Chapter 6 Endocrine Flashcards
1
Q
What symptoms would you expect in diabetes inspidus?
A
Polyuria (extremely diluted urine) and polydipsia
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
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
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
5
Q
Treatment for DI?
A
Vasopressin or Desmopressin
Desmopressin = long duration of action, more potent and is used to diagnose DI.
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
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.
8
Q
Normal range of Na?
A
136-145mmol/L
9
Q
Treatment of SIADH?
A
1) fluid restriction (e.g. 1L/day)
2) demeclecycline
3) tolvaptan
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
11
Q
Name four different diabetes types
A
Type 1
Type 2
Secondary dm (drug related)
Gestational
12
Q
How often do you have to check blood sugars whilst driving as a type 1 diabetic?
A
Every two hours
13
Q
What is the minimum blood sugar levels when driving as a type 1 diabetic?
A
Minimum 5mmol/L
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
15
Q
What drug class can mask hypoglycaemia?
A
Beta blockers
16
Q
How often should hba1c be measured in those that are diabetic?
A
Every 3-6 momths then every 6 months once stable
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
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
19
Q
How often do you monitor BMs as a type 1 diabetic?
A
Four times a day
20
Q
Complications of DM?
A
Retinopathy Neuropathy Nephropathy Cvs disease PAD
21
Q
Symptoms of T1 DM
A
Hyperglycaemia
Ketosis
Weight loss
<50 years
22
Q
What is basal-bolus?
A
Basal- intermediate/long acting
Bolus - short acting
(Cannot tailor to amount of carbs daily)
23
Q
Mixed insulin?
A
1/2/3 insulins per day of short and intermediate acting
24
Q
Continuous sc insulin?
A
Continuous rapid/soluble delivered via programmed pump
25
What is type 2 diabetes?
Insulin resistance and/or reduced insulin secretion so it cannot keep up with high glucose demand
26
Complications of type 2 diabetes?
Micro:
Retinopathy
Neuropathy
Nephropathy
Macro:
Brain - stroke/tia
Heart - Hypertension
Legs - PVD (treat with naftidouryl oxalate)
27
Symptoms of type 2 diabetes?
```
Polyuria
Polydipsia
Weight Loss
Fatigue
Blurred vision
Increase in infections eg thrush
```
28
Hba1c targets:
Lifestyle + non-hypo - 48mmol/mol
Hypoglycaemic drug - 53mmol/mol
Pregnant - 48mmol/mol
29
NICE algorithm of step 1 in T2D?
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)
30
NICE algorithm step 2 for T2D?
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
31
Metformin MOA?
Biguanide - increases glucose uptake eg by skeletal muscle and reduces glucose sythesis in the liver
Requires functioning b-cells in the pancreas
32
Max dose of metformin?
2g daily - BNF, 3g daily SPC
33
Side-effects of Metformin?
GI: N/V/D (take with meals)
Altered taste
Lactic acidosis
Vit B12 desorption
34
Risk factors for lactic acidosis?
Dehydration
Infection
Renal impairment (hence caution when IV contrast media used as can cause renal impairment - check crcl)
35
Benefits of using Metformin?
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)
36
Signs of lactic acidosis?
```
Dyspnoea
Cramps
Abd pain
Hypothermia (<35degrees body temp)
Asthenia: fatigue
```
37
Contra-indications of metformin:
not for EGFR <30
Caution EGFR <45
IV contrast media can cause renal impairment that can lead to lactic acidosis
38
Give examples of DPP4 inhibitors.
Saxa, Sita, Lina, Vida, Alo - gliptins
Sita: adjust dose in renal impairment
Lina - safe in renal impairment
39
How do DPP4inh work?
Increase incretin and inhibit glucagon release increasing insulin secretion, reducing gastric emptying and reducing glucose levels
40
Side-effects of DPP4inh?
Acute pancreatitis (STOP) - severe, persistent abdominal pain
Rare - SJS
Weight Gain
Hypoglycaemia (less than SU)
41
Which DPP4inh causes liver toxicity?
Vidagliptin
with acei - increased risk of angioedema
42
What category of drug is pioglitazone?
Thiazolidinedione
43
How does pioglitazone work?
Reduces peripheral insulin resistance
44
Side-effects of Pioglitazone?
- Bone fractures
- Increased infection risk
- Visual impairment
- Weight gain
- Hypoglycaemia
45
MHRA warnings for pioglitazone?
- Heart failure
- Bladder cancer (dysuria, haematuria)
- Liver toxicity (pale stools, dark urine, jaundice, abdominal pain)
46
SGLT-2 inhibitor examples?
Gliflozins: Cana/Dapa/Empa-gliflozin
47
How do SGLT2 inhibitors work?
Inhibit SGLT2 in renal PCT and reduce glucose reabsorption whilst increasing urinary glucose excretion (hence linked to thrush/gangrene)
48
SGLT2 inhibitors MHRA?
- Fatal DKA
- Limb amputation
- Fourniere's gangrene
49
Side-effects for SGLT-2inhibitors?
