Chapter 6: Endocrine system

Question 1

What shoud all diabetic drivers carry in their car?

Answer 1

Glucose strips and fast-acting carbohydrate

Question 2

Do you have to fast before a HbA1c test?

Answer 2

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 3

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

Answer 3

Both should not be used for diagnosis of Type 1

Question 4

How often should HbA1c be measured in diabetes?

Answer 4

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

Question 5

What is the recommended HbA1c target in Type 1 diabetes?

Answer 5

48mmol/mol or lower

Question 6

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

Answer 6

At least 4 times a day

Question 7

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

Answer 7

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 8

What is a basal bolus insulin regimen?

Answer 8

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 9

What insulin regimen is first choice for Type 1 diabetics?

Answer 9

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 10

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

Answer 10

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

Once daily insulin glargine (Lantus)

Question 11

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

Answer 11

No Should only be considered after trying basal bolus regimen

Question 12

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

Answer 12

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

Question 13

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

Answer 13

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

Question 14

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

Answer 14

Gold or Clarke score

Question 15

What cardiac class of drug can blunt hypoglycaemia awareness?

Answer 15

Beta blockersWill reducing warning signs such as tremor

Question 16

What is an impaired awareness of hypoglcyaemia?

Answer 16

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

Question 17

What are the 3 types of insulin sources?

Answer 17

Human insulinHuman insulin analoguesAnimal insulin

Question 18

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

Answer 18

Abdomen

Question 19

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

Answer 19

LipohypertrophyCan cause erratic absorption of insulin

Question 20

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

Answer 20

15-30 minutes before

Question 21

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

Answer 21

Soluble insulin IV

Question 22

What are the 3 types of rapid acting insulin?

Answer 22

Insulin aspartInsulin glulisineInsulin lispro

Question 23

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

Answer 23

Immediately before

Question 24

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

Answer 24

NAME?

Question 25

Is injecting short acting insulins post meals recommended?

Answer 25

No

Question 26

What type of insulin is isophane?

Answer 26

Intermediate - designed to mimic the effect of endogenous basal insulin

Question 27

What are biphasic insulins?

Answer 27

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

Question 28

What are the long acting insulins?

Answer 28

Insulin detemirInsulin glargineInsulin degludecRarely prescribed:Protamine zinc insulinInsulin zinc suspension

Question 29

Does metformin cause hypoglycaemia?

Answer 29

No

Question 30

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

Answer 30

Modified release metformin

Question 31

Give examples of sulfonylureas

Answer 31

Glibenclamide GliclazideTolbutamide

Question 32

Give examples of meglitinides

Answer 32

NateglinideRepaglinide

Question 33

Give examples of DPP-4 inhibitors

Answer 33

AlogliptinLinagliptinSitagliptinSaxagliptinVildagliptin

Question 34

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

Answer 34

Not associated with weight gain and have less incidence of hypoglycaemia

Question 35

Give examples of SGLT2 inhibitors

Answer 35

CanaglifozinDapaglifozinEmpaglifozin

Question 36

Give examples of GLP-1 receptor agonists

Answer 36

DulaglutideExenatideLiraglutideLixisenatide

Question 37

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 37

48 mmol/mol

Question 38

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

Answer 38

53 mmol/mol

Question 39

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

Answer 39

58 mmol/mol or higher

Question 40

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

Answer 40

53 mmol/mol

Question 41

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

Answer 41

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

Question 42

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 42

Short acting one e.g. gliclazide or tolbutamide

Question 43

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

Answer 43

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

Question 44

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

Answer 44

Pioglitazone

Question 45

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

Answer 45

• Metformin + DPP-4 + sulphonylurea- Metformin + pioglitazone + sulphonylurea- Metformin + sulphonylurea + SGLT-2 inhibitor - Metformin + pioglitazone + SGLT-2 inhibitor (not dapaglifozin) May be appropriate to start insulin at this stage

Question 46

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

Answer 46

• 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 47

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 47

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 48

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

Answer 48

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 49

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

Answer 49

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

Question 50

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 50

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

Question 51

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

Answer 51

Insulin

Question 52

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

Answer 52

Metformin: Continue if tolerated.
Sulfonylureas: Consider stopping to reduce hypoglycemia risk.
DPP-4 inhibitors, GLP-1 agonists, SGLT-2 inhibitors: Can be continued alongside insulin.
Pioglitazone: Continue if beneficial but monitor weight gain/edema.

