Chapter 6: Endocrine system

Question 1

What is the advice from the DVLA regarding insulin dependent diabetic drivers?

Answer 1

• 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

Question 2

True or false:Alcohol can cause delayed hyperglycaemia

Answer 2

False- can cause delayed HYPOglycaemia

Question 3

Do you have to fast before a HbA1c test?

Answer 3

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

Question 4

Is HbA1c used for monitoring glycaemic control in Type 1 diabetes, Type 2 diabetes, or both?

Answer 4

Both Should not be used for diagnosis of Type 1

Question 5

How often should HbA1c be measured in diabetes?

Answer 5

Every 3-6 months If type 2 and stable, can be every 6 months

Question 6

What is the recommended HbA1c target in Type 1 diabetes?

Answer 6

48mmol/mol or lower

Question 7

How often should blood glucose be measured in Type 1 diabetes?

Answer 7

At least 4 times a day

Question 8

What are the blood glucose aims in Type 1 diabetes for:a) Wakingb) Before meals c) 90 minutes after eatingd) Driving

Answer 8

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

Question 9

What is a basal bolus insulin regimen?

Answer 9

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

Question 10

What is a mixed (biphasic) insulin regimen?

Answer 10

One, two, or three insulin injections per day of short-acting insulin mixed with intermediate-acting insulin

Question 11

What insulin regimen is first choice for Type 1 diabetics?

Answer 11

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

Question 12

In a basal bolus regimen for Type 1 diabetes, what basal insulin would be first choice?What would be the second choice?

Answer 12

Insulin determir (Levemir) BD - can also be offered as once daily

Once daily insulin glargine (Lantus)

Question 13

Are non-basal bolus regimens recommended in newly diagnosed Type 1 diabetics?

Answer 13

No Should only be considered after trying basal bolus regimen

Question 14

In basal bolus regimen in Type 1 diabetes, what type of insulin is recommended for the bolus aspect?

Answer 14

Rapid acting insulin (LAG - Lispro - Humalog, Aspart - novorapid, Glulisine - apidra) (Rather than soluble human or animal insulin)

Question 15

Continuous subcut insulin infusion therapy should only be offered to what group of people?

Answer 15

• Suffer from disabling hypoglycaemia- High HbA1c of 69 or above with multiple daily injection therapy

Question 16

What situations can cause an INCREASE in required insulin dose?

Answer 16

NAME?

Question 17

What situations can cause an DECREASE in required insulin dose?

Answer 17

NAME?

Question 18

Patients’ awareness of hypoglycaemia should be assessed annually using what score tools?

Answer 18

Gold or Clarke score

Question 19

What cardiac class of drug can blunt hypoglycaemia awareness?

Answer 19

Beta blockersWill reducing warning signs such as tremor

Question 20

What is an impaired awareness of hypoglcyaemia?

Answer 20

Can occur when the ability to recognise usual symptoms of hypoglycaemia is lost, or when the symptoms are blunted or no longer present

Question 21

What are the 3 types of insulin sources?

Answer 21

Human insulinHuman insulin analoguesAnimal insulin

Question 22

Which area of the body has the fastest absorption rate for insulin?

Answer 22

Abdomen

Question 23

What can occur if you repeatedly inject insulin into the same area without rotating?

Answer 23

LipohypertrophyCan cause erratic absorption of insulin

Question 24

How much time before meals do you administer short acting soluble insulin?

Answer 24

15-30 minutes before

Question 25

What is the most appropriate form of insulin to use in diabetic emergencies e.g. DKA

Answer 25

Soluble insulin IV

Question 26

What are the 3 types of rapid acting insulin?

Answer 26

Insulin aspartInsulin glulisineInsulin lispro

Question 27

How much time before meals do you administer rapid acting insulin?

Answer 27

Immediately before

Question 28

What are the advantages of rapid acting insulin over short acting insulin?

Answer 28

NAME?

Question 29

Is injecting short acting insulins post meals recommended?

Answer 29

No

Question 30

What type of insulin is isophane?

Answer 30

Intermediate - designed to mimic the effect of endogenous basal insulin

Question 31

What are biphasic insulins?

Answer 31

Pre-mixed insulin preparations containing various combinations of short-acting insulin (soluble insulin or rapid-acting analogue insulin) and an intermediate-acting insulin.

Question 32

What are the long acting insulins?

Answer 32

Insulin detemirInsulin glargineInsulin degludecRarely prescribed:Protamine zinc insulinInsulin zinc suspension

Question 33

Does metformin cause hypoglycaemia?

Answer 33

No

Question 34

If standard release metformin is not tolerated e.g. GI side effects, what should be given?

Answer 34

Modified release metformin

Question 35

Give examples of sulfonylureas

Answer 35

Glibenclamide GliclazideTolbutamide

Question 36

Give examples of meglitinides

Answer 36

NateglinideRepaglinide

Question 37

Give examples of DPP-4 inhibitors

Answer 37

AlogliptinLinagliptinSitagliptinSaxagliptinVildagliptin

Question 38

What is an advantage of DPP-4 inhibitors over sulphonylureas in terms of side effects?

Answer 38

Not associated with weight gain and have less incidence of hypoglycaemia

Question 39

Give examples of SGLT2 inhibitors

Answer 39

CanaglifozinDapaglifozinEmpaglifozin

Question 40

Give examples of GLP-1 receptor agonists

Answer 40

DulaglutideExenatideLiraglutideLixisenatide

Question 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?

Answer 41

48 mmol/mol

Question 42

What should be the target HbA1c in a Type 2 diabetic that is managed with one or more antidiabetic drugs that cause hypoglycaemia?

Answer 42

53 mmol/mol

Question 43

In terms of HbA1c, when should treatment in a Type 2 diabetic on ONE antidiabetic drug be intensified?

Answer 43

58 mmol/mol or higher

Question 44

What should be the target HbA1c in a Type 2 diabetic that is managed with 2 or more antidiabetic drugs?

Answer 44

53 mmol/mol

Question 45

What is first line drug treatment in Type 2 diabetes and why?

Answer 45

Metformin-Positive effect on weight loss-Reduced risk of hypoglycaemia-Long term cardiovascular benefits

Question 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?

Answer 46

Short acting one e.g. gliclazide or tolbutamide

Question 47

If a Type 2 diabetic is not been adequately controlled on metformin and requires intensification of treatment, what are the add in options?

Answer 47

• Sulphonylurea- Pioglitazone- DPP-4 inhibitorSGLT-2 inhibitor - only when sulphonylureas are contraindicated or if patient is at significant risk of hypoglycaemia

Question 48

Type 2 diabetes:Dapagliflozin is not recommended in a triple therapy regimen with what drug?

Answer 48

Pioglitazone

Question 49

Type 2 diabetes:If dual therapy is unsuccessful, what are the triple therapy combination options?

Answer 49

• 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

Question 50

When is GLP-1 receptor agonists indicated in Type 2 diabetes?

Answer 50

• 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.

Question 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?

Answer 51

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).

Question 52

If metformin is contraindicated or not tolerated, what should be used for initial treatment?

Answer 52

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

Question 53

What is the problem with using repaglinide monotherapy in Type 2 diabetes?

Answer 53

If intensification of treatment is required, can only be given with metforminIt is NOT licensed in combination with any other antidiabetic drugs

Question 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?

Answer 54

• DPP-4 inhibitor and pioglitazone- DPP-4 inhibitor and sulfonylurea - Pioglitazone and sulfonylureaIf dual therapy does not provide control, consider insulin

Question 55

If a patient is on dual therapy for Type 2 diabetes, and metformin is contraindicated/not tolerated, what should be considered?

Answer 55

Insulin

Question 56

In Type 2 diabetes, if insulin therapy is required, what should happen to their other antidiabetic drugs?

Answer 56

NAME?

Question 57

In Type 2 diabetics, what insulin regimens can you use?

Answer 57

• 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

Question 58

In Type 2 diabetics, at what HbA1c would the following insulin regimen be particularly appropriate:Isophane + short acting insulin (separate or pre-mixed)

Answer 58

75 or higher

Question 59

In type 2 diabetics requiring insulin therapy, when would long acting insulin (glargine or detemir) be preferable?

Answer 59

NAME?

Question 60

When starting insulin therapy in Type 2 diabetes, when should the first basal insulin be given and how do you adjust the dose?

Answer 60

Bedtime basal insulin should be initiated and the dose titrated against fasting glucose in the morning

Question 61

Providing there are no contraindications, what should you give for diabetic nephropathy that is causing proteinuria or established microalbuminuria?

Answer 61

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

Question 62

What is the potential problem with ACEis in diabetics if the patient is on insulin or oral antidiabetic drugs?

