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2021 Pre-registration > Chapter 6 Endocrine > Flashcards

Chapter 6 Endocrine Flashcards

1
Q

What symptoms would you expect in diabetes inspidus?

A

Polyuria (extremely diluted urine) and polydipsia

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2
Q

Differences between diabetes inspidus and diabetes mellitus?

A

DI - dilute urine, caused by low levels of ADH

DM - sweet urine (due to glucose) and due to inappropriate insulin secretion/resistance

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3
Q

Two types of diabetes insipidus?

A

Cranial - inappropriate ADH secretion from hypothalamus e.g post trauma

Nephrogenic - kidneys do not respond to secreted ADH

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4
Q

How do you diagnose whether diabetes inspidus is cranial or nephrogenic?

A

Use desmopressin.

If urine is concentrated, there was a response to desmopressin so it’s cranial

If urine still very diluted, no response so nephrogenic

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5
Q

Treatment for DI?

A

Vasopressin or Desmopressin

Desmopressin = long duration of action, more potent and is used to diagnose DI.

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6
Q

Important warning about Desmopressin

A

Important message is that it can cause water intoxication as can dilute blood too much which can lead to hyponatraemic seizures

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7
Q

What is SIADH?

A

Syndrome of inappropriate adh secretion. Too MUCH ADH.

This causes water retention, blood is over diluted and so this causes hyponatraemia.

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8
Q

Normal range of Na?

A

136-145mmol/L

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9
Q

Treatment of SIADH?

A

1) fluid restriction (e.g. 1L/day)
2) demeclecycline
3) tolvaptan

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10
Q

Important issue with SIADH treatment?

A

If Na is corrected too fast, it can cause demyelination and CNS effects. This can cause permanent brain damage.

Constantly monitor Na levels

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11
Q

Name four different diabetes types

A

Type 1
Type 2
Secondary dm (drug related)
Gestational

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12
Q

How often do you have to check blood sugars whilst driving as a type 1 diabetic?

A

Every two hours

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13
Q

What is the minimum blood sugar levels when driving as a type 1 diabetic?

A

Minimum 5mmol/L

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14
Q

What do you do if you have a hypo whilst driving as a T1D?

A

Stop, eat and then wait 45mins till normal

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15
Q

What drug class can mask hypoglycaemia?

A

Beta blockers

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16
Q

How often should hba1c be measured in those that are diabetic?

A

Every 3-6 momths then every 6 months once stable

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17
Q

What is type 1 diabetes?

A

Pancreas can’t produce sufficient insulin and there is an absolute insulin deficiency due to destruction of pancreatic bcells from islets of langerhans

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18
Q

Hba1c targets?

A

Waking: 5-7mmol/L
During the day: 4-7mmol/L
After eating: 5-9mmol/L
Driving: min 5mmol/L

Hba1c target <48mmol/mol or <53mmol/mol if on hypoglycaemic agents

Monitor QDS

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19
Q

How often do you monitor BMs as a type 1 diabetic?

A

Four times a day

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20
Q

Complications of DM?

A 
Retinopathy
Neuropathy
Nephropathy
Cvs disease
PAD
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21
Q

Symptoms of T1 DM

A

Hyperglycaemia
Ketosis
Weight loss
<50 years

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22
Q

What is basal-bolus?

A

Basal- intermediate/long acting

Bolus - short acting

(Cannot tailor to amount of carbs daily)

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23
Q

Mixed insulin?

A

1/2/3 insulins per day of short and intermediate acting

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24
Q

Continuous sc insulin?

A

Continuous rapid/soluble delivered via programmed pump

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25
Q

What is type 2 diabetes?

A

Insulin resistance and/or reduced insulin secretion so it cannot keep up with high glucose demand

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26
Q

Complications of type 2 diabetes?

A

Micro:
Retinopathy
Neuropathy
Nephropathy

Macro:
Brain - stroke/tia
Heart - Hypertension
Legs - PVD (treat with naftidouryl oxalate)

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27
Q

Symptoms of type 2 diabetes?

