Chapter 6: Endocrine system Flashcards
What is the advice from the DVLA regarding insulin dependent diabetic drivers?
- Should always carry a glucose meter and test strips when driving
- Check blood glucose no more than 2 hours before driving and then every 2 hours during driving
- Blood glucose should always be above 5 mmol/L whilst driving
- Should always ensure a fast-acting carbohydrate is available in the vehicle
- If blood glucose is <4 mmol/L, should NOT drive
This may also be the case in patients taking oral antidiabetic drugs, in particular those that cause hypoglycaemia
True or false:
Alcohol can cause delayed hyperglycaemia
False- can cause delayed HYPOglycaemia
Do you have to fast before a HbA1c test?
No
Is HbA1c used for monitoring glycaemic control in Type 1 diabetes, Type 2 diabetes, or both?
Both
Should not be used for diagnosis of Type 1
How often should HbA1c be measured in diabetes?
Every 3-6 months
If type 2 and stable, can be every 6 months
What is the recommended HbA1c target in Type 1 diabetes?
48 or lower
How often should blood glucose be measured in Type 1 diabetes?
At least 4 times a day
What are the blood glucose aims in Type 1 diabetes for:
a) Waking
b) Before meals
c) 90 minutes after eating
d) Driving
a) 5-7 on waking
b) 4-7 before meals
c) 5-9 at least 90 mins after eating
d) at least 5 when driving
What is a basal bolus insulin regimen?
One or more separate daily injections of intermediate-acting insulin or long-acting insulin analogue as the basal insulin; alongside multiple bolus injections of short-acting insulin before meals
What is a mixed (biphasic) insulin regimen?
One, two, or three insulin injections per day of short-acting insulin mixed with intermediate-acting insulin
What insulin regimen is first choice for Type 1 diabetics?
Basal bolus
Insulin detemir BD should be offered as the long insulin therapy
In a basal bolus regimen for Type 1 diabetes, what basal insulin would be first choice?
What would be the second choice?
Insulin determir BD - can also be offered as once daily
Once daily insulin glargine
Are non-basal bolus regimens recommended in newly diagnosed Type 1 diabetics?
No
Should only be considered after trying basal bolus regimen
In basal bolus regimen in Type 1 diabetes, what type of insulin is recommended for the bolus aspect?
Rapid acting insulin
Rather than soluble human or animal insulin
Continuous subcut insulin infusion therapy should only be offered to what group of people?
- Suffer from disabling hypoglycaemia
- High HbA1c of 69 or above with multiple daily injection therapy
What situations can cause an INCREASE in required insulin dose?
- Infection
- Stress
- Accidental/surgical trauma
What situations can cause an DECREASE in required insulin dose?
- Physical activity
- Intercurrent illness
- Reduced food intake
- Impaired renal function
- Certain endocrine disorders
Patients’ awareness of hypoglycaemia should be assessed annually using what score tools?
Gold or Clarke score
What cardiac class of drug can blunt hypoglycaemia awareness?
Beta blockers
Will reducing warning signs such as tremor
What is an impaired awareness of hypoglcyaemia?
Can occur when the ability to recognise usual symptoms of hypoglycaemia is lost, or when the symptoms are blunted or no longer present
What are the 3 types of insulin sources?
Human insulin
Human insulin analogues
Animal insulin
Which area of the body has the fastest absorption rate for insulin?
Abdomen
What can occur if you repeatedly inject insulin into the same area without rotating?
Lipohypertrophy
Can cause erratic absorption of insulin
How much time before meals do you administer short acting soluble insulin?
15-30 minutes before
What is the most appropriate form of insulin to use in diabetic emergencies e.g. DKA
Soluble insulin IV
What are the 3 types of rapid acting insulin?
Insulin aspart
Insulin glulisine
Insulin lispro
How much time before meals do you administer rapid acting insulin?
Immediately before
What are the advantages of rapid acting insulin over short acting insulin?
- Can be given immediately before meals
- Improved glucose control, reduction of HbA1c, and reduction in the incidence of severe hypoglycaemia, including nocturnal hypoglycaemia.
Is injecting short acting insulins post meals recommended?
No
What type of insulin is isophane?
Intermediate - designed to mimic the effect of endogenous basal insulin
What are biphasic insulins?
Pre-mixed insulin preparations containing various combinations of short-acting insulin (soluble insulin or rapid-acting analogue insulin) and an intermediate-acting insulin.
What are the long acting insulins?
Insulin detemir
Insulin glargine
Insulin degludec
Rarely prescribed:
Protamine zinc insulin
Insulin zinc suspension
Does metformin cause hypoglycaemia?
No
If standard release metformin is not tolerated e.g. GI side effects, what should be given?
Modified release metformin
Give examples of sulfonylureas
Glibenclamide
Gliclazide
Tolbutamide
Give examples of meglitinides
Nateglinide
Repaglinide
Give examples of DPP-4 inhibitors
Alogliptin Linagliptin Sitagliptin Saxagliptin Vildagliptin
What is an advantage of DPP-4 inhibitors over sulphonylureas in terms of side effects?
