Chapter 6: Endocrine system Flashcards
1
Q
What is the advice from the DVLA regarding insulin dependent diabetic drivers?
A
- Should always carry a glucose meter and test strips when driving
- Check blood glucose no more than 2 hours before driving and then every 2 hours during driving
- Blood glucose should always be above 5 mmol/L whilst driving
- Should always ensure a fast-acting carbohydrate is available in the vehicle
- If get hypo, stop car, have sugary beverage and then drive after 45mins if BMs in range
- If blood glucose is <4 mmol/L, should NOT drive
- This may also be the case in patients taking oral antidiabetic drugs (sulfonylureas, nateglinide, repaglinide), in particular, those that cause hypoglycaemia
2
Q
True or false:Alcohol can cause delayed hyperglycaemia
A
False- can cause delayed HYPOglycaemia
3
Q
Do you have to fast before a HbA1c test?
A
No
WHO: HbA1c below 42 mmol/mol (6.0%): Non-diabetic
HbA1c between 42 and 47 mmol/mol (6.0–6.4%): Impaired glucose regulation or Prediabetes
HbA1c of 48 mmol/mol (6.5%) or over: Type 2 diabetes
4
Q
Is HbA1c used for monitoring glycaemic control in Type 1 diabetes, Type 2 diabetes, or both?
A
Both Should not be used for diagnosis of Type 1
5
Q
How often should HbA1c be measured in diabetes?
A
Every 3-6 months If type 2 and stable, can be every 6 months
6
Q
What is the recommended HbA1c target in Type 1 diabetes?
A
48mmol/mol or lower
7
Q
How often should blood glucose be measured in Type 1 diabetes?
A
At least 4 times a day
8
Q
What are the blood glucose aims in Type 1 diabetes for:a) Wakingb) Before meals c) 90 minutes after eatingd) Driving
A
a) 5-7mmol/L on waking
b) 4-7mmol/L before meals
c) 5-9mmol/L at least 90 mins after eating
d) at least 5mmol/L when driving
9
Q
What is a basal bolus insulin regimen?
A
One or more separate daily injections of intermediate-acting insulin or long-acting insulin analogue as the basal insulin; (mimics background insulin)
alongside multiple bolus injections of short-acting insulin before meals
10
Q
What is a mixed (biphasic) insulin regimen?
A
One, two, or three insulin injections per day of short-acting insulin mixed with intermediate-acting insulin
11
Q
What insulin regimen is first choice for Type 1 diabetics?
A
Basal bolus
1) Insulin detemir (Levemir) BD (has a plataeu effect over 24hrs hence BD) should be offered as the long insulin therapy
2) Insulin glargine (Lantus) OD if dosing issues
3) Insuline detemir (Levemir) OD
12
Q
In a basal bolus regimen for Type 1 diabetes, what basal insulin would be first choice?What would be the second choice?
A
Insulin determir (Levemir) BD - can also be offered as once daily
Once daily insulin glargine (Lantus)
13
Q
Are non-basal bolus regimens recommended in newly diagnosed Type 1 diabetics?
A
No Should only be considered after trying basal bolus regimen
14
Q
In basal bolus regimen in Type 1 diabetes, what type of insulin is recommended for the bolus aspect?
A
Rapid acting insulin (LAG - Lispro - Humalog, Aspart - novorapid, Glulisine - apidra) (Rather than soluble human or animal insulin)
15
Q
Continuous subcut insulin infusion therapy should only be offered to what group of people?
A
- Suffer from disabling hypoglycaemia- High HbA1c of 69 or above with multiple daily injection therapy
16
Q
What situations can cause an INCREASE in required insulin dose?
A
NAME?
17
Q
What situations can cause an DECREASE in required insulin dose?
A
NAME?
18
Q
Patients’ awareness of hypoglycaemia should be assessed annually using what score tools?
A
Gold or Clarke score
19
Q
What cardiac class of drug can blunt hypoglycaemia awareness?
A
Beta blockersWill reducing warning signs such as tremor
20
Q
What is an impaired awareness of hypoglcyaemia?
A
Can occur when the ability to recognise usual symptoms of hypoglycaemia is lost, or when the symptoms are blunted or no longer present
21
Q
What are the 3 types of insulin sources?
A
Human insulinHuman insulin analoguesAnimal insulin
22
Q
Which area of the body has the fastest absorption rate for insulin?
A
Abdomen
23
Q
What can occur if you repeatedly inject insulin into the same area without rotating?
A
LipohypertrophyCan cause erratic absorption of insulin
24
Q
How much time before meals do you administer short acting soluble insulin?
A
15-30 minutes before
25
What is the most appropriate form of insulin to use in diabetic emergencies e.g. DKA
Soluble insulin IV
26
What are the 3 types of rapid acting insulin?
Insulin aspartInsulin glulisineInsulin lispro
27
How much time before meals do you administer rapid acting insulin?
Immediately before
28
What are the advantages of rapid acting insulin over short acting insulin?
#NAME?
29
Is injecting short acting insulins post meals recommended?
No
30
What type of insulin is isophane?
Intermediate - designed to mimic the effect of endogenous basal insulin
31
What are biphasic insulins?
Pre-mixed insulin preparations containing various combinations of short-acting insulin (soluble insulin or rapid-acting analogue insulin) and an intermediate-acting insulin.
32
What are the long acting insulins?
Insulin detemirInsulin glargineInsulin degludecRarely prescribed:Protamine zinc insulinInsulin zinc suspension
33
Does metformin cause hypoglycaemia?
No
34
If standard release metformin is not tolerated e.g. GI side effects, what should be given?
Modified release metformin
35
Give examples of sulfonylureas
Glibenclamide GliclazideTolbutamide
36
Give examples of meglitinides
NateglinideRepaglinide
37
Give examples of DPP-4 inhibitors
AlogliptinLinagliptinSitagliptinSaxagliptinVildagliptin
38
What is an advantage of DPP-4 inhibitors over sulphonylureas in terms of side effects?
Not associated with weight gain and have less incidence of hypoglycaemia
39
Give examples of SGLT2 inhibitors
CanaglifozinDapaglifozinEmpaglifozin
40
Give examples of GLP-1 receptor agonists
DulaglutideExenatideLiraglutideLixisenatide
41
What should be the target HbA1c in a Type 2 diabetic that is managed by lifestyle/ a single antidiabetic agent that is NOT associated with hypoglycaemia?
48 mmol/mol
42
What should be the target HbA1c in a Type 2 diabetic that is managed with one or more antidiabetic drugs that cause hypoglycaemia?
53 mmol/mol
43
In terms of HbA1c, when should treatment in a Type 2 diabetic on ONE antidiabetic drug be intensified?
58 mmol/mol or higher
44
What should be the target HbA1c in a Type 2 diabetic that is managed with 2 or more antidiabetic drugs?
53 mmol/mol
45
What is first line drug treatment in Type 2 diabetes and why?
Metformin-Positive effect on weight loss-Reduced risk of hypoglycaemia-Long term cardiovascular benefits
46
If a sulphonylurea is indicated in one of the following:- Elderly patients- Renal impairment- Particular risk of hypoglycaemia What sulphonylurea should you opt for?
Short acting one e.g. gliclazide or tolbutamide
47
If a Type 2 diabetic is not been adequately controlled on metformin and requires intensification of treatment, what are the add in options?
- Sulphonylurea- Pioglitazone- DPP-4 inhibitorSGLT-2 inhibitor - only when sulphonylureas are contraindicated or if patient is at significant risk of hypoglycaemia
48
Type 2 diabetes:Dapagliflozin is not recommended in a triple therapy regimen with what drug?
Pioglitazone
49
Type 2 diabetes:If dual therapy is unsuccessful, what are the triple therapy combination options?
- Metformin + DPP-4 + sulphonylurea- Metformin + pioglitazone + sulphonylurea- Metformin + sulphonylurea + SGLT-2 inhibitor - Metformin + sulphonylurea + SGLT-2 inhibitor (not dapaglifozin) May be appropriate to start insulin at this stage
50
When is GLP-1 receptor agonists indicated in Type 2 diabetes?
- If triple therapy with metformin and 2 other oral drugs are tried -BMI of 35 kg/m2 or above (adjusted for ethnicity) and who also have specific psychological or medical problems associated with obesity; or for those who have a BMI lower than 35 kg/m2 but for whom insulin therapy would have significant occupational implications or if the weight loss associated with glucagon-like peptide-1 receptor agonists would benefit other significant obesity-related comorbidities.
51
If started on a GLP-1 receptor agonist for Type 2 diabetes, when should this be reviewed and how do you know it is okay to continue?
After 6 months, the drug should be reviewed and only continued if there has been a beneficial metabolic response (a reduction of at least 11 mmol/mol [1.0%] in HbA1c and a weight loss of at least 3% of initial body-weight).
52
If metformin is contraindicated or not tolerated, what should be used for initial treatment?
Sulphonylurea or DPP-4 inhibitor monotherapySGLT2 inhibitor monotherapy can be used only if the above are not appropriate Repaglinide can be used as monotherapy however cannot be used in combination with anything else other than metformin
53
What is the problem with using repaglinide monotherapy in Type 2 diabetes?
If intensification of treatment is required, can only be given with metforminIt is NOT licensed in combination with any other antidiabetic drugs
54
In patients where metformin is contraindicated/not tolerated:If a patient is on a non-metformin single therapy however requires intensification of treatment, what dual combinations can be prescribed?