A 
Polyuria
Polydipsia
Weight Loss
Fatigue
Blurred vision
Increase in infections eg thrush
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28
Q

Hba1c targets:

A

Lifestyle + non-hypo - 48mmol/mol
Hypoglycaemic drug - 53mmol/mol

Pregnant - 48mmol/mol

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29
Q

NICE algorithm of step 1 in T2D?

A

1) lifestyle + non-hypo drug
Target: 48mmol/mol

Metformin IR, if not tolerated then
Metformin MR

(With meals and titrate up 500mg od for 1/52 then 500mg bd for 1/52 then 500mg tds)

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30
Q

NICE algorithm step 2 for T2D?

A

Hba1c of 58mmol/mol (target = 53)

Metformin +

Dual therapy:

  • DPP4inh (gliptins)
  • Pioglitazone
  • Sulfonylureas (G and Tolbutamide)
  • SGLT-2 inhibitors - gliflozins

Triple therapy:
Met + DPP4 + SU

Met + Pio + SU

Met/Pio/SU + SGLT2

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31
Q

Metformin MOA?

A

Biguanide - increases glucose uptake eg by skeletal muscle and reduces glucose sythesis in the liver

Requires functioning b-cells in the pancreas

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32
Q

Max dose of metformin?

A

2g daily - BNF, 3g daily SPC

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33
Q

Side-effects of Metformin?

A

GI: N/V/D (take with meals)
Altered taste
Lactic acidosis
Vit B12 desorption

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34
Q

Risk factors for lactic acidosis?

A

Dehydration
Infection
Renal impairment (hence caution when IV contrast media used as can cause renal impairment - check crcl)

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35
Q

Benefits of using Metformin?

A

Can be used in obese patients as does not cause weight gain.

Does not cause hypoglycaemia

Can be used for PCOS (unlicensed - same dosing titration, COC can also be used in PCOS)

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36
Q

Signs of lactic acidosis?

A 
Dyspnoea
Cramps
Abd pain
Hypothermia (<35degrees body temp)
Asthenia: fatigue
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37
Q

Contra-indications of metformin:

A

not for EGFR <30
Caution EGFR <45
IV contrast media can cause renal impairment that can lead to lactic acidosis

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38
Q

Give examples of DPP4 inhibitors.

A

Saxa, Sita, Lina, Vida, Alo - gliptins

Sita: adjust dose in renal impairment
Lina - safe in renal impairment

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39
Q

How do DPP4inh work?

A

Increase incretin and inhibit glucagon release increasing insulin secretion, reducing gastric emptying and reducing glucose levels

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40
Q

Side-effects of DPP4inh?

A

Acute pancreatitis (STOP) - severe, persistent abdominal pain

Rare - SJS
Weight Gain
Hypoglycaemia (less than SU)

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41
Q

Which DPP4inh causes liver toxicity?

A

Vidagliptin

with acei - increased risk of angioedema

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42
Q

What category of drug is pioglitazone?

A

Thiazolidinedione

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43
Q

How does pioglitazone work?

A

Reduces peripheral insulin resistance

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44
Q

Side-effects of Pioglitazone?

A
  • Bone fractures
  • Increased infection risk
  • Visual impairment
  • Weight gain
  • Hypoglycaemia
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45
Q

MHRA warnings for pioglitazone?

A
  • Heart failure
  • Bladder cancer (dysuria, haematuria)
  • Liver toxicity (pale stools, dark urine, jaundice, abdominal pain)
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46
Q

SGLT-2 inhibitor examples?

A

Gliflozins: Cana/Dapa/Empa-gliflozin

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47
Q

How do SGLT2 inhibitors work?

A

Inhibit SGLT2 in renal PCT and reduce glucose reabsorption whilst increasing urinary glucose excretion (hence linked to thrush/gangrene)

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48
Q

SGLT2 inhibitors MHRA?