Answer 62

Can potentiate the hypoglycaemic effect More likely in the first few weeks of combined treatment and in patients with renal impairment

Question 63

The management of DKA involves what?What should happen to their basal insulin?What should be monitored and how often?

Answer 63

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

Question 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?

Answer 64

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.

Question 65

In the management of HHS, are lower or higher rates of insulin infusion usually required compared to DKA?

Answer 65

Lower rates usually required

Question 66

During DKA management, what rate should you give the insulin infusion?

Answer 66

0.1 units/kg/hr

Question 67

Diabetic women who are planning on becoming pregnant should aim to keep their HbA1c to what?

Answer 67

Below 48 if possible without causing any problematic hypoglycaemia

Question 68

What is the folic acid supplementation recommendation in diabetic patients planning on becoming pregnant?

Answer 68

High dose - 5mg daily as classed in the high risk group of neural tube defects

Question 69

What is the treatment recommendation for diabetic patients when they become pregnant? What about during breastfeeding?

Answer 69

All antidiabetic drugs APART from metformin should be stopped and substituted with insulin therapyFor breastfeeding, the options are:- Insulin continued- Metformin continued- all other antidiabetic agents should be avoided during breastfeeding

Question 70

What is the first choice for long acting insulin therapy during pregnancy?

Answer 70

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.

Question 71

What is the patient advice regarding insulin therapy during pregnancy?

Answer 71

Should be aware of the risk of hypoglycaemia and should always carry a fast-acting form of glucose

Question 72

It is recommended that pregnant women with Type 1 diabetes should be prescribed what just in case of hypoglycaemia?

Answer 72

Glucagon

Question 73

Women with pre-existing diabetes treated with insulin during pregnancy are at an increased risk of what?

Answer 73

Hypoglycaemia during the postnatal period Should reduce their insulin immediately after birth and blood glucose levels monitored

Question 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?

Answer 74

ACEi or ARB should be discontinued and an alternative antihypertensive suitable in pregnancy should be used(Preferably before conception if pregnancy is planned)

Question 75

If a diabetic patient becomes pregnant but is on a statin, what would be the most appropriate action?

Answer 75

Discontinue the statin during pregnancy (Preferably before conception if pregnancy is planned)

Question 76

True or false:A patient with gestational diabetes should continue their hypoglycaemic treatment after birth

Answer 76

False - should discontinue hypoglycaemic treatment immediately after giving birth

Question 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)

Answer 77

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

Question 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?

Answer 78

Long acting insulinYou give 80% of normal dose

Question 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)

Answer 79

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

Question 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?

Answer 80

<6 - Give IV glucose 20% and check blood glucose hourly<4 - Give IV glucose 20% and check blood glucose every 15 mins

Question 81

After surgery, if a patient is on VRII, they must not restart their subcut insulin until when?

Answer 81

They are eating/drinking without nausea or vomiting Note- their insulin dose may need adjusting due to altered food intake/post-op stress/infection

Question 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?

Answer 82

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

Question 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?

Answer 83

Should be restarted before breakfast or evening meal (not at any other time) Stop VRII 30-60 mins after

Question 84

In type 2 diabetes, when would you consider VRII for surgery?

Answer 84

• 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 -

Question 85

If VRII is required for surgery in a type 2 diabetic, what antidiabetic drugs should be stopped?When should they be restarted?

Answer 85

• Acarbose- Sulfonylureas- DPP-4 inhibitors- Pioglitazone- Meglitinides- SGLT-2 inhibitorsShould not be restarted until the patient is eating and drinking normally

Question 86

If VRII is required for surgery in a type 2 diabetic, can GLP-1 receptor agonists be continued?

Answer 86

Yes

Question 87

If a type 2 diabetic requires a minor surgical period, what should you do about their antidiabetic treatment?

Answer 87

If it requires a short fasting period (one missed meal), it may be possible to adjust antidiabetic drugs to avoid a switch to VRII

Question 88

SGLT2 inhibitors are associated with an increased risk of DKA, particularly the case in what situations?

Answer 88

Dehydration, stress, surgery, trauma, acute medical illness or any other catabolic state

Question 89

What is the maximum licensed daily dose of standard release metformin compared to MR metformin?

Answer 89

Standard release- 3g/dayMR - 2g/day

Question 90

What are the side effects of metformin?

Answer 90

NAME?

Question 91

At what eGFR should you avoid metformin?

Answer 91

<30

Question 92

What are the risk factors for lactic acidosis?

Answer 92

Chronic heart failureConcomitant use of drugs that acutely impair renal function

Question 93

What is the patient advice with metformin?

Answer 93

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

Question 94

MR gliclazide is equivalent to what standard release gliclazide dose?

Answer 94

30mg MR = 80mg standard release

Question 95

What are the main side effects of gliclazide to warn your patient about?

Answer 95

Weight gainHypoglycaemia

Question 96

What is the important safety information regarding pioglotazone?

Answer 96

NAME?

Question 97

What is the MHRA advice surrounding SGLT2 inhibitors?

Answer 97

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

Question 98

What is the MHRA advice surrounding the use of canagliflozin?

Answer 98

Risk of lower-limb amputation

Question 99

Which antidiabetic class can cause pancreatitis?

Answer 99

DPP-4 inhibitors (gliptins)

Question 100

Which antidiabetic drug class commonly causes UTIs?

Answer 100

SGLT2 inhibitors

Question 101

Can you use nateglinide as monotherapy in diabetes?

Answer 101

No - only with metformin

Question 102

With what antidiabetic drug would it not be suitable in those with hernias or GI obstructions?

Answer 102

Acarbose

Question 103

What is the dose frequency of the 4 different GLP-1 receptor agonists?

Answer 103

Weekly for albiglutide and dulaglutide Twice daily with exenatide (modified release can be once weekly)Liraglutide is once weekly

Question 104

What is the important safety information regarding insulin pen devices?

Answer 104

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.

Question 105

What is the name of the ultrarapid acting insulin?

Answer 105

Fiasp (aspart)

Question 106

What are the types of soluble insulin (short acting)?

Answer 106

Humulin SActrapidInsuman rapidHypurin neutral (povine/porcine)

Question 107

What insulins can be used for VRII or in DKA as in infusion?

Answer 107

Soluble insulinHumulin S Actrapid

Question 108

Is Actrapid classed as a rapid acting insulin?

Answer 108

No- it is a short acting insulin

Question 109

What insulins are classed as rapid acting?

Answer 109

Novorapid (aspart)Humalog (lispro)Apidra (glulisine)

Question 110

What insulins are classed as intermediate acting?

Answer 110

Insulatard Humulin I (isophane)Insuman basalHypurin isophane Isophane can be otherwise known as NPH

Question 111

What insulins are classed as long acting?

Answer 111

Levemir (detemir)Lantus/Absalgar (glargine)Tresiba (degludec)Toujeo (glargine)

Question 112

What insulins are classed as biphasic (pre-mixed)?

Answer 112

Novomix 30Humalog Mix 25 or 50 Humulin M3 Insuman Combo 15 or 25 or 30

Question 113

What does the 30 mean in Novomix 30?

Answer 113

The suspension contains rapid-acting and intermediate-acting insulin aspart in the ratio 30/70

Question 114

What is recommended for the treatment of acute hypoglycaemia and the patient is conscious?

Answer 114

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.

Question 115

What is recommended for the treatment of acute hypoglycaemia and the patient is UNconscious?

Answer 115

Glucagon is given as an injection (subcut or IM)If this does not work within 10 minutes, IV glucose 20% needs to be given

Question 116

Can glucagon be used for chronic hypoglycaemia?

Answer 116

No

Question 117

What is given for chronic hypoglycaemia?

Answer 117

Diazoxide

Question 118

What is used in diabetes insipidus?

Answer 118

Desmopressin or vasopressin

Question 119

Is desmopressin or vasopressin more potent?

Answer 119

Desmopressin is more potent and has a longer duration of action Desmopressin is an analogue of vasopressinHas no vasoconstrictor effect compared to vasopressin

Question 120

What is vasopressin used for?

Answer 120

Diabetes insipidus Initial control of oesophageal variceal bleeding

Question 121

What is demeclocycline used for?

Answer 121

Treatment of hyponatraemia resulting from inappropriate secretion of antidiuretic hormone (if fluid restriction does not work)

Question 122

What is tolvaptan used for?

Answer 122

Treatment of hyponatraemia secondary to syndrome of inappropriate antidiuretic hormone secretion

Question 123

What mineralocorticoid can be used for postural hypotension?

Answer 123

Fludrocortisone

Question 124

True or false:High dose steroids should be used in the management of septic shock

Answer 124

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.

Question 125

What is the MHRA advice surrounding corticosteroids?

Answer 125

Rare risk of central serous chorioretinopathy with local as well as systemic administrationPatients should report any blurred vision/visual disturbances

Question 126

What are the side effects of mineralocorticoids?With which mineralocorticoid is this most present with?