Question 53

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

Answer 53

• 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 54

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

Answer 54

75 or higher

Question 55

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

Answer 55

High risk of hypoglycemia with other insulin regimens.
Frequent nocturnal hypoglycemia.
Patients needing a once-daily regimen for better adherence.
Marked fasting hyperglycemia despite other treatments.

Question 56

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

Answer 56

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

Question 57

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

Answer 57

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 58

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

Answer 58

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

Question 59

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

Answer 59

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 60

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 60

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 61

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

Answer 61

Lower rates usually required

Question 62

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

Answer 62

0.1 units/kg/hr

Question 63

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

Answer 63

Below 48 if possible without causing any problematic hypoglycaemia

Question 64

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

Answer 64

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

Question 65

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

Answer 65

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 66

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

Answer 66

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 67

What is the patient advice regarding insulin therapy during pregnancy?

Answer 67

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

Question 68

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

Answer 68

Glucagon

Question 69

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

Answer 69

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

Question 70

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 70

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

Question 71

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

Answer 71

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

Question 72

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

Answer 72

False - should discontinue hypoglycaemic treatment immediately after giving birth

Question 73

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 73

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 74

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 74

Long acting insulinYou give 80% of normal dose

Question 75

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 75

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 76

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 76

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

Question 77

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

Answer 77

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 78

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 78

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 79

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 79

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

Question 80

In type 2 diabetes, when would you consider VRII for surgery? (5)

Answer 80

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 81

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

Answer 81

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

Question 82

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

Answer 82

Yes

Question 83

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

Answer 83

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 84

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

Answer 84

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

Question 85

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

Answer 85

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

Question 86

What are the side effects of metformin?

Answer 86

Common:Gastrointestinal issues (nausea, diarrhea, abdominal pain). And altered taste
Rare but serious: Lactic acidosis (increased risk with renal impairment).
Other: Vitamin B12 deficiency with long-term use.

Question 87

At what eGFR should you avoid metformin?

Answer 87

<30

Question 88

What are the risk factors for lactic acidosis?

Answer 88

Chronic heart failureConcomitant use of drugs that acutely impair renal function

Question 89

What is the patient advice with metformin?

Answer 89

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 90

MR gliclazide is equivalent to what standard release gliclazide dose?

Answer 90

30mg MR = 80mg standard release

Question 91

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

Answer 91

Weight gainHypoglycaemia

Question 92

What is the important safety information regarding pioglotazone?

Answer 92

Heart failure risk: Avoid in patients with heart failure or history of it.
Bladder cancer risk: Use with caution, assess risk factors.
Fracture risk: Increased in long-term use, especially in women.
Weight gain & edema: Monitor for fluid retention.

Question 93

What is the MHRA advice surrounding SGLT2 inhibitors?

Answer 93

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 94

What is the MHRA advice surrounding the use of canagliflozin?

Answer 94

Risk of lower-limb amputation

Question 95

Which antidiabetic class can cause pancreatitis?

Answer 95

DPP-4 inhibitors (gliptins)

Question 96

Which antidiabetic drug class commonly causes UTIs?

Answer 96

SGLT2 inhibitors

Question 97

Can you use nateglinide as monotherapy in diabetes?

Answer 97

No - only with metformin

Question 98

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

Answer 98

Acarbose

Question 99

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

Answer 99

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

Question 100

What is the important safety information regarding insulin pen devices?

Answer 100

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 101

What is the name of the ultrarapid acting insulin?

Answer 101

Fiasp (aspart)

Question 102

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

Answer 102

Humulin S
Actrapid
Insuman Rapid
Hypurin Neutral (available in porcine or bovine forms)

Question 103

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

Answer 103

Soluble insulinHumulin S Actrapid

Question 104

Is Actrapid classed as a rapid acting insulin?

Answer 104

No- it is a short acting insulin

Question 105

What insulins are classed as rapid acting?

Answer 105

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

Question 106

What insulins are classed as intermediate acting?

Answer 106

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

Question 107

What insulins are classed as long acting?

Answer 107

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

Question 108

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

Answer 108

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

Question 109

What does the 30 mean in Novomix 30?

Answer 109

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

Question 110

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

Answer 110

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 111

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

Answer 111

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 112

Can glucagon be used for chronic hypoglycaemia?

Answer 112

No

Question 113

What is given for chronic hypoglycaemia?