A
  • Fatal DKA
  • Limb amputation
  • Fourniere’s gangrene
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49
Q

Side-effects for SGLT-2inhibitors?

A
  • increased infection
  • urosepsis
  • Balanaposthitis (penal inflammation)
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50
Q

Renal function must be monitored for SGLT-2 inhibitors, true or false?

A

True

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51
Q

How would you counsel patients on recognising signs of DKA with SGLT-2 Inhibitors?

A

Weight loss
N/V
Sweet smelling breath/odour

Also counsel on signs of volume depletion: dizziness/postural hypotension

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52
Q

Give examples of sulfonylureas.

A

Glibenclamide
Gliclazide
Glimeperide
Glipizide

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53
Q

Side-effects of sulfonylureas?

A 
Weight gain
Hypoglycaemia
SJS/SCARS
Vision disorders
GI - Abd pain/diarrhoea
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54
Q

Give examples of GLP-1 agonists.

A

Dulaglutide (Once weekly)
Exenatide
Liroglutide
Semaglutide

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55
Q

MHRA warning for GLP-1 agonists.

A

Fatal DKA (report signs of sweet smelling odour/breath, weight loss, n/v)

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56
Q

Side-effects of GLP-1 agonists?

A
  • Acute pancreatitis
  • GI
  • Hypoglycaemia
57
Q

Examples of Meglitinides

A

Repaglinide

Nateglinide

58
Q

How do meglitinides work?

A

Stimulates insulin secretion - take 30mins before meals

59
Q

Why are meglitinides not used as much?

A

Can rarely cause CVS issues e.g. ACS (most diabetics already have underlying CVS issues)

60
Q

Side-effects of meglitinides?

A

GI

Hypoglycaemia

61
Q

What levels of glucose is characterised as hypoglycaemia?

A

<4mmol/L

62
Q

Drugs that can cause hypoglycaemia?

A

beta-blockers - mask hypo
insulin
sulfonylureas
DPP4inhibitors

63
Q

A patient comes into your pharmacy and is walkin unsteadily and feels confused. You are well known to this patient and the patient is on gliclazide and metformin. What would you do right away?

A

Signs of hypoglycaemia.
Give them a fast-acting high carb snack. E.g. slice of bread, 3/4 sugar teaspoons, 150-200ml fruit juice, 4-5 glucose tablets, 10-20g glucose juice, 1.5-2 tubes of oralgel glucose 40%

64
Q

Why would you not give chocolates/biscuits to those presenting with hypoglycaemia?

A

low sugar content, high fat content.

65
Q

A patient carries around glucogel and asks for your advice on its use. What would you recommend?

A

If an episode of hypo occurs, use 2 tubes then repeat after 10-15mins for a maximum of 3 treatments. Then call 999 as may require IM glucagon/IV glucose

66
Q

If hypo is still not treated after initial carb snack/gluco gel what would be the next option?

A

1) IM glucagon

2) IV glucose 10%/20% (not 50% as increased risk of extravasation)

67
Q

What is osteoporosis?

A

Low bone mass and bone tissue deterioration (BMD and DEXA scan)

68
Q

What is the risk of osteoporosis?

A

Increased risk of fractures.

69
Q

Risk factors for osteoporosis?

A
  • age >50
  • Vit d and calcium deficiency
  • HRT
  • Smoking/alcohol
  • family history
  • menopause
  • high dose corticosteroids
70
Q

Osteoporosis is linked to two other conditions. What are they?

A

Diabetes

Rheumatoid Arthiritis

71
Q

Aim of treatment in osteoporosis?

A

Prevent fractures

72
Q

Lifestyle advise for osteoporosis?

A
  • Exercise
  • Supplements - vit d and calcium
  • no smoking or alcohol
  • Reduce weight if obese
73
Q

First line drug treatment for post-menopausal osteoporosis and steroid-induced?

