Chapter 6: Endocrine system Flashcards
What is the advice from the DVLA regarding insulin dependent diabetic drivers?
- 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
True or false:Alcohol can cause delayed hyperglycaemia
False- can cause delayed HYPOglycaemia
Do you have to fast before a HbA1c test?
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
Is HbA1c used for monitoring glycaemic control in Type 1 diabetes, Type 2 diabetes, or both?
Both Should not be used for diagnosis of Type 1
How often should HbA1c be measured in diabetes?
Every 3-6 months If type 2 and stable, can be every 6 months
What is the recommended HbA1c target in Type 1 diabetes?
48mmol/mol or lower
How often should blood glucose be measured in Type 1 diabetes?
At least 4 times a day
What are the blood glucose aims in Type 1 diabetes for:a) Wakingb) Before meals c) 90 minutes after eatingd) Driving
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
What is a basal bolus insulin regimen?
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
What is a mixed (biphasic) insulin regimen?
One, two, or three insulin injections per day of short-acting insulin mixed with intermediate-acting insulin
What insulin regimen is first choice for Type 1 diabetics?
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
In a basal bolus regimen for Type 1 diabetes, what basal insulin would be first choice?What would be the second choice?
Insulin determir (Levemir) BD - can also be offered as once daily
Once daily insulin glargine (Lantus)
Are non-basal bolus regimens recommended in newly diagnosed Type 1 diabetics?
No Should only be considered after trying basal bolus regimen
In basal bolus regimen in Type 1 diabetes, what type of insulin is recommended for the bolus aspect?
Rapid acting insulin (LAG - Lispro - Humalog, Aspart - novorapid, Glulisine - apidra) (Rather than soluble human or animal insulin)
Continuous subcut insulin infusion therapy should only be offered to what group of people?
- Suffer from disabling hypoglycaemia- High HbA1c of 69 or above with multiple daily injection therapy
What situations can cause an INCREASE in required insulin dose?
NAME?
What situations can cause an DECREASE in required insulin dose?
NAME?
Patients’ awareness of hypoglycaemia should be assessed annually using what score tools?
Gold or Clarke score
What cardiac class of drug can blunt hypoglycaemia awareness?
Beta blockersWill reducing warning signs such as tremor
What is an impaired awareness of hypoglcyaemia?
Can occur when the ability to recognise usual symptoms of hypoglycaemia is lost, or when the symptoms are blunted or no longer present
What are the 3 types of insulin sources?
Human insulinHuman insulin analoguesAnimal insulin
Which area of the body has the fastest absorption rate for insulin?
Abdomen
What can occur if you repeatedly inject insulin into the same area without rotating?
LipohypertrophyCan cause erratic absorption of insulin
How much time before meals do you administer short acting soluble insulin?
15-30 minutes before
What is the most appropriate form of insulin to use in diabetic emergencies e.g. DKA
Soluble insulin IV
What are the 3 types of rapid acting insulin?
Insulin aspartInsulin glulisineInsulin lispro
How much time before meals do you administer rapid acting insulin?
Immediately before
What are the advantages of rapid acting insulin over short acting insulin?
NAME?
Is injecting short acting insulins post meals recommended?
No
What type of insulin is isophane?
Intermediate - designed to mimic the effect of endogenous basal insulin
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.
What are the long acting insulins?
Insulin detemirInsulin glargineInsulin degludecRarely prescribed:Protamine zinc insulinInsulin zinc suspension
Does metformin cause hypoglycaemia?
No
If standard release metformin is not tolerated e.g. GI side effects, what should be given?
Modified release metformin
Give examples of sulfonylureas
Glibenclamide GliclazideTolbutamide
Give examples of meglitinides
NateglinideRepaglinide
Give examples of DPP-4 inhibitors
AlogliptinLinagliptinSitagliptinSaxagliptinVildagliptin
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
Give examples of SGLT2 inhibitors
CanaglifozinDapaglifozinEmpaglifozin
Give examples of GLP-1 receptor agonists
DulaglutideExenatideLiraglutideLixisenatide
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
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
In terms of HbA1c, when should treatment in a Type 2 diabetic on ONE antidiabetic drug be intensified?
58 mmol/mol or higher
What should be the target HbA1c in a Type 2 diabetic that is managed with 2 or more antidiabetic drugs?
53 mmol/mol
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
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
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
Type 2 diabetes:Dapagliflozin is not recommended in a triple therapy regimen with what drug?
Pioglitazone
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
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.
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).
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
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
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
If a patient is on dual therapy for Type 2 diabetes, and metformin is contraindicated/not tolerated, what should be considered?
Insulin
In Type 2 diabetes, if insulin therapy is required, what should happen to their other antidiabetic drugs?
NAME?
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
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
In type 2 diabetics requiring insulin therapy, when would long acting insulin (glargine or detemir) be preferable?
NAME?
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
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
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
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
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.
In the management of HHS, are lower or higher rates of insulin infusion usually required compared to DKA?
Lower rates usually required
During DKA management, what rate should you give the insulin infusion?
0.1 units/kg/hr
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
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
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
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.
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
It is recommended that pregnant women with Type 1 diabetes should be prescribed what just in case of hypoglycaemia?
Glucagon
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
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)
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)
True or false:A patient with gestational diabetes should continue their hypoglycaemic treatment after birth
False - should discontinue hypoglycaemic treatment immediately after giving birth
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
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
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
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
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
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
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
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 -
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
If VRII is required for surgery in a type 2 diabetic, can GLP-1 receptor agonists be continued?
