Chapter 6: Endocrine Flashcards
Mr. T. is a 65 – year -old patient who has a history of *heart failure, *asthma, *COPD, *BMI of 40kg/m2 and *low vitamin B12 levels. His recent *Qrisk score is 12% and *Egfr IS 40 ml/min. He has been taking *Metformin as first line treatment for the management of *TYPE 2 diabetes mellitus. Consider all the information provided about Mr T and choose a drug that NICE guidelines recommend as 2nd line in this scenario.
A. Linagliptin
B. pioglitazone
C. Gliclazide
D. Insulin glargine
E. Dapagliflozin
QRISK >10+, patient is at higher risk of CVD=>pt should be put on SGLT-2 inhibitor, proven evidence to reduce risk of CVD
Glicazide: increased risk of hypoglycaemia, causes weight gain=>patient already obese
Metformin: causing low B12 levels in pt
if pt is on another medication, can give SGLT-2 inhibitor with metformin as long as eFGR not less than 15 (if less than 15, do not give datagliflozin on its own)
E. Dapagliflozin
You are working as a locum pharmacist in a pharmacy when a mother walks into your pharmacy and asks to speak to you privately. She explains that her 12-year-old son is suffering from severe symptoms of hyperglycaemia and his condition is deteriorating quickly. She would like to administer insulin, but she noticed the one she has is expired. She seems rather worried about the situation. Which of the following options is the most appropriate next line of action for you to take ?
A. Ask the mother to order a new prescription from the GP surgery.
B. Offer the patient an emergency supply of insulin.
C. Request a new prescription and place an order for insulin from your suppliers.
D. Advice the mother to administer the expired insulin.
E. Refer her to another pharmacy.
B. Offer the patient an emergency supply of insulin.
Corticosteroids
TYPES - mineralocorticoids and glucocorticoids
mineralocorticoids – high mineralocorticoid effect: fludrocortisone
>hydrocortisone has 50/50 mineralocorticoid/glucocorticoid effect
Glucocorticoid examples – dexamethasone, betamethasone, prednisolone, beclomethasone etc.
Offer a steroid card (long-term): in case of emergency treatments
Avoid large doses in septic shock !!
potencies of topical corticosteroids: skin, ch 13–betnovate, eumovate, hydrocortisone, dermovate have different levels of potency
> very potent: dermovate (clobetasol), mild potent: hydrocortisone (OTC: use sparingly, apply small amount to affected area twice a day, 1 week use only), moderate: eumovate (clobetasone, mometasone), potent: betnovate (betametasone 0.025 and 0.1=>0.025 (moderate renovate RD, 0.1 potent)
Can affect growth of children . Check every year
Corticosteroid SE
> corticosteroids can cause retinal disorder. MHRA !!
Patients on long-term corticosteroids are susceptible to adrenal insufficiency, chickenpox, measles, infections, psychiatric reactions.
Take in the morning to increase efficacy and reduce insomnia.
Corticosteroids are no longer recommended in routine emergency
treatment for anaphylaxis.
mineralocorticoids Side-effect – sodium retention (high sodium means high blood pressure), water retention (increase in sodium, wherever salt goes, water follows); sodium and potassium has inverse relationship, when sodium goes into cell, then potassium/calcium goes out (change in electrolyte level causes metabolic acidosis: system becomes more acidic), hypertension, potassium loss, calcium loss and , metabolic acidosis.
Glucocorticoids side-effect (organs and tissues)- Diabetes, osteoporosis, gastric ulcers, psychosis, muscle wasting and necrosis of the femoral head.
Thyroid Disease
There are two main types of thyroid disorder.
Hyperthyroidism and hypothyroidism
Hypothyroidism is more common in the UK=>levothyroxine, due to genetics and diet, need iodine to form thyroid hormones, iodine=>seafood, salt
Hypothyroidism results from decreased production of hormones from the thyroid gland
Increasing age, Gender, women are at increased risk
Autoimmune diseases, where the immune system attacks the body’s own cells
Family history, Thyroid surgery, where a portion or all of the gland is removed
Radiation therapy to treat cancers in the head and neck region. Certain medications, for example, antipsychotic medications
Defective thyroid gland or absence of the gland at birth
Pituitary disorder which can result in decreased production of thyroid-stimulating - Hormone (TSH) and Iodine deficiency
Symptoms of Hypothyroidism
MNEMONIC IS MOM’S SO TIRED
M-Memory loss.