A

1) Bisphosphonates - alendronic acid (70mg once weekly), risedronate

74
Q

Alternatives to PO bisphosphonates e.g. if unable to sit upright?

A

1) Injections e.g.
zolendronic acid (annual injection)
denosumab (monoclonal - expensive)
raloxifene

2) HRT
Preferred in younger post-menopausal women as increased risk of CVS disease and cancer in older women

75
Q

In terms of efficacy, when should bisphosphonate treatment be reviewed due to the lack of evidence in benefit.

A

After 5 years

3 years - zolendronic acid

76
Q

How do bisphosphonates work?

A

Slow rate and growth of crystals and therefore reduce the rate of bone turnover.

77
Q

MHRA warnings for bisphosphonates and denosumab?

A

1) Risk of femoral fractures (report hip, groin and thigh pain)
2) Risk of jaw osteonecrosis (report jaw pain and oral symptoms such as dysphagia, heartburn and pain on swallowing)
3) Auditory canal osteonecrosis - report hearing difficulties, ear discharge and ear infection

78
Q

Is there a STOPP criteria for bisphosphonates?

A

Yes - elderly as risk of GI disease and GI bleeds

79
Q

Rare skin side-effect of bisphosphonates?

A

SJS

80
Q

MHRA warnings for denosumab?

A

1) Risk of femoral fractures (report hip, groin and thigh pain)
2) Risk of jaw osteonecrosis (report jaw pain and oral symptoms such as dysphagia, heartburn and pain on swallowing)
3) Auditory canal osteonecrosis - report hearing difficulties, ear discharge and ear infection
4) Risk of bone tumour and bone malignancies

81
Q

Give a situation that would require lactate suppression.

A

Post-partum e.g. still birth

82
Q

What two dopamine-receptor agonists are licensed for suppression of lactation?

A

Cabergoline (preferred)

Bromocriptine

83
Q

What is routinely recommended for lactate suppression over drug therapy?

A

Simple analgesia

Breast support

84
Q

Why are oestrogens no longer used for lactate suppression?

A

Due to the risk of thromboembolism

85
Q

Which hormones are natural and which are synthetic. Which ones are preferred?

A

Natural: Estriol, Estradiol
Synthetic: Ethinylestradiol

86
Q

Symptoms of menopause (oestrogen deficiency)?

A

1) Vasomotor symptoms: hot flushes, BP changes, night sweats, palpitations
2) Vaginal atrophy (dryness)

87
Q

What combination of HRT should be given to a woman with an intact uterus?

A

Oestrogen + Progestogen (reduces risk of cancer and cystic hyperplasia of endometrium)

88
Q

How does systemic HRT help menopausal women?

A

Reduces vasomotor symptoms and risk of post-menopausal osteoporosis

89
Q

How does topical HRT help menopausal women?

A

Helps alleviate dryness and combat vaginal atrophy. Can be given as a short course for few weeks and repeated if necessary.

90
Q

What age is early menopause?

A

<45 years

91
Q

What age is natural menopause?

A

around 50 years - give HRT up till age 50 as after that there is an increased risk of CVS issues and cancer

92
Q

Alternative to HRT therapy for vasomotor symptoms?

A

Clonidine

93
Q

What risks are increased with HRT therapy?

A

Increased risk of:

  • stroke
  • ovarian cancer
  • breast cancer
  • endometrial cancer (only valid for those with uterus and risk reduced with progestogen)
  • VTE
  • Coronary heart disease - especially with combined HRT and risk intact even 10 years after menopause
94
Q

There is limited evidence for using HRT in women aged >65years, true or false?

A

True

95
Q

How long after is the risk of breast cancer increased in someone using HRT?

A

1 year.

Increased risk if using combined HRT (oestrogen and progestogen)

96
Q

For how long is there an imposed risk of breast cancer and coronary heart disease even after stopping HRT?

A

10 years

97
Q

Do topical vaginal preparations also increase the risks of cancers/VTE/CHD?