- increased infection
- urosepsis
- Balanaposthitis (penal inflammation)
50
Renal function must be monitored for SGLT-2 inhibitors, true or false?
True
51
How would you counsel patients on recognising signs of DKA with SGLT-2 Inhibitors?
Weight loss
N/V
Sweet smelling breath/odour
Also counsel on signs of volume depletion: dizziness/postural hypotension
52
Give examples of sulfonylureas.
Glibenclamide
Gliclazide
Glimeperide
Glipizide
53
Side-effects of sulfonylureas?
```
Weight gain
Hypoglycaemia
SJS/SCARS
Vision disorders
GI - Abd pain/diarrhoea
```
54
Give examples of GLP-1 agonists.
Dulaglutide (Once weekly)
Exenatide
Liroglutide
Semaglutide
55
MHRA warning for GLP-1 agonists.
Fatal DKA (report signs of sweet smelling odour/breath, weight loss, n/v)
56
Side-effects of GLP-1 agonists?
- Acute pancreatitis
- GI
- Hypoglycaemia
57
Examples of Meglitinides
Repaglinide
| Nateglinide
58
How do meglitinides work?
Stimulates insulin secretion - take 30mins before meals
59
Why are meglitinides not used as much?
Can rarely cause CVS issues e.g. ACS (most diabetics already have underlying CVS issues)
60
Side-effects of meglitinides?
GI
| Hypoglycaemia
61
What levels of glucose is characterised as hypoglycaemia?
<4mmol/L
62
Drugs that can cause hypoglycaemia?
beta-blockers - mask hypo
insulin
sulfonylureas
DPP4inhibitors
63
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?
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
Why would you not give chocolates/biscuits to those presenting with hypoglycaemia?
low sugar content, high fat content.
65
A patient carries around glucogel and asks for your advice on its use. What would you recommend?
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
If hypo is still not treated after initial carb snack/gluco gel what would be the next option?
1) IM glucagon
| 2) IV glucose 10%/20% (not 50% as increased risk of extravasation)
67
What is osteoporosis?
Low bone mass and bone tissue deterioration (BMD and DEXA scan)
68
What is the risk of osteoporosis?
Increased risk of fractures.
69
Risk factors for osteoporosis?
- age >50
- Vit d and calcium deficiency
- HRT
- Smoking/alcohol
- family history
- menopause
- high dose corticosteroids
70
Osteoporosis is linked to two other conditions. What are they?
Diabetes
| Rheumatoid Arthiritis
71
Aim of treatment in osteoporosis?
Prevent fractures
72
Lifestyle advise for osteoporosis?
- Exercise
- Supplements - vit d and calcium
- no smoking or alcohol
- Reduce weight if obese
73
First line drug treatment for post-menopausal osteoporosis and steroid-induced?
1) Bisphosphonates - alendronic acid (70mg once weekly), risedronate
74
Alternatives to PO bisphosphonates e.g. if unable to sit upright?
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
In terms of efficacy, when should bisphosphonate treatment be reviewed due to the lack of evidence in benefit.
After 5 years
| 3 years - zolendronic acid
76
How do bisphosphonates work?
Slow rate and growth of crystals and therefore reduce the rate of bone turnover.
77
MHRA warnings for bisphosphonates and denosumab?
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
Is there a STOPP criteria for bisphosphonates?
Yes - elderly as risk of GI disease and GI bleeds
79
Rare skin side-effect of bisphosphonates?
SJS
80
MHRA warnings for denosumab?
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
Give a situation that would require lactate suppression.
Post-partum e.g. still birth
82
What two dopamine-receptor agonists are licensed for suppression of lactation?
Cabergoline (preferred)
| Bromocriptine
83
What is routinely recommended for lactate suppression over drug therapy?
Simple analgesia
| Breast support
84
Why are oestrogens no longer used for lactate suppression?
Due to the risk of thromboembolism
85
Which hormones are natural and which are synthetic. Which ones are preferred?
Natural: Estriol, Estradiol
Synthetic: Ethinylestradiol
86
Symptoms of menopause (oestrogen deficiency)?
1) Vasomotor symptoms: hot flushes, BP changes, night sweats, palpitations
2) Vaginal atrophy (dryness)
87
What combination of HRT should be given to a woman with an intact uterus?
Oestrogen + Progestogen (reduces risk of cancer and cystic hyperplasia of endometrium)
88
How does systemic HRT help menopausal women?
Reduces vasomotor symptoms and risk of post-menopausal osteoporosis
89
How does topical HRT help menopausal women?
Helps alleviate dryness and combat vaginal atrophy. Can be given as a short course for few weeks and repeated if necessary.
90
What age is early menopause?
<45 years
91
What age is natural menopause?
around 50 years - give HRT up till age 50 as after that there is an increased risk of CVS issues and cancer
92
Alternative to HRT therapy for vasomotor symptoms?
Clonidine
93
What risks are increased with HRT therapy?
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
There is limited evidence for using HRT in women aged >65years, true or false?
True
95
How long after is the risk of breast cancer increased in someone using HRT?