Yes
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
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
What is the maximum licensed daily dose of standard release metformin compared to MR metformin?
Standard release- 3g/dayMR - 2g/day
What are the side effects of metformin?
NAME?
At what eGFR should you avoid metformin?
<30
What are the risk factors for lactic acidosis?
Chronic heart failureConcomitant use of drugs that acutely impair renal function
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
MR gliclazide is equivalent to what standard release gliclazide dose?
30mg MR = 80mg standard release
What are the main side effects of gliclazide to warn your patient about?
Weight gainHypoglycaemia
What is the important safety information regarding pioglotazone?
NAME?
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
What is the MHRA advice surrounding the use of canagliflozin?
Risk of lower-limb amputation
Which antidiabetic class can cause pancreatitis?
DPP-4 inhibitors (gliptins)
Which antidiabetic drug class commonly causes UTIs?
SGLT2 inhibitors
Can you use nateglinide as monotherapy in diabetes?
No - only with metformin
With what antidiabetic drug would it not be suitable in those with hernias or GI obstructions?
Acarbose
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
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.
What is the name of the ultrarapid acting insulin?
Fiasp (aspart)
What are the types of soluble insulin (short acting)?
Humulin SActrapidInsuman rapidHypurin neutral (povine/porcine)
What insulins can be used for VRII or in DKA as in infusion?
Soluble insulinHumulin S Actrapid
Is Actrapid classed as a rapid acting insulin?
No- it is a short acting insulin
What insulins are classed as rapid acting?
Novorapid (aspart)Humalog (lispro)Apidra (glulisine)
What insulins are classed as intermediate acting?
Insulatard Humulin I (isophane)Insuman basalHypurin isophane Isophane can be otherwise known as NPH
What insulins are classed as long acting?
Levemir (detemir)Lantus/Absalgar (glargine)Tresiba (degludec)Toujeo (glargine)
What insulins are classed as biphasic (pre-mixed)?
Novomix 30Humalog Mix 25 or 50 Humulin M3 Insuman Combo 15 or 25 or 30
What does the 30 mean in Novomix 30?
The suspension contains rapid-acting and intermediate-acting insulin aspart in the ratio 30/70
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.
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
Can glucagon be used for chronic hypoglycaemia?
No
What is given for chronic hypoglycaemia?
Diazoxide
What is used in diabetes insipidus?
Desmopressin or vasopressin
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
What is vasopressin used for?
Diabetes insipidus Initial control of oesophageal variceal bleeding
What is demeclocycline used for?
Treatment of hyponatraemia resulting from inappropriate secretion of antidiuretic hormone (if fluid restriction does not work)
What is tolvaptan used for?
Treatment of hyponatraemia secondary to syndrome of inappropriate antidiuretic hormone secretion
What mineralocorticoid can be used for postural hypotension?
Fludrocortisone
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.
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
What are the side effects of mineralocorticoids?With which mineralocorticoid is this most present with?
hypertensionsodium retentionwater retentionpotassium losscalcium lossFludrocortisone
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.
For corticosteroid replacement therapy, what combination is usually given?
Hydrocortisone and fludrocortisoneHydrocortisone alone is not sufficient as it does not provide sufficient activity
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.
In acute adrenocorticol insufficiency, what is given?
IV hydrocortisone
What are the side effects of corticosteroids?
NAME?
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.
What is the physiological daily dose equivalent of prednisolone?
7.5mg daily
True or false:During corticosteroid withdrawal the dose may be reduced rapidly down to physiological doses (equivalent to prednisolone 7.5 mg daily)
TRUE
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.
Prednisolone 5mg is equivalent to how much beclomethasone?
750 micrograms
Prednisolone 5mg is equivalent to how much dexamethasone?
750 micrograms
Prednisolone 5mg is equivalent to how much hydrocortisone?
20mg
Prednisolone 5mg is equivalent to how much methylprednisolone?
4mg
What is the most commonly used steroid for long-term disease suppression?
Prednisolone
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
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
- What is first line for postmenopausal osteoporosis?2. What would be alternatives if this is not appropriate?
- 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
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.
- What would be first line for glucocorticoid-induced osteoporosis?2. What would be alternatives if this was not appropriate?
- Oral bisphosphonates- alendronic acid or risedronate sodium2. IV zolendronic acid or teripartide are alternatives
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
- What would be first line in men with osteoporosis?2. What would be alternatives if this was not appropriate?
- Oral bisphosphonates- alendronic acid or risedronate sodium2. IV zolendronic acid or denosumab
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
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
What is the warnings surrounding the use of bisphosphonates?
- 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
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
Is estradiol a natural or synthetic oestrogen?
Natural
Is ethinylestradiol a natural or synthetic oestrogen?
Synthetic
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
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.
What is first line in hyperthyroidism?What is second line?
CarbimazolePropylthiouracil
What is the important safety information regarding carbimazole?
NAME?
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.
How should a thyroid storm be treated?
Emergency situationIV fluids, propranolol and hydrocortisoneas well as oral iodine, and carbimazole/propylthiouracil
What is first line for hypothyroidism?What is an alternative?
LevothyroxineLiothyronine
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.
What is tibolone used for?
For womenShort term treatment of oestrogen deficiency Osteoporosis prophylaxis
Is norethisterone an oestrogen or progesterone?
Progesterone
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
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)
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
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.
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)
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.
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.
Which antidiabetic drug can cause lactic acidosis and B12 deficiency?
Metformin
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
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
What are the complications of gestational diabetes?
Hydramnios- a condition in which excess amniotic fluid accumulates during pregnancyMacrosomia- larger than normal baby