- DPP-4 inhibitor and pioglitazone- DPP-4 inhibitor and sulfonylurea - Pioglitazone and sulfonylureaIf dual therapy does not provide control, consider insulin
55
If a patient is on dual therapy for Type 2 diabetes, and metformin is contraindicated/not tolerated, what should be considered?
Insulin
56
In Type 2 diabetes, if insulin therapy is required, what should happen to their other antidiabetic drugs?
#NAME?
57
In Type 2 diabetics, what insulin regimens can you use?
- Isophane (NPH) OD/BD- Isophane + short acting (either separate or pre-mixed) - particularly appropriate if HbA1c is 75 or higher - Insulin detemir or glargine can be an alternative to isophane
58
In Type 2 diabetics, at what HbA1c would the following insulin regimen be particularly appropriate:Isophane + short acting insulin (separate or pre-mixed)
75 or higher
59
In type 2 diabetics requiring insulin therapy, when would long acting insulin (glargine or detemir) be preferable?
#NAME?
60
When starting insulin therapy in Type 2 diabetes, when should the first basal insulin be given and how do you adjust the dose?
Bedtime basal insulin should be initiated and the dose titrated against fasting glucose in the morning
61
Providing there are no contraindications, what should you give for diabetic nephropathy that is causing proteinuria or established microalbuminuria?
Blood pressure should be reduced to the lowest achievable level to reduce the glomerular filtration rateARB or ACEi to be started even if the blood pressure is normal
62
What is the potential problem with ACEis in diabetics if the patient is on insulin or oral antidiabetic drugs?
Can potentiate the hypoglycaemic effect More likely in the first few weeks of combined treatment and in patients with renal impairment
63
The management of DKA involves what?What should happen to their basal insulin?What should be monitored and how often?
Replacement of fluid and electrolytesInclude potassium chloride in the fluids unless anuria is suspected Administration of soluble insulin in sodium chloride 0.1 units/kg/hrLong acting insulin (basal) should be continued in the background If blood glucose falls below 14, give glucose 10%Monitor ketones and glucose hourlyMonitor BP Blood pH
64
During DKA treatment when the patient is on an insulin infusion, when should you recommence the short acting subcut insulin and stop the infusion and how is this done?
Continue insulin infusion until blood-ketone concentration is below 0.3 mmol/litre, blood pH is above 7.3 and the patient is able to eat and drink; ideally give subcutaneous fast-acting insulin and a meal, and stop the insulin infusion 1 hour later.
65
In the management of HHS, are lower or higher rates of insulin infusion usually required compared to DKA?
Lower rates usually required
66
During DKA management, what rate should you give the insulin infusion?
0.1 units/kg/hr
67
Diabetic women who are planning on becoming pregnant should aim to keep their HbA1c to what?
Below 48 if possible without causing any problematic hypoglycaemia
68
What is the folic acid supplementation recommendation in diabetic patients planning on becoming pregnant?
High dose - 5mg daily as classed in the high risk group of neural tube defects
69
What is the treatment recommendation for diabetic patients when they become pregnant? What about during breastfeeding?
All antidiabetic drugs APART from metformin should be stopped and substituted with insulin therapyFor breastfeeding, the options are:- Insulin continued- Metformin continued- Glibenclamide is fine to restart if originally on it However, all other antidiabetic agents should be avoided during breastfeeding
70
What is the first choice for long acting insulin therapy during pregnancy?
Isophane insulin However in women who have good blood-glucose control before pregnancy with the long-acting insulin analogues (insulin detemir or insulin glargine), it may be appropriate to continue using them throughout pregnancy.
71
What is the patient advice regarding insulin therapy during pregnancy?
Should be aware of the risk of hypoglycaemia and should always carry a fast-acting form of glucose
72
It is recommended that pregnant women with Type 1 diabetes should be prescribed what just in case of hypoglycaemia?
Glucagon
73
Women with pre-existing diabetes treated with insulin during pregnancy are at an increased risk of what?
Hypoglycaemia during the postnatal period Should reduce their insulin immediately after birth and blood glucose levels monitored
74
If a diabetic patient is on an ACEi or ARB for diabetic complications, however wishes to become pregnant, what would be the most appropriate action?
ACEi or ARB should be discontinued and an alternative antihypertensive suitable in pregnancy should be used(Preferably before conception if pregnancy is planned)
75
If a diabetic patient becomes pregnant but is on a statin, what would be the most appropriate action?
Discontinue the statin during pregnancy (Preferably before conception if pregnancy is planned)
76
True or false:A patient with gestational diabetes should continue their hypoglycaemic treatment after birth
False - should discontinue hypoglycaemic treatment immediately after giving birth
77
How would you manage an insulin dependent diabetic patient with good glycaemic control due for an elective minor procedure?(Day before surgery and during the operative period)
On the day before surgery, give the usual insulin dose However, once daily long acting insulins should be given at 80% of normal doseThen their usual insulin regimen can be adjusted accordingly during the operative period
78
On the day before a minor op in an insulin dependent diabetic with good glycaemic control, you can give their usual insulin dose as normal. With what insulin would you not give the full dose?
Long acting insulinYou give 80% of normal dose
79
How would you manage an insulin dependent diabetic due for major elective surgery or in patients pre-op who have poor glycaemic control?(Day before surgery, day of surgery, during the operative period)
VRII - Continued until the patient is eating/drinking and stabilised on their previous diabetes medicationDay before surgery - Give normal insulin dose (Apart from once daily long acting insulin is given at 80% usual dose)Day of surgery and during the operative period:- Once daily insulin given at 80% usual dose. All of the other patient's insulin should be stopped until the patient is eating and drinking again- Start IV infusion of potassium chloride with glucose and sodium chloride AND a variable rate insulin infusion of soluble human insulin in 0.9% sodium chloride Blood glucose monitored hourly for at least the first 12 hours
80
In patients that are on VRII during an operative period, what would you do if their blood glucose drops below 6?What about if it drops before 4?
<6 - Give IV glucose 20% and check blood glucose hourly<4 - Give IV glucose 20% and check blood glucose every 15 mins
81
After surgery, if a patient is on VRII, they must not restart their subcut insulin until when?
They are eating/drinking without nausea or vomiting Note- their insulin dose may need adjusting due to altered food intake/post-op stress/infection
82
After surgery, a patient is ready to stop their VRII and go back to their BASAL-BOLUS regimen when would you stop the VRII and restart their subcut insulin?
Should be restarted when the first post-op meal is due Give the first short-acting insulin first and then stop VRII 30-60 mins after Note- the long acting insulin is continued in the background of VRII at 80% dose - should continue at that dose until the patient leaves hospital
83
After surgery, a patient is ready to stop their VRII and go back to their TWICE DAILY MIXED insulin regimen when would you stop the VRII and restart their subcut insulin?
Should be restarted before breakfast or evening meal (not at any other time) Stop VRII 30-60 mins after
84
In type 2 diabetes, when would you consider VRII for surgery?
- When the fasting period requires more than one missed meal - major elective surgery - Patients with poor glycaemic control- Risk of renal injury- If on insulin as part of their treatment anyway -
85
If VRII is required for surgery in a type 2 diabetic, what antidiabetic drugs should be stopped?When should they be restarted?
- Acarbose- Sulfonylureas- DPP-4 inhibitors- Pioglitazone- Meglitinides- SGLT-2 inhibitorsShould not be restarted until the patient is eating and drinking normally
86
If VRII is required for surgery in a type 2 diabetic, can GLP-1 receptor agonists be continued?
Yes
87
If a type 2 diabetic requires a minor surgical period, what should you do about their antidiabetic treatment?
If it requires a short fasting period (one missed meal), it may be possible to adjust antidiabetic drugs to avoid a switch to VRII
88
SGLT2 inhibitors are associated with an increased risk of DKA, particularly the case in what situations?
Dehydration, stress, surgery, trauma, acute medical illness or any other catabolic state
89
What is the maximum licensed daily dose of standard release metformin compared to MR metformin?
Standard release- 3g/dayMR - 2g/day
90
What are the side effects of metformin?
#NAME?
91
At what eGFR should you avoid metformin?
<30
92
What are the risk factors for lactic acidosis?
Chronic heart failureConcomitant use of drugs that acutely impair renal function
93
What is the patient advice with metformin?
Should be informed of the risk of lactic acidosis and told to seek immediate medical attention if symptoms such as dyspnoea, muscle cramps, abdominal pain, hypothermia, or asthenia (weakness/lack of energy) occurTake with meals
94
MR gliclazide is equivalent to what standard release gliclazide dose?
30mg MR = 80mg standard release
95
What are the main side effects of gliclazide to warn your patient about?
Weight gainHypoglycaemia
96
What is the important safety information regarding pioglotazone?
#NAME?
97
What is the MHRA advice surrounding SGLT2 inhibitors?
Risk of DKA Inform patients to be aware of signs e.g. rapid weight loss, sweet smell to breath, different odour in urine/sweatReports of Fournier’s gangrene (necrotising fasciitis of the genitalia or perineumCanagliflozin - risk of lower-limb amputation
98
What is the MHRA advice surrounding the use of canagliflozin?
Risk of lower-limb amputation
99
Which antidiabetic class can cause pancreatitis?
DPP-4 inhibitors (gliptins)
100
Which antidiabetic drug class commonly causes UTIs?