Not associated with weight gain and have less incidence of hypoglycaemia
Give examples of SGLT2 inhibitors
Canaglifozin
Dapaglifozin
Empaglifozin
Give examples of GLP-1 receptor agonists
Dulaglutide
Exenatide
Liraglutide
Lixisenatide
What should be the target HbA1c in a Type 2 diabetic that is managed by lifestyle/ a single antidiabetic agent that is NOT associated with hypoglycaemia?
48 mmol/mol
What should be the target HbA1c in a Type 2 diabetic that is managed with one or more antidiabetic drugs that cause hypoglycaemia?
53 mmol/mol
In terms of HbA1c, when should treatment in a Type 2 diabetic on ONE antidiabetic drug be intensified?
58 mmol/mol or higher
What should be the target HbA1c in a Type 2 diabetic that is managed with 2 or more antidiabetic drugs?
53 mmol/mol
What is first line drug treatment in Type 2 diabetes and why?
Metformin
- Positive effect on weight loss
- Reduced risk of hypoglycaemia
- Long term cardiovascular benefits
If a sulphonylurea is indicated in one of the following:
- Elderly patients
- Renal impairment
- Particular risk of hypoglycaemia
What sulphonylurea should you opt for?
Short acting one e.g. gliclazide or tolbutamide
If a Type 2 diabetic is not been adequately controlled on metformin and requires intensification of treatment, what are the add in options?
- Sulphonylurea
- Pioglitazone
- DPP-4 inhibitor
SGLT-2 inhibitor - only when sulphonylureas are contraindicated or if patient is at significant risk of hypoglycaemia
Type 2 diabetes:
Dapagliflozin is not recommended in a triple therapy regimen with what drug?
Pioglitazone
Type 2 diabetes:
If dual therapy is unsuccessful, what are the triple therapy combination options?
- Metformin + DPP-4 + sulphonylurea
- Metformin + pioglitazone + sulphonylurea
- Metformin + sulphonylurea + SGLT-2 inhibitor
- Metformin + sulphonylurea + SGLT-2 inhibitor (not dapaglifozin)
May be appropriate to start insulin at this stage
When is GLP-1 receptor agonists indicated in Type 2 diabetes?
- If triple therapy with metformin and 2 other oral drugs are tried
- BMI of 35 kg/m2 or above (adjusted for ethnicity) and who also have specific psychological or medical problems associated with obesity; or for those who have a BMI lower than 35 kg/m2 but for whom insulin therapy would have significant occupational implications or if the weight loss associated with glucagon-like peptide-1 receptor agonists would benefit other significant obesity-related comorbidities.
If started on a GLP-1 receptor agonist for Type 2 diabetes, when should this be reviewed and how do you know it is okay to continue?
After 6 months, the drug should be reviewed and only continued if there has been a beneficial metabolic response (a reduction of at least 11 mmol/mol [1.0%] in HbA1c and a weight loss of at least 3% of initial body-weight).
If metformin is contraindicated or not tolerated, what should be used for initial treatment?
Sulphonylurea or DPP-4 inhibitor monotherapy
SGLT2 inhibitor monotherapy can be used only if the above are not appropriate
Repaglinide can be used as monotherapy however cannot be used in combination with anything else other than metformin
What is the problem with using repaglinide monotherapy in Type 2 diabetes?
If intensification of treatment is required, can only be given with metformin
It is NOT licensed in combination with any other antidiabetic drugs
In patients where metformin is contraindicated/not tolerated:
If a patient is on a non-metformin single therapy however requires intensification of treatment, what dual combinations can be prescribed?
- DPP-4 inhibitor and pioglitazone
- DPP-4 inhibitor and sulfonylurea
- Pioglitazone and sulfonylurea
If dual therapy does not provide control, consider insulin
If a patient is on dual therapy for Type 2 diabetes, and metformin is contraindicated/not tolerated, what should be considered?
Insulin
In Type 2 diabetes, if insulin therapy is required, what should happen to their other antidiabetic drugs?
- Continue metformin if not contraindicated or tolerated
- Review all others and stop if necessary
In Type 2 diabetics, what insulin regimens can you use?
- Isophane (NPH) OD/BD
- Isophane + short acting (either separate or pre-mixed) - particularly appropriate if HbA1c is 75 or higher
- Insulin detemir or glargine can be an alternative to isophane
In Type 2 diabetics, at what HbA1c would the following insulin regimen be particularly appropriate:
Isophane + short acting insulin (separate or pre-mixed)
75 or higher
In type 2 diabetics requiring insulin therapy, when would long acting insulin (glargine or detemir) be preferable?
- If once daily injection is beneficial e.g. assistance is needed to inject, trouble with the device
- If recurrent symptomatic hypoglycaemic episodes are a problem
- If BD isophane would still require oral antidiabetics
When starting insulin therapy in Type 2 diabetes, when should the first basal insulin be given and how do you adjust the dose?