Answer 126

hypertensionsodium retentionwater retentionpotassium losscalcium lossFludrocortisone

Question 127

What are the side effects of glucocorticoids?

Answer 127

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.

Question 128

For corticosteroid replacement therapy, what combination is usually given?

Answer 128

Hydrocortisone and fludrocortisoneHydrocortisone alone is not sufficient as it does not provide sufficient activity

Question 129

In Addision’s Disease or following adrenalectomy, what is usually given?How is it given?

Answer 129

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.

Question 130

In acute adrenocorticol insufficiency, what is given?

Answer 130

IV hydrocortisone

Question 131

What are the side effects of corticosteroids?

Answer 131

NAME?

Question 132

ADULTS:In what patients would you want a gradual withdrawal of systemic corticosteroids?

Answer 132

• 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.

Question 133

What is the physiological daily dose equivalent of prednisolone?

Answer 133

7.5mg daily

Question 134

True or false:During corticosteroid withdrawal the dose may be reduced rapidly down to physiological doses (equivalent to prednisolone 7.5 mg daily)

Answer 134

TRUE

Question 135

CHILDREN:In what patients would you want a gradual withdrawal of systemic corticosteroids?

Answer 135

• 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.

Question 136

Prednisolone 5mg is equivalent to how much beclomethasone?

Answer 136

750 micrograms

Question 137

Prednisolone 5mg is equivalent to how much dexamethasone?

Answer 137

750 micrograms

Question 138

Prednisolone 5mg is equivalent to how much hydrocortisone?

Answer 138

20mg

Question 139

Prednisolone 5mg is equivalent to how much methylprednisolone?

Answer 139

4mg

Question 140

What is the most commonly used steroid for long-term disease suppression?

Answer 140

Prednisolone

Question 141

What is the MHRA advice surrounding the methylprenisolone injectable preparation Solu-Medrone 40mg?

Answer 141

Contains lactose- not suitable for those with a cow’s milk allergy

Question 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?

Answer 142

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

Question 143

1. What is first line for postmenopausal osteoporosis?2. What would be alternatives if this is not appropriate?

Answer 143

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

Question 144

What is teriparatide used for?

Answer 144

Reserved for postmenopausal women with severe osteoporosis at very high risk for vertebral fractures. Its duration of treatment is limited to 24 months.

Question 145

1. What would be first line for glucocorticoid-induced osteoporosis?2. What would be alternatives if this was not appropriate?

Answer 145

1. Oral bisphosphonates- alendronic acid or risedronate sodium2. IV zolendronic acid or teripartide are alternatives

Question 146

Men who are receiving androgen deprivation therapy for prostate cancer have an increased risk of what?

Answer 146

FracturesFracture risk should be assessed at the start of therapy

Question 147

1. What would be first line in men with osteoporosis?2. What would be alternatives if this was not appropriate?

Answer 147

1. Oral bisphosphonates- alendronic acid or risedronate sodium2. IV zolendronic acid or denosumab

Question 148

Bisphosphonate treatment should be reviewed after how many years?

Answer 148

5 years of treatment of alendronic acid, risedronate sodium or ibandronic acid3 years of treatment with zolendronic acid

Question 149

Which patient groups can continue their bisphosphonate therapy after 5 years?

Answer 149

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

Question 150

What is the warnings surrounding the use of bisphosphonates?

Answer 150

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

Question 151

What are the side effects of bisphosphonates?

Answer 151

• 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

Question 152

Is estradiol a natural or synthetic oestrogen?

Answer 152

Natural

Question 153

Is ethinylestradiol a natural or synthetic oestrogen?

Answer 153

Synthetic

Question 154

If long term oestrogen therapy is needed for women who still have a uterus, what should be added and why?

Answer 154

Progesterone to reduce the risk of hyperplasia of endometrium and cancer

Question 155

HRT increases the risk of what?

Answer 155

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.

Question 156

What is first line in hyperthyroidism?What is second line?

Answer 156

CarbimazolePropylthiouracil

Question 157

What is the important safety information regarding carbimazole?

Answer 157

NAME?

Question 158

What is the patient advice regarding propylthiouracil?

Answer 158

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.

Question 159

How should a thyroid storm be treated?

Answer 159

Emergency situationIV fluids, propranolol and hydrocortisoneas well as oral iodine, and carbimazole/propylthiouracil

Question 160

What is first line for hypothyroidism?What is an alternative?

Answer 160

LevothyroxineLiothyronine

Question 161

What is the patient advice regarding the administration of levothyroxine?

Answer 161

Dose to be taken preferably at least 30 minutes before breakfast, caffeine-containing liquids (e.g. coffee, tea), or other medication.

Question 162

What is tibolone used for?

Answer 162

For womenShort term treatment of oestrogen deficiency Osteoporosis prophylaxis

Question 163

Is norethisterone an oestrogen or progesterone?

Answer 163

Progesterone

Question 164

What is the advice regarding missing a dose of progesterone only pill for contraception?

Answer 164

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

Question 165

What is the advice regarding vomiting if taking a progesterone only pill?

Answer 165

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)

Question 166

True or false:You should take the progesterone only pill (for contraception) at the same time every day

Answer 166

True If delayed longer than 3 hours, then the contraceptive effect may be lost

Question 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?

Answer 167

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.

Question 168

If you are changing from a combined oral contraceptive pill to the progesterone only, when should this happen?

Answer 168

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)

Question 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?

Answer 169

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.

Question 170

If on a progesterone only pill for contraception, in what situations would you need emergency contraception?

Answer 170

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.

Question 171

Which antidiabetic drug can cause lactic acidosis and B12 deficiency?

Answer 171

Metformin

Question 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?

Answer 172

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

Question 173

If a pregnant patient diagnosed with gestational diabetes presents with a fasting glucose of >7mmol/L, what should be done?

Answer 173

Should be treated with insulin immediately, with or without metformin hydrochloride, in addition to a change in diet and exercise

Question 174

What are the complications of gestational diabetes?

Answer 174

Hydramnios- a condition in which excess amniotic fluid accumulates during pregnancyMacrosomia- larger than normal baby

Question 175

If a pregnant lady presents with complications of gestational diabetes, how should this be managed?

Answer 175

Should be considered for immediate insulin treatment, with or without metformin hydrochloride.

Question 176

What is the advice surrounding patients on metformin who is going to have contrast media administered as part of radiologic studies?

Answer 176

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

Question 177

What is the advice surrounding metformin during surgery?

Answer 177

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

Question 178

If a patient is on 500mg OD metformin, due for surgery and the metformin needs to be stopped beforehand, would you give VRII?

Answer 178

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

Question 179

What is the risk of continuing metformin during surgery?

Answer 179

Renal impairment may lead to accumulation and lactic acidosis

Question 180

What is the advice surrounding sulphonylureas and surgery?

Answer 180

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

Question 181

If a patient does not require VRII, what antidiabetic drugs can be continued during surgery?

Answer 181

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

Question 182

Do gliptins or sulphonylureas have a higher incidence of hypoglycaemia?

Answer 182

Sulphonylureas

Question 183

A HbA1c alone at what level would indicate diabetes?

Answer 183

48

Question 184

HbA1c should not be used for diagnosis in what patients groups?

Answer 184

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

Question 185

Zolendronic acid is contraindicated in what patient group?

Answer 185

Women of child bearing potential

Question 186

For DKA, what strength glucose do you give?

Answer 186

10%

Question 187

For hypoglycaemia when glucose is needed, what strength do you give?

Answer 187

20%

Question 188

A high TSH level with a low FT4 and FT3 level indicates what?

Answer 188

Hypothyroidism

Question 189

A low TSH level with a high T4 level and a high T3 level indicates what?

Answer 189

Hyperthyroidism

Question 190

How do you manage hyperthyroidism during pregnancy?

Answer 190

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

Question 191

What is the blocking replacement regime?

Answer 191

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.

Question 192

Why should you avoid rapid correction of sodium in SIADH?

Answer 192

Can cause serious CNS effects and demyelination of neurones

Question 193

What effect can corticosteroids have on potassium levels?

Answer 193

Can cause hypokalaemia

Question 194

If chicken pox develops in a person taking corticosteroids, what is recommended?

Answer 194

Seek urgent medical attention as they are immunocompromised

Question 195

When would you issue patients with a steroid card?

Answer 195

Taking long term steroids for more than 3 weeksHigh dose ICS

Question 196

When would you consider a statin in Type 1 and Type 2 diabetics?

Answer 196

Type 1 if >40 yearsTYpe 2 if QRISK >10%

Question 197

If a woman presents with gestational diabetes with a blood glucose of <7 , what is first line?What is second line?