SGLT2 inhibitors
101
Can you use nateglinide as monotherapy in diabetes?
No - only with metformin
102
With what antidiabetic drug would it not be suitable in those with hernias or GI obstructions?
Acarbose
103
What is the dose frequency of the 4 different GLP-1 receptor agonists?
Weekly for albiglutide and dulaglutide Twice daily with exenatide (modified release can be once weekly)Liraglutide is once weekly
104
What is the important safety information regarding insulin pen devices?
Insulin should not be extracted from insulin pen devices.The strength of insulin in pen devices can vary by multiples of 100 units/mL. Insulin syringes have graduations only suitable for calculating doses of standard 100 units/mL. If insulin extracted from a pen or cartridge is of a higher strength, and that is not considered in determining the volume required, it can lead to a significant and potentially fatal overdose.
105
What is the name of the ultrarapid acting insulin?
Fiasp (aspart)
106
What are the types of soluble insulin (short acting)?
Humulin SActrapidInsuman rapidHypurin neutral (povine/porcine)
107
What insulins can be used for VRII or in DKA as in infusion?
Soluble insulinHumulin S Actrapid
108
Is Actrapid classed as a rapid acting insulin?
No- it is a short acting insulin
109
What insulins are classed as rapid acting?
Novorapid (aspart)Humalog (lispro)Apidra (glulisine)
110
What insulins are classed as intermediate acting?
Insulatard Humulin I (isophane)Insuman basalHypurin isophane Isophane can be otherwise known as NPH
111
What insulins are classed as long acting?
Levemir (detemir)Lantus/Absalgar (glargine)Tresiba (degludec)Toujeo (glargine)
112
What insulins are classed as biphasic (pre-mixed)?
Novomix 30Humalog Mix 25 or 50 Humulin M3 Insuman Combo 15 or 25 or 30
113
What does the 30 mean in Novomix 30?
The suspension contains rapid-acting and intermediate-acting insulin aspart in the ratio 30/70
114
What is recommended for the treatment of acute hypoglycaemia and the patient is conscious?
Initially glucose 10–20 g is given by mouth either in liquid form or as granulated sugar or sugar lumps. If necessary this may be repeated after 10–15 minutes. After initial treatment, a snack providing sustained availability of carbohydrate (e.g. a sandwich, fruit, milk, or biscuits) or the next meal (if it is due) can prevent blood-glucose concentration from falling again.
115
What is recommended for the treatment of acute hypoglycaemia and the patient is UNconscious?
Glucagon is given as an injection (subcut or IM)If this does not work within 10 minutes, IV glucose 20% needs to be given
116
Can glucagon be used for chronic hypoglycaemia?
No
117
What is given for chronic hypoglycaemia?
Diazoxide
118
What is used in diabetes insipidus?
Desmopressin or vasopressin
119
Is desmopressin or vasopressin more potent?
Desmopressin is more potent and has a longer duration of action Desmopressin is an analogue of vasopressinHas no vasoconstrictor effect compared to vasopressin
120
What is vasopressin used for?
Diabetes insipidus Initial control of oesophageal variceal bleeding
121
What is demeclocycline used for?
Treatment of hyponatraemia resulting from inappropriate secretion of antidiuretic hormone (if fluid restriction does not work)
122
What is tolvaptan used for?
Treatment of hyponatraemia secondary to syndrome of inappropriate antidiuretic hormone secretion
123
What mineralocorticoid can be used for postural hypotension?
Fludrocortisone
124
True or false:High dose steroids should be used in the management of septic shock
False - they should be avoided However, there is evidence that administration of lower doses of hydrocortisone and fludrocortisone acetate is of benefit in adrenocortical insufficiency resulting from septic shock.
125
What is the MHRA advice surrounding corticosteroids?
Rare risk of central serous chorioretinopathy with local as well as systemic administrationPatients should report any blurred vision/visual disturbances
126
What are the side effects of mineralocorticoids?With which mineralocorticoid is this most present with?
hypertensionsodium retentionwater retentionpotassium losscalcium lossFludrocortisone
127
What are the side effects of glucocorticoids?
diabetesosteoporosis, which is a danger, particularly in the elderly, as it can result in osteoporotic fractures for example of the hip or vertebrae;in addition high doses are associated with avascular necrosis of the femoral head.muscle wasting (proximal myopathy) can also occur.corticosteroid therapy is also weakly linked with peptic ulceration and perforation.psychiatric reactions may also occur.
128
For corticosteroid replacement therapy, what combination is usually given?
Hydrocortisone and fludrocortisoneHydrocortisone alone is not sufficient as it does not provide sufficient activity
129
In Addision's Disease or following adrenalectomy, what is usually given?How is it given?
HydrocortisoneThis is given in 2 doses, the larger in the morning and the smaller in the evening, mimicking the normal diurnal rhythm of cortisol secretion.
130
In acute adrenocorticol insufficiency, what is given?
IV hydrocortisone
131
What are the side effects of corticosteroids?
#NAME?
132
ADULTS:In what patients would you want a gradual withdrawal of systemic corticosteroids?
- Received more than 40 mg prednisolone (or equivalent) daily for more than 1 week;been given repeat doses in the evening- Received more than 3 weeks’ treatment- Recently received repeated courses (particularly if taken for longer than 3 weeks)- Taken a short course within 1 year of stopping long-term therapyOther possible causes of adrenal suppression.
133
What is the physiological daily dose equivalent of prednisolone?
7.5mg daily
134
True or false:During corticosteroid withdrawal the dose may be reduced rapidly down to physiological doses (equivalent to prednisolone 7.5 mg daily)
TRUE
135
CHILDREN:In what patients would you want a gradual withdrawal of systemic corticosteroids?
- Received more than 40 mg prednisolone (or equivalent) daily for more than 1 week or 2 mg/kg daily for 1 week or 1 mg/kg daily for 1 month- Been given repeat doses in the evening- Received more than 3 weeks’ treatment- Recently received repeated courses (particularly if taken for longer than 3 weeks)-Taken a short course within 1 year of stopping long-term therapy- Other possible causes of adrenal suppression.
136
Prednisolone 5mg is equivalent to how much beclomethasone?
750 micrograms
137
Prednisolone 5mg is equivalent to how much dexamethasone?
750 micrograms
138
Prednisolone 5mg is equivalent to how much hydrocortisone?
20mg
139
Prednisolone 5mg is equivalent to how much methylprednisolone?
4mg
140
What is the most commonly used steroid for long-term disease suppression?
Prednisolone
141
What is the MHRA advice surrounding the methylprenisolone injectable preparation Solu-Medrone 40mg?
Contains lactose- not suitable for those with a cow's milk allergy
142
If a newly diagnosed type 1 diabetic weighing 60kg was to be started on a basal bolus regime, what would their starting daily insulin unit dose be?How would you split this between basal bolus?
Starting at 0.5 units/kg/daySo 30 unitsHalf basal and half bolus 15 units basal e.g. Lantus And split the other 15 into 3 for meal times, so 5 units TDS of rapid acting insulin
143
1. What is first line for postmenopausal osteoporosis?2. What would be alternatives if this is not appropriate?
1. Oral bisphosphonates alendronic acid or risedronate as they have a broad spectrum of anti-fracture efficacy 2. IV bisphosphonate (ibandronic or zolendronic acid) Denosumab Raloxifene
144
What is teriparatide used for?
Reserved for postmenopausal women with severe osteoporosis at very high risk for vertebral fractures. Its duration of treatment is limited to 24 months.
145
1. What would be first line for glucocorticoid-induced osteoporosis?2. What would be alternatives if this was not appropriate?
1. Oral bisphosphonates- alendronic acid or risedronate sodium2. IV zolendronic acid or teripartide are alternatives
146
Men who are receiving androgen deprivation therapy for prostate cancer have an increased risk of what?
FracturesFracture risk should be assessed at the start of therapy
147
1. What would be first line in men with osteoporosis?2. What would be alternatives if this was not appropriate?
1. Oral bisphosphonates- alendronic acid or risedronate sodium2. IV zolendronic acid or denosumab
148
Bisphosphonate treatment should be reviewed after how many years?
5 years of treatment of alendronic acid, risedronate sodium or ibandronic acid3 years of treatment with zolendronic acid
149
Which patient groups can continue their bisphosphonate therapy after 5 years?
Patients over 75 years of age, or with a history of previous hip or vertebral fracture, or patients who have had one or more fragility fractures during treatment, or who are taking long-term glucocorticoid therapy
150
What is the warnings surrounding the use of bisphosphonates?
1. Risk of atypical femoral fracturesPatients should be advised to report any thigh/hip/groin pain Review treatment after 5 years 2. Risk of osteonecrosis of the jawDental check up and any necessary work is needed before therapy Any oral symptoms should be reported e.g. non-healing sores, swelling, pain If the patient wears dentures, need to ensure they fit properly before starting therapy 3. Risk of osteonecrosis of external auditory canalAny ear symptoms e.g. ear infections, ear discharge, ear pain should be reported 4. 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
151
What are the side effects of bisphosphonates?
- Anaemia- Severe oesophageal reactions (ulcers, strictures, erosions) - Risk of atypical fracture- Osteonecrosis of jaw or auditory canal- Altered taste-Joint swelling- Hypophosphatemia NB- absorption is affected by other meds e.g. iron, so needs to be taken 30 mins before food and other meds
152
Is estradiol a natural or synthetic oestrogen?