Bedtime basal insulin should be initiated and the dose titrated against fasting glucose in the morning
Providing there are no contraindications, what should you give for diabetic nephropathy that is causing proteinuria or established microalbuminuria?
Blood pressure should be reduced to the lowest achievable level to reduce the glomerular filtration rate
ARB or ACEi to be started even if the blood pressure is normal
What is the potential problem with ACEis in diabetics if the patient is on insulin or oral antidiabetic drugs?
Can potentiate the hypoglycaemic effect
More likely in the first few weeks of combined treatment and in patients with renal impairment
The management of DKA involves what?
What should happen to their basal insulin?
What should be monitored and how often?
Replacement of fluid and electrolytes
Include potassium chloride in the fluids unless anuria is suspected
Administration of soluble insulin in sodium chloride 0.1 units/kg/hr
Long acting insulin (basal) should be continued in the background
If blood glucose falls below 14, give glucose 10%
Monitor ketones and glucose hourly
Monitor BP
Blood pH
During DKA treatment when the patient is on an insulin infusion, when should you recommence the short acting subcut insulin and stop the infusion and how is this done?
Continue insulin infusion until blood-ketone concentration is below 0.3 mmol/litre, blood pH is above 7.3 and the patient is able to eat and drink; ideally give subcutaneous fast-acting insulin and a meal, and stop the insulin infusion 1 hour later.
In the management of HHS, are lower or higher rates of insulin infusion usually required compared to DKA?
Lower rates usually required
During DKA management, what rate should you give the insulin infusion?
0.1 units/kg/hr
Diabetic women who are planning on becoming pregnant should aim to keep their HbA1c to what?
Below 48 if possible without causing any problematic hypoglycaemia
What is the folic acid supplementation recommendation in diabetic patients planning on becoming pregnant?
High dose - 5mg daily as classed in the high risk group of neural tube defects
What is the treatment recommendation for diabetic patients when they become pregnant?
What about during breastfeeding?
All antidiabetic drugs APART from metformin should be stopped and substituted with insulin therapy
For breastfeeding, the options are:
- Insulin continued
- Metformin continued
- Glibenclamide is fine to restart if originally on it
However, all other antidiabetic agents should be avoided during breastfeeding
What is the first choice for long acting insulin therapy during pregnancy?
Isophane insulin
However in women who have good blood-glucose control before pregnancy with the long-acting insulin analogues (insulin detemir or insulin glargine), it may be appropriate to continue using them throughout pregnancy.
What is the patient advice regarding insulin therapy during pregnancy?
Should be aware of the risk of hypoglycaemia and should always carry a fast-acting form of glucose
It is recommended that pregnant women with Type 1 diabetes should be prescribed what just in case of hypoglycaemia?
Glucagon
Women with pre-existing diabetes treated with insulin during pregnancy are at an increased risk of what?
Hypoglycaemia during the postnatal period
Should reduce their insulin immediately after birth and blood glucose levels monitored
If a diabetic patient is on an ACEi or ARB for diabetic complications, however wishes to become pregnant, what would be the most appropriate action?
ACEi or ARB should be discontinued and an alternative antihypertensive suitable in pregnancy should be used
(Preferably before conception if pregnancy is planned)
If a diabetic patient becomes pregnant but is on a statin, what would be the most appropriate action?
Discontinue the statin during pregnancy (Preferably before conception if pregnancy is planned)
True or false:
A patient with gestational diabetes should continue their hypoglycaemic treatment after birth
False - should discontinue hypoglycaemic treatment immediately after giving birth
How would you manage an insulin dependent diabetic patient with good glycaemic control due for an elective minor procedure?
(Day before surgery and during the operative period)
On the day before surgery, give the usual insulin dose
However, once daily long acting insulins should be given at 80% of normal dose
Then their usual insulin regimen can be adjusted accordingly during the operative period
On the day before a minor op in an insulin dependent diabetic with good glycaemic control, you can give their usual insulin dose as normal. With what insulin would you not give the full dose?
Long acting insulin
You give 80% of normal dose
How would you manage an insulin dependent diabetic due for major elective surgery or in patients pre-op who have poor glycaemic control?
(Day before surgery, day of surgery, during the operative period)
VRII - Continued until the patient is eating/drinking and stabilised on their previous diabetes medication
Day before surgery - Give normal insulin dose (Apart from once daily long acting insulin is given at 80% usual dose)
Day of surgery and during the operative period:
- Once daily insulin given at 80% usual dose. All of the other patient’s insulin should be stopped until the patient is eating and drinking again
- Start IV infusion of potassium chloride with glucose and sodium chloride AND a variable rate insulin infusion of soluble human insulin in 0.9% sodium chloride
Blood glucose monitored hourly for at least the first 12 hours
In patients that are on VRII during an operative period, what would you do if their blood glucose drops below 6?
What about if it drops before 4?