Answer 197

Diet and exercise If blood glucose targets are not met within 1-2 weeks, metformin can be prescribed (if not, insulin)

Question 198

If a woman presents with gestational diabetes with a blood glucose of >7, what should happen?

Answer 198

Should be treated with insulin immediately, with or without metformin hydrochloride, in addition to a change in diet and exercise

Question 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?

Answer 199

Should be considered for immediate insulin treatment, with or without metformin

Question 200

What is macrosomia?

Answer 200

Larger than average foetus- usually a complication for women with diabetes

Question 201

If a driver experiences hypoglycaemia, what should they do?

Answer 201

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

Question 202

What class of antidiabetic drugs can cause volume depletion?

Answer 202

SGLT2 inhibitors

Question 203

In a woman without a uterus requiring HRT, what preparation should be used?

Answer 203

Continuous oestrogen

Question 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?

Answer 204

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

Question 205

What kind of cancer must you rule out if irregular bleeding continues after stopping continuous HRT?

Answer 205

Endometrial cancer

Question 206

Coronary heart disease risk is increased if combined HRT is started how many years after menopause?

Answer 206

10 years

Question 207

If combined HRT is started 10 years after menopause, the risk of what is increased?

Answer 207

Coronary heart disease

Question 208

What is a severe side effect of exenatide?

Answer 208

Severe pancreatitis

Question 209

Can you take risedronate and alendronic acid daily?

Answer 209

Yes at lower doses5mg risedronate OD (or 35mg weekly)10mg alendronic acid OD (or 70mg weekly)

Question 210

What is the advice if a patient is on levothyroxine and iron tablets?

Answer 210

Iron can decrease the absorption of levothyroxine, so separate administration by at least 4 hours

Question 211

What is used if a patient wants to delay her period, and what is the dosing regimen?

Answer 211

Norethisterone5 mg 3 times a day, to be started 3 days before expected onset (menstruation occurs 2–3 days after stopping).

Question 212

Abrupt withdrawal of steroids can lead to what?

Answer 212

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.

Question 213

The most commonly prescribed treatments for cholesterol are

Answer 213

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.

Question 214

Name the 3 <strong>rapid acting</strong> insulins<p></p><p>Can you think of their brand names?</p>

Answer 214

<p>Insulin <strong>Glulisine<em>Apidra</em></strong>®</p>

<p>Insulin <strong>Aspart<em>Novorapid</em></strong>®</p>

<p>Insulin <strong>Lispro<em> Humalog</em></strong>®</p>

<p><em>That GAL is RAPID!</em></p>

Question 215

What type of insulin is Novorapid?

Answer 215

<p><strong>Insulin Aspart</strong></p>

<p><em>Rapid-acting</em></p>

Question 216

When should the rapid acting insulins be injected?

Answer 216

<p><strong>Immediately before eating</strong></p>

<p>(0- 15 mins before food)</p>

Question 217

How long does it generally take rapid acting insulins to start working?

Answer 217

<p>~10 - 20 minutes</p>

Question 218

How long is the duration of action of rapid acting insulins?

Answer 218

<p>around <strong>2 - 5 hours</strong></p>

Question 219

How many units of insulin do the Flexpen, Flextouch,Kwikpen and Solostar (<strong>all pre-filled disposable pens</strong>) tend to contain?

Answer 219

<p><strong>300 units</strong></p>

<p>3ml pens containing 100 units/ ml</p>

Question 220

Are patients more or less at risk of hypglyceamia when using rapid-acting insulins compared to other insulins?

Answer 220

<p>Less at risk of hypoglyceamia as it is only in body for a few hours and is used with meals</p>

Question 221

Whattype of insulin are<strong>short acting </strong>insulins?

Answer 221

<p><strong>Short </strong>acting insulin= <strong>Soluble </strong>insulin (S S)</p>

<p>Can get different types of soluble insulins:</p>

<p>Soluble human</p>

<p>Soluble bovine ('neutral') Beef</p>

<p>Soluble porcine ('neutral') Pig</p>

Question 222

What kind of insulin is Actrapid?

Answer 222

<p>Insulin soluble (human)</p>

<p><strong>Short- acting</strong></p>

Question 223

When should short acting insulins be injected?

Answer 223

<p><strong>15 - 30 mins before food</strong></p>

<p><em>Must eat food within 30 mins of injecting to avoid hypoglyceamia</em></p>

<p><em>They start working after 30 mins</em></p>

Question 224

How long do short acting insulins work for and when is their peak activity?

Answer 224

<p><strong>Duration of action:</strong> 4 - 8 hours</p>

<p><strong>Peak activity:</strong> 2 - 4 hours</p>

Question 225

What type of insulin is intermediate acting?

Answer 225

<p><strong>I</strong>ntermediate acting = <strong>I</strong>sophane insulin (i,i)</p>

<p>Human isophane insulin usually used</p>

<p>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</p>

<p>Usually found in biphasic preparations</p>

Question 226

Can you think of any brands of Intermediate acting insulins?

Answer 226

<p>Isophane insulins:</p>

<p>Insulatard®</p>

<p>Humulin I®</p>

<p>(all of the i's!)</p>

Question 227

When should intermediate acting (isophane) insulins be injected?

Answer 227

<p>They usually need to be injected twice daily, sometime once daily in eldery</p>

<p>No need to inject with meals</p>

<p>They have a peak action at 4 - 12 hour and last for around 21 hours</p>

Question 228

What are the three types of long- acting insulins? Do you know their brand names?

Answer 228

<p>Insulin <strong>Detemir </strong>Levemir®</p>

<p>Insulin <strong>Glargine </strong>Lantus <strong>®</strong></p>

<p>Insulin <strong>Degludec </strong>Tresiba<strong>®</strong></p>

Question 229

How long do the long-acting insulins usually work for?Which one works for up to 42 hours?

Answer 229

<p>around 18 - 24 hours</p>

<p></p>

<p>42 hours: <strong>Degludec </strong>(tresiba)</p>

Question 230

Which type of insulin is used in medical emergencies such as diabetic ketoacidosis and before surgery?

Answer 230

<p><strong>Soluble </strong>insulin</p>

Question 231

What is the rational behind biphasic insulin preparations?

Answer 231

<p>These are basically pre-mixed preparations of a <strong>rapid orshort acting </strong>insulin plus a <strong>intermediate acting </strong>insulin (either the protamine [longer chain version of the short/ rapid acting one] or isophane insulin).</p>

<p>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)</p>

<p>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 rapidor short acting insulin for this.</p>

Question 232

NovoMix is a Biphasic insulin (intermediate acting). It contains a mixture of which insulins?

Answer 232

<p>Insulin <strong>aspart </strong>(rapid acting)<br></br>Insulin <strong>aspart protamine </strong>(long acting)</p>

<p>Together it becomes intermediate acting- injected twice daily</p>

Question 233

What do Biphasic insulins look like in appearance?

Answer 233

<p><strong>Cloudy</strong></p>

<p>Needto be resuspended before use- tell patient this- by rolling in their hands (not shaking)</p>

<p></p>

Question 234

Can you name 4 brands of Biphasic insulins, and their ingredients?

Answer 234

<p><strong>Novomix 30</strong> (insulin aspart+ aspart protamine)</p>

<p><strong>Humalog Mix 25 / </strong>Humalog Mix 50 (Insulin Lispro + lispro protamine)</p>

<p><strong>Humulin M3 </strong>(soluble insulin + isophane insulin)</p>

<p><strong>Insuman Comb 50 </strong>(soluble insulin + isophane insulin)</p>

Question 235

What electrolyte disturbance can insulins cause?

Answer 235

<p>HypoKaleamia</p>

Question 236

When should Biphasic insulins be injected?

Answer 236

<p>Think about what each one contains: short or rapid acting?</p>

<p>The ones containing rapid acting (NovoMix 30, Humalog Mix) should be injected 0-15 mins before a meal</p>

<p>Containing short acting (Humulin M3, Insuman Comb) inject 15 - 30 mins before a meal</p>

Question 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?

Answer 237

<p><strong>Protamine</strong></p>

Question 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?

Answer 238

<p>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)</p>

Question 239

To diagnose diabetes, a random venous plasma glucose concentration would need to read > __ mmol/L

Answer 239

<p><strong>Over 11 mmol/L</strong></p>

Question 240

To diagnose diabetes, a <strong>fasting </strong>plasma glucose concentration would need to read over __ mmol/L

Answer 240

<p>Fasting= <strong>over 7 mmol/L</strong></p>

Question 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

Answer 241

<p>Two hour post food/ glucose: <strong>Over 11 mmol/L</strong></p>

Question 242

a HbA1c of __ mmol/mol or __% is needed to diagnose diabetes

Answer 242

<p>HbA1c of over <strong>48 mmol/mol</strong></p>

<p>or <strong>6.5%</strong></p>

Question 243

What situations would a HbA1c test be inappropriate to diagnose diabetes? (try and think of around 5)

Answer 243

<ul> <li>Children/ young adults</li> <li>Suspected Type 1 diabetes</li> <li>Symptoms less than 2 months</li> <li>Medication related glucose effects e.g. steroids, antipsychotics</li> <li>Pancreas damage</li> <li>Pregnancy</li> <li>Acutely unwell/ in hospital</li></ul>

Question 244

Which insulins are cloudy in appearance?