O-Obesity.
M-Malar flush/Menorrhagia.
S-Slowness (mentally and physically)
S-Skin and hair dryness.
O-Onset gradual.
T-Tiredness.
I-Intolerance to cold
R- Really low BP
E-Energy levels fall
D-Depression
Other Symptoms - Constipation, weight gain, cold intolerance, depression, hair loss, fatigue, bradycardia
Safe prescribing of insulin
❖ Use full word units not abbreviation
❖ Prescribe and dispense by brand name
❖ Counselling- don’t withdraw insulin using a syringe
❖ 25 - 50 RULE
❖ Question any dose of rapid acting insulin over 25 units.
❖ Question any dose of long-acting insulin over 50 units.
❖ SICK DAY RULES (dont miss insulin dose, test for ketones, n+v, some meds may need to be stopped temporarily)
Hyperthyroidism
Hyperthyroidism results from increased production of hormones from the thyroid gland.
Factors that influence the overproduction of hormones include:
❖ Graves’ disease, an autoimmune disease.
❖ Excessive intake of iodine through diet, dietary supplements or medications.
❖ Tumour or infection of the thyroid gland.
❖Certain tumours of the ovaries, testes, or pituitary gland.
Symptoms of Hyperthyroidism – MNEMONIC IS WASTHE DAD
Weight loss, arrhythmias, sweating, Tremors, heat-sensitivity, Excitability, diarrhoea, angina pain, difficulty-sleeping.
Lab Test Results
Hypothalamus produces TRH=>TRH goes to pituitary gland=>Pituitary produces TSH=>TSH travels to thyroid gland=>Thyroid produces hormones: T4 (stored, 94%), T3 (active, 6%)
When T3 is depleting, then T4 is converted by the liver to T3. When T4 runs out, negative feedback starts back at hypothalamus.
T3 or T4 is high=>hyperthyroidism
T3 or T4 is low=>hypothyroidism
Lab Test Results
LABORATORY TEST RESULTS
What are the roles of the following
TRH - Thyrotropin-releasing hormone (TRH) is a hormone produced in the hypothalamus. It stimulates the release of TSH from the pituitary.
TSH - TSH stimulates the thyroid gland to produce thyroid hormone. T3 Hormone
The T3 hormone is also known as triiodothyronine, is an active hormone. T3 is fours times as potent as the T4 Hormone. There are two types of T3 Hormone:
T3 is a converted form of T4. At first, the thyroid gland produces 96% of T4 hormone which is then converted by a deiodinase enzyme to form the T3 hormone in the liver. The other organs in the body may also break down the T4, but only in smaller amounts.
T4 Hormone
The T4 hormone is the “partner” of the T3 Hormone. Also known as thyroxine, the T4 hormone consists of four iodine atoms. Most thyroid hormones are bound to protein atoms, but a small fraction of these hormones are free or unbound.
One afternoon a 69-year-old man walks into your pharmacy with his blood test results in his hand. He would like you to interpret the results as he does not understand the implications of the test result.
You notice that his results indicate ‘’ low TRH, low TSH’’ and high T4 and T3’’ levels.
Choose a statement which is appropriate to say to the patient.
A. Your results suggest the development of hypothyroidism and your doctor could prescribe you levothyroxine tablets.
B. Your results suggest the development of hyperthyroidism and your doctor could prescribe you liothyronine tablets
C. It seems like you could be suffering from graves’ disease and would certainly need to have surgery- thyroidectomy to resolve it.
D. Your results suggest the development of hyperthyroidism and your doctor could prescribe you propylthiouracil tablets.
E. Your results suggest the development of hypothyroidism and your doctor could prescribe you carbimazole tablets.
D. Your results suggest the development of hyperthyroidism and your doctor could prescribe you propylthiouracil tablets.
Quick Points
> Which drugs require a check on thyroid level
statins (before initiate satins, check to see if patient has hypothyroidism first, treat hypo before statins started)
Amiodarone=> causes both hypo/hyper
Lithium=> before initiat lithium, check for hypothyroidism
iodine and iodine-containing drugs=>causes hyper
Treatment: hyper (Propylthiouracil , carbimazole), hypo (levothyroxine, LIOTHYRONINE) hypo is Low; levo/lio…
Hypothyroidism
Levothyroxine (pro-drug)
Synthetic version of T4 (converted from T4 to T3 in the body)
To be taken in the morning at least 30 minutes before breakfast, caffeine-containing
drinks or other medicines. (Adcal D3/calcium/risondrate/alendronic acid=>wait 4 hrs, reduce chelation affects (calcium forms chelates around drug reducing absorption), 2 hrs for iron
CAUTION – baseline ECG is valuable because changes induced by hypothyroidism can be confused with ischaemia.