Natural
153
Is ethinylestradiol a natural or synthetic oestrogen?
Synthetic
154
If long term oestrogen therapy is needed for women who still have a uterus, what should be added and why?
Progesterone to reduce the risk of hyperplasia of endometrium and cancer
155
HRT increases the risk of what?
Venous thromboembolism, stroke, endometrial cancer (reduced by a progestogen), breast cancer, and ovarian cancer; there is an increased risk of coronary heart disease in women who start combined HRT more than 10 years after menopause.
156
What is first line in hyperthyroidism?What is second line?
CarbimazolePropylthiouracil
157
What is the important safety information regarding carbimazole?
#NAME?
158
What is the patient advice regarding propylthiouracil?
Severe hepatic reactions have been reportedPatients should be told how to recognise signs of liver disorder and advised to seek prompt medical attention if symptoms such as anorexia, nausea, vomiting, fatigue, abdominal pain, jaundice, dark urine, or pruritus develop.
159
How should a thyroid storm be treated?
Emergency situationIV fluids, propranolol and hydrocortisoneas well as oral iodine, and carbimazole/propylthiouracil
160
What is first line for hypothyroidism?What is an alternative?
LevothyroxineLiothyronine
161
What is the patient advice regarding the administration of levothyroxine?
Dose to be taken preferably at least 30 minutes before breakfast, caffeine-containing liquids (e.g. coffee, tea), or other medication.
162
What is tibolone used for?
For womenShort term treatment of oestrogen deficiency Osteoporosis prophylaxis
163
Is norethisterone an oestrogen or progesterone?
Progesterone
164
What is the advice regarding missing a dose of progesterone only pill for contraception?
Take it as soon as you rememberHowever if it is not taken within 3 hours of the normal time of taking the pill- additional precautions should be used and for 2 days after
165
What is the advice regarding vomiting if taking a progesterone only pill?
If vomiting occurs within 2 hours of taking an oral progestogen-only contraceptive, another pill should be taken as soon as possible. If a replacement pill is not taken within 3 hours of the normal time for taking the progestogen-only pill, or in cases of persistent vomiting or very severe diarrhoea, additional precautions should be used during illness and for 2 days after recovery (but still keep taking the pill as usual)
166
True or false:You should take the progesterone only pill (for contraception) at the same time every day
True If delayed longer than 3 hours, then the contraceptive effect may be lost
167
When starting a progesterone only pill for contraception, what is the advice surrounding when to start during the menstrual cycle and if additional contraceptive cover is needed?
Should ideally start taking on day 1 of the cycleAdditional contraceptive precautions are not required if norethisterone is started up to and including day 5 of the menstrual cycle; if started after this time, additional contraceptive precautions are required for 2 days.
168
If you are changing from a combined oral contraceptive pill to the progesterone only, when should this happen?
Start on the day following completion of the combined oral contraceptive course without a break (or in the case of ED tablets omitting the inactive ones)
169
When starting a progesterone only pill for contraception AFTER CHILDBIRTH, what is the advice surrounding when to start and if additional contraceptive cover is needed?
Can be started up to and including day 21 postpartum without the need for additional contraceptive precautions. If started more than 21 days postpartum, additional contraceptive precautions are required for 2 days.
170
If on a progesterone only pill for contraception, in what situations would you need emergency contraception?
If one or more progestogen-only contraceptive tablets are missed or taken more than 3 hours late and unprotected intercourse has occurred before 2 further tablets (2 days worth) have been correctly taken.
171
Which antidiabetic drug can cause lactic acidosis and B12 deficiency?
Metformin
172
If a pregnant patient diagnosed with gestational diabetes presents with a fasting glucose of <7mmol/L, what should be done?If this does not work after 1-2 weeks, what should then be done?
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
173
If a pregnant patient diagnosed with gestational diabetes presents with a fasting glucose of >7mmol/L, what should be done?
Should be treated with insulin immediately, with or without metformin hydrochloride, in addition to a change in diet and exercise
174
What are the complications of gestational diabetes?
Hydramnios- a condition in which excess amniotic fluid accumulates during pregnancyMacrosomia- larger than normal baby
175
If a pregnant lady presents with complications of gestational diabetes, how should this be managed?
Should be considered for immediate insulin treatment, with or without metformin hydrochloride.
176
What is the advice surrounding patients on metformin who is going to have contrast media administered as part of radiologic studies?
Can lead to nephrotoxicityIf patient's eGFR >60 and only missing one meal, then there is no need to stop metformin afterIf eGFR < 60:Metformin should be discontinued prior to, or at the time of the imaging procedure and not restarted until at least 48 hours after, provided that renal function has been re-evaluated and found to be stable
177
What is the advice surrounding metformin during surgery?
If EGFR > 60 or only one meal will be missed, and low risk of AKI:It may be possible to continue metformin hydrochloride throughout the peri-operative period—just the lunchtime dose should be omitted if the usual dose is prescribed three times a day.If there is a risk of AKI or more than one meal will be missed:Metformin should be stopped when the pre-operative fast begins. A variable rate intravenous insulin infusion should be started if the metformin dose is more than once daily. Otherwise insulin should only be started if blood-glucose concentration is greater than 12 mmol/litre on two consecutive occasions - metformin should not be recommended until the patient is eating and drinking and renal function is stable
178
If a patient is on 500mg OD metformin, due for surgery and the metformin needs to be stopped beforehand, would you give VRII?
No, only give VRII if their usual metformin dose is more than once daily OR if their blood glucose is >12 on 2 consecutive occasions
179
What is the risk of continuing metformin during surgery?
Renal impairment may lead to accumulation and lactic acidosis
180
What is the advice surrounding sulphonylureas and surgery?
Sulfonylureas are associated with hypoglycaemia in the fasted state and therefore should always be omitted on the day of surgery until the patient is eating and drinking again. Monitor blood glucose and give insulin if necessary
181
If a patient does not require VRII, what antidiabetic drugs can be continued during surgery?
Pioglitazone, dipeptidylpeptidase-4 inhibitors (gliptins) and glucagon-like peptide-1 receptor agonists can be taken as normal during the whole peri-operative period.Metformin- depends on AKI risk, eGFR, how many doses they are missing
182
Do gliptins or sulphonylureas have a higher incidence of hypoglycaemia?
Sulphonylureas
183
A HbA1c alone at what level would indicate diabetes?
48
184
HbA1c should not be used for diagnosis in what patients groups?
Those with suspected type 1 diabetes, in children, during pregnancy, or in women who are up to two months postpartumAlso should not be used in the following:- Symptoms for less than 2 months- Treatment with medication that may cause hyperglycaemia- Acute pancreatic damage- HIV- End stage CKD
185
Zolendronic acid is contraindicated in what patient group?
Women of child bearing potential
186
For DKA, what strength glucose do you give?
10%
187
For hypoglycaemia when glucose is needed, what strength do you give?
20%
188
A high TSH level with a low FT4 and FT3 level indicates what?
Hypothyroidism
189
A low TSH level with a high T4 level and a high T3 level indicates what?
Hyperthyroidism
190
How do you manage hyperthyroidism during pregnancy?
Carbimazole is associated with congenital defects, including aplasia cutis of the neonate, therefore propylthiouracil remains the drug of choice during the first trimester of pregnancy. In the second trimester, consider switching to carbimazole because of the potential risk of hepatotoxicity with propylthiouracil
191
What is the blocking replacement regime?
Hyperthyroidism A combination of carbimazole with levothyroxine sodium daily, may be used in a blocking-replacement regimen; therapy is usually given for 18 months. The blocking-replacement regimen is not suitable during pregnancy.
192
Why should you avoid rapid correction of sodium in SIADH?
Can cause serious CNS effects and demyelination of neurones
193
What effect can corticosteroids have on potassium levels?
Can cause hypokalaemia
194
If chicken pox develops in a person taking corticosteroids, what is recommended?
Seek urgent medical attention as they are immunocompromised
195
When would you issue patients with a steroid card?
Taking long term steroids for more than 3 weeksHigh dose ICS
196
When would you consider a statin in Type 1 and Type 2 diabetics?
Type 1 if >40 yearsTYpe 2 if QRISK >10%
197
If a woman presents with gestational diabetes with a blood glucose of <7 , what is first line?What is second line?
Diet and exercise If blood glucose targets are not met within 1-2 weeks, metformin can be prescribed (if not, insulin)
198
If a woman presents with gestational diabetes with a blood glucose of >7, what should happen?
Should be treated with insulin immediately, with or without metformin hydrochloride, in addition to a change in diet and exercise
199
If a woman presents with gestational diabetes with a blood glucose of 6-6.9 along with complications e.g. macrosomia, what should happen?
Should be considered for immediate insulin treatment, with or without metformin
200
What is macrosomia?
Larger than average foetus- usually a complication for women with diabetes
201
If a driver experiences hypoglycaemia, what should they do?
Stop vehicle in safe placeFast acting sugar and long acting carbohydrateWait for 45 minutes after blood glucose has returned back to normal before continuing journey
202
What class of antidiabetic drugs can cause volume depletion?
SGLT2 inhibitors
203
In a woman without a uterus requiring HRT, what preparation should be used?
Continuous oestrogen
204
i) In a woman with a uterus requiring HRT, what preparation should be used?ii) What kind of HRT is unsuitable if the patient is peri-menopausal or <12 months after last period?