Answer 244

<p><strong>Intermediate acting (Isophane)</strong></p>

<p><strong>Biphasic preparations- Novomix, Humulin M3, Humalog Mix, Insuman Comb</strong></p>

Question 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?

Answer 245

<p><strong>Within 2 hours </strong>of starting their journey</p>

<p><strong>Every 2 hours</strong> whilst driving</p>

<p>If a hypo occurs: stop, pull over, get out of drivers seat, eat sugar,<strong> wait 45 mins</strong> after BG has returned to normal to continue driving</p>

Question 246

How many months worth of BGreadings must Lorry drivers provide to the DVLA if they are to drive?

Answer 246

<p><strong>3 months</strong></p>

Question 247

How often should Lorry/ Bus drivers test their blood glucose whilst driving, and on days when theyre not driving?

Answer 247

<p>Within 2 hours of starting to drive</p>

<p>every 2 hours whilst driving</p>

<p>at least twice daily when not</p>

Question 248

What are the side effects of insulin?

Answer 248

<p>Fat hypertrophy at injection site</p>

<p>Local reactions at injection site</p>

<p>Transient oedema</p>

Question 249

What are the insulin sick day rules?

Answer 249

<p>Just because the patient is ill and not eating does not mean they should stop injecting their insulin</p>

<p>ill/ infection= stress hormones/ steroids released<br></br><strong>steroids increase blood glucose</strong><br></br>stay well hydrated to avoid DKA<br></br>patient should monitor their BG and urine ketones more frequently and be prepared to inject accordingly</p>

Question 250

When should insulin be resuspended before use?

Answer 250

<p>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.</p>

Question 251

First line insulin used in Type 2 diabetes?NB: Insulin chosen if persons BG inadequately controlled by metformin + sulfonylurea or <strong>triple therapy</strong>: 3 oral antidiabetic drugs together has failed

Answer 251

<p>Intermediate acting: Human isophane insulin</p>

Question 252

Novomix is a biphasic insulin with an onset of action of _____ mins and peak activity of ______ hours.

Answer 252

<p>Onset of action of 10-20 mins<br></br><br></br>Peak acivity of 1-4 hours</p>

Question 253

What is it that makes Insulin Degludec (tresiba) different from all the other insulins licensed in the UK?

Answer 253

<p>It is the first insulin to be available in<strong> two different strengths:</strong></p>

<p></p>

<p>100 units/ml<br></br>200 units/ml</p>

Question 254

How do Sulfonylureas work?

Answer 254

<p>Increase insulin secretion from the pancreas</p>

Question 255

Which are short acting and which are long acting sulfonylureas? (5)

Answer 255

<p><strong>Short acting:</strong></p>

<p>Gliclazide<br></br>Glipizide<br></br>Tolbutamide</p>

<p><strong>Longer acting:</strong><br></br>Glimepramide<br></br>Glibenclamide (longest acting)</p>

Question 256

Which sulfonyurea is most prone to causing Hypoglyceamia, and therefore should be avoided in which population group?

Answer 256

<p>Glibencamide (longest acting)</p>

<p>Avoid use in the elderly</p>

Question 257

How should sulfonylurea induce Hypoglyceamia be treated?

Answer 257

<p>Hypoglyceamia can persist for many hours.<br></br>It must always be treated in hospital</p>

<p></p>

<p>NB: Hypoglyceamia with sulfonylureas is <strong>uncommon </strong>and usually indicates <strong>excessive dosage</strong></p>

Question 258

When in the T2diabetes treatment guidelines is a sulfonylurea indicated?

Answer 258

<p>After diet/ lifestyle, then metformin alone have been tried:</p>

<p>Can use a sulfonylurea instead if metformin Contra-indicated, patient is NOT overweight <strong>or rapid response is needed as glucose levels very high.</strong></p>

<p><em>If metformin alone does not work, can then add in a sulfonylurea</em></p>

Question 259

What side effects can sulphonylureas cause? (4)

Answer 259

<p>Weight gain</p>

<p>GI disturbance: Diarrhoea, constipation, nausea, vomitting</p>

<p>Fever (usually in first 6- 8 weeks)</p>

<p>Jaundice (avoid in severe liver impairment)</p>

Question 260

What is Metformins Mechanism of Action?

Answer 260

<p>It is a Biguanide:</p>

<p>Decreases gluconeogenesis (production of new glucose) and increases peripheral utilisation of glucose</p>

<p>Remember: metformin produce <strong>normoglyceamia </strong>rather than hypoglyceamia</p>

<p><em>NB: It does <strong>not </strong>increase insulin secretion like other oral antidiabetics, therefore it does not cause weight gain!</em></p>

Question 261

Main side effects of Metformin? (3)

Answer 261

<p>GI upset- take with food, use MR if intolerable</p>

<p>Weight loss</p>

<p>Taste disturbance</p>

Question 262

Metformin can cause <strong>Lactic Acidosis</strong>. What would be potential risk factors for this?

Answer 262

<p>risk factors such as</p>

<p>renal dysfunction (as metformin accumulates),</p>

<p>liver disease,</p>

<p>heavy alcohol ingestion</p>

<p>IV contrast media- reduces renal function therefore lactic acidosis risk</p>

<p><strong>Poor tissue perfusion/ poor renal function= risk of lactic acidosis</strong></p>

Question 263

What vitamin can Metformin cause deficiency in?

Answer 263

<p>Vitamin B12</p>

<p>Can lead to vitamin B12 deficient aneamia: symptoms= increased tirednes, weakness, mouth ulcers, pins and needles</p>

Question 264

When does metformin become contra-indicated in renal impairment?

Answer 264

<p>In severe renal impairment</p>

<p>eGFR falls below 30 ml/min/ 1.73m2</p>

<p></p>

<p>In moderate impairment (eGFR under 45) a dose reduction is needed</p>

Question 265

Max dose of metformin?

Answer 265

<p>2g a day</p>

Question 266

What is Acarbose and what is its mechanism?

Answer 266

<p><strong>Alpha glucosidase inhibitor- (remember A</strong>lpha<strong>= A</strong>carb<strong>) </strong>this enzyme<strong> breaks down starch and disaccharides </strong>to glucose, so Acarbose stops this, thereby delaying the digestion and absorption of starch and sucrose- small but significant effect in loweing blood glucose.</p>

<p>A<em><strong>carb</strong></em>ose= Starchy effects (potatoes!)</p>

Question 267

What are the common Side effects of acarbose?

Answer 267

<p>FLATULENCE- advise this will decrease with time</p>

<p>Diarrhoea/ Soft stools(as poo becomes sugary due to limited glucose absorption)</p>

<p>Other GI effects</p>

<p></p>

Question 268

How should patients be advised to take Acarbose?

Answer 268

<p>Chew with first moutful of food or swallow with a little liquid immediately before food.</p>

Question 269

What happens if a patient on <strong>metformin </strong>is injected with <strong>Iodine X-ray contrast media?</strong>

Answer 269

<p>Interaction:</p>

<p><strong>Renal function deteriorates rapidly</strong></p>

<p><span>can then increase risk of Lactic acidosis</span></p>

Question 270

What enzyme do the Gliptins inhibit?How does this help lower glucose?<strong>Linagliptin<br></br>Sitagliptin<br></br>Vildagliptin<br></br>Saxagliptin</strong>

Answer 270

<p>Inhibit an enzyme called <strong>Dipeptidylpeptidase-4 </strong></p>

<p>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.</p>

<p>Gliptins.. incretins... gliptins.... incretins!</p>

Question 271

What are the side effects of the gliptins (dipeptidylpeptidase 4 inhibitors)? (5)

Answer 271

<p>Upper <strong>respiratory tract</strong> infections</p>

<p>Gatro-intestinal upset</p>

<p>Peripheral oedema</p>

<p>Pancreatitis</p>

<p><em>Trigger insulin release so some weight gain?</em></p>

<p></p>

<p><strong><em>There is less risk of Hypoglyceamia with the gliptins!</em></strong></p>

Question 272

Which of the gliptins (Dipeptidylpeptidase-4 inhibitors) should patients have their liver function monitored if taking?