In pregnancy? Yes but monitor dose
Liothyronine (when patient has liver dysfunction as unable to convert T4 in levo)
Synthetic version of T3
Has a more rapid effect and rapidly metabolised than levothyroixine.
Note – different brands/manufacturer may not be bioequivalent: good practice
Ideal in severe hypothyroid emergencies
20-25 mcg of liothyronine is equivalent to approximately 100 mcg of levothyroxine
>medical emergency: liothyronine
Hyperthyroidism
CARBIMAZOLE (first line)
1mg of carbimazole is equivalent to 10mg of propylthiouracil unless instructed otherwise. Carbimazole has been reported to cause the following
1. Neutropeunia (break down of white blood cells, neutrophils=>making them susceptible to infection, immune system weakened)
2. Agranulocytosis (break down of agranulytes)
3. Risk of acute pancreatitis (similar to hepatic dysfunction, but no dark urine/jaundice)
4. Risk of congenital malformations
5.Symptoms of blood disorder (sulfasalzin, methotrexate, trimethoprim, vancomycin, mirtazipine) such as —-bleeding, bruising, sore throat, purpura, fatigue
>cannot give in pregnancy bc if congenital deformities
PROPYLTHIOURACIL
Used to treat hyperthyroidism as second line treatment
It can be given in pregnancy but the blocking –replacement regimen is not suitable.
Side-effects
Alopecia, fever, taste altered, agranulocytosis, encephalopathy
NOTE – it should be monitored for signs of liver disorder such as ..jaudince , vomiting, nausea, dark urine, abdominal pain ,
Ms. Neil is a 63-year-old female patient who walks into your pharmacy and asks to speak to you. She mentions that her consultant prescribed both carbimazole and levothyroxine and asked her to take both medicines as directed. She read the leaflet and noticed that one drug is used to treat hyperthyroidism and the other is used to treat hypothyroidism. She wants you to explain why the consultant may have done this ? Choose the most appropriate option below.
A. She was prescribed levothyroxine to counteract the side-effects of carbimazole.
B. Refer her back to her consultant as this is definitely a mistake.
C. Refer her to her doctor and ask to change carbimazole to propylthiouracil instead.
D. She should take either drug on a day-to-day basis depending on the symptoms she is experiencing.
E. She may have been prescribed both drugs to bring her to a euthyroid state.
E. She may have been prescribed both drugs to bring her to a euthyroid state.
both medication: blocking-replacement therapy to bring patient to euthyroid (balanced) state
Osteoporosis
Is a bone disease characterised by low bone mass measured by bone mineral density and deterioration of bone tissue.
Risk factors include – postmenopausal women (Gina less than 50 without period for 2 yrs=>menopausal, over 50 without period for 1 yr=>menopausal, HRT medicines as prophylaxis for osteoporosis, menopause=>low levels of oestrogen=>can lead to osteoporosis as bones are supported by this hormone), men over 50 years, long term corticosteroids (especially glucocorticoids) , low BMI, smoking, excessive alcohol, lack of physical exercise, low vit D and calcium levels.
Offer lifestyle advice to patients such as increase BMI (min of 20 kg/m2), stop smoking, Vitamin D supplementation.
>Sri Lanka pt: asks about vitamin D, does she need it throughout the year? Assume bc they are brown/black they have natural vitamin D? regardless of colour, it’s needed all year round; lighter skin complexion make vitamin D quicker=>20000 units booster for 7 weeks, then 1000 u daily, everyone also needs sunscreen
Note – elderly patients are at risk of falls (drugs increase risk of falls: benzos-azepams, z-drugs, risperidone, loop diuretics: furosemide)
Osteoporosis Treatment
✓ strontium, raloxifene, HRT meds, oral bisphosphonates (first line).
