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BNF > Chapter 6: Endocrine: Bone, Sex Hormones, Thyroid > Flashcards

Chapter 6: Endocrine: Bone, Sex Hormones, Thyroid Flashcards

1
Q

In which population does osteoporosis most commonly occur?

A

Postmenopausal women

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2
Q

As well as in postmenopausal women, osteoporosis can also occur in people on long-term oral treatment with which drugs?

A

Corticosteroids

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3
Q

As well as menopause and corticosteroids, what are the other risk factors for osteoporosis? (6)

A
  1. Low body weight
  2. Cigarette smoking
  3. Excess alcohol intake
  4. Lack of physical activity
  5. Family history
  6. Early menopause
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4
Q

What should those at risk of osteoporosis maintain an adequate intake of through diet or supplementation? (2)

A
  1. Calcium

2. Vitamin D

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5
Q

What are some reversible causes of osteoporosis? These should be excluded before treatment is started (4)

A
  1. Hyperthyroidism
  2. Hyperparathyroidism
  3. Osteomalacia
  4. Hypogonadism
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6
Q

Which class of drug is effective in preventing post-menopausal osteoporosis?

A

Bisphosphonates

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7
Q

If other therapies for postmenopausal osteoporosis are contra-indicated, not effective or cannot be tolerated, what is an option?

A

HRT

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8
Q

True or false: HRT should NOT be considered first line in the long-term prevention of osteoporosis in women over 50

A

TRUE

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9
Q

When is HRT of most benefit for the prophylaxis of postmenopausal osteoporosis?

A

If started early in the menopause and continued for 5 up to years

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10
Q

On stopping HRT, what happens to the rate of bone loss?

A

It resumes - possible accelerates

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11
Q

As well as for prophylaxis, which class of drug can be used to TREAT postmenopausal osteoporosis?

A

Bisphosphonates - reduce the risk of fracture

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12
Q

If bisphosphonates are unsuitable in the treatment of osteoporosis, what can be considered? (2)

A
  1. Calcitriol

2. Strontium

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13
Q

Which medication is no longer recommended for the treatment of osteoporosis in postmenopausal women due to the risk of malignancy outweighing the benefit?

A

Calcitonin

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14
Q

In patients being treated with corticosteroids, when does the greatest rate of bone loss occur?

A

During first 6-12 months

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15
Q

As well as oral corticosteroids, which other formulation may also contribute to the risk of osteoporosis if used long term?

A

Inhaled

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16
Q

Patients who are likely to take corticosteroids for how long should be assessed and provided osteoporosis prophylaxis if necessary?

A

3 months

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17
Q

Patients over which age, taking corticosteroids for longer than 3 months are at greater risk of osteoporosis?

A

65

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18
Q

Patients taking oral corticosteroids and have sustained what should be given treatment for osteoporosis?

A

Low trauma fracture

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19
Q

What are the therapeutic options for prophylaxis of osteoporosis induced by corticosteroids?

A
  1. Bisphosphonate
  2. Calcitriol
  3. HRT (men and women)
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20
Q

Which substance is involved with the parathyroid hormone in the regulation of bone turnover and maintenance of calcium?

A

Calcitonin

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21
Q

What is the main indication for calcitonin?

A

To lower the plasma-concentration of calcium in patients with hypercalceamia associated with malignancy

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22
Q

As well as hypercalcemia in malignancy, what are the other indications for calcitonin? (2)

A
  1. Paget’s disease

2. Prevention of acute bone loss in sudden immobility

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23
Q

Which are the bisphosphonates of choice in osteoporosis and corticosteroid-induced osteoporosis?

A
  1. Alendronic acid

2. Risendronate

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24
Q

After how many years of treatment should further treatment with bisphosphonates be discussed with the patient? Lack of evidence of efficacy past this point

A

3 years

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25
Q

As well as osteoporosis, what are bisphonates also licensed for? (3)

A
  1. Hypercalcemia of malignancy
  2. Paget’s disease
  3. Bone metastases in breast cancer
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26
Q

What has strontium treatment been associated with increased risk of?

A

Serious cardiovascular disease, including MI

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27
Q

Can a GP initiate strontium?

A

No, specialist initiation only

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28
Q

What is the only indication for strontium?

A

Severe osteoporosis in postmenopausal women or men at high risk of fracture where other treatments have not been tolerated

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29
Q

What are the MHRA warnings associated with bisphosphonates? (3)

A
  1. Atypical femoral fractures
  2. Osteonecrosis of the jaw
    Osteonecrosis of the external auditory canal
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30
Q

Due to association with atypical femoral fractures, which symptom must patients report if they experience it?