Answer 272

<p><strong>Vildagliptin</strong></p>

<p></p>

<p>Report symptoms of liver disease:<strong> nausea, vomitting, abdominal pain, fatigue, dark urine</strong></p>

Question 273

Which oral antidiabetics can cause acute pancreatitis?<br></br>What are the symptoms of this?

Answer 273

<p>Dipeptidylpeptidase-4 inhibitors (gliptins- sitagliptin, Linagliptin etc)</p>

<p>Glucagon-like peptide-1 receptor agonists (Exenatide, Liraglutide, Lixisenatide)</p>

<p>Exanatide especially can cause SEVERE PANCREATITIS</p>

<p>Symtpoms: <strong>Persistent and severe abdominal pain<br></br>Nausea and vomitting</strong></p>

Question 274

What is the mechanism of action of the Thiazolidinediones?(Only one licensed in UK is pioglitazone)

Answer 274

<p>Reduces peripheral insulin resistance</p>

Question 275

Which oral antidiabetics must care be taken with in<strong><em> Heart Failure? And what cancer can it possibly increase risk of?</em></strong>

Answer 275

<p>Pioglitazone</p>

<p>Incidence of HF increased when pioglitazone is combined with insulin</p>

<p>Also small risk of BLADDER cancer</p>

<p>Signs of bladder cancer: blood in urine, pain on urination, urinaryurgency</p>

Question 276

can oral anti-diabetic drugs cause headaches?

Answer 276

<p>Yes- alot of them cause a headache, particularly pioglitazone and the gliptins</p>

Question 277

How do the Meglitinides work?<br></br>Can you name them?When should they be taken?

Answer 277

<p><strong>Nateglinide<br></br>Repaglinide</strong></p>

<p><em>Stimulate insulin secretion</em></p>

<p><strong><em>Take 30 minutes before meals</em></strong></p>

Question 278

Can you name any oral anti-diabetic drugs that can cause liver toxicity?

Answer 278

<p><strong>Pioglitazone</strong></p>

<p>The Gliptins- linagliptin, sitagliptin, vildagliptin</p>

Question 279

What are GLP-1 agonists? How do they work?

Answer 279

<p><strong>Glucagon-like peptide-1 receptor agonists</strong></p>

<p><strong>Examples:<br></br>Exenatide<br></br>Liraglutide<br></br>Lixisenatide</strong></p>

<p><strong>These are given by SUBCUTANEOUS INJECTION- not oral</strong></p>

<p>These work by binding to the GLP-1 receptor causing:</p>

<p>-> Increase in insulin secretion</p>

<p>-> suppression of glucagon secretion (glucagon gets converted in glucose usually)</p>

<p>-> Slow gastric emptying</p>

<p><strong>If given with sulfonylureas or insulin, their dose may need to be reduced as increased risk of hypoglyceamia!</strong></p>

Question 280

What drug do we have to be particularly vigelant for symptoms such as persistent and severe abdominal pain, nausea and vomitting?

Answer 280

<p><strong>Exenatide (GLP-1 agonist)</strong></p>

<p>These are symptoms of pancreatitis- exanatide can cause severe pancreatitis- discontinue permanently</p>

Question 281

What should patients be advised to do if they <strong>miss a dose of Exenatide? How should it usually be administered?</strong>

Answer 281

<p>Miss that dose out and just <strong>continue with the next scheduled dose.</strong></p>

<p>Usual dose is to be injected <strong>1 hour before </strong>2 main meals a day that are at least 6 hours apart</p>

<p><strong>Do not administer the dose after a meal</strong></p>

<p><em><strong>Some oral med's need to be given 1 hour before or 4 hours after this drug</strong></em></p>

Question 282

What are the SGLT2 inhibitors?3 examples?How do they work?

Answer 282

<p>Sodium Glucose Co-transporter 2 inhibitors</p>

<p><strong>Gliflozins</strong></p>

<p>Examples:<br></br><strong>Canagliflozin<br></br>Dapagliflozin<br></br>Empagliflozin</strong></p>

<p><strong>(DECeeeee!)</strong></p>

<p><strong>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</strong></p>

<p></p>

Question 283

What important Side effect can the SGLT2 inhibitors (Canagliflozin, dapagliflozin, empagliflozin) cause?<br></br>What concomitant drugs/ conditionscould increase the risk of this?

Answer 283

<p><span><strong>Volume depletion !</strong></span></p>

<p><strong>Think floz= flow</strong></p>

<p><strong>Think: these are inhibiting glucose rer-absorption into the renal tubules. Water usually follows the glucose- less reabsorbed= less water follows= more weeing etc</strong></p>

<p>Patients need to report signs of this:<br></br>Dizzy, postural hypotension<br></br><strong>Side effects: </strong><br></br>Thirst<br></br>Constipation (less water in stools)<br></br>UTI's</p>

<p><strong><u>Increased risk: things that also decrease fluid volume</u></strong></p>

<p>Antihypertensives<br></br>Elderly<br></br>diarrhoea</p>

Question 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

Answer 284

<p>0.5 percentage points</p>

Question 285

Which class of oral anti-diabetics can increase the risk of <strong>Genital infections- Thrush and UTI’</strong>s? Name me some of them

Answer 285

<p>The SGLT2 inhibitors:</p>

<p><strong>Dapagliflozin</strong></p>

<p><strong>Canagliflozin</strong></p>

<p><strong>Empagliflozin</strong></p>

Question 286

What condition, other than diabetes, can metformin be used in Unlicensed?

Answer 286

<p>Poylcystic ovary syndrome</p>

<p>It helps to normalise the menstrual cycle an ovulation</p>

Question 287

What are patients on pioglitazone urged to report?

Answer 287

<p>Symptoms of bladder cancer:</p>

<p>heamatruria</p>

<p>dysuria</p>

<p>urinary urgency</p>

<p>Also signs of liver toxicity: blood in urine, severe stomach pain/ nausea and vomiting</p>

Question 288

When should sulfonylureas be taken?

Answer 288

<p>WITH MEALS</p>

Question 289

Patient with hepatic impairment prescribed a sulfonylurea?

Answer 289

<p>Reduce the dose- sulfonylureas metabolised hepatically- they will accumulate and cause hypoglyceamia</p>

Question 290

How should Acarbose be taken?

Answer 290

<p>Chewed with first mouthful of food/ with a bit of water immediately before food</p>

Question 291

What is the name of the thiazide diuretic that can be chronic intractable hypoglyceamia in Neonates/ children?

Answer 291

<p>Diazoxide</p>

<p></p>

<p>(remember diuretics can cause hyperglyceamia)</p>

Question 292

You have a patient suffering from newly diagnosed T2 diabetes with poor renal function, What would be your first line choice of antidiabetic?

Answer 292

<p>A sulfonylurea- Gliclazide</p>

Question 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?

Answer 293

<p>Exenatide</p>

<p><br></br>This is a NICE recommendation</p>

Question 294

Which bisphosphonate needs to be discontinued if a skin rash develops?

Answer 294

Strontium ranelateSevere allergic reaction:Symptoms known as DRESS ‘Drug rash with eosinophilia and systemic symptoms’ Starts with: fever, rash, swollen glands, high WCC

Question 295

What is the side effect we need to be vigilant about with Bisphosphonate treatment?

Answer 295

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

Question 296

If patients taking Alendronic acid experience dysphagia, heartburn, pain on swallowing or retrosternal pain what should they do?

Answer 296

Stop taking and Report it- may be an oesophageal reaction: can be serious

Question 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?

Answer 297

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.

Question 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.

Answer 298

Not for more than 6 cyclesIncreased risk of ovarian cancer with clomifene use.

Question 299

Which drug used in thyroid therapy can cause agranulocytosis and neutropenia? what is this drug used for?

Answer 299

CarbimazoleUsed for HyperthyroidismUsed in the 18 month blocking-replacement regimen together with levothyroxine.

Question 300

What test is indicated prior to therapy with levothyroxine and Liothyronine?

Answer 300

Baseline ECG- this is because we want to check we haven’t mistaken hypothyroidism with ischaemia/ cardiovascular disease.

Question 301

Which antithyroid drug is used if carbimazole is contraindicated?What do we need to monitor with this drug?

Answer 301

Propylthiouracil Liver function- severe hepatic reactions have taken place.

Question 302

What drugs are used for management of thyrotoxic symptoms (when too much thyroid hormone has been given)?

Answer 302

Beta blockers- propranolol IV fluidshydrocortisone

Question 303

What side effect of carbimazole is common and can be treated with antihistamines without the need to discontinue?

Answer 303

Rashes and pruritis- don’t say ‘discontinue’ in exam cause you’ve mistaken it for neutropenia/agran

Question 304

Sick day rule for patients on a systemic steroid and fall mildly ill?

Answer 304

Double dose for 2 days

Question 305

Sick day rule for patients on a systemic steroid and severely ill?

