Chapter 6- Endocrine System Flashcards
What is vasopressin and desmopressin?
Antidiuretic hormone (ADH)
Which is more potent and has a longer duration of action: desmopressin or vasopressin?
Desmopressin
Which has a vasoconstrictor effect: desmopressin or vasopressin
Vasopressin
Vasopressin can be used to stop variceal bleeding in what?
Portal hypertension
Name two antidiuretic hormone antagonists
Demeclocycline
Tolvaptan
Rapid correct of hyponatraemia with tolvaptan can cause what
Osmotic demyelination leading to serious neurological events
The antidiuretic hormones vasopressin and desmopressin can cause what
Hyponatraemia
Name 5 mineralocorticoid side effects
Hypertension Sodium retention Water retention Potassium loss Calcium loss
Name 6 side effects from glucocorticoids
Diabetes Osteoporosis Avascular necrosis of femoral head Muscle wasting Peptic ulceration Psychiatric reactions
Children under 15 years should use what to inhale corticosteroids
Large volume spacer
Name two drugs used in cushings
Ketoconazole
Metyrapone
Name 3 rapid acting insulin analogues
Insulin aspart
Insulin glulisine
Insulin lispro
When soluble insulin is injected subcutaneously what’s its onset of action, peak action and duration of action?
Onset: 30-60mins
Peak: 1-4hrs
Duration: 9 hours
When soluble insulin is given intravenously what’s its half life and onset of action - as a result of this when is it used
Half life: few mins
Onset: instantaneous
Used: in medical emergencies e.g DKA & Peri-operatively
Onset and duration of action of the rapid acting insulins (aspart, glulisine,lispro)
Onset: 15 mins
Duration: 2-5hrs
Name an intermediate acting insulin and what’s its onset of action and duration
Isophane insulin
Onset: 1-2hrs
Duration: 11-24hrs
Name three long acting insulins
Insulin degludec (OD) Insulin detemir (BD) Insulin glargine (OD)
Metformin when given alone does not cause hypos- why?
Because it does not stimulate insulin secretion
Name 5 sulfonylureas and which one is most recommended for pregnancy?
Glibenclamide Gliclazide Glimepiride Glipizide Tolbutamide
Sulfonylureas can cause hypos but it is more associated with the long acting sulfonylureas such as ?
Glibenclamide
True or false: sulfonylureas can cause modest weight gain
True
Name two meglitinides and what’s their onset of action and duration like?
Nateglinide
Repaglinide
Rapid onset of action
Short duration of activity
Name a thiazolidinedione
Pioglitazone
The dipeptidylpeptidase-4 inhibitors (gliptins) are not associated with weight gain and cause hypos to a lesser extent than the sulfonylureas, name these drugs
Alogliptin Linagliptin Sitagliptin Saxagliptin Vildagliptin
Name three sodium glucose co-transporter 2 inhibitors
Canagliflozin
Dapagliflozin
Empagliflozin
Which class of oral diabetic medication is associated with DKA
Sodium glucose co-transporter 2 inhibitors
Name 4 glucagon- like peptide 1 receptor agonists
Albiglutide Dulaglutide Exenatide Liraglutide Lixisenatide
What’s another indication for metformin
Used as an insulin sensitising drug in women with polycystic ovary syndrome who are not planning pregnancy (unlicensed)
Normal HbA1c target for patient with diabetes
48 mmol/mol (6.5%) or lower
If someone is on an antidiabetic drug that causes hypos or two or more antidiabetic drugs, what’s their HbA1c target
53mmol/mol
When do you use glucagon-like peptide 1 receptor agonists
Triple therapy with metformin + sulfonylureas in patient with BMI 35+, or if <35 but have other conditions that would benefit from weight loss
When should you review glucagon-like peptide 1 receptor agonists
6 months after initiation- only continue if there’s a reduction of at least 11mmol/mol in HbA1c and a weight loss of at least 3% of initial body weight
True or false: ACEI can potentiate the hypoglycaemic effect of insulin and oral antidiabetic drugs
TRUE
MOA of acarbose
Inhibitor of alpha glucosidases, delays the digestion and absorption of starch and sucrose, it has small but significant effect in lowering blood glucose
Cautions with acarbose
May enhance hypoglycaemia effects of insulin and sulfonylureas (hypoglycaemic episodes must be treated with oral glucose but not sucrose)
MOA of metformin
Decreases gluconeogenesis and increases peripheral utilisation of glucose
True or false: metformin acts only in presence of endogenous insulin it is effective only if there are some residual functioning pancreatic islet cells
True dat
Metformin and pregnancy?
Metformin can be used for both pre-existing and gestational diabetes
Metformin- avoid if what renal impairment?