A

Thigh, hip or groin pain

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31
Q

The risk of osteonecrosis of the jaw is much greater in patients receiving IV bisphosphonates to treat which condition?

A

Cancer

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32
Q

What are the risk factors of developing osteonecrosis of the jaw that should be considered? (8)

A
  1. History of dental disease
  2. Co-morbidities
  3. Route of administration
  4. Cumulative dose
  5. Duration and type of malignancy
  6. Smoking
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33
Q

Which bisphosphonate carries the highest risk of osteonecrosis of the jaw?

A

Zolendronate

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34
Q

Due to the risk of osteonecrosis of the jaw, which check up should patients have before starting treatment with bisphosphonates?

A

Dental check up

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35
Q

As well as maintaining good dental hygiene and going for regular check ups, which symptoms should patients report during treatment with bisphosphonates due to the risk of osteonecrosis of the jaw? (5)

A
  1. Dental mobility
  2. Pain
  3. Swelling
  4. Non-healing sores
  5. Discharge
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36
Q

What should patients be given before starting bisphosphonate treatment due to the risk of osteonecrosis of the jaw?

A

Patient reminder card

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37
Q

If a patient wears dentures, what should they make sure of before commencing treatment with bisphosphonates due to the risk of osteonecrosis of the jaw?

A

That they fit properly

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38
Q

Before receiving dental treatment, what must the patient tell their doctor if they are taking IV bisphosphonates due to the risk of osteonecrosis of the jaw?

A

That they are on IV bisphosphonates

39
Q

Osteonecrosis of the external auditory canal has been reported very rarely in patients taking bisphosphonates for how long?

A

2 years or longer

40
Q

The possibility of osteonecrosis of the external auditory canal should be considered in patients presenting with what? (3)

A
  1. Ear symptoms
  2. Ear infections
  3. Suspects cholesteatoma
41
Q

What are risk factors of osteonecrosis of the external auditory canal in patients taking bisphosphonates? (5)

A
  1. Steroids
  2. Chemotherapy
  3. Infection
  4. Ear operation
  5. Cotton bud use
42
Q

What is a common side effect of alendronic acid that requires us to counsel patients on how to take it?

A

Oesophageal reactions

43
Q

If patients develop symptoms of oesophageal reactions while taking alendronic acid, what should they do?

A

Stop taking it and seek medical attention

44
Q

How should alendronic acid be administered?

A

Swallowed whole (100ml liquid swallowed as one dose) with plenty of water while sitting or standing

45
Q

How long before food or any other oral medication should alendronic acid be taken?

A

30 minutes

46
Q

How long after administration should the patient sit upright after taking alendronic acid?

A

30 minutes

47
Q

How long after administration of risendronate should food or drink be avoided?

A

2 hours - avoid milk and mineral supplements

48
Q

Which drug is a human monoclonal antibody that inhibits osteoclast formation, function and survival. Thereby decreasing bone resorption?

A

Denosumab

49
Q

What are the MHRA alerts associated with Denosumab?

A
  1. Osteonecrosis of the jaw
  2. Hypocalcaemia
  3. Atypical femoral fractures
50
Q

Osteonecrosis of the jaw is a well known side effect of patients receiving which dose of denosumab for cancer?

A

120mg

51
Q

What is now recommended for all patients before starting denosumab both 120mg cancer and 60mg osteoporosis?

A

Dental examination and appropriate treatment

52
Q

As well as oral health, what should be monitored in people receiving denosumab both 120mg cancer and 60mg osteoporosis?

A

Plasma calcium, can cause hypocalcaemia

53
Q

All patients receiving denosumab should report symptoms of hypocalcaemia, what are these? (4)

A
  1. Muscle spasms
  2. Twitches
  3. Cramps
  4. Numbness or tingling of fingers/toes/mouth
54
Q

What is the dopamine receptor agonist bromocriptine used to treat?

A
  1. Galactorrhoea

2. Prolactinomas

55
Q

Sometimes used to treat acromegaly, bromocriptine inhibits the release of growth hormone. However, which treatment is more effective?

A

Octreotide

56
Q

Which drug has the same effect and side-effects of bromocriptine which can be used if patients do not tolerate bromocriptine and vise versa?

A

Carbergoline

57
Q

What sort of reactions can dopamine agonists cause?