Answer 305

Double dose until symptoms improve

Question 306

If a patients has severe diarrhoea or vomiting and can’t keep their steroid down?

Answer 306

Hydrocortisone emergency injection may be needed from GP

Question 307

Difference between Addisons and Cushings (hint: they are opposites)?

Answer 307

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

Question 308

Symptoms of DKA?(8)

Answer 308

Rapid weight lossAbdominal painNausea and vomitingRapid and deep breathing?Sweet smelling breathSweet/metallic tasting breathAltered odour of urine/sweatSleepiness

Question 309

In adults:Gradual withdrawal of systematic corticosteroids is considered in those where the disease is unlikely to relapse and have….? (6)

Answer 309

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

Question 310

How to withdraw corticosteroids from adults and children?

Answer 310

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

Question 311

When can systemic steroids be stopped abruptly?

Answer 311

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)

Question 312

How long can corticosteroid-induced adrenal suppression last for after stopping drug

Answer 312

1 year or more

Question 313

What is the duration of dexamethasone and betamethasone?

Answer 313

Long duration of actionMakes it good for suppression of corticotrophin secretion (e.g. congenital adrenal hyperplasia)

Question 314

Steroid with high mineralocorticoid activity

Answer 314

Fludrocortisone acetateCan be used to treat postural hypotension

Question 315

Steroid with very high glucocorticoid activity and insignificant mineralocorticoid activity?

Answer 315

Betamethasoneand Dexamethasone

Question 316

Corticosteroid with moderate glucocorticoid activity and high mineralocorticoid activity - good for topical use because side-effects are less marked?

Answer 316

HYDROCORTISONE

Question 317

What are prednisolone and prednisones predominant activity on?

Answer 317

Glucocorticoids

Question 318

Side effects of glucocorticoids? (6)

Answer 318

DiabetesOsteoporosis (particularly in elderly)At high doses - avascular necrosis of femoral headMuscle wastingWeekly linked with peptic ulcer/perforationsPsychiatric reactions

Question 319

Side effects of mineralocorticoids (5)Think minerals2 increase, 2 decrease

Answer 319

Hypertension (hence why it can tx postural hypo)Sodium retentionWater retentionPotassium lossCalcium loss

Question 320

What is Deflazacort?

Answer 320

Derived from prednisoloneHas high glucocorticoid activity

Question 321

What happens to prednisolone when it crosses the placenta in pregnancy?

Answer 321

88% is inactivated

Question 322

What is the advise with ketoconazole and hepatic inpairment?In treating Cushing syndrome

Answer 322

Avoid in acute or chronic impairment Do not initiate the drug if liver enzymes are greater than 2X the normal upper limit

Question 323

Symptoms suggestive of adrenal Insufficiency?

Answer 323

FatigueAnorexiaNausea and vomitingHypotensionHyponatraemia HypoglycaemiaHyperkalaemia

Question 324

Characterised by persistent hyperglycaemia, what are the two ways in which diabetes can manifest?

Answer 324

1. Deficient insulin secretion2. Resistance to actions of insulin

Question 325

What are the 4 types of diabetes?

Answer 325

1. Type 1 2. Type 23. Gestational4. Secondary

Question 326

To which 3 conditions can diabetes be secondary?

Answer 326

1. Pancreatic damage2. Hepatitis3. Endocrine disease

Question 327

Which agency must be notified if someone has diabetes and is being treated with insulin?

Answer 327

DVLA

Question 328

Which adverse event should drivers be particularly careful of?

Answer 328

Hypoglycaemia

Question 329

What must diabetics always carry to ensure they are informed about their plasma glucose?

Answer 329

1. Glucose meter2. Test strips

Question 330

Diabetics using insulin should check their plasma glucose how long before driving?

Answer 330

Two hours

Question 331

While driving how often should diabetics using insulin test their plasma glucose?

Answer 331

Every two hours - more frequent if recent activity that may increase risk of hypo

Question 332

While driving, plasma glucose of diabetic drivers should always be above what threshold?

Answer 332

5mmol/L

Question 333

If plasma glucose falls slightly below 5mmol/L, what should diabetic drivers using insulin do?

Answer 333

Have a fast-acting carbohydrated

Question 334

What are the 3 steps that diabetic drivers using insulin should take if their plasma glucose falls below 4mmol/L

Answer 334

1. Stop driving2. Switch off the engine, remove keys and move from driver’s seat3. Consume source of sugar

Question 335

How long should diabetic drivers using insulin wait before driving after stopping due to it falling below 4mmol/L?

Answer 335

45 minutes after it has returned to normal

Question 336

Under which circumstances should diabetic drivers using insulin not drive?

Answer 336

If hypoglycaemia awareness has been lost

Question 337

As well as insulin, which other diabetic medicines may it be necessary to inform the DVLA about? (3)

Answer 337

1. Sulphonylureas2. Nateglinide3. Repaglinide

Question 338

Which lifestyle activity can mask the signs of hypoglycaemia?

Answer 338

Alcohol

Question 339

Is it advised for all diabetics to avoid drinking alcohol?

Answer 339

No, they must drink in moderation and with food

Question 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

Answer 340

Oral Glucose Tolerance Test

Question 341

If symptoms are already present, should the OGTT be used to diagnose diabetes?

Answer 341

No

Question 342

In which type of diabetes is OGTT especially useful in diagnosing?

Answer 342

Gestational diabetes

Question 343

How is the OGTT conducted?

Answer 343

Plasma glucose is measured after fasting.Patient drinks glucose drink.Plasma glucose is measured 2 hours after

Question 344

Which test is a good indicator for glycaemic control?

Answer 344

HbA1c

Question 345

What does HbA1c measure?

Answer 345

The amount of glycated haemoglobin

Question 346

HbA1c shows average glucose control over how long?

Answer 346

The last 2-3 months

Question 347

Should a patient fast before their HbA1c test?

Answer 347

No

Question 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)

Answer 348

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

Question 349

In Type 1 Diabetes, how often should HbA1c be measured?

Answer 349

every 2-3months

Question 350

In Type 2 Diabetes, how often should HbA1c be measured?

Answer 350

every 2-3months

Question 351

In which patients is HbA1c monitoring invalid?

Answer 351

1. Disturbed erythrocyte turnover2. Lack of/abnormal haemoglobin

Question 352

In patients which HbA1c monitoring is invalid, what can be used instead?

Answer 352

1. Quality controlled blood glucose profiles2. Total glycated haemoglobin estimation3. Fructosamine estimation

Question 353

What does fructosamine estimation measure?

Answer 353

Glycated concentration of ALL plasma proteins over 14-21 days

Question 354

Can type 1 diabetes produce endogenous insulin?

Answer 354

No (little to none)

Question 355

Why is there no insulin secretion in type 1 diabetes?

Answer 355

Destruction of insulin-producing pancreatic beta cells

Question 356

What causes the destruction of pancreatic beta cells in type 1 diabetes?

Answer 356

Auto-immune basis

Question 357

At what age does type 1 diabetes most commonly occur?

Answer 357

Before adulthood

Question 358

What are the microvascular complications of diabetes? (3)

Answer 358

1. Nephropathy2. Neuropathy3. Retinopathy

Question 359

What are the macrovascular complications of diabetes? (3)

Answer 359

1. Stroke2. Cardiovascular disease (MI)3. Peripheral arterial disease

Question 360

What blood glucose reading would you expect an adult presenting with Type 1 Diabetes to have?

Answer 360

Over 11mmol/L

Question 361

What BMI would you expect an adult presenting with Type 1 Diabetes to have?

Answer 361

Less than 25kg/m2

Question 362

How old would you expect an adult presenting with Type 1 Diabetes to be?

Answer 362

Less than 50

Question 363

As well as hyperglycaemia, low BMI, and younger than 50, what other characteristics do adults presenting with T1DM have? (3)

Answer 363

1. Rapid weight loss2. Ketosis3. (Family) history of autoimmune disease

Question 364

Increasingly used in T2DM, what is the mainstay of treatment for T1DM?

Answer 364

Insulin

Question 365

Using insulin regimens, what are the 3 aims of treating T1DM?

Answer 365

1. Achieve blood glucose control2. Reduce frequency of hypoglycaemic episodes3. Minimise the risk of microvascular and macrovascular complications

Question 366

What is the target HbA1c for T1DM?

Answer 366

Less than 48mmol/mol

Question 367

How often must T1DM patients monitor their blood glucose daily?

Answer 367

at least 4 times daily - before each meal and before bed

Question 368

What is the target fasting blood glucose for T1DM patients?

Answer 368

5-7mmol/L

Question 369

What is the target random blood glucose for T1DM patients?

Answer 369

4-7mmol/L

Question 370

What is the target blood glucose for T1DM patients after eating?