A

No - unless high oestrogen content

98
Q

Breast cancer signs and symptoms?

A
  • A lump or swelling in the breast, upper chest or armpit. You might feel the lump, but not see it
  • Change in the size or shape of the breast
  • A change in skin texture such as puckering or dimpling of the skin
  • A change in the colour of the breast, such as redness
  • Rash, crusting or changes to the nipple
  • Any unusual discharge from either nipple
99
Q

Those on progestogen containing HRT have a reduced risk of endometrial cancer and breast cancer. True or false.

A

False - They have a reduced risk of endometrial cancer (if used for minimum 10 days per 28 day cycle, if given continuously then the risk is eliminated) but not a reduced risk of breast cancer

100
Q

The higher the BMI, the higher the risk of endometrial cancer in HRT-naive patients. True or false.

A

True.

101
Q

HRT increases the risk of VTE. What timeframe imposes the highest risk?

A

1st year of use (caution in those that travel as there is increased prolonged immobility)

102
Q

Choice of HRT therapy in a women with an intact uterus?

A

Oestrogen + cyclical progestogen (for last 12-14days of cycle)

103
Q

Choice of HRT therapy in a women without an intact uterus?

A

Oestrogen only

104
Q

Routes of oestrogen administration?

A

Oral, transdermal or topical

105
Q

STOPP criteria for HRT?

A

Hx of breast cancer, Hx of VTE

Ensure to check if patient has a uterus or not.

106
Q

When should HRT be stopped if a patient is undergoing major surgery such as orthopaedia/vascular leg?

A

Stop 4-6 weeks before surgery and restart after full mobilisation

107
Q

Reasons to stop HRT?

A
  • sudden, severe chest pain (PE)
  • Swelling of calf/hot and tender to touch (DVT) unilateral
  • Severe stomach pain
  • Serious neurological effects e.g. prolonged headache, seizure (Stroke)
  • Liver impairment/hepatitis
  • BP >160/95
  • Prolonged immobility
108
Q

What can Raloxifene be used for?

A

Prevention and treatment of postmenopausal osteoporosis but does not reduce menopausal vasomotor symptoms.

109
Q

Give examples of progestogens.

A

1) Prog analogues: medroxyprogesterone
2) Testosterone analogues: norethisterone
3) Contraception: desogestrel/levonorgestrel/norethisterone
4) Progesterone receptor modulator: Ulipristral (used for uterine fibroids and EHC - within 5 days and no age limit)

110
Q

How long is a woman fertile for after her last menstrual period?

A

2 years if <50yrs
1 year if >50yrs

Hence HRT does NOT provide contraception.

111
Q

What is endometriosis?

A

Growth of tissue outside uterus - affects those of reproductive age.
Symptoms: pelvic pain, painful periods and subfertility, fatigue, more sick days, physical/mental impact

112
Q

Aim of endometriosis treatment?

A

Improve fertility, reduce symptoms and improve QOL

113
Q

Endometriosis treatment?

A

1) Analgesia
2) Hormonal treatment - COC/progestogen
3) Surgical removal of tissue

114
Q

Define heavy, menstrual bleeding.

A
  • > 80ml blood loss
  • > 7days
  • changing menstrual products every 1-2 hours
  • Regular heavy bleeds every 24-35 days
115
Q

Heavy bleeding treatment options?

A

1) levonorgestrel- releasing intra uterine system
2) tranexamic acid
3) NSAID
4) COC/CYCLICAL progestogen

116
Q

Estradiol patch application counselling?

A

Remove patch every 3-4days ( or once weekly if 7-day patch), change site of patch and use on clean, dry, unbroken skin below waistline.

Do not apply on or near breasts or under waistband - if patch falls off then allow skin to cool before applying new patch

117
Q

What would you counsel a patient on oral contraceptives regarding vomiting and diarrhoea.

A

If you vomit within 2 hours, take another pill STAT.