1 year.
| Increased risk if using combined HRT (oestrogen and progestogen)
96
For how long is there an imposed risk of breast cancer and coronary heart disease even after stopping HRT?
10 years
97
Do topical vaginal preparations also increase the risks of cancers/VTE/CHD?
No - unless high oestrogen content
98
Breast cancer signs and symptoms?
- 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
Those on progestogen containing HRT have a reduced risk of endometrial cancer and breast cancer. True or false.
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
The higher the BMI, the higher the risk of endometrial cancer in HRT-naive patients. True or false.
True.
101
HRT increases the risk of VTE. What timeframe imposes the highest risk?
1st year of use (caution in those that travel as there is increased prolonged immobility)
102
Choice of HRT therapy in a women with an intact uterus?
Oestrogen + cyclical progestogen (for last 12-14days of cycle)
103
Choice of HRT therapy in a women without an intact uterus?
Oestrogen only
104
Routes of oestrogen administration?
Oral, transdermal or topical
105
STOPP criteria for HRT?
Hx of breast cancer, Hx of VTE
| Ensure to check if patient has a uterus or not.
106
When should HRT be stopped if a patient is undergoing major surgery such as orthopaedia/vascular leg?
Stop 4-6 weeks before surgery and restart after full mobilisation
107
Reasons to stop HRT?
- 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
What can Raloxifene be used for?
Prevention and treatment of postmenopausal osteoporosis but does not reduce menopausal vasomotor symptoms.
109
Give examples of progestogens.
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
How long is a woman fertile for after her last menstrual period?
2 years if <50yrs
1 year if >50yrs
Hence HRT does NOT provide contraception.
111
What is endometriosis?
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
Aim of endometriosis treatment?
Improve fertility, reduce symptoms and improve QOL
113
Endometriosis treatment?
1) Analgesia
2) Hormonal treatment - COC/progestogen
3) Surgical removal of tissue
114
Define heavy, menstrual bleeding.
- >80ml blood loss
- >7days
- changing menstrual products every 1-2 hours
- Regular heavy bleeds every 24-35 days
115
Heavy bleeding treatment options?
1) levonorgestrel- releasing intra uterine system
2) tranexamic acid
3) NSAID
4) COC/CYCLICAL progestogen
116
Estradiol patch application counselling?
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
What would you counsel a patient on oral contraceptives regarding vomiting and diarrhoea.
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
Routine for staring oral progestogen only contraceptives e.g. norethisterone?
One tablet daily. Same time each day. Start on day 1 of cycle.
119
If switching from combined to progestogen only when should a patient start taking POP?
Start on the day following completion of COC without a break.
120
When should a woman start POP after childbirth
Can start on day 21 post partum
if >21days - additional methods 2 days after.
121
If using clomifene for infertility what is the MHRA warning?
Do not use longer than 6 cycles. (increased risk of ovarian cancer)
122
Give some indications for the use of androgens.
Androgens cause masculinisation. Can be used in castrated adults and those that are hypogonadal.
123
What risk of cancer is increased with androgen use?
Breast cancer and prostate cancer
124
The use of testosterone to treat low sexual desire in women is a licensed indication. True or false.
False, it is unlicensed.
It can also cause hirsutism, frontal balding and deepening of the voice.
125
A common side-effect of testosterone is _____
Hypertriglyceridaemia
126
Patient counselling on testosterone gel.
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
What is the consequence of overusing anti-thyroid drugs in pregnancy?
Rapid development of hypothyroidism and this can cause fatal goitre (swelling around neck)
128
What is a blocking replacement regimen in thyroid disorders?
Carbimazole (for hyperglycaemia) and levothyroxine (for hypoglycaemia) - helps to stabilise the levels
129
What drugs can be used in thyrotoxicosis?
```
IV fluids
Propranolol
+ hydrocortisone
+/- radioactive iodine
+ carbimazole/propylthiouracil (NG tube)
```
130
Drug of choice for thyrotoxicosis in pregnancy?
Carbimazole = congenital defects so use propylthiouracil in 1st trimester and can switch to carbimazole in 2nd trimester as propylthiouracil can cause hepatotoxicity
131
Carbimazole indication, MHRA, CI and counselling.
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
What risk does propylthiouracil impose?
Hepatotoxic - report abd pain, pale stools, dark urine, yellowing of skin, n/v, fatigue, pruritus
133
Hyperthyroidism and TSH/T3,T4 levels?
Low TSH levels
| Increased T3, T4 levels
134
Hypothyroidism and TSH/T3,T4 levels?
High TSH levels
| Decreased T3, T4 levels
135
Drugs used in hypothyroidism?
levothyroxine
| liothyronine
136
What is the difference between levothyroxine and liothyronine?
Liothyronine is rapid acting as its rapidly metabolised. Can be used in severe hypothyroid states.
137
What additional tests have to be run when initiating thyroid therapy?
baseline ECG as changes induced by hypothyroidism can be confused with ischaemia.
138
Levothyroxine CALS
Take 30-60mins before food, on an empty stomach and with plenty of water.
139
Common side effect of oral liothyronine?
Heat intolerance (maintain on same brand)