Answer 370

5-9mmol/L

Question 371

As well as controlling blood glucose with insulin, which other cardiovascular risk factors must be actively managed in patients with diabetes?

Answer 371

1. Hypertension2. Blood lipids

Question 372

Unlicensed, which oral antidiabetic can be used alongside insulin in the management of T1DM?

Answer 372

Metformin

Question 373

Unlicensed, in which patients can Metformin be used alongside insulin in the management of T1DM?

Answer 373

BMI over 25 (over 23 S. Asian)

Question 374

What are the advantages of usince Metformin alongside insulin (unlicensed) in T1DM?

Answer 374

1. Improve blood glucose2. Minimise insulin dose

Question 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?

Answer 375

Dietician

Question 376

What type of training must T1DM patients receive in order to tailor their insulin dose throughout the day?

Answer 376

Carbohydrate-counting training

Question 377

Can insulin be initiated by the GP?

Answer 377

No, specilist initiation and management

Question 378

What are the 3 main insulin REGIMENS?

Answer 378

1. Multiple daily BASAL-BOLUS regimens2. Mixed (BIPHASIC) regimens3. Continuous subcutaneous insulin infusion

Question 379

A basal insulin injection is…

Answer 379

Long acting

Question 380

A bolus insulin injection is…

Answer 380

Short acting

Question 381

What does a mixed (biphasic) regimen injection contain?

Answer 381

Short acting + intermediate acting

Question 382

What is the first line recommended insulin regimen for patients with T1DM?

Answer 382

Basal-bolus

Question 383

Give 2 examples of long acting insulin injections

Answer 383

1. Insulin detemir2. Insulin glargine

Question 384

Are non basal-bolus insulin regimens recommended for patients newly diagnosed with T1DM? Examples: biphasic, basal-only, bolus-only

Answer 384

NO

Question 385

When should rapid acting insulin be administered?

Answer 385

Before meals

Question 386

What is the second line insulin regimen for patients with T1DM?

Answer 386

Biphasic

Question 387

Which insulin regimen should patients with disabling hyperglyceamia or high HbA1c above 69 mmol/mol be given? Specialist initiation only

Answer 387

Continuous subcutaneous insulin infusion

Question 388

What can persistent poor glucose control be due to?

Answer 388

1. Adherence issues2. Poor injection technique3. Injection site issues4. Poor blood-glucose monitoring skills5. Lifestyle (diet/exercise/alcohol)6. Psychological issues7. Organic disease

Question 389

Give 5 examples of organic disease that may cause poor glucose control

Answer 389

1. Renal disease2. Thyroid disorder3. Coeliac disease4. Addison’s disease5. Gastroparesis

Question 390

Under which circumstances might a patient require increased insulin? (3)

Answer 390

1. Infection2. Stress3. Accidental/Surgical trauma

Question 391

Under which circumstances might a patient require decreased insulin? (3)

Answer 391

1. Physical activity2. Intercurrent illness3. Reduced food intake4. Impaired renal function5. Endocrine disorders

Question 392

What are the early symptoms of hypoglycaemia? (8)

Answer 392

1. Palour2. Tingling lips3. Sweating4.Palpitations5. Fatigue6. Hunger7. Shaking/Trembling8.Irritable

Question 393

What are the symptoms of more advanced hypoglycaemia? (8)

Answer 393

1. Weakness2. Blurred vision3. Difficulty concentrating4. Slurred speech5. Confusion6. Sleepiness7. Seizures8. Coma

Question 394

What is an invetiable adverse effect of insulin?

Answer 394

Hypoglycaemia

Question 395

When can impaired hypoglycaemia awareness occur? (2)

Answer 395

1. Ability to recognise symptoms is lost2. Symptoms are blunted / no longer present

Question 396

Which questionnaire can be used to assess hypoglycaemia awareness?

Answer 396

Gold/Clarke score

Question 397

What may reduce warning signs of hypoglyacemia?

Answer 397

Increased frequency of hypoglycaemia episodes

Question 398

Impaired awareness of symptoms at which plasma glucose reading is considered significant?

Answer 398

less than 3mmol/L

Question 399

Which class of drug can blunt awareness of hypoglycaemia by reducing the warning sign: tremor?

Answer 399

Beta blockers

Question 400

Provided by the GP or community pharmacy, which container is used when disposing of insulin pens and needles?

Answer 400

Yellow sharps bin

Question 401

How is the yellow sharps bin full of insulin pens and needles disposed of?

Answer 401

Taken from the patient by the local authority

Question 402

What are the two functions of insulin?

Answer 402

1. Increase glucose uptake by adipose tissue and muscles2. Suppress hepatic glucose release

Question 403

Which insulin regimen best mimics the normal profile of the body releasing endogenous insulin?

Answer 403

Basal-bolus

Question 404

Insulins from which source are no longer initiated in patients with diabetes?

Answer 404

Animals

Question 405

How common is insulin allergy?

Answer 405

Rare

Question 406

Through which route is insulin usually administered?

Answer 406

Subcutaneous

Question 407

With plenty of subcutaneous fat, to which areas of the body is insulin injected? (3)

Answer 407

1. Abdomen2. Outer thighs3. Buttocks

Question 408

Which factors can change rate of absorption? (6)

Answer 408

1. Local tissue reactions2. Injection site3. Depth of injection4. Changes in insulin sensitivity5. Blood flow6. Amount injected

Question 409

What can increase the amount of blood flow at the injection site?

Answer 409

Exercise

Question 410

Causing erratic absorption of insulin, what can occur if injections are repeatedly administered to the same site?

Answer 410

Lipohypertrophy

Question 411

What does short-acting insulin replicate?

Answer 411

The insulin released by the body in response to a meal

Question 412

What are the 3 short-acting insulins?

Answer 412

1. Insulin glulisine2. Insulin aspart3. Insulin lispro

Question 413

How long does short-acting insulin take to act?

Answer 413

15mins

Question 414

How long before meals should short-acting insulin be administered

Answer 414

Immediately

Question 415

Why should post-meal injections be avoided? (2)

Answer 415

1. Poorer glucose control2. Hypoglycemia

Question 416

What is the intermediate-acting insulin called?

Answer 416

Isophane insulin

Question 417

What does intermediate-acting insulin mimic?

Answer 417

Endogenous basal insulin continuously secreted in response to glucose production by liver

Question 418

How long does intermediate-acting insulin take to work?

Answer 418

1-2hours

Question 419

How long does intermediate-acting insulin last?

Answer 419

11-24hours

Question 420

What are the 2 regimen options for intermediate-acting insulins?

Answer 420

1. One or more daily injections of intermediate insulin + short-acting insulins at meal times2. Mixed (biphasic) insulin injections

Question 421

What are the 3 long-acting insulins?

Answer 421

1. Insulin detemir2. Insulin glargine3. Insulin degludec

Question 422

Which long-acting insulin can be administered either once or twice daily? The other two can only be administered once daily

Answer 422

Insulin detemir

Question 423

Mimimicing endogenous insulin, what is the duration of action of long-acting insulin?

Answer 423

36 hours

Question 424

How long does it take for long-acting insulin to reach steady state?

Answer 424

2-4 days

Question 425

What is the NHS improvement important safety alert regarding insulin devices?

Answer 425

Risk of severe harm and death due to withdrawing insulin from pen devices - Insulin should not be extracted from pen devices

Question 426

What is the recommended plasma glucose level in children with T1DM most of the time?

Answer 426

Between 4 and 10mmol/L

Question 427

When prescribing and dispensing insulin, which word should NOT be abbreviated?

Answer 427

“unit”

Question 428

When handing out insulin to a patient, what must you do?

Answer 428

Show them the contained to confirm the expected version is dispensed

Question 429

What is the initial treatment of hypoglycaemia?

Answer 429

10-20g glucose by mouth

Question 430

After the initial treatment of hypoglycaemia, what can be given to prevent levels falling again?

Answer 430

A carbohydrate snack

Question 431

When is hypoglycaemia an emergency?

Answer 431

If it cause unconsciousness

Question 432

In hypoglycaemia, if sugar cannot be given by mouth, what can be administered by injection?

Answer 432

Glucagon - increases the plasma-glucose concentration by mobilising glucagon stored in the liver

Question 433

True of false: Glucagon can be issued to close relatives of patients taking insulin to treat hypoglyacemia

Answer 433

TRUE

Question 434

In hypoglycaemia, what is the alternative treatment to glucagon?

Answer 434

Glucose 20% IV Infusion into a large vein

Question 435

In hyperglycaemia, glucose 20% can be administered as an alternative to glucagon. Why can’t glucose 50% be given? (2)

Answer 435

1. High risk of extravasation2. Difficult to administer

Question 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 ?

Answer 436

Diazoxide