who has been on prednisolone 10 mg OD for 4 weeks
Gradual withdrawal of systemic corticosteroids should be considered in those whose disease is unlikely to relapse and have:
- Received more than 40 mg prednisolone (or equivalent) daily for more than one week
- Been given repeat doses in the evening
- Received more than three weeks treatment
- recently received repeated courses
- taken a short course within one year of stopping long-term therapy
- other possible causes of adrenal suppression
Mrs F is a patient with diabetes who is in hospital for an elective gastrectomy. She usually takes Lantus (insulin glargine) and the eight units at night and then NovoRapid (insulin aspart) eight units TDS when needed. since her operation, Mrs F has been on a variable rate insulin infusion with soluble insulin and continuation of the Lantus at 80% of normal dose. She has now started to eat small amounts and is going home the next day, so the variable rate insulin is to be stopped. A junior doctor asks what to do with respect to restarting the NovoRapid (insulin aspart).
Which of the following would be the most appropriate course of action?
A. Give any insulin until the patient is eating regularly again
B. Do not restart Novorapid and wait for the diabetic nurse specialist to see him at home
next week
C. Monitor blood glucose sugar levels and give NovoRapid as required
D. Place the patient back onto his usual insulin dosage
E. Recommend that now the patient is eating and drinking, his insulin can be converted to
oral route
If the patient does not have the rapid acting insulin, they will be at risk of hypoglycaemia. Previous subcutaneous Basal-bolus regimens should be restarted when the first post-operative meal time insulin dose is due or the patient begins to eat. The NovoRapid can be adjusted according to her glucose levels.
You have a 500 ML infusion of glucose 10%. You discard 100mL of this infusion bag and replace it with 100 ML glucose 50%.
The volume and concentration of glucose do you now have?
A. 150mL glucose 50% bag
B. 350mL glucose 50% bag
C. 500mL glucose 10% bag
D. 500mL glucose 18% bag
E. 600mL glucose 18% bag
D. 500mL glucose 18% bag
10% glucose = 10g glucose in 100mL. So, after discarding 100mL you have 40g in 400mL. 500mL-100mL= 400mL. 50% is 50g in 100mL so after adding 100mL you have 90g in 500mL. To get concentration you need g/100mL therefore 90g/5 = 18g, so the answer is 18%.