Progesterone cyclically and oestrogen Or continuous progesterone and oestrogen (avoids withdrawal bleed)ii) Continuous combined HRT is unsuitable for peri-menopausal or <12 months after last period as it can cause irregular bleeding so you would use cyclic
205
What kind of cancer must you rule out if irregular bleeding continues after stopping continuous HRT?
Endometrial cancer
206
Coronary heart disease risk is increased if combined HRT is started how many years after menopause?
10 years
207
If combined HRT is started 10 years after menopause, the risk of what is increased?
Coronary heart disease
208
What is a severe side effect of exenatide?
Severe pancreatitis
209
Can you take risedronate and alendronic acid daily?
Yes at lower doses5mg risedronate OD (or 35mg weekly)10mg alendronic acid OD (or 70mg weekly)
210
What is the advice if a patient is on levothyroxine and iron tablets?
Iron can decrease the absorption of levothyroxine, so separate administration by at least 4 hours
211
What is used if a patient wants to delay her period, and what is the dosing regimen?
Norethisterone5 mg 3 times a day, to be started 3 days before expected onset (menstruation occurs 2–3 days after stopping).
212
Abrupt withdrawal of steroids can lead to what?
Abrupt withdrawal after a prolonged period can lead to acute adrenal insufficiency, hypotension or death. Withdrawal can also be associated with fever, myalgia, arthralgia, rhinitis, conjunctivitis, painful itchy skin nodules and weight loss.
213
The most commonly prescribed treatments for cholesterol are
statins (HMGCoA Reductase inhibitors) which inhibit endogenous production of LDL Cholesterol and up-regulate its uptake by the liver. The only other therapy in routine use and suggested by NICE is Ezetimibe. Other medication includes; Fibrates (especially if triglycerides are >10mmol/l), Omacor and Bile acid sequestrants but are not for routine use.
214
Name the 3 rapid acting insulins
Can you think of their brand names?
Insulin Glulisine Apidra®
Insulin Aspart Novorapid®
Insulin Lispro Humalog®
That GAL is RAPID!
215
What type of insulin is Novorapid?
Insulin Aspart
Rapid-acting
216
When should the rapid acting insulins be injected?
Immediately before eating
(0- 15 mins before food)
217
How long does it generally take rapid acting insulins to start working?
~10 - 20 minutes
218
How long is the duration of action of rapid acting insulins?
around 2 - 5 hours
219
How many units of insulin do the Flexpen, Flextouch, Kwikpen and Solostar (all pre-filled disposable pens) tend to contain?
300 units
3ml pens containing 100 units/ ml
220
Are patients more or less at risk of hypglyceamia when using rapid-acting insulins compared to other insulins?
Less at risk of hypoglyceamia as it is only in body for a few hours and is used with meals
221
What type of insulin are short acting insulins?
Short acting insulin= Soluble insulin (S S)
Can get different types of soluble insulins:
Soluble human
Soluble bovine ('neutral') Beef
Soluble porcine ('neutral') Pig
222
What kind of insulin is Actrapid?
Insulin soluble (human)
Short- acting
223
When should short acting insulins be injected?
15 - 30 mins before food
Must eat food within 30 mins of injecting to avoid hypoglyceamia
They start working after 30 mins
224
How long do short acting insulins work for and when is their peak activity?
Duration of action: 4 - 8 hours
Peak activity: 2 - 4 hours
225
What type of insulin is intermediate acting?
Intermediate acting = Isophane insulin (i,i)
Human isophane insulin usually used
Isophane insulin is a suspension of Insulin with protamine: bovine porcine or human insulin in the form of a complex obtained by the addition of protamine
Usually found in biphasic preparations
226
Can you think of any brands of Intermediate acting insulins?
Isophane insulins:
Insulatard®
Humulin I®
(all of the i's!)
227
When should intermediate acting (isophane) insulins be injected?
They usually need to be injected twice daily, sometime once daily in eldery
No need to inject with meals
They have a peak action at 4 - 12 hour and last for around 21 hours
228
What are the three types of long- acting insulins? Do you know their brand names?
Insulin Detemir Levemir®
Insulin Glargine Lantus ®
Insulin Degludec Tresiba®
229
How long do the long-acting insulins usually work for?Which one works for up to 42 hours?
around 18 - 24 hours
42 hours: Degludec (tresiba)
230
Which type of insulin is used in medical emergencies such as diabetic ketoacidosis and before surgery?
Soluble insulin
231
What is the rational behind biphasic insulin preparations?
These are basically pre-mixed preparations of a rapid or short acting insulin plus a intermediate acting insulin (either the protamine [longer chain version of the short/ rapid acting one] or isophane insulin).
They are to be injected twice daily, and are good for patients who don't like multiple injecting regimens ( also called basal bolus- where people have to inject short acting with meals plus a long acting insulin)
Disadvantages of these are that there may be less control as proportions are fixed- if unwell and need to boost their insulin they cannot use these and would need a rapid or short acting insulin for this.
232
NovoMix is a Biphasic insulin (intermediate acting). It contains a mixture of which insulins?
Insulin aspart (rapid acting)
Insulin aspart protamine (long acting)
Together it becomes intermediate acting- injected twice daily
233
What do Biphasic insulins look like in appearance?
Cloudy
Need to be resuspended before use- tell patient this- by rolling in their hands (not shaking)
234
Can you name 4 brands of Biphasic insulins, and their ingredients?
Novomix 30 (insulin aspart+ aspart protamine)
Humalog Mix 25 / Humalog Mix 50 (Insulin Lispro + lispro protamine)
Humulin M3 (soluble insulin + isophane insulin)
Insuman Comb 50 (soluble insulin + isophane insulin)
235
What electrolyte disturbance can insulins cause?
HypoKaleamia
236
When should Biphasic insulins be injected?
Think about what each one contains: short or rapid acting?
The ones containing rapid acting (NovoMix 30, Humalog Mix) should be injected 0-15 mins before a meal
Containing short acting (Humulin M3, Insuman Comb) inject 15 - 30 mins before a meal
237
What substance in some insulins can cause injection site reactions and therefore is important to make patients aware the importance of rotating the site of action?
Protamine
238
The fridge on one of your wards is broken, therefore the not-in-use pens are having to be stored at room temperature. What should inform staff/ label these with?
These will now have a 28 day expiry, as not-in-use pens need to be in the fridge to be used by their original expiry date (i.e. now follow the same rules that In-use pens have)
239
To diagnose diabetes, a random venous plasma glucose concentration would need to read > __ mmol/L
Over 11 mmol/L
240
To diagnose diabetes, a fasting plasma glucose concentration would need to read over __ mmol/L
Fasting= over 7 mmol/L
241
To diagnose diabetes, a two hour plasma glucose concentration (two hours after eating/ two hours after 75g glucose in a glucose tolerance test) would need to read over __ mmol/L
Two hour post food/ glucose: Over 11 mmol/L
242
a HbA1c of __ mmol/mol or __% is needed to diagnose diabetes
HbA1c of over 48 mmol/mol
or 6.5%
243
What situations would a HbA1c test be inappropriate to diagnose diabetes? (try and think of around 5)
- Children/ young adults
- Suspected Type 1 diabetes
- Symptoms less than 2 months
- Medication related glucose effects e.g. steroids, antipsychotics
- Pancreas damage
- Pregnancy
- Acutely unwell/ in hospital
244
Which insulins are cloudy in appearance?
Intermediate acting (Isophane)
Biphasic preparations- Novomix, Humulin M3, Humalog Mix, Insuman Comb
245
For a driver of a car/ motorbike, who has been deemed fit to drive due to the presence of only 1 episode of severe hypoglyceamia in the last year, how often should you advise them to check their BG levels?
Within 2 hours of starting their journey
Every 2 hours whilst driving
If a hypo occurs: stop, pull over, get out of drivers seat, eat sugar, wait 45 mins after BG has returned to normal to continue driving
246
How many months worth of BG readings must Lorry drivers provide to the DVLA if they are to drive?
3 months
247
How often should Lorry/ Bus drivers test their blood glucose whilst driving, and on days when theyre not driving?
Within 2 hours of starting to drive
every 2 hours whilst driving
at least twice daily when not
248
What are the side effects of insulin?
Fat hypertrophy at injection site
Local reactions at injection site
Transient oedema
249
What are the insulin sick day rules?
Just because the patient is ill and not eating does not mean they should stop injecting their insulin
ill/ infection= stress hormones/ steroids released
steroids increase blood glucose
stay well hydrated to avoid DKA
patient should monitor their BG and urine ketones more frequently and be prepared to inject accordingly
250
When should insulin be resuspended before use?
For all insulin preparations, except rapid- and short-acting insulin and insulin glargine (Lantus), the vial or pen should be gently rolled in the palms of the hands (or shaken gently) to resuspend the insulin.
251
First line insulin used in Type 2 diabetes?NB: Insulin chosen if persons BG inadequately controlled by metformin + sulfonylurea or triple therapy: 3 oral antidiabetic drugs together has failed
Intermediate acting: Human isophane insulin
252
Novomix is a biphasic insulin with an onset of action of _____ mins and peak activity of ______ hours.
Onset of action of 10-20 mins
Peak acivity of 1-4 hours
253
What is it that makes Insulin Degludec (tresiba) different from all the other insulins licensed in the UK?
It is the first insulin to be available in two different strengths:
100 units/ml
200 units/ml
254
How do Sulfonylureas work?