<6 - Give IV glucose 20% and check blood glucose hourly
<4 - Give IV glucose 20% and check blood glucose every 15 mins
After surgery, if a patient is on VRII, they must not restart their subcut insulin until when?
They are eating/drinking without nausea or vomiting
Note- their insulin dose may need adjusting due to altered food intake/post-op stress/infection
After surgery, a patient is ready to stop their VRII and go back to their BASAL-BOLUS regimen when would you stop the VRII and restart their subcut insulin?
Should be restarted when the first post-op meal is due
Give the first short-acting insulin first and then stop VRII 30-60 mins after
Note- the long acting insulin is continued in the background of VRII at 80% dose - should continue at that dose until the patient leaves hospital
After surgery, a patient is ready to stop their VRII and go back to their TWICE DAILY MIXED insulin regimen when would you stop the VRII and restart their subcut insulin?
Should be restarted before breakfast or evening meal (not at any other time)
Stop VRII 30-60 mins after
In type 2 diabetes, when would you consider VRII for surgery?
- When the fasting period requires more than one missed meal - major elective surgery
- Patients with poor glycaemic control
- Risk of renal injury
- If on insulin as part of their treatment anyway
-
If VRII is required for surgery in a type 2 diabetic, what antidiabetic drugs should be stopped?
When should they be restarted?
- Acarbose
- Sulfonylureas
- DPP-4 inhibitors
- Pioglitazone
- Meglitinides
- SGLT-2 inhibitors
Should not be restarted until the patient is eating and drinking normally
If VRII is required for surgery in a type 2 diabetic, can GLP-1 receptor agonists be continued?
Yes
If a type 2 diabetic requires a minor surgical period, what should you do about their antidiabetic treatment?
If it requires a short fasting period (one missed meal), it may be possible to adjust antidiabetic drugs to avoid a switch to VRII
SGLT2 inhibitors are associated with an increased risk of DKA, particularly the case in what situations?
Dehydration, stress, surgery, trauma, acute medical illness or any other catabolic state
What is the maximum licensed daily dose of standard release metformin compared to MR metformin?
Standard release- 3g/day
MR - 2g/day
What are the side effects of metformin?
- GI upset - a slow increase in dose may improve tolerability
- Taste altered - metallic
- Lactic acidosis
- Vitamin B12 absorption decreased
At what eGFR should you avoid metformin?
<30
What are the risk factors for lactic acidosis?
Chronic heart failure
Concomitant use of drugs that acutely impair renal function
What is the patient advice with metformin?
Should be informed of the risk of lactic acidosis and told to seek immediate medical attention if symptoms such as dyspnoea, muscle cramps, abdominal pain, hypothermia, or asthenia (weakness/lack of energy) occur
Take with meals
MR gliclazide is equivalent to what standard release gliclazide dose?
30mg MR = 80mg standard release
What are the main side effects of gliclazide to warn your patient about?
Weight gain
Hypoglycaemia
What is the important safety information regarding pioglotazone?
- Cardiovascular safety - heart failure. This is especially the case if combined with insulin and patients with risk factors. Should not be used in those with history of heart failure
- Risk of bladder cancer
Not appropriate for those who have uninvestigated macroscopic haematuria
Risk of bladder cancer increases with age so cautioned in the elderly
- Liver toxicity- Patients should be advised to seek immediate medical attention if symptoms such as nausea, vomiting, abdominal pain, fatigue and dark urine develop.
What is the MHRA advice surrounding SGLT2 inhibitors?
Risk of DKA
Inform patients to be aware of signs e.g. rapid weight loss, sweet smell to breath, different odour in urine/sweat
Reports of Fournier’s gangrene (necrotising fasciitis of the genitalia or perineum
Canagliflozin - risk of lower-limb amputation
What is the MHRA advice surrounding the use of canagliflozin?
Risk of lower-limb amputation
Which antidiabetic class can cause pancreatitis?
DPP-4 inhibitors (gliptins)
Which antidiabetic drug class commonly causes UTIs?
SGLT2 inhibitors
Can you use nateglinide as monotherapy in diabetes?
No - only with metformin
With what antidiabetic drug would it not be suitable in those with hernias or GI obstructions?
Acarbose
What is the dose frequency of the 4 different GLP-1 receptor agonists?
Weekly for albiglutide and dulaglutide
Twice daily with exenatide (modified release can be once weekly)
Liraglutide is once weekly
What is the important safety information regarding insulin pen devices?
Insulin should not be extracted from insulin pen devices.
The strength of insulin in pen devices can vary by multiples of 100 units/mL. Insulin syringes have graduations only suitable for calculating doses of standard 100 units/mL. If insulin extracted from a pen or cartridge is of a higher strength, and that is not considered in determining the volume required, it can lead to a significant and potentially fatal overdose.
What is the name of the ultrarapid acting insulin?
Fiasp (aspart)
What are the types of soluble insulin (short acting)?