❖ Strontium (not prescribed routinely, increases risk of Cardiovascular events)- Severe osteoporosis in men and postmenopausal women at increased risk of fractures [when other
treatments are contra-indicated or not tolerated] (initiated by a specialist) . Contra-indications
>Contra-indications For strontium ranelate Cerebrovascular disease; current or previous venous thromboembolic event; ischaemic heart disease; peripheral arterial disease; temporary or permanent immobilisation; uncontrolled hypertension
❖ Raloxifene - used to prevent osteoporosis and does not help with vasomotor symptoms of menopause.
❖ HRT meds - Only for young women who have early menopause .
With uterus
● Combined HRT (oestrogen + cyclical progesterone for last 12 - 14 days per 28-day cycle)
- reduce chance of endometrial cancer
● Can give Tibolone
No uterus
● Oestrogen only HRT
● If patient has endometriosis: Combined HRT
Osteoporosis Drug Treatment
❖ First choice – oral bisphosphonates e.g. alendronic acid (once daily 10mg/once weekly 70mg), risedronate sodium, Zolendronic (injection, most potent) acid, ibandronic acid (taken once a month).
❖ How should oral bisphosphonates be taken?
* Take the tablet preferably in the morning ONCE A WEEK – dose dependent
* Take it before you eat any food or have anything to drink other than water.
* You must drink a large glassful of plain water as you take your dose. If you are taking tablets, swallow the tablet whole - you must not chew, break, or crush alendronic acid tablets.
* It is important that you take your dose while you are standing or sitting in an upright position.
* Continue to sit or stand upright for 30 minutes after taking your dose - you must not lie down during this time.
* Do not have anything to eat or drink (other than plain water), or take any other medicines during the 30 minutes after taking a dose
Quick Points
Ibandronic acid— should be taken once a MONTH
Zoledronic acid— available via injection not TABLETS
Complications
Oesophageal reactions- OESOPHAGITIS, oesophageal ulcers, oesophageal erosions - if symptoms such as dysphagia, heartburn is developed, stop taking and refer to GP.
Osteonecrosis of jaw – advice oral hygiene, dental check up before initiating, report oral symptoms
Atypical femoral fractures – thigh pain, groin pain,
Osteonecrosis of external auditory canal – ear pain, hearing impairment, ear
discharge
In all these cases, stop taking and refer to GP.
Ms VB, a 69-year-old female patient comes into your pharmacy with a new prescription for Alendronic acid 70mg tablets for the management of osteoporosis. Which of the following options is incorrect advice you can give Ms. VB regarding her new medicine?
A. She should not lie down for at least 30 minutes after taking
the drug.
B. She must be told the drug can cause blood disorders.
C. She should not chew or suck the tablet.
D. She should be aware that the drug can cause ear pain, and this must be reported.
E. She needs to leave 4 hours before taking calcium tablets.
B. She must be told the drug can cause blood disorders.
Diabetes Mellitus
➢Type 1 and Type 2
General signs and symptoms of diabetes
✓ Polydipsia
✓ Increased hunger
✓ Polyuria
✓ Fatigue
✓ Blurred vision
✓ Weigh loss in type 2
✓ Increased UTIs
Complications
❖Leg ulcers: fluclox
❖Visual problems
❖Neuropathy
❖Nephropathy (ACE inhibitor additional protection kidneys, Afro: ARB
❖Gastroparesis: metoclopramide
❖Erectile dysfunction
❖Cardiovascular disease (diabetes is a precursor to CVD)
DIAGNOSIS / TEST
HBA1C (most accurate biomarker)
● Reflect plasma control over 2-3 months
● Used to diagnose type 2 diabetes (but not type 1) or monitoring in type 1 or 2 diabetes ● When shouldn’t you use HBA1C ?
type 1 diabetes (diagnosis), children, pregnancy + 2 months postpartum, symptoms <2 months, treatment with meds that cause hyperglycaemia, pancreatic damage.
● Monitor every 3-6 months
Oral Glucose Tolerance Test
● Used to diagnose gestational diabetes
● Measure blood glucose after fasting for 8h + 2h after drinking a glucose drink
In asymptomatic people, at least 2 readings are needed to be diagnosed
Target Ranges
Table
**high blood glucose levels not controlled=>DKA, diabetic hyperglycaemic emergency
Target Ranges
Learn target ranges
✓ Normal: Below 42 mmol/mol (6.0%)
✓ Prediabetes: 42 to 47 mmol/mol (6.0 to 6.4%) ✓ Diabetes: 48 mmol/mol (6.5% or over)
✓ Driving – 5mmol/litre
✓ Hypoglycaemia - less than 4 mmol/L
Hypoglycaemia
Symptoms include- Dizziness, Sweating, Hunger , Headache ,Difficulty concentrating, confusion, slurred speech, convulsions – emergency.