If a replacement pill is not taken within 3 hours (contraception protection is lost) e.g severe diarrhoea/vomiting, use additional precautions during illness and 2 days after recovery.

> 3hrs: continue taking POP but use barrier methods for 2 days.

118
Q

Routine for staring oral progestogen only contraceptives e.g. norethisterone?

A

One tablet daily. Same time each day. Start on day 1 of cycle.

119
Q

If switching from combined to progestogen only when should a patient start taking POP?

A

Start on the day following completion of COC without a break.

120
Q

When should a woman start POP after childbirth

A

Can start on day 21 post partum

if >21days - additional methods 2 days after.

121
Q

If using clomifene for infertility what is the MHRA warning?

A

Do not use longer than 6 cycles. (increased risk of ovarian cancer)

122
Q

Give some indications for the use of androgens.

A

Androgens cause masculinisation. Can be used in castrated adults and those that are hypogonadal.

123
Q

What risk of cancer is increased with androgen use?

A

Breast cancer and prostate cancer

124
Q

The use of testosterone to treat low sexual desire in women is a licensed indication. True or false.

A

False, it is unlicensed.

It can also cause hirsutism, frontal balding and deepening of the voice.

125
Q

A common side-effect of testosterone is _____

A

Hypertriglyceridaemia

126
Q

Patient counselling on testosterone gel.

A

Apply on clean, dry, healthy skin e.g. shoulders, arms or abdomen STAT after opening the sachet. Do not apply to genitals as high alcohol content and this can cause irritation. Allow to dry for 3-5mins and avoid bath/shower for a minimum of 6 hours.

127
Q

What is the consequence of overusing anti-thyroid drugs in pregnancy?

A

Rapid development of hypothyroidism and this can cause fatal goitre (swelling around neck)

128
Q

What is a blocking replacement regimen in thyroid disorders?

A

Carbimazole (for hyperglycaemia) and levothyroxine (for hypoglycaemia) - helps to stabilise the levels

129
Q

What drugs can be used in thyrotoxicosis?

A 
IV fluids
Propranolol 
\+ hydrocortisone
\+/- radioactive iodine 
\+ carbimazole/propylthiouracil (NG tube)
130
Q

Drug of choice for thyrotoxicosis in pregnancy?

A

Carbimazole = congenital defects so use propylthiouracil in 1st trimester and can switch to carbimazole in 2nd trimester as propylthiouracil can cause hepatotoxicity

131
Q

Carbimazole indication, MHRA, CI and counselling.

A

Used in hyperthyroidism.

MHRA:

  • Bone marrow suppression risk - report sore throat, signs of infection. - do WBC test
  • Congenital malformations: especially 1st trimester and doses >15mg
  • Acute pancreatitis: stop if severe, persistent abd pain.

CI: severe blood disorders
Counselling: report sore throat, mouth ulcers, bruising, fever, malaise

132
Q

What risk does propylthiouracil impose?

A

Hepatotoxic - report abd pain, pale stools, dark urine, yellowing of skin, n/v, fatigue, pruritus

133
Q

Hyperthyroidism and TSH/T3,T4 levels?

A

Low TSH levels

Increased T3, T4 levels

134
Q

Hypothyroidism and TSH/T3,T4 levels?

A

High TSH levels

Decreased T3, T4 levels

135
Q

Drugs used in hypothyroidism?

A

levothyroxine

liothyronine

136
Q

What is the difference between levothyroxine and liothyronine?

A

Liothyronine is rapid acting as its rapidly metabolised. Can be used in severe hypothyroid states.

137
Q

What additional tests have to be run when initiating thyroid therapy?

A

baseline ECG as changes induced by hypothyroidism can be confused with ischaemia.

138
Q

Levothyroxine CALS

A

Take 30-60mins before food, on an empty stomach and with plenty of water.

139
Q

Common side effect of oral liothyronine?

A

Heat intolerance (maintain on same brand)

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