If eGFR < 30ml/min/1.73m^2
Potential signs of lactic acidosis with metformin
Dyspnoea Hypothermia Abdominal pain Muscle cramps Asthenia (weakness)
“DHAMA”
Side effects/ caution with DPP-4 inhibitors (gliptins)
Pancreatitis
Which DPP-4 inhibitor has reports of liver toxicity
Vildagliptin
How do the meglitinides work (nateglinide + repaglinide)
Stimulates insulin secretion
Mode of action of sodium glucose co-transporter 2 (SGLT2) inhibitors (canagliflozin, dapagliflozin, empagliflozin)
Reversible inhibits SGLT2 in the renal proximal convoluted tubule to reduce glucose reabsorbtion and increase urinary glucose excretion
Patients on canagliflozin and rifampicin - increase the SGLT2 dose to want?
300mg OD
MHRA warning with all SGLT2 inhibitors (canagliflozin, dapagliflozin, empagliflozin
Risk of DKA
In addition to risk of DKA, what other caution is there with canagliflozin
Increased risk of lower limb amputation (mainly toes)
The SGLT2 inhibitors have an increased risk of volume depletion - true or false?
True - therefore caution in hypotension, elderly, heart failure, and when your pissing out salt and glucose, water follows so loosing water = hypotension
MOA of sulfonylureas
Augment insulin secretion therefore effective only when there’s some residual pancreatic beta cell activity
Cautions for sulfonylureas
Weight gain
Elderly (hypos)
G6PD deficiency
Contraindication for glibenclamide
Acute porphyrias
True or false: the sulfonylurea ‘glibenclamide’ can be used in the second and third trimesters to treat gestational diabetes
True
Sulfonylureas should be avoided in porphyria- which two are thought to be safe?
Glimepiride
Glipizide
MOA of the thiazolidinedione ‘pioglitazone’
Reduces peripheral insulin resistance
Contraindication to pioglitazone
History of heart failure
Previous or active bladder cancer
Univestigated macroscopic haematuria
Patient and carer advice for pioglitazone
Seek immediate medical attention if symptoms of nausea, vomiting, abdominal pain, fatigue and dark urine develop
HRT is of most benefit for the prophylaxis of postmenopausal osteoporosis if started early in menopause and continued for how long?
Up to 5 years
If bisphosphonates for treating postmenopausal osteoporosis what can be considered
Calcitriol or strontium ranelate
There is no consistent evidence of any further benefit from continuing treatment with a bisphosphonate beyond how many years in patients with osteoporosis
3 years
Name the anabolic steroid that can be used (but not recommended) in postmenopausal women
Nandrolone
Highest potency bisphosphonate
Zoledronate
Three MHRA warnings of bisphosphonates
Atypical femoral fractures
Osteonecrosis of the jaw
Osteonecrosis of external auditory canal
What is denosumab
Monoclonal antibody that inhibits osteoclast formation, function and survival thereby decreasing bone resorption
Name three dopamine agonists used to suppress lactation
Bromocriptine
Cabergoline
Quinagolide
Name a growth hormone receptor antagonist
Pegvisomant
Name the recombinant growth hormone used in Turner syndrome and deficiency of growth hormone
Somatropin
What are the risks of HRT
VTE Stroke Endometrial cancer Breast cancer Ovarian cancer Condo art heart disease
How can you reduce the increased risk of endometrial cancer with HRT
By a progestogen
Cyproterone is an anti-androgen given to prevent tumour flare with what initial therapy?
Gonadorelin analogue therapy
Name two drugs used for hyperthyroidism
Carbimazole
Propylthiouracil
Hypothyroidism in pregnancy can cause what to the baby
Fetal goitre
What’s the block and replace regimen, how long is it used and when should it not be used
Carbimazole and levothyroxine for 18 months - do not use block and replace in pregnancy
Beta blockers can be used for rapid relief of thyrotoxic symptoms - in particular which beta blocker?
Propranolol (nadolol can also be used)
Can propylthiouracil and carbimazole be used I preganancy
In the smallest doses possible - propylthiouracil is preferred in first trimester and carbimazole has beeen associated with congenital defects (but consider switching in 2nd trimester due to hepatotoxicity risk with propylthiouracil)
What do you need to recognise with carbimazole
Bone marrow suppression - signs of infection, WCC and stop promptly if lab evidence of neutropenia
Name two drugs used in hypothyroidism and what’s the difference between them?
Levothyroxine
Liothyronine (rapidly metabolised and quicker onset)
How do insulin requirements change in the second or third trimester
They increase
True or false: insulin causes hyperkalaemia
FALSE it causes hypokalaemia cos it drive potassium into cells
In obese patients would you choose pioglitazone or a sulfonylureas
Pioglitazone cos sulfonylureas can cause weight gain
True or false: in second and third trimester patients often need lower dose of levothyroxine
False they often need higher
Outline the treatment for Diabetes insipidus?