Answer 113

Diazoxide

Question 114

What is used in diabetes insipidus?

Answer 114

Desmopressin or vasopressin

Question 115

Is desmopressin or vasopressin more potent?

Answer 115

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

Question 116

What is vasopressin used for?

Answer 116

Diabetes insipidus Initial control of oesophageal variceal bleeding

Question 117

What is demeclocycline used for?

Answer 117

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

Question 118

What is tolvaptan used for?

Answer 118

Treatment of hyponatraemia secondary to syndrome of inappropriate antidiuretic hormone secretion

Question 119

What mineralocorticoid can be used for postural hypotension?

Answer 119

Fludrocortisone

Question 120

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

Answer 120

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 121

What is the MHRA advice surrounding corticosteroids?

Answer 121

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

Question 122

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

Answer 122

hypertensionsodium retentionwater retentionpotassium losscalcium lossFludrocortisone

Question 123

What are the side effects of glucocorticoids?

Answer 123

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 124

For corticosteroid replacement therapy, what combination is usually given?

Answer 124

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

Question 125

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

Answer 125

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 126

In acute adrenocorticol insufficiency, what is given?

Answer 126

IV hydrocortisone

Question 127

What are the side effects of corticosteroids?

Answer 127

NAME?

Question 128

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

Answer 128

• 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 129

What is the physiological daily dose equivalent of prednisolone?

Answer 129

7.5mg daily

Question 130

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

Answer 130

TRUE

Question 131

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

Answer 131

• 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 132

Prednisolone 5mg is equivalent to how much beclomethasone?

Answer 132

750 micrograms

Question 133

Prednisolone 5mg is equivalent to how much dexamethasone?

Answer 133

750 micrograms

Question 134

Prednisolone 5mg is equivalent to how much hydrocortisone?

Answer 134

20mg

Question 135

Prednisolone 5mg is equivalent to how much methylprednisolone?

Answer 135

4mg

Question 136

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

Answer 136

Prednisolone

Question 137

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

Answer 137

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

Question 138

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 138

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 139

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

Answer 139

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 140

What is teriparatide used for?

Answer 140

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

Question 141

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

Answer 141

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

Question 142

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

Answer 142

FracturesFracture risk should be assessed at the start of therapy

Question 143

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

Answer 143

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

Question 144

Bisphosphonate treatment should be reviewed after how many years?

Answer 144

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

Question 145

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

Answer 145

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 146

What is the warnings surrounding the use of bisphosphonates?

Answer 146

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 147

What are the side effects of bisphosphonates?

Answer 147

• 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 148

Is estradiol a natural or synthetic oestrogen?

Answer 148

Natural

Question 149

Is ethinylestradiol a natural or synthetic oestrogen?

Answer 149

Synthetic

Question 150

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

Answer 150

Progesterone to reduce the risk of hyperplasia of endometrium and cancer

Question 151

HRT increases the risk of what?

Answer 151

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 152

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

Answer 152

CarbimazolePropylthiouracil

Question 153

What is the important safety information regarding carbimazole?

Answer 153

NAME?

Question 154

What is the patient advice regarding propylthiouracil?

Answer 154

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 155

How should a thyroid storm be treated?

Answer 155

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

Question 156

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

Answer 156

LevothyroxineLiothyronine

Question 157

What is the patient advice regarding the administration of levothyroxine?

Answer 157

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

Question 158

What is tibolone used for?

Answer 158

For womenShort term treatment of oestrogen deficiency Osteoporosis prophylaxis

Question 159

Is norethisterone an oestrogen or progesterone?

Answer 159

Progesterone

Question 160

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

Answer 160

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 161

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

Answer 161

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 162

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

Answer 162

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

Question 163

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 163

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 164

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

Answer 164

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 165

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 165

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 166

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

Answer 166

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 167

Which antidiabetic drug can cause lactic acidosis and B12 deficiency?

Answer 167

Metformin

Question 168

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 168

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 169

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

Answer 169

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

Question 170

What are the complications of gestational diabetes?

Answer 170

Hydramnios - a condition in which excess amniotic fluid accumulates during pregnancy

Macrosomia- larger than normal baby

Question 171

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

Answer 171

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

Question 172

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

Answer 172

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 173

What is the advice surrounding metformin during surgery?

Answer 173

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 174

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

Answer 174

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 175

What is the risk of continuing metformin during surgery?