Treatment
> For conscious patients
1. 15 – 20g fast acting carb (ie. sugar) , 1.5 - 2 tubes of glucogel , 3-4 teaspoons of sugar , 4-5 glucose tablets
○ 150-200ml of pure fruit juice (orange juice is high in potassium - do not give to people with CKD)
○ 60-80ml of Lift or other oral glucose liquid
○ Avoid chocolates and biscuits - not as high on sugar
can of coke, original lucozade, apple juice
2. Wait 10 – 15 mins
3. If glucose levels are still <4 mmol/L repeat (up to 3 times)
4. If after 3 times, glucose levels are still low, give IM glucagon
5. If it still doesn’t work, IV glucose infusion
6. Once glucose levels are >4 mmol/L, give a slow-release carbohydrate: bread or toast, biscuits, cows’ milk.
> For unconscious patient
1. IM glucagon (orange, stored in fridge)
2. Wait 10 – 15 mins
3. If ineffective, give IV glucose infusion
Driving
Blood-glucose should always be above 5 mmol/litre while driving. If blood-glucose falls to 5 mmol/litre or below, a snack should be taken. Drivers treated with insulin should ensure that a supply of fast-acting carbohydrate is always available in the vehicle. If blood-glucose is less than 4 mmol/litre, or warning signs of hypoglycaemia develop, the driver should not drive. Check 2 hours before driving and every 2 hours while driving. If already driving, the driver should:
*stop the vehicle in a safe place;
*switch off the engine, remove keys from the ignition, and move from the
driver’s seat;
*eat or drink a suitable source of sugar first, after can have slow-release rice, sandwich;
*wait until 45 minutes after blood-glucose has returned to normal, before
continuing journey.
Drivers must not drive if hypoglycaemia awareness has been lost and the DVLA must be notified; driving may resume if a medical report confirms that awareness has been regained.
> freestyle libre 3: no continuius monitoring needed
Insulin Summary
❖STOREINFRIDGE–IDEALTEMPIS 2C TO8C.
❖ Bolus and Basal
❖ All patients on long-term insulin must notify the DVLA
❖ Insulin can cause significant weight gain. OTHER DRUGS include – olanzapine, lithium, beta blockers
❖ Insulin requirements can increase in pregnancy, puberty, infection, stress and trauma.
❖ Insulin requirement could decrease in celiac disease, hepatic impairment and Addison’s disease.
❖ Rotate site of insulin injection to prevent …lipidystrophy (thickening/scarring of the skin, hard, inflamed).
❖ In pregnancy give metformin (oral) or insulin aspart (novorapid) and insulin lispro (Humalog) .
Isophane insulin is the first-choice for long-acting insulin during pregnancy
❖ Women who have a fasting plasma glucose above 7 mmol/litre at diagnosis should be treated with insulin immediately, with or without metformin hydrochloride, in addition to a change in diet and exercise.
❖Electrolyte imbalance such as hypokalaemia (ch3: beta agonists, corticosteroids, theophylline). Drug interactions?
INSULIN - SUMMARY
Insulin safety
▪ All regular and single insulin doses are measured and administered using an insulin syringe or commercial insulin pen device. Intravenous syringes must never be used for insulin administration.
An insulin syringe must always be used to measure and prepare insulin for intravenous infusions.
Insulin should always be written in units and NEVER abbreviated i.e. “U” or “IU” must NOT be used.
>do not use syringe to withdraw dose
>brand names only
All healthcare professionals who prescribe, prepare and administer insulin should have adequate training.
Adult patients on insulin therapy receive a patient information booklet and an Insulin Passport to help provide accurate identification of their current insulin products and provide essential information across healthcare sectors
INSULIN - SUMMARY
❖ Use of insulin during surgery.