Humulin S
Actrapid
Insuman rapid
Hypurin neutral (povine/porcine)
What insulins can be used for VRII or in DKA as in infusion?
Soluble insulin
Humulin S
Actrapid
Is Actrapid classed as a rapid acting insulin?
No- it is a short acting insulin
What insulins are classed as rapid acting?
Novorapid (aspart)
Humalog (lispro)
Apidra (glulisine)
What insulins are classed as intermediate acting?
Insulatard
Humulin I (isophane)
Insuman basal
Hypurin isophane
Isophane can be otherwise known as NPH
What insulins are classed as long acting?
Levemir (detemir)
Lantus/Absalgar (glargine)
Tresiba (degludec)
Toujeo (glargine)
What insulins are classed as biphasic (pre-mixed)?
Novomix 30
Humalog Mix 25 or 50
Humulin M3 Insuman Combo 15 or 25 or 30
What does the 30 mean in Novomix 30?
The suspension contains rapid-acting and intermediate-acting insulin aspart in the ratio 30/70
What is recommended for the treatment of acute hypoglycaemia and the patient is conscious?
Initially glucose 10–20 g is given by mouth either in liquid form or as granulated sugar or sugar lumps. If necessary this may be repeated after 10–15 minutes. After initial treatment, a snack providing sustained availability of carbohydrate (e.g. a sandwich, fruit, milk, or biscuits) or the next meal (if it is due) can prevent blood-glucose concentration from falling again.
What is recommended for the treatment of acute hypoglycaemia and the patient is UNconscious?
Glucagon is given as an injection (subcut or IM)
If this does not work within 10 minutes, IV glucose 20% needs to be given
Can glucagon be used for chronic hypoglycaemia?
No
What is given for chronic hypoglycaemia?
Diazoxide
What is used in diabetes insipidus?
Desmopressin or vasopressin
Is desmopressin or vasopressin more potent?
Desmopressin is more potent and has a longer duration of action
Desmopressin is an analogue of vasopressin
Has no vasoconstrictor effect compared to vasopressin
What is vasopressin used for?
Diabetes insipidus
Initial control of oesophageal variceal bleeding
What is demeclocycline used for?
Treatment of hyponatraemia resulting from inappropriate secretion of antidiuretic hormone (if fluid restriction does not work)
What is tolvaptan used for?
Treatment of hyponatraemia secondary to syndrome of inappropriate antidiuretic hormone secretion
What mineralocorticoid can be used for postural hypotension?
Fludrocortisone
True or false:
High dose steroids should be used in the management of septic shock
False - they should be avoided
However, there is evidence that administration of lower doses of hydrocortisone and fludrocortisone acetate is of benefit in adrenocortical insufficiency resulting from septic shock.
What is the MHRA advice surrounding corticosteroids?
Rare risk of central serous chorioretinopathy with local as well as systemic administration
Patients should report any blurred vision/visual disturbances
What are the side effects of mineralocorticoids?
With which mineralocorticoid is this most present with?
hypertension sodium retention water retention potassium loss calcium loss
Fludrocortisone
What are the side effects of glucocorticoids?
diabetes
osteoporosis, which is a danger, particularly in the elderly, as it can result in osteoporotic fractures for example of the hip or vertebrae;
in addition high doses are associated with avascular necrosis of the femoral head.
muscle wasting (proximal myopathy) can also occur.
corticosteroid therapy is also weakly linked with peptic ulceration and perforation.
psychiatric reactions may also occur.
For corticosteroid replacement therapy, what combination is usually given?
Hydrocortisone and fludrocortisone
Hydrocortisone alone is not sufficient as it does not provide sufficient activity
In Addision’s Disease or following adrenalectomy, what is usually given?
How is it given?
Hydrocortisone
This is given in 2 doses, the larger in the morning and the smaller in the evening, mimicking the normal diurnal rhythm of cortisol secretion.
In acute adrenocorticol insufficiency, what is given?
IV hydrocortisone
What are the side effects of corticosteroids?
- Adrenal suppression
- Infections
- Chickenpox and measles
- Psychiatric conditions- insomnia, irritability, behavioural disturbances
ADULTS:
In what patients would you want a gradual withdrawal of systemic corticosteroids?
- Received more than 40 mg prednisolone (or equivalent) daily for more than 1 week;
been given repeat doses in the evening - Received more than 3 weeks’ treatment
- Recently received repeated courses (particularly if taken for longer than 3 weeks)
- Taken a short course within 1 year of stopping long-term therapy
Other possible causes of adrenal suppression.
What is the physiological daily dose equivalent of prednisolone?
7.5mg daily
True or false:
During corticosteroid withdrawal the dose may be reduced rapidly down to physiological doses (equivalent to prednisolone 7.5 mg daily)
True
CHILDREN:
In what patients would you want a gradual withdrawal of systemic corticosteroids?