Answer 175

Renal impairment may lead to accumulation and lactic acidosis

Question 176

What is the advice surrounding sulphonylureas and surgery?

Answer 176

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 177

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

Answer 177

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 178

Do gliptins or sulphonylureas have a higher incidence of hypoglycaemia?

Answer 178

Sulphonylureas

Question 179

A HbA1c alone at what level would indicate diabetes?

Answer 179

48

Question 180

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

Answer 180

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 181

Zolendronic acid is contraindicated in what patient group?

Answer 181

Women of child bearing potential

Question 182

For DKA, what strength glucose do you give?

Answer 182

10%

Question 183

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

Answer 183

20%

Question 184

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

Answer 184

Hypothyroidism

Question 185

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

Answer 185

Hyperthyroidism

Question 186

How do you manage hyperthyroidism during pregnancy?

Answer 186

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 187

What is the blocking replacement regime?

Answer 187

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 188

Why should you avoid rapid correction of sodium in SIADH?

Answer 188

Can cause serious CNS effects and demyelination of neurones

Question 189

What effect can corticosteroids have on potassium levels?

Answer 189

Can cause hypokalaemia

Question 190

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

Answer 190

Seek urgent medical attention as they are immunocompromised

Question 191

When would you issue patients with a steroid card?

Answer 191

Taking long term steroids for more than 3 weeksHigh dose ICS

Question 192

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

Answer 192

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

Question 193

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

Answer 193

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

Question 194

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

Answer 194

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

Question 195

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 195

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

Question 196

What is macrosomia?

Answer 196

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

Question 197

If a driver experiences hypoglycaemia, what should they do?

Answer 197

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 198

What class of antidiabetic drugs can cause volume depletion?

Answer 198

SGLT2 inhibitors

Question 199

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

Answer 199

Continuous oestrogen

Question 200

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 200

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 201

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

Answer 201

Endometrial cancer

Question 202

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

Answer 202

10 years

Question 203

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

Answer 203

Coronary heart disease

Question 204

What is a severe side effect of exenatide?

Answer 204

Severe pancreatitis

Question 205

Can you take risedronate and alendronic acid daily?

Answer 205

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

Question 206

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

Answer 206

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

Question 207

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

Answer 207

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

Question 208

Abrupt withdrawal of steroids can lead to what?

Answer 208

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 209

The most commonly prescribed treatments for cholesterol are

Answer 209

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 210

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

Answer 210

<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 211

What type of insulin is Novorapid?

Answer 211

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

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

Question 212

When should the rapid acting insulins be injected?

Answer 212

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

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

Question 213

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

Answer 213

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

Question 214

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

Answer 214

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

Question 215

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

Answer 215

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

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

Question 216

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

Answer 216

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

Question 217

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

Answer 217

<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 218

What kind of insulin is Actrapid?

Answer 218

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

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

Question 219

When should short acting insulins be injected?

Answer 219

<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 220

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

Answer 220

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

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

Question 221

What type of insulin is intermediate acting?

Answer 221

<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 222

Can you think of any brands of Intermediate acting insulins?

Answer 222

<p>Isophane insulins:</p>

<p>Insulatard®</p>

<p>Humulin I®</p>

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

Question 223

When should intermediate acting (isophane) insulins be injected?

Answer 223

<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 224

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

Answer 224

<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 225

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

Answer 225

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

<p></p>

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

Question 226

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

Answer 226

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

Question 227

What is the rational behind biphasic insulin preparations?

Answer 227

<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 228

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

Answer 228

<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 229

What do Biphasic insulins look like in appearance?

Answer 229

<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 230

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

Answer 230

<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 231

What electrolyte disturbance can insulins cause?

Answer 231

<p>HypoKaleamia</p>

Question 232

When should Biphasic insulins be injected?

Answer 232

<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 233

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 233

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

Question 234

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 234

<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 235

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

Answer 235

> Over 11 mmol/L

Question 236

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

Answer 236

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

Question 237

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 237

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

Question 238

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

Answer 238

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

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

Question 239

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

Answer 239

<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 240

Which insulins are cloudy in appearance?

Answer 240

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

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

Question 241

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 241

<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 242

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

Answer 242

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

Question 243

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

Answer 243

<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 244

What are the side effects of insulin?

Answer 244

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

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

<p>Transient oedema</p>

Question 245

What are the insulin sick day rules?

Answer 245

<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 246

When should insulin be resuspended before use?