Increase insulin secretion from the pancreas
255
Which are short acting and which are long acting sulfonylureas? (5)
Short acting:
Gliclazide
Glipizide
Tolbutamide
Longer acting:
Glimepramide
Glibenclamide (longest acting)
256
Which sulfonyurea is most prone to causing Hypoglyceamia, and therefore should be avoided in which population group?
Glibencamide (longest acting)
Avoid use in the elderly
257
How should sulfonylurea induce Hypoglyceamia be treated?
Hypoglyceamia can persist for many hours.
It must always be treated in hospital
NB: Hypoglyceamia with sulfonylureas is uncommon and usually indicates excessive dosage
258
When in the T2 diabetes treatment guidelines is a sulfonylurea indicated?
After diet/ lifestyle, then metformin alone have been tried:
Can use a sulfonylurea instead if metformin Contra-indicated, patient is NOT overweight or rapid response is needed as glucose levels very high.
If metformin alone does not work, can then add in a sulfonylurea
259
What side effects can sulphonylureas cause? (4)
Weight gain
GI disturbance: Diarrhoea, constipation, nausea, vomitting
Fever (usually in first 6- 8 weeks)
Jaundice (avoid in severe liver impairment)
260
What is Metformins Mechanism of Action?
It is a Biguanide:
Decreases gluconeogenesis (production of new glucose) and increases peripheral utilisation of glucose
Remember: metformin produce normoglyceamia rather than hypoglyceamia
NB: It does not increase insulin secretion like other oral antidiabetics, therefore it does not cause weight gain!
261
Main side effects of Metformin? (3)
GI upset- take with food, use MR if intolerable
Weight loss
Taste disturbance
262
Metformin can cause Lactic Acidosis. What would be potential risk factors for this?
risk factors such as
renal dysfunction (as metformin accumulates),
liver disease,
heavy alcohol ingestion
IV contrast media- reduces renal function therefore lactic acidosis risk
Poor tissue perfusion/ poor renal function= risk of lactic acidosis
263
What vitamin can Metformin cause deficiency in?
Vitamin B12
Can lead to vitamin B12 deficient aneamia: symptoms= increased tirednes, weakness, mouth ulcers, pins and needles
264
When does metformin become contra-indicated in renal impairment?
In severe renal impairment
eGFR falls below 30 ml/min/ 1.73m2
In moderate impairment (eGFR under 45) a dose reduction is needed
265
Max dose of metformin?
2g a day
266
What is Acarbose and what is its mechanism?
Alpha glucosidase inhibitor- (remember Alpha= Acarb) this enzyme breaks down starch and disaccharides to glucose, so Acarbose stops this, thereby delaying the digestion and absorption of starch and sucrose- small but significant effect in loweing blood glucose.
Acarbose= Starchy effects (potatoes!)
267
What are the common Side effects of acarbose?
FLATULENCE- advise this will decrease with time
Diarrhoea/ Soft stools (as poo becomes sugary due to limited glucose absorption)
Other GI effects
268
How should patients be advised to take Acarbose?
Chew with first moutful of food or swallow with a little liquid immediately before food.
269
What happens if a patient on metformin is injected with Iodine X-ray contrast media?
Interaction:
Renal function deteriorates rapidly
can then increase risk of Lactic acidosis
270
What enzyme do the Gliptins inhibit?How does this help lower glucose?Linagliptin
Sitagliptin
Vildagliptin
Saxagliptin
Sitagliptin
Vildagliptin
Saxagliptin
Inhibit an enzyme called Dipeptidylpeptidase-4
This enzyme breaks down incretins, incretins trigger insulin secretion and lower glucagon secretion, therefore they are good at helping control glucose, so by inhibiting the enzyme that breaks them down, gliptins increase incretin levels.
Gliptins.. incretins... gliptins.... incretins!
271
What are the side effects of the gliptins (dipeptidylpeptidase 4 inhibitors)? (5)
Upper respiratory tract infections
Gatro-intestinal upset
Peripheral oedema
Pancreatitis
Trigger insulin release so some weight gain?
There is less risk of Hypoglyceamia with the gliptins!
272
Which of the gliptins (Dipeptidylpeptidase-4 inhibitors) should patients have their liver function monitored if taking?
Vildagliptin
Report symptoms of liver disease: nausea, vomitting, abdominal pain, fatigue, dark urine
273
Which oral antidiabetics can cause acute pancreatitis?
What are the symptoms of this?
What are the symptoms of this?
Dipeptidylpeptidase-4 inhibitors (gliptins- sitagliptin, Linagliptin etc)
Glucagon-like peptide-1 receptor agonists (Exenatide, Liraglutide, Lixisenatide)
Exanatide especially can cause SEVERE PANCREATITIS
Symtpoms: Persistent and severe abdominal pain
Nausea and vomitting
274
What is the mechanism of action of the Thiazolidinediones? (Only one licensed in UK is pioglitazone)
Reduces peripheral insulin resistance
275
Which oral antidiabetics must care be taken with in Heart Failure? And what cancer can it possibly increase risk of?
Pioglitazone
Incidence of HF increased when pioglitazone is combined with insulin
Also small risk of BLADDER cancer
Signs of bladder cancer: blood in urine, pain on urination, urinary urgency
276
can oral anti-diabetic drugs cause headaches?
Yes- alot of them cause a headache, particularly pioglitazone and the gliptins
277
How do the Meglitinides work?
Can you name them?When should they be taken?
Can you name them?When should they be taken?
Nateglinide
Repaglinide
Stimulate insulin secretion
Take 30 minutes before meals
278
Can you name any oral anti-diabetic drugs that can cause liver toxicity?
Pioglitazone
The Gliptins- linagliptin, sitagliptin, vildagliptin
279
What are GLP-1 agonists? How do they work?
Glucagon-like peptide-1 receptor agonists
Examples:
Exenatide
Liraglutide
Lixisenatide
These are given by SUBCUTANEOUS INJECTION- not oral
These work by binding to the GLP-1 receptor causing:
-> Increase in insulin secretion
-> suppression of glucagon secretion (glucagon gets converted in glucose usually)
-> Slow gastric emptying
If given with sulfonylureas or insulin, their dose may need to be reduced as increased risk of hypoglyceamia!
280
What drug do we have to be particularly vigelant for symptoms such as persistent and severe abdominal pain, nausea and vomitting?
Exenatide (GLP-1 agonist)
These are symptoms of pancreatitis- exanatide can cause severe pancreatitis- discontinue permanently
281
What should patients be advised to do if they miss a dose of Exenatide? How should it usually be administered?
Miss that dose out and just continue with the next scheduled dose.
Usual dose is to be injected 1 hour before 2 main meals a day that are at least 6 hours apart
Do not administer the dose after a meal
Some oral med's need to be given 1 hour before or 4 hours after this drug
282
What are the SGLT2 inhibitors?3 examples?How do they work?
Sodium Glucose Co-transporter 2 inhibitors
Gliflozins
Examples:
Canagliflozin
Dapagliflozin
Empagliflozin
(DECeeeee!)
The sodium glucose transporter is found in the kidneys: by inhibiting this they stop glucose be re-absorbed in the renal tubule and therefore more glucose is excreted
283
What important Side effect can the SGLT2 inhibitors (Canagliflozin, dapagliflozin, empagliflozin) cause?
What concomitant drugs/ conditions could increase the risk of this?
What concomitant drugs/ conditions could increase the risk of this?
Volume depletion !
Think floz= flow
Think: these are inhibiting glucose rer-absorption into the renal tubules. Water usually follows the glucose- less reabsorbed= less water follows= more weeing etc
Patients need to report signs of this:
Dizzy, postural hypotension
Side effects:
Thirst
Constipation (less water in stools)
UTI's
Increased risk: things that also decrease fluid volume
Antihypertensives
Elderly
diarrhoea
284
Sitagliptin and Vildagliptin, dipeptidyl peptidase enzyme inhibtior enhancing incretin hormone, should only be continued if HbA1c has been reduced by at least ___ percentage points within 6 months of starting treatment
0.5 percentage points
285
Which class of oral anti-diabetics can increase the risk of Genital infections- Thrush and UTI's? Name me some of them
The SGLT2 inhibitors:
Dapagliflozin
Canagliflozin
Empagliflozin
286
What condition, other than diabetes, can metformin be used in Unlicensed?
Poylcystic ovary syndrome
It helps to normalise the menstrual cycle an ovulation
287
What are patients on pioglitazone urged to report?
Symptoms of bladder cancer:
heamatruria
dysuria
urinary urgency
Also signs of liver toxicity: blood in urine, severe stomach pain/ nausea and vomiting
288
When should sulfonylureas be taken?
WITH MEALS
289
Patient with hepatic impairment prescribed a sulfonylurea?
Reduce the dose- sulfonylureas metabolised hepatically- they will accumulate and cause hypoglyceamia
290
How should Acarbose be taken?
Chewed with first mouthful of food/ with a bit of water immediately before food
291
What is the name of the thiazide diuretic that can be chronic intractable hypoglyceamia in Neonates/ children?
Diazoxide
(remember diuretics can cause hyperglyceamia)
292
You have a patient suffering from newly diagnosed T2 diabetes with poor renal function, What would be your first line choice of antidiabetic?
A sulfonylurea- Gliclazide
293
If a patient is of European Descent and they have a BMI of over 35, and metformin and gliclazide have failed to control their BG, what agent would you consider next?
Exenatide
This is a NICE recommendation
294
Which bisphosphonate needs to be discontinued if a skin rash develops?