Diabetes insipidus:
(1) vasopressin/desmopressin used
(2) Dose tailored to produce slight diuresis every 24 hours to prevent water intoxication
(3) Desmopressin is more potent and has a longer action than vasopressin
(a) Also has no vasoconstrictor activity
(4) Carbamazepine sometimes used to sensitise the kidneys to remaining vasopressin
What can inappropriate ADH secretion cause and how do we treat that
Demeclocycline can be used to treat hyponatremia resulting from inappropriate antidiuretic hormone secretion
under what grounds should HRT be stopped?
(4) REASONS TO STOP HRT:
(a) Sudden severe chest pain (even if not radiating to left arm)
(b) Sudden breathlessness or cough with blood stained sputum
(c) Unexplained swelling or severe pain in calf of one leg
(d) Severe stomach pain
(e) Serious neurological effects
(f) Hepatitis, jaundice, liver enlargement
(g) Blood pressure > 160/95
(h) Prolonged immobility after surgery or leg injury
(i) Detection of a risk factor that contraindicates therapy
key side effect of Desmopressin?
Hyponatremia
Signs of Hyponatremia and what is the therapeutic range?
i) Hyponatremia (Range 135-145 mEq/L)
(1) Signs of Hyponatremia are: Nausea, vomiting, headaches, short term memory loss, confusion, fatigue, irritability, muscle weakness
Signs of Hypernatremia?
ii) Hypernatremia
(1) Thirst, confusion, muscle weakness or spasm
(2) Higher - seizures, coma
in what case is high-dose corticosteroids avoided?
septic shock management. Your immune system needs to fight
Indications for corticoseroids?
Common indications for Corticosteroids?
- Common indications for Corticosteroids : To Treat Alergic or Inflammatory disorders e.g Anaphylaxis, Asthma, Autoimmune Disease, Inflammatory Bowel disease, Inflammatory Arthritis. In treatment of some cancers as part of tumor-associated swelling
- Hormone replacement in adrenal insufficiency or hypopituitarism
how do corticosteroids work?
- How Corticosteroids work: They bind to cytosolic glucocorticoid receptors which translocate to the nucleus that regulates gene expression.
- Corticosteroids are most commonly prescribed to modify the immune response, upregulating the anti-inflammatory response
- Their Metabolic Affects can include increased gluconeogenesis from increased circulating amino and fatty acids.
- They have mineralocorticoid effects, stimulating Na+ and water retention and K+ excretion in the renal tubles
What is the MHRA advice on corticosteroids?
There is a rare risk of central serious chorioretinopathy with local as well as systemic administration. Patients are to report any blurred vision or any visual disturbances with corticosteroid treatment of any route
What head-related conditions are contortionists licensed for?
Cerebral oedema or Intracranial pressure
How do we treat hypothyroidism?
Give Levothyroxine (T4)
If we give levothyroxine with insulin, is there a need to change anything?
Yes– we need to increase the dose if taking insulin and levothyroxine
What do we give in Hyperthyroidism and if its not tolerated what then?
Carbimazole is first line. If this is not effective OR if patient is as risk of blood dyscrasia (which means any abnormal condition of the blood) the we give Propylthiouracil
Is the block and replace therapy ok in pregnancy?
nope.
what do we give for partial thryroidectomy
iodine for 10-14 days
what is being used more often for the treatment of thyrotoxicosis?
Radioactive iodine
What is the symptoms of thyrotoxic crisis?
Fast heart rate, restlessness, fever, diarrhoea.
What is the treatment for thyrotoxic crisis?
Emergency fluids Propranolol Hydrocortisone sodium succinate Oral Iodine solution Carbimazole OR Propylthiouracil
How do we treat hypothyroidism other than T4?
T3 (Liothyronine!)
20-25 mcg equivalent to 100mcg levothroxine. .
What is a key thing to note about prescribing T3?
brands may not be interchangeable.
In the Oral Glucose toerance test, what is a:
Healthy value of fasting
Impaired Tolerance
diabetes?
Healthy value fasting: less than 6mmol/L
Impaired tolerance fasting: 6-7mmlol/L
Diabetes fasting: above 7mmol/L
Two hours past a meal for:
Healthy:
Impaired:
Diabetic:
at 2 hours past healthy: 7.8
at 2 hours past impaired: 7.9-11
at 2 hours diabetic: greater than 11?
all values mmol/l
List the diabetes sick day rules?
1) Never stop taking insuline
2) Drink 100-200 ml of water/non-sugary drinks every 30min - 1 hour to prevent dehydration.