Answer 246

<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 247

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 247

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

Question 248

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

Answer 248

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

Question 249

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

Answer 249

<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 250

How do Sulfonylureas work?

Answer 250

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

Question 251

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

Answer 251

<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 252

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

Answer 252

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

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

Question 253

How should sulfonylurea induce Hypoglyceamia be treated?

Answer 253

<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 254

When in the T2diabetes treatment guidelines is a sulfonylurea indicated?

Answer 254

<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 255

What side effects can sulphonylureas cause? (4)

Answer 255

<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 256

What is Metformins Mechanism of Action?

Answer 256

<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 257

Main side effects of Metformin? (3)

Answer 257

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

<p>Weight loss</p>

<p>Taste disturbance</p>

Question 258

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

Answer 258

<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 259

What vitamin can Metformin cause deficiency in?

Answer 259

<p>Vitamin B12</p>

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

Question 260

When does metformin become contra-indicated in renal impairment?

Answer 260

<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 261

Max dose of metformin?

Answer 261

<p>2g a day</p>

Question 262

What is Acarbose and what is its mechanism?

Answer 262

<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 263

What are the common Side effects of acarbose?

Answer 263

<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 264

How should patients be advised to take Acarbose?

Answer 264

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

Question 265

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

Answer 265

<p>Interaction:</p>

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

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

Question 266

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 266

<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 267

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

Answer 267

<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 268

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

Answer 268

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

<p></p>

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

Question 269

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

Answer 269

<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 270

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

Answer 270

<p>Reduces peripheral insulin resistance</p>

Question 271

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 271

<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 272

can oral anti-diabetic drugs cause headaches?

Answer 272

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

Question 273

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

Answer 273

<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 274

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

Answer 274

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

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

Question 275

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

Answer 275

<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 276

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

Answer 276

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

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

Question 277

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

Answer 277

<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 278

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

Answer 278

<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 279

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

Answer 279

<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 280

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 280

<p>0.5 percentage points</p>

Question 281

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 281

<p>The SGLT2 inhibitors:</p>

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

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

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

Question 282

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

Answer 282

<p>Poylcystic ovary syndrome</p>

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

Question 283

What are patients on pioglitazone urged to report?

Answer 283

<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 284

When should sulfonylureas be taken?

Answer 284

<p>WITH MEALS</p>

Question 285

Patient with hepatic impairment prescribed a sulfonylurea?

Answer 285

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

Question 286

How should Acarbose be taken?

Answer 286

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

Question 287

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

Answer 287

<p>Diazoxide</p>

<p></p>

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

Question 288

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

Answer 288

<p>A sulfonylurea- Gliclazide</p>

Question 289

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 289

<p>Exenatide</p>

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

Question 290

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

Answer 290

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

Question 291

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

Answer 291

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 292

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

Answer 292

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

Question 293

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 293

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 294

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 294

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

Question 295

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

Answer 295

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

Question 296

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

Answer 296

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

Question 297

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

Answer 297

Propylthiouracil Liver function- severe hepatic reactions have taken place.

Question 298

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

Answer 298

Beta blockers- propranolol IV fluidshydrocortisone

Question 299

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

Answer 299

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

Question 300

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

Answer 300

Double dose for 2 days

Question 301

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

Answer 301

Double dose until symptoms improve

Question 302

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

Answer 302

Hydrocortisone emergency injection may be needed from GP

Question 303

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

Answer 303

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 304

Symptoms of DKA?(8)

Answer 304

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

Question 305

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

Answer 305

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 306

How to withdraw corticosteroids from adults and children?

Answer 306

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 307

When can systemic steroids be stopped abruptly?

Answer 307

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 308

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

Answer 308

1 year or more

Question 309

What is the duration of dexamethasone and betamethasone?

Answer 309

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

Question 310

Steroid with high mineralocorticoid activity

Answer 310

Fludrocortisone acetateCan be used to treat postural hypotension

Question 311

Steroid with very high glucocorticoid activity and insignificant mineralocorticoid activity?

Answer 311

Betamethasoneand Dexamethasone

Question 312

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

Answer 312

HYDROCORTISONE

Question 313

What are prednisolone and prednisones predominant activity on?

Answer 313

Glucocorticoids

Question 314

Side effects of glucocorticoids? (6)

Answer 314

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

Question 315

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

Answer 315

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

Question 316

What is Deflazacort?