Strontium ranelateSevere allergic reaction:Symptoms known as DRESS 'Drug rash with eosinophilia and systemic symptoms' Starts with: fever, rash, swollen glands, high WCC
295
What is the side effect we need to be vigilant about with Bisphosphonate treatment?
Osteonecrosis of the JawThe risk is higher with IV therapy for cancer treatment than it is with oral. Patients have a dental check up before starting and need to maintain good oral hygiene and attend regular check ups. They should report any oral symptoms: Pain, inflammation, difficulty swallowing
296
If patients taking Alendronic acid experience dysphagia, heartburn, pain on swallowing or retrosternal pain what should they do?
Stop taking and Report it- may be an oesophageal reaction: can be serious
297
Desmopressin, used for diabetes insipidous and first line for nocturnal enuresis, can cause electrolyte disturbance: hyponatreamia. What can this lead to, and what can be done to stop this?
Hyponatreamic convulsions mentioned in the BNF. This can be minimised by sticking to the recommended start dose and avoiding drugs that increase secretion of vasopressin such as TCA's.
298
Clomifene is a drug used to treat female infertility as it is anti-oestrogen. The CSM have advised that it should not be used for more than __ cycles, due to increased risk of _____ cancer.
Not for more than 6 cyclesIncreased risk of ovarian cancer with clomifene use.
299
Which drug used in thyroid therapy can cause agranulocytosis and neutropenia? what is this drug used for?
CarbimazoleUsed for HyperthyroidismUsed in the 18 month blocking-replacement regimen together with levothyroxine.
300
What test is indicated prior to therapy with levothyroxine and Liothyronine?
Baseline ECG- this is because we want to check we haven't mistaken hypothyroidism with ischaemia/ cardiovascular disease.
301
Which antithyroid drug is used if carbimazole is contraindicated?What do we need to monitor with this drug?
Propylthiouracil Liver function- severe hepatic reactions have taken place.
302
What drugs are used for management of thyrotoxic symptoms (when too much thyroid hormone has been given)?
Beta blockers- propranolol IV fluidshydrocortisone
303
What side effect of carbimazole is common and can be treated with antihistamines without the need to discontinue?
Rashes and pruritis- don't say 'discontinue' in exam cause you've mistaken it for neutropenia/agran
304
Sick day rule for patients on a systemic steroid and fall mildly ill?
Double dose for 2 days
305
Sick day rule for patients on a systemic steroid and severely ill?
Double dose until symptoms improve
306
If a patients has severe diarrhoea or vomiting and can't keep their steroid down?
Hydrocortisone emergency injection may be needed from GP
307
Difference between Addisons and Cushings (hint: they are opposites)?
Addisons is a deficiency of ACTH- (adrenocorticotropic hormone) because the immune system has turned against the adrenal glands. Symptoms: anorexia, Nausea and vomiting, weightloss- treat with glucocorticoids Cushings- too much ACTH, caused by long term glucocorticoid therapy or tumour. Moon face, buffalo hump, mood swings, weight gain. Treatment- withdraw the steroid
308
Symptoms of DKA?(8)
Rapid weight lossAbdominal painNausea and vomitingRapid and deep breathing?Sweet smelling breathSweet/metallic tasting breathAltered odour of urine/sweatSleepiness
309
In adults:Gradual withdrawal of systematic corticosteroids is considered in those where the disease is unlikely to relapse and have....? (6)
Received more than 40mg of prednisolone (or equiv) daily in the last weekGiven repeated doses in the evening Received more than 3 weeks treatmentRecently received repeated courses (particularly for longer than 3 weeks)Taken short-course within a 1 year of stopping long-term treatmentOther possible causes of adrenal suppression
310
How to withdraw corticosteroids from adults and children?
Adult:Dose may be reduced rapidly down to physiological dose (equivalent to 7.5mg prednisolone daily) and then reduced more slowlyChild:Dose may be reduced rapidly down to physiological dose (equivalent to 2-2.5 mg/m2 prednisolone daily) and then reduced more slowly
311
When can systemic steroids be stopped abruptly?
When disease is unlikely to relapse and those who have received less than 3-weeks treatment (and those not included in the patient groups described on page 659)
312
How long can corticosteroid-induced adrenal suppression last for after stopping drug
1 year or more
313
What is the duration of dexamethasone and betamethasone?
Long duration of actionMakes it good for suppression of corticotrophin secretion (e.g. congenital adrenal hyperplasia)
314
Steroid with high mineralocorticoid activity
Fludrocortisone acetateCan be used to treat postural hypotension
315
Steroid with very high glucocorticoid activity and insignificant mineralocorticoid activity?
Betamethasoneand Dexamethasone
316
Corticosteroid with moderate glucocorticoid activity and high mineralocorticoid activity - good for topical use because side-effects are less marked?
HYDROCORTISONE
317
What are prednisolone and prednisones predominant activity on?
Glucocorticoids
318
Side effects of glucocorticoids? (6)
DiabetesOsteoporosis (particularly in elderly)At high doses - avascular necrosis of femoral headMuscle wastingWeekly linked with peptic ulcer/perforationsPsychiatric reactions
319
Side effects of mineralocorticoids (5)**Think minerals**2 increase, 2 decrease
Hypertension (hence why it can tx postural hypo)Sodium retentionWater retentionPotassium lossCalcium loss
320
What is Deflazacort?
Derived from prednisoloneHas high glucocorticoid activity
321
What happens to prednisolone when it crosses the placenta in pregnancy?
88% is inactivated
322
What is the advise with ketoconazole and hepatic inpairment?In treating Cushing syndrome
Avoid in acute or chronic impairment Do not initiate the drug if liver enzymes are greater than 2X the normal upper limit
323
Symptoms suggestive of adrenal Insufficiency?
FatigueAnorexiaNausea and vomitingHypotensionHyponatraemia HypoglycaemiaHyperkalaemia
324
Characterised by persistent hyperglycaemia, what are the two ways in which diabetes can manifest?
1. Deficient insulin secretion2. Resistance to actions of insulin
325
What are the 4 types of diabetes?
1. Type 1 2. Type 23. Gestational4. Secondary
326
To which 3 conditions can diabetes be secondary?
1. Pancreatic damage2. Hepatitis3. Endocrine disease
327
Which agency must be notified if someone has diabetes and is being treated with insulin?
DVLA
328
Which adverse event should drivers be particularly careful of?
Hypoglycaemia
329
What must diabetics always carry to ensure they are informed about their plasma glucose?
1. Glucose meter2. Test strips
330
Diabetics using insulin should check their plasma glucose how long before driving?
Two hours
331
While driving how often should diabetics using insulin test their plasma glucose?
Every two hours - more frequent if recent activity that may increase risk of hypo
332
While driving, plasma glucose of diabetic drivers should always be above what threshold?
5mmol/L
333
If plasma glucose falls slightly below 5mmol/L, what should diabetic drivers using insulin do?
Have a fast-acting carbohydrated
334
What are the 3 steps that diabetic drivers using insulin should take if their plasma glucose falls below 4mmol/L
1. Stop driving2. Switch off the engine, remove keys and move from driver's seat3. Consume source of sugar
335
How long should diabetic drivers using insulin wait before driving after stopping due to it falling below 4mmol/L?
45 minutes after it has returned to normal
336
Under which circumstances should diabetic drivers using insulin not drive?
If hypoglycaemia awareness has been lost
337
As well as insulin, which other diabetic medicines may it be necessary to inform the DVLA about? (3)
1. Sulphonylureas2. Nateglinide3. Repaglinide
338
Which lifestyle activity can mask the signs of hypoglycaemia?
Alcohol
339
Is it advised for all diabetics to avoid drinking alcohol?
No, they must drink in moderation and with food
340
Which test is mainly used to diagnose impaired glucose control? It is useful for when patients do not have severe symptoms but glucose tolerance is impaired
Oral Glucose Tolerance Test
341
If symptoms are already present, should the OGTT be used to diagnose diabetes?
No
342
In which type of diabetes is OGTT especially useful in diagnosing?
Gestational diabetes
343
How is the OGTT conducted?
Plasma glucose is measured after fasting.Patient drinks glucose drink.Plasma glucose is measured 2 hours after
344
Which test is a good indicator for glycaemic control?
HbA1c
345
What does HbA1c measure?
The amount of glycated haemoglobin
346
HbA1c shows average glucose control over how long?
The last 2-3 months
347
Should a patient fast before their HbA1c test?
No
348
HbA1c is used in Type 1 and Type 2 monitoring and diagnosis of Type 2, in which situations should it not be used? (10)
1. Type 1 diagnosis2. Children3. Pregnancy4. Up to 2 months post-partum5. Symptoms of diabetes less than 2 months6. High risk diabetes or critically ill7. Treatment with medication that causes hyperglyacemia8. Acute pancreatic damage9. End stage CKD10. HIV
349
In Type 1 Diabetes, how often should HbA1c be measured?
every 2-3months
350
In Type 2 Diabetes, how often should HbA1c be measured?
every 2-3months
351
In which patients is HbA1c monitoring invalid?
1. Disturbed erythrocyte turnover2. Lack of/abnormal haemoglobin
352
In patients which HbA1c monitoring is invalid, what can be used instead?
1. Quality controlled blood glucose profiles2. Total glycated haemoglobin estimation3. Fructosamine estimation
353
What does fructosamine estimation measure?