- Received more than 40 mg prednisolone (or equivalent) daily for more than 1 week or 2 mg/kg daily for 1 week or 1 mg/kg daily for 1 month
- Been given repeat doses in the evening
- Received more than 3 weeks’ treatment
- Recently received repeated courses (particularly if taken for longer than 3 weeks)
- Taken a short course within 1 year of stopping long-term therapy
- Other possible causes of adrenal suppression.
Prednisolone 5mg is equivalent to how much beclomethasone?
750 micrograms
Prednisolone 5mg is equivalent to how much dexamethasone?
750 micrograms
Prednisolone 5mg is equivalent to how much hydrocortisone?
20mg
Prednisolone 5mg is equivalent to how much methylprednisolone?
4mg
What is the most commonly used steroid for long-term disease suppression?
Prednisolone
What is the MHRA advice surrounding the methylprenisolone injectable preparation Solu-Medrone 40mg?
Contains lactose- not suitable for those with a cow’s milk allergy
If a newly diagnosed type 1 diabetic weighing 60kg was to be started on a basal bolus regime, what would their starting daily insulin unit dose be?
How would you split this between basal bolus?
Starting at 0.5 units/kg/day
So 30 units
Half basal and half bolus
15 units basal e.g. Lantus
And split the other 15 into 3 for meal times, so 5 units TDS of rapid acting insulin
- What is first line for postmenopausal osteoporosis?
2. What would be alternatives if this is not appropriate?
- Oral bisphosphonates alendronic acid or risedronate as they have a broad spectrum of anti-fracture efficacy
- IV bisphosphonate (ibandronic or zolendronic acid)
Denosumab
Raloxifene
What is teriparatide used for?
Reserved for postmenopausal women with severe osteoporosis at very high risk for vertebral fractures. Its duration of treatment is limited to 24 months.
- What would be first line for glucocorticoid-induced osteoporosis?
- What would be alternatives if this was not appropriate?
- Oral bisphosphonates- alendronic acid or risedronate sodium
- IV zolendronic acid or teripartide are alternatives
Men who are receiving androgen deprivation therapy for prostate cancer have an increased risk of what?
Fractures
Fracture risk should be assessed at the start of therapy
- What would be first line in men with osteoporosis?
2. What would be alternatives if this was not appropriate?
- Oral bisphosphonates- alendronic acid or risedronate sodium
- IV zolendronic acid or denosumab
Bisphosphonate treatment should be reviewed after how many years?
5 years of treatment of alendronic acid, risedronate sodium or ibandronic acid
3 years of treatment with zolendronic acid
Which patient groups can continue their bisphosphonate therapy after 5 years?
Patients over 75 years of age, or with a history of previous hip or vertebral fracture, or patients who have had one or more fragility fractures during treatment, or who are taking long-term glucocorticoid therapy
What is the warnings surrounding the use of bisphosphonates?
- Risk of atypical femoral fractures
Patients should be advised to report any thigh/hip/groin pain
Review treatment after 5 years - Risk of osteonecrosis of the jaw
Dental 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 - Risk of osteonecrosis of external auditory canal
Any ear symptoms e.g. ear infections, ear discharge, ear pain should be reported - Severe oesophageal reactions (oesophagitis, oesophageal ulcers, oesophageal stricture and oesophageal erosions) have been reported; patients should be advised to stop taking the tablets and to seek medical attention if they develop symptoms of oesophageal irritation such as dysphagia, new or worsening heartburn, pain on swallowing or retrosternal pain
What are the side effects of bisphosphonates?
- Anaemia
- Severe oesophageal reactions (ulcers, strictures, erosions)
- Risk of atypical fracture
- Osteonecrosis of jaw or auditory canal
- Altered taste
- Joint swelling
- Hypophosphatemia
NB- absorption is affected by other meds e.g. iron, so needs to be taken 30 mins before food and other meds
Is estradiol a natural or synthetic oestrogen?
Natural
Is ethinylestradiol a natural or synthetic oestrogen?
Synthetic
If long term oestrogen therapy is needed for women who still have a uterus, what should be added and why?
Progesterone to reduce the risk of hyperplasia of endometrium and cancer
HRT increases the risk of what?
Venous thromboembolism, stroke, endometrial cancer (reduced by a progestogen), breast cancer, and ovarian cancer; there is an increased risk of coronary heart disease in women who start combined HRT more than 10 years after menopause.
What is first line in hyperthyroidism?
What is second line?
Carbimazole
Propylthiouracil
What is the important safety information regarding carbimazole?
- Neutropenia and agranulocytosis
- Increased risk of congenital malformations - need to use effective contraception
- Risk of acute pancreatitis
What is the important safety information regarding carbimazole?
- Neutropenia and agranulocytosis - patient or carers to tell doctor immediately if sore throat, mouth ulcers, bruising, fever, malaise, or non-specific illness develops
- Increased risk of congenital malformations - need to use effective contraception
- Risk of acute pancreatitis
What is the patient advice regarding propylthiouracil?