Answer 316

Derived from prednisoloneHas high glucocorticoid activity

Question 317

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

Answer 317

88% is inactivated

Question 318

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

Answer 318

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

Question 319

Symptoms suggestive of adrenal Insufficiency?

Answer 319

FatigueAnorexiaNausea and vomitingHypotensionHyponatraemia HypoglycaemiaHyperkalaemia

Question 320

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

Answer 320

1. Deficient insulin secretion2. Resistance to actions of insulin

Question 321

What are the 4 types of diabetes?

Answer 321

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

Question 322

To which 3 conditions can diabetes be secondary?

Answer 322

1. Pancreatic damage2. Hepatitis3. Endocrine disease

Question 323

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

Answer 323

DVLA

Question 324

Which adverse event should drivers be particularly careful of?

Answer 324

Hypoglycaemia

Question 325

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

Answer 325

1. Glucose meter2. Test strips

Question 326

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

Answer 326

Two hours

Question 327

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

Answer 327

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

Question 328

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

Answer 328

5mmol/L

Question 329

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

Answer 329

Have a fast-acting carbohydrated

Question 330

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

Answer 330

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

Question 331

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

Answer 331

45 minutes after it has returned to normal

Question 332

Under which circumstances should diabetic drivers using insulin not drive?

Answer 332

If hypoglycaemia awareness has been lost

Question 333

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

Answer 333

1. Sulphonylureas2. Nateglinide3. Repaglinide

Question 334

Which lifestyle activity can mask the signs of hypoglycaemia?

Answer 334

Alcohol

Question 335

Is it advised for all diabetics to avoid drinking alcohol?

Answer 335

No, they must drink in moderation and with food

Question 336

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 336

Oral Glucose Tolerance Test

Question 337

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

Answer 337

No

Question 338

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

Answer 338

Gestational diabetes

Question 339

How is the OGTT conducted?

Answer 339

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

Question 340

Which test is a good indicator for glycaemic control?

Answer 340

HbA1c

Question 341

What does HbA1c measure?

Answer 341

The amount of glycated haemoglobin

Question 342

HbA1c shows average glucose control over how long?

Answer 342

The last 2-3 months

Question 343

Should a patient fast before their HbA1c test?

Answer 343

No

Question 344

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 344

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 345

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

Answer 345

every 2-3months

Question 346

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

Answer 346

every 2-3months

Question 347

In which patients is HbA1c monitoring invalid?

Answer 347

1. Disturbed erythrocyte turnover2. Lack of/abnormal haemoglobin

Question 348

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

Answer 348

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

Question 349

What does fructosamine estimation measure?

Answer 349

Glycated concentration of ALL plasma proteins over 14-21 days

Question 350

Can type 1 diabetes produce endogenous insulin?

Answer 350

No (little to none)

Question 351

Why is there no insulin secretion in type 1 diabetes?

Answer 351

Destruction of insulin-producing pancreatic beta cells

Question 352

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

Answer 352

Auto-immune basis

Question 353

At what age does type 1 diabetes most commonly occur?

Answer 353

Before adulthood

Question 354

What are the microvascular complications of diabetes? (3)

Answer 354

1. Nephropathy2. Neuropathy3. Retinopathy

Question 355

What are the macrovascular complications of diabetes? (3)

Answer 355

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

Question 356

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

Answer 356

Over 11mmol/L

Question 357

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

Answer 357

Less than 25kg/m2

Question 358

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

Answer 358

Less than 50

Question 359

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

Answer 359

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

Question 360

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

Answer 360

Insulin

Question 361

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

Answer 361

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

Question 362

What is the target HbA1c for T1DM?

Answer 362

Less than 48mmol/mol

Question 363

How often must T1DM patients monitor their blood glucose daily?

Answer 363

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

Question 364

What is the target fasting blood glucose for T1DM patients?

Answer 364

5-7mmol/L

Question 365

What is the target random blood glucose for T1DM patients?

Answer 365

4-7mmol/L

Question 366

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

Answer 366

5-9mmol/L

Question 367

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

Answer 367

1. Hypertension2. Blood lipids

Question 368

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

Answer 368

Metformin

Question 369

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

Answer 369

BMI over 25 (over 23 S. Asian)

Question 370

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

Answer 370

1. Improve blood glucose2. Minimise insulin dose

Question 371

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 371

Dietician

Question 372

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

Answer 372

Carbohydrate-counting training

Question 373

Can insulin be initiated by the GP?