A

Hypotensive

58
Q

Patients taking dopamine receptor agonists should be counselled on what? This could impact driving or operating machinery

A

Sudden onset of sleep, Excessive daytime sleepiness

59
Q

What should be added to oestrogen for HRT in women with a uterus and why?

A

A progestogen - to reduce the risk of cystic hyperplasia of the endometrium and possible transformation into cancer

60
Q

What are the reasons for giving women HRT? (2)

A
  1. Alleviate symptoms of menopause (night sweats, flushing etc)
  2. Reduce risk of osteoporosis
61
Q

As well as oestrogen (+ progestogens if uterus) what is an option for HRT?

A

Tibolone

62
Q

What are the risks of HRT? (5)

A
  1. VTE Stroke
  2. Endometrial cancer (reduced by giving progestogen)
  3. Breast cancer
  4. Ovarian cancer
  5. Coronary heart disease
63
Q

How often should HRT be reviewed?

A

At least annually

64
Q

Is HRT the best option for postmenopausal osteoporosis prophylaxis?

A

No - bisphosphonates

65
Q

Can HRT be given forever?

A

No - lowest dose, shortest duration

66
Q

At what age do the benefits especially outweigh the risks of HRT?

A

Below 60, limited experience over 65

67
Q

Within how long of initiating treatment does the risk of breast cancer increase when taking HRT?

A

1-2 years

68
Q

How long after stopping HRT does the risk of breast cancer decrease?

A

5 years

69
Q

How should progestogen be taken alongside oestrogen to reduce the risk of endometrial cancer?

A

Cyclically - for at least 10 days per 28 day cycle

70
Q

Women using HRT are at increased risk of VTE and PE especially when?

A

In the first year of use

71
Q

What are the predisposing factors of VTE or PE? (4)

A
  1. Severe varicose veins
  2. Obesity
  3. Trauma
  4. Prolonged bed rest
72
Q

Due to the risk of VTE, how long before surgery should HRT be stopped?

A

4-6 weeks

73
Q

To which organ can HRT be toxic?

A

Liver

74
Q

Does HRT provide contraceptive protection?

A

NO

75
Q

What is the most commonly used drug for hyperthyroidism?

A

Carbimazole

76
Q

What is the second line option for hyperthyroidism after carbimazole? Reserved if it is intolerable or if they have a sensitivity reaction to it?

A

Propylthiouracil

77
Q

Over-treatment with antithyroid drugs can cause which condition?

A

Hypothyroidism

78
Q

Are antithyroid drugs safe to give in pregnancy?

A

No - can cause fetal goitre

79
Q

Which drugs may be used for 18 months as part of a blocking-replacement regimen?

A

Carbimazole and Levothyroxine

80
Q

Is the blocking regimen safe in pregnancy?

A

No

81
Q

What is used for the treatment of thyrotoxicosis?

A

Radioactive sodium iodide

82
Q

Which surgical procedure can be used to treat hyperthyroidism?

A

Thyroidectomy

83
Q

Which beta blocker is useful for rapid relief of thyrotoxic symptoms, in neonatal thyrotoxicosis and in supraventricular arrhythmias due to hyperthyroidism?

A

Propranolol

84
Q

Which drugs are used in the emergency treatment of thyrotoxic crisis? (5)

A
  1. IV Fluids
  2. Propranolol
  3. Hydrocortisone
  4. Oral iodine solution
  5. Carbimazole / Propylthiouracil
85
Q

Which drugs can be used during pregnancy to treat hyperthyoridism? (2)

A
  1. Carbimazole

2. Propylthiouracil (first choice in first trimester)

86
Q

Which side effect requireing immediate discontinuation of treatment can carbimazole cause?

A

Bone marrow suppression - agranulocytosis and neutropenia

87
Q

Patients taking carbimazole should report signs of what?

A

Infection - e.g. sore throat

88
Q

Rashes and itching are common with carbimazole. Are they a reason to discontinue treatment?

A

No, treat with antihistamines or swap for propylthiouracil

89
Q

To which organ is propylthiouracil toxic?

A

Liver - discontinue treatment, can require transplant

90
Q

Symptoms of which toxicity should patients taking propylthiouracil report?

A

Liver

91
Q

What is the treatment of choice for maintenance therapy in hypothyroidism?

A

Levothyroxine

92
Q

Which drug can be used in severe hypothyroid states where a rapid response is required?

A

Liothyronine

93
Q

What is the treatment of choice in hypothyroid coma? (5)

A
  1. Liothyronine
  2. IV Fluids
  3. Treatment of infection
  4. Assisted ventilation
  5. Hydrocortisone

BNF (28 decks)

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