Severe hepatic reactions have been reported
Patients should be told how to recognise signs of liver disorder and advised to seek prompt medical attention if symptoms such as anorexia, nausea, vomiting, fatigue, abdominal pain, jaundice, dark urine, or pruritus develop.
How should a thyroid storm be treated?
Emergency situation
IV fluids, propranolol and hydrocortisone
as well as oral iodine, and carbimazole/propylthiouracil
What is first line for hypothyroidism?
What is an alternative?
Levothyroxine
Liothyronine
What is the patient advice regarding the administration of levothyroxine?
Dose to be taken preferably at least 30 minutes before breakfast, caffeine-containing liquids (e.g. coffee, tea), or other medication.
What is tibolone used for?
For women
Short term treatment of oestrogen deficiency
Osteoporosis prophylaxis
Is norethisterone an oestrogen or progesterone?
Progesterone
What is the advice regarding missing a dose of progesterone only pill for contraception?
Take it as soon as you remember
However if it is not taken within 3 hours of the normal time of taking the pill- additional precautions should be used and for 2 days after
What is the advice regarding vomiting if taking a progesterone only pill?
If vomiting occurs within 2 hours of taking an oral progestogen-only contraceptive, another pill should be taken as soon as possible. If a replacement pill is not taken within 3 hours of the normal time for taking the progestogen-only pill, or in cases of persistent vomiting or very severe diarrhoea, additional precautions should be used during illness and for 2 days after recovery (but still keep taking the pill as usual)
True or false:
You should take the progesterone only pill (for contraception) at the same time every day
True
If delayed longer than 3 hours, then the contraceptive effect may be lost
When starting a progesterone only pill for contraception, what is the advice surrounding when to start during the menstrual cycle and if additional contraceptive cover is needed?
Should ideally start taking on day 1 of the cycle
Additional contraceptive precautions are not required if norethisterone is started up to and including day 5 of the menstrual cycle; if started after this time, additional contraceptive precautions are required for 2 days.
If you are changing from a combined oral contraceptive pill to the progesterone only, when should this happen?
Start on the day following completion of the combined oral contraceptive course without a break (or in the case of ED tablets omitting the inactive ones)
When starting a progesterone only pill for contraception AFTER CHILDBIRTH, what is the advice surrounding when to start and if additional contraceptive cover is needed?
Can be started up to and including day 21 postpartum without the need for additional contraceptive precautions. If started more than 21 days postpartum, additional contraceptive precautions are required for 2 days.
If on a progesterone only pill for contraception, in what situations would you need emergency contraception?
If one or more progestogen-only contraceptive tablets are missed or taken more than 3 hours late and unprotected intercourse has occurred before 2 further tablets (2 days worth) have been correctly taken.
Which antidiabetic drug can cause lactic acidosis and B12 deficiency?
Metformin
If a pregnant patient diagnosed with gestational diabetes presents with a fasting glucose of <7mmol/L, what should be done?
If this does not work after 1-2 weeks, what should then be done?
First attempt a change in diet and exercise alone in order to reduce blood-glucose.
If blood-glucose targets are not met within 1 to 2 weeks, metformin hydrochloride may be prescribed [unlicensed use]. Insulin may be prescribed if metformin is contraindicated or not acceptable, and may also be added to treatment if metformin is not effective alone
If a pregnant patient diagnosed with gestational diabetes presents with a fasting glucose of >7mmol/L, what should be done?
Should be treated with insulin immediately, with or without metformin hydrochloride, in addition to a change in diet and exercise
What are the complications of gestational diabetes?
Hydramnios- a condition in which excess amniotic fluid accumulates during pregnancy
Macrosomia- larger than normal baby
If a pregnant lady presents with complications of gestational diabetes, how should this be managed?
Should be considered for immediate insulin treatment, with or without metformin hydrochloride.
What is the advice surrounding patients on metformin who is going to have contrast media administered as part of radiologic studies?
Can lead to nephrotoxicity
If patient’s eGFR >60 and only missing one meal, then there is no need to stop metformin after
If 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
What is the advice surrounding metformin during surgery?
If EGFR > 60 or only one meal will be missed, and low risk of AKI:
It may be possible to continue metformin hydrochloride throughout the peri-operative period—just the lunchtime dose should be omitted if the usual dose is prescribed three times a day.
If there is a risk of AKI or more than one meal will be missed:
Metformin should be stopped when the pre-operative fast begins. A variable rate intravenous insulin infusion should be started if the metformin dose is more than once daily. Otherwise insulin should only be started if blood-glucose concentration is greater than 12 mmol/litre on two consecutive occasions - metformin should not be recommended until the patient is eating and drinking and renal function is stable
If a patient is on 500mg OD metformin, due for surgery and the metformin needs to be stopped beforehand, would you give VRII?
No, only give VRII if their usual metformin dose is more than once daily OR if their blood glucose is >12 on 2 consecutive occasions
What is the risk of continuing metformin during surgery?
Renal impairment may lead to accumulation and lactic acidosis
What is the advice surrounding sulphonylureas and surgery?