3) Keep eating as normal
4) Monitor sugar more regularly (every 2-4 hours) and adjust insulin appropriately.
5) Monitor ketones at the same interval and keep and eye out for Diabetic Ketoacidosis. As ketone strips aren’t often used – check theyre in date.
What are the signs of diabetic ketoacidosis?
Signs of DKA:
increased urination increased thirst being sick tummy pain fruity smelling breath deep or fast breathing feeling overly tired or sleepy confusion passing out.
what causes diabetic ketoacidosis?
infection / poor adherence / surgery or injury / binge drinking / illegal drugs / pregnancy / menstruation.
Drivers treated with insulin should always carry a what when driving?
Glucose meter and blood-glucose test strips.
How often should a diabetic driver check their blood sugar?
Every two hours before driving and every two hours while driving, More frequent checking is required if there is a greater risk of hypoglycemia e.g after exercise.
Blood glucose should always be above what while driving?
Blood glucose should be at least 5mmol/litre while driving.
Diabetic drivers should always that what is always in the vehicle?
a fast-acting carbohydrate snack.
At what mmol/L should a driver not drive and what should they do?
Do not drive at 4mmol/l.
stop at a safe place, eat or drink a suitable source of sugar, and wait for 45 minutes after blood glucose has returned to normal, before continuing journey.
what is the key advice to diabetics on alcohol?
Diabetics should not drink alcohol – ONLY in moderation. and when accompanied by food.
How many months of glucose plasma does the HBA1C reflect?
2-3 months of average plasma glucose.
does hba1c require fasting?
obviously not.. hba1c does not require fasting.
what does mmol/mol stand for?
mmol of glycated haemoglobin per mol of haemoglobin.
who do we not give HBA1C testing for?
we dont do hba1c for:
- patients with diabetes for less than 2 months
- high diabetes risk and are acutely ill
- treatment with medication that may cause hyperglycaemia
- acute pancreatic damage
- HIV infection
- End stage CKD
Monitoring for HBA1C in
T1 Diabetics:
T2 Diabetics
T1D – Monitoring is every 3-6 months for HBA1C
T2D – Monitoring is every 3-6 months until Meds and HBA1C are more stable, and then every 6 months thereafter
in T1D, blood glucose is measured how often at least?
at least QDS particularly before meals and bed.
State targets for Type 1 Diabetes in these instances:
Fasting blood glucose reading on waking
A blood glucose conc before meals at other times of the day
a blood glucose conc at least 90 minutes after eating
a blood glucose conc of at least 5mmol/l when driving
T1D:
5-7mmol/L on waking (fasted)
4-7mmol/L before meals at other times of day
5-9mmol/L at least 90 minutes after eating
5mmol/L at least when driving. `
AS part of a srtuctured education programme, what should diabetics in T1 be offered?
carbohydrate-counting training.
what is basal-bolus insulin regimen
One or more separate daily injections of intermediate-acting insulin OR one acting as long acting (basal) and multiple short acting insulin (bolus). This is much more flexible, and you can tailor your insulin according to your requirements.
what is mixed, biphasic insulin? and how does it differ from basal-bolus
biphasic insulin consists of mixing insulin preparations to achieve both short and long acting insulin
whats first line regimen for T1D
multiple daily injection: The Basal-Bolus insulin regimen:
- BD insulin detemir (long acting basal) or OD insulin glargine if not tolerated
Who do we offer continuous subcutaneous insulin to?
adults who suffer diabling hypoglycaemia or who have hba1c concentrations of 68mmol/mol (8.5%) or above
what key factors lead to reduction in required insulin dose?
physical activity / intercurrent illness / reduced food intake / impaired renal function
what factors means a diabetic patient must increase insulin dose?
infection - stress and accidental or surgical trauma.
what key drug reduces the warning signs of a patient going into hypoglecaemia?
beta blockers – they blunt tremor which is a warning sign of hypo
Can i switch insulin brands?
No. Can cause hypo or decrease awareness of hypo.
do we give insulin before or after meals and why?
Give insulin before a meal. When insulin is given during or after a meal it is associated with poorer glucose control and increased risk of high postprandial glucose concentration.
name some sglut 2 inhibitors and what is the associated risk?
dapagliflozin – associated with diabetic ketoacidosis
what is the hba1c target if you are diabetic and on one drug such as metformin
48mmol/mol
if you are on a sulphonylurea or on two antidiabetic drugs what is your target for hba1c
53mmol/mol(7.0%)
if metformim and a sulfonylurea is not enough or sulfomylurea not tolerated what next
sglut2 inhibitor
what sglut2 inhibitor is not recommended with pioglitazone as triple therapy
dapagliflozij
1 foot in metres
1 foot = 0.3m