Answer 373

No, specilist initiation and management

Question 374

What are the 3 main insulin REGIMENS?

Answer 374

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

Question 375

A basal insulin injection is…

Answer 375

Long acting

Question 376

A bolus insulin injection is…

Answer 376

Short acting

Question 377

What does a mixed (biphasic) regimen injection contain?

Answer 377

Short acting + intermediate acting

Question 378

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

Answer 378

Basal-bolus

Question 379

Give 2 examples of long acting insulin injections

Answer 379

1. Insulin detemir2. Insulin glargine

Question 380

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

Answer 380

NO

Question 381

When should rapid acting insulin be administered?

Answer 381

Before meals

Question 382

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

Answer 382

Biphasic

Question 383

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

Answer 383

Continuous subcutaneous insulin infusion

Question 384

What can persistent poor glucose control be due to?

Answer 384

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

Question 385

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

Answer 385

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

Question 386

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

Answer 386

1. Infection2. Stress3. Accidental/Surgical trauma

Question 387

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

Answer 387

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

Question 388

What are the early symptoms of hypoglycaemia? (8)

Answer 388

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

Question 389

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

Answer 389

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

Question 390

What is an invetiable adverse effect of insulin?

Answer 390

Hypoglycaemia

Question 391

When can impaired hypoglycaemia awareness occur? (2)

Answer 391

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

Question 392

Which questionnaire can be used to assess hypoglycaemia awareness?

Answer 392

Gold/Clarke score

Question 393

What may reduce warning signs of hypoglyacemia?

Answer 393

Increased frequency of hypoglycaemia episodes

Question 394

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

Answer 394

less than 3mmol/L

Question 395

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

Answer 395

Beta blockers

Question 396

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

Answer 396

Yellow sharps bin

Question 397

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

Answer 397

Taken from the patient by the local authority

Question 398

What are the two functions of insulin?

Answer 398

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

Question 399

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

Answer 399

Basal-bolus

Question 400

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

Answer 400

Animals

Question 401

How common is insulin allergy?

Answer 401

Rare

Question 402

Through which route is insulin usually administered?

Answer 402

Subcutaneous

Question 403

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

Answer 403

1. Abdomen2. Outer thighs3. Buttocks

Question 404

Which factors can change rate of absorption? (6)

Answer 404

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

Question 405

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

Answer 405

Exercise

Question 406

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

Answer 406

Lipohypertrophy

Question 407

What does short-acting insulin replicate?

Answer 407

The insulin released by the body in response to a meal

Question 408

What are the 3 short-acting insulins?

Answer 408

1. Insulin glulisine2. Insulin aspart3. Insulin lispro

Question 409

How long does short-acting insulin take to act?

Answer 409

15mins

Question 410

How long before meals should short-acting insulin be administered

Answer 410

Immediately

Question 411

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

Answer 411

1. Poorer glucose control2. Hypoglycemia

Question 412

What is the intermediate-acting insulin called?

Answer 412

Isophane insulin

Question 413

What does intermediate-acting insulin mimic?

Answer 413

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

Question 414

How long does intermediate-acting insulin take to work?

Answer 414

1-2hours

Question 415

How long does intermediate-acting insulin last?

Answer 415

11-24hours

Question 416

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

Answer 416

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

Question 417

What are the 3 long-acting insulins?

Answer 417

1. Insulin detemir2. Insulin glargine3. Insulin degludec

Question 418

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

Answer 418

Insulin detemir

Question 419

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

Answer 419

36 hours

Question 420

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

Answer 420

2-4 days

Question 421

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

Answer 421

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

Question 422

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

Answer 422

Between 4 and 10mmol/L

Question 423

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

Answer 423

“unit”

Question 424

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

Answer 424

Show them the contained to confirm the expected version is dispensed

Question 425

What is the initial treatment of hypoglycaemia?

Answer 425

10-20g glucose by mouth

Question 426

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

Answer 426

A carbohydrate snack

Question 427

When is hypoglycaemia an emergency?

Answer 427

If it cause unconsciousness

Question 428

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

Answer 428

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

Question 429

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

Answer 429

TRUE

Question 430

In hypoglycaemia, what is the alternative treatment to glucagon?

Answer 430

Glucose 20% IV Infusion into a large vein

Question 431

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

Answer 431

1. High risk of extravasation2. Difficult to administer

Question 432

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 432

Diazoxide