Sulfonylureas are associated with hypoglycaemia in the fasted state and therefore should always be omitted on the day of surgery until the patient is eating and drinking again.
Monitor blood glucose and give insulin if necessary
If a patient does not require VRII, what antidiabetic drugs can be continued during surgery?
Pioglitazone, dipeptidylpeptidase-4 inhibitors (gliptins) and glucagon-like peptide-1 receptor agonists can be taken as normal during the whole peri-operative period.
Metformin- depends on AKI risk, eGFR, how many doses they are missing
Do gliptins or sulphonylureas have a higher incidence of hypoglycaemia?
Sulphonylureas
A HbA1c alone at what level would indicate diabetes?
48
HbA1c should not be used for diagnosis in what patients groups?
Those with suspected type 1 diabetes, in children, during pregnancy, or in women who are up to two months postpartum
Also 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
Zolendronic acid is contraindicated in what patient group?
Women of child bearing potential
For DKA, what strength glucose do you give?
10%
For hypoglycaemia when glucose is needed, what strength do you give?
20%
A high TSH level with a low FT4 and FT3 level indicates what?
Hypothyroidism
A low TSH level with a high T4 level and a high T3 level indicates what?
Hyperthyroidism
How do you manage hyperthyroidism during pregnancy?
Carbimazole is associated with congenital defects, including aplasia cutis of the neonate, therefore propylthiouracil remains the drug of choice during the first trimester of pregnancy.
In the second trimester, consider switching to carbimazole because of the potential risk of hepatotoxicity with propylthiouracil
What is the blocking replacement regime?
Hyperthyroidism
A combination of carbimazole with levothyroxine sodium daily, may be used in a blocking-replacement regimen; therapy is usually given for 18 months. The blocking-replacement regimen is not suitable during pregnancy.
Why should you avoid rapid correction of sodium in SIADH?
Can cause serious CNS effects and demyelination of neurones
What effect can corticosteroids have on potassium levels?
Can cause hypokalaemia
If chicken pox develops in a person taking corticosteroids, what is recommended?
Seek urgent medical attention as they are immunocompromised
When would you issue patients with a steroid card?
Taking long term steroids for more than 3 weeks
High dose ICS
When would you consider a statin in Type 1 and Type 2 diabetics?
Type 1 if >40 years
TYpe 2 if QRISK >10%
If a woman presents with gestational diabetes with a blood glucose of <7 , what is first line?
What is second line?
Diet and exercise
If blood glucose targets are not met within 1-2 weeks, metformin can be prescribed
(if not, insulin)
If a woman presents with gestational diabetes with a blood glucose of >7, what should happen?
Should be treated with insulin immediately, with or without metformin hydrochloride, in addition to a change in diet and exercise
If a woman presents with gestational diabetes with a blood glucose of 6-6.9 along with complications e.g. macrosomia, what should happen?
Should be considered for immediate insulin treatment, with or without metformin
What is macrosomia?
Larger than average foetus- usually a complication for women with diabetes
If a driver experiences hypoglycaemia, what should they do?
Stop vehicle in safe place
Fast acting sugar and long acting carbohydrate
Wait for 45 minutes after blood glucose has returned back to normal before continuing journey
What class of antidiabetic drugs can cause volume depletion?
SGLT2 inhibitors
In a woman without a uterus requiring HRT, what preparation should be used?
Continuous oestrogen
i) In a woman with a uterus requiring HRT, what preparation should be used?
ii) What kind of HRT is unsuitable if the patient is peri-menopausal or <12 months after last period?
Progesterone cyclically and oestrogen
Or continuous progesterone and oestrogen (avoids withdrawal bleed)
ii) Continuous combined HRT is unsuitable for peri-menopausal or <12 months after last period as it can cause irregular bleeding so you would use cyclic
What kind of cancer must you rule out if irregular bleeding continues after stopping continuous HRT?
Endometrial cancer
Coronary heart disease risk is increased if combined HRT is started how many years after menopause?
10 years
If combined HRT is started 10 years after menopause, the risk of what is increased?
Coronary heart disease
What is a severe side effect of exenatide?
Severe pancreatitis
Can you take risedronate and alendronic acid daily?
Yes at lower doses
5mg risedronate OD (or 35mg weekly)
10mg alendronic acid OD (or 70mg weekly)
What is the advice if a patient is on levothyroxine and iron tablets?
Iron can decrease the absorption of levothyroxine, so separate administration by at least 4 hours
What is used if a patient wants to delay her period, and what is the dosing regimen?
Norethisterone
5 mg 3 times a day, to be started 3 days before expected onset (menstruation occurs 2–3 days after stopping).
Abrupt withdrawal of steroids can lead to what?
Abrupt withdrawal after a prolonged period can lead to acute adrenal insufficiency, hypotension or death. Withdrawal can also be associated with fever, myalgia, arthralgia, rhinitis, conjunctivitis, painful itchy skin nodules and weight loss.