❖ Elective surgery - minor procedures in patients with good glycaemic control
❖ 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 %. (pt can go into hypoglycaemia during surgery)
❖ Elective surgery - major procedures or poor glycaemic control -
on the day before surgery, once daily long-acting insulin analogues should be given at 80 % of the usual dose; otherwise, the patient’s usual insulin should be given as normal;
on the day of surgery and throughout the intra-operative period, once daily long-acting insulin analogues should be continued at 80 % of the usual dose; all other insulin should be stopped until the patient is eating and drinking again after surgery;
TYPES OF INSULIN
> SHORT ACTING
RAPID – take just before or with a meal. Starts working in 15 mins. Bolus regimen and S/C insulin pumps. Apidra (glulisine) , lispro (humalog), aspart (Novorapid)
SOLUBLE – usually taken before meals. Onset 30 mins ( Actrapid, humuln S, insuman raid, Hypurin neutral). For diabetic emergencies (DKA)
INTERMEDIATE ACTING
Biphasic insulin
Humulin I, insuman basal, insulatard
onset of action – 1 to 2 hours
LONG-ACTING duration up to 36 hours
Usually given once daily – insulin gargine (Lantus Solostar, toujeo) and insulin degludec (tresiba)
Given Once or twice a day - Levemir (insulin determir)
Insulin Table
Mr. Choi a 55-year-old patient has been diagnosed with type 2 diabetes. His HBAIC is 53mmol/mol and eGFR is 30ml/min. He is aware that some drugs can exacerbate his condition. Which of the following drugs listed below is the least likely to exacerbate diabetes ?
A. Furosemide 40mg tablets
B. Bendroflumethiazide 2.5mg tablets
C. Dexamethasone 2mg tablets (increase glucose)
D. Ramipril 5mg tablets
E. Olanzapine 20mg tablets (increase glucose)
D. Ramipril 5mg tablets (SADMAN RULES)
New Nice Guidelines
T2DM
1st line: metformin
QRISK score >10+=>SGLT-2 inhibitor (dapagliflozin)+metformin, if QRISK of 5, just stays on metformin and follow previous guidelines (pioglitazone: do not give in HF, gliptins: do not give in pancreatitis, sulphurenuea: do not give in elderly, hypoglycaemia risk, obese, SGLT-2 inhibitor: do not give risk of DKA/ frequent UTI),
Mr. R is a 57 – year -old patient who presents in your pharmacy and hands you
a new prescription for Canagliflozin 100mg tablets. He explains to you that he
could not tolerate metformin and his doctor has prescribed canagliflozin. He
also mentions that he suffers from type 2 diabetes and that his father passed
away due to an ischaemic stroke last year. He would like to know about the
side-effects. Which of the following is the least likely side-effect associated
with canagliflozin?
A. Lower limb amputation (increases the risk, do not give in foot ulcer)
B. Weight gain=>normally causes weight loss
C. Liver toxicity
D. Diabetic ketoacidosis
E. Fournier’sgangrene
B. Weight gain
SGLT-2 inhibitors: learn side effects
Biguanides
e.g., Metformin
Works by increasing peripheral utilization of glucose.
how to initiate treatment? Standard (can cause GI irritation/discomfort/effects, so switch or titrate dose: start small and then increase every week) vs M/R, must take with food
Generally regarded as first line treatment by NICE guidelines
>Metformin can be used to treat DM & polycystic ovary syndrome.
* Patient conselling - Take with or just after food.
* Preganancy – yes . Discontinue after giving birth in gestational diabetes (stop metformin and then monitor, insulin also safe)
>Can cause weight loss due to decreased appetite.
Side effects include –
abdominal pain
appetite decreased…
….taste altered (metallic, iron causes this too)
lactic acidosis: Egfr value: must be more than 30mL/min, if less than can cause lactic acidosis
VIT B12 deficiency
Nausea
Monitoring- renal function
SULPHONYLUREAS
eg. Gliclazide, glipizide, Gliblenclamide, Glimepiride
How do they work? Stimulate Beta pancreatic cells to Release insulin, alpha cells produce glucagon
>known for causing hypoglycaemia, especially in elderly
* 2 types short acting and long acting (more likely to cause hypoglycaemia)
Examples include — Short – gliclazide Long - Gliblenclamide
Pregnancy - Not recommended due to neonatal hypoglycaemia
Side –effects
Hypoglycaemia
Hyponatraemia
Weight gain
Jaundice – liver toxicity!
Skin rashes esp in first 6 – 8 weeks.
➢ Avoid in elderly who also have severe renal impairment.
>Interactions – NSAIDs, ACE inhibitors, st john wort (inducer)