Glycated concentration of ALL plasma proteins over 14-21 days
354
Can type 1 diabetes produce endogenous insulin?
No (little to none)
355
Why is there no insulin secretion in type 1 diabetes?
Destruction of insulin-producing pancreatic beta cells
356
What causes the destruction of pancreatic beta cells in type 1 diabetes?
Auto-immune basis
357
At what age does type 1 diabetes most commonly occur?
Before adulthood
358
What are the microvascular complications of diabetes? (3)
1. Nephropathy2. Neuropathy3. Retinopathy
359
What are the macrovascular complications of diabetes? (3)
1. Stroke2. Cardiovascular disease (MI)3. Peripheral arterial disease
360
What blood glucose reading would you expect an adult presenting with Type 1 Diabetes to have?
Over 11mmol/L
361
What BMI would you expect an adult presenting with Type 1 Diabetes to have?
Less than 25kg/m2
362
How old would you expect an adult presenting with Type 1 Diabetes to be?
Less than 50
363
As well as hyperglycaemia, low BMI, and younger than 50, what other characteristics do adults presenting with T1DM have? (3)
1. Rapid weight loss2. Ketosis3. (Family) history of autoimmune disease
364
Increasingly used in T2DM, what is the mainstay of treatment for T1DM?
Insulin
365
Using insulin regimens, what are the 3 aims of treating T1DM?
1. Achieve blood glucose control2. Reduce frequency of hypoglycaemic episodes3. Minimise the risk of microvascular and macrovascular complications
366
What is the target HbA1c for T1DM?
Less than 48mmol/mol
367
How often must T1DM patients monitor their blood glucose daily?
at least 4 times daily - before each meal and before bed
368
What is the target fasting blood glucose for T1DM patients?
5-7mmol/L
369
What is the target random blood glucose for T1DM patients?
4-7mmol/L
370
What is the target blood glucose for T1DM patients after eating?
5-9mmol/L
371
As well as controlling blood glucose with insulin, which other cardiovascular risk factors must be actively managed in patients with diabetes?
1. Hypertension2. Blood lipids
372
Unlicensed, which oral antidiabetic can be used alongside insulin in the management of T1DM?
Metformin
373
Unlicensed, in which patients can Metformin be used alongside insulin in the management of T1DM?
BMI over 25 (over 23 S. Asian)
374
What are the advantages of usince Metformin alongside insulin (unlicensed) in T1DM?
1. Improve blood glucose2. Minimise insulin dose
375
Which other healthcare professional should be involved in manageing patients with diabetes to ensure they control their weight, lower cardiovascular risk and understand the hyperglycaemia effects of food?
Dietician
376
What type of training must T1DM patients receive in order to tailor their insulin dose throughout the day?
Carbohydrate-counting training
377
Can insulin be initiated by the GP?
No, specilist initiation and management
378
What are the 3 main insulin REGIMENS?
1. Multiple daily BASAL-BOLUS regimens2. Mixed (BIPHASIC) regimens3. Continuous subcutaneous insulin infusion
379
A basal insulin injection is...
Long acting
380
A bolus insulin injection is...
Short acting
381
What does a mixed (biphasic) regimen injection contain?
Short acting + intermediate acting
382
What is the first line recommended insulin regimen for patients with T1DM?
Basal-bolus
383
Give 2 examples of long acting insulin injections
1. Insulin detemir2. Insulin glargine
384
Are non basal-bolus insulin regimens recommended for patients newly diagnosed with T1DM? Examples: biphasic, basal-only, bolus-only
NO
385
When should rapid acting insulin be administered?
Before meals
386
What is the second line insulin regimen for patients with T1DM?
Biphasic
387
Which insulin regimen should patients with disabling hyperglyceamia or high HbA1c above 69 mmol/mol be given? Specialist initiation only
Continuous subcutaneous insulin infusion
388
What can persistent poor glucose control be due to?
1. Adherence issues2. Poor injection technique3. Injection site issues4. Poor blood-glucose monitoring skills5. Lifestyle (diet/exercise/alcohol)6. Psychological issues7. Organic disease
389
Give 5 examples of organic disease that may cause poor glucose control
1. Renal disease2. Thyroid disorder3. Coeliac disease4. Addison's disease5. Gastroparesis
390
Under which circumstances might a patient require increased insulin? (3)
1. Infection2. Stress3. Accidental/Surgical trauma
391
Under which circumstances might a patient require decreased insulin? (3)
1. Physical activity2. Intercurrent illness3. Reduced food intake4. Impaired renal function5. Endocrine disorders
392
What are the early symptoms of hypoglycaemia? (8)
1. Palour2. Tingling lips3. Sweating4.Palpitations5. Fatigue6. Hunger7. Shaking/Trembling8.Irritable
393
What are the symptoms of more advanced hypoglycaemia? (8)
1. Weakness2. Blurred vision3. Difficulty concentrating4. Slurred speech5. Confusion6. Sleepiness7. Seizures8. Coma
394
What is an invetiable adverse effect of insulin?
Hypoglycaemia
395
When can impaired hypoglycaemia awareness occur? (2)
1. Ability to recognise symptoms is lost2. Symptoms are blunted / no longer present
396
Which questionnaire can be used to assess hypoglycaemia awareness?
Gold/Clarke score
397
What may reduce warning signs of hypoglyacemia?
Increased frequency of hypoglycaemia episodes
398
Impaired awareness of symptoms at which plasma glucose reading is considered significant?
less than 3mmol/L
399
Which class of drug can blunt awareness of hypoglycaemia by reducing the warning sign: tremor?
Beta blockers
400
Provided by the GP or community pharmacy, which container is used when disposing of insulin pens and needles?
Yellow sharps bin
401
How is the yellow sharps bin full of insulin pens and needles disposed of?
Taken from the patient by the local authority
402
What are the two functions of insulin?
1. Increase glucose uptake by adipose tissue and muscles2. Suppress hepatic glucose release
403
Which insulin regimen best mimics the normal profile of the body releasing endogenous insulin?
Basal-bolus
404
Insulins from which source are no longer initiated in patients with diabetes?
Animals
405
How common is insulin allergy?
Rare
406
Through which route is insulin usually administered?
Subcutaneous
407
With plenty of subcutaneous fat, to which areas of the body is insulin injected? (3)
1. Abdomen2. Outer thighs3. Buttocks
408
Which factors can change rate of absorption? (6)
1. Local tissue reactions2. Injection site3. Depth of injection4. Changes in insulin sensitivity5. Blood flow6. Amount injected
409
What can increase the amount of blood flow at the injection site?
Exercise
410
Causing erratic absorption of insulin, what can occur if injections are repeatedly administered to the same site?
Lipohypertrophy
411
What does short-acting insulin replicate?
The insulin released by the body in response to a meal
412
What are the 3 short-acting insulins?
1. Insulin glulisine2. Insulin aspart3. Insulin lispro
413
How long does short-acting insulin take to act?
15mins
414
How long before meals should short-acting insulin be administered
Immediately
415
Why should post-meal injections be avoided? (2)
1. Poorer glucose control2. Hypoglycemia
416
What is the intermediate-acting insulin called?
Isophane insulin
417
What does intermediate-acting insulin mimic?
Endogenous basal insulin continuously secreted in response to glucose production by liver
418
How long does intermediate-acting insulin take to work?
1-2hours
419
How long does intermediate-acting insulin last?
11-24hours
420
What are the 2 regimen options for intermediate-acting insulins?
1. One or more daily injections of intermediate insulin + short-acting insulins at meal times2. Mixed (biphasic) insulin injections
421
What are the 3 long-acting insulins?
1. Insulin detemir2. Insulin glargine3. Insulin degludec
422
Which long-acting insulin can be administered either once or twice daily? The other two can only be administered once daily
Insulin detemir
423
Mimimicing endogenous insulin, what is the duration of action of long-acting insulin?
36 hours
424
How long does it take for long-acting insulin to reach steady state?
2-4 days
425
What is the NHS improvement important safety alert regarding insulin devices?
Risk of severe harm and death due to withdrawing insulin from pen devices - Insulin should not be extracted from pen devices
426
What is the recommended plasma glucose level in children with T1DM most of the time?
Between 4 and 10mmol/L
427
When prescribing and dispensing insulin, which word should NOT be abbreviated?
"unit"
428
When handing out insulin to a patient, what must you do?
Show them the contained to confirm the expected version is dispensed
429
What is the initial treatment of hypoglycaemia?
10-20g glucose by mouth
430
After the initial treatment of hypoglycaemia, what can be given to prevent levels falling again?
A carbohydrate snack
431
When is hypoglycaemia an emergency?
If it cause unconsciousness
432
In hypoglycaemia, if sugar cannot be given by mouth, what can be administered by injection?
Glucagon - increases the plasma-glucose concentration by mobilising glucagon stored in the liver
433
True of false: Glucagon can be issued to close relatives of patients taking insulin to treat hypoglyacemia
TRUE
434
In hypoglycaemia, what is the alternative treatment to glucagon?
Glucose 20% IV Infusion into a large vein
435
In hyperglycaemia, glucose 20% can be administered as an alternative to glucagon. Why can't glucose 50% be given? (2)
1. High risk of extravasation2. Difficult to administer
436
Glucagon is not appropriate for use in chronic hypoglycaemia. Which drug can be administered by mouth to treat hypoglycaemia due to excess endogenous insulin secretion ?
Diazoxide
