Endo treatment summaries

Question 1

T2DM

Answer 1

3 MONTHS BALANCED DIET AND EXERCISE BEFORE TAKING MEDICATION
METFORMIN 1ST LINE
- Causes GI problems and weight loss (from diarrhoea)
- Less risk of hypos
- Can cause renal/hepatic impairment (monitor)
- Avoid if GFR <30 and in metabolic acidosis
SULFONYLUREAS
- Gliclazide, glipizide, glibenclamide, tolbutamide and glimepiride
- Cause weight gain and higher risk of hypos
- Avoid in severe hepatic and renal failure, porphyria, obese patients, ketoacidosis, breastfeeding and pregnancy
DPP4 INHIBITORS (GLIPTINS)
- Linagliptin, sitagliptin, saxagliptin
SGL2 INHIBITORS (FLOZIN)
- Canagliflozin, dapagliflozin, empagliflozin
- Avoid in renal impairment
- Increase risk of genital infection (glucose in urine), diabetic ketoacidosis, amputation and Fournier’s gangrene
- Cardioprotective
GLP-1 AGONISTS (TIDE)
- Exenatide, liraglutide, semaglutide and dulaglutide SC modified release once weekly
- Encourage weight loss and cardioprotective but increase risk of diabetic ketoacidosis
- Review after 6 months and continue only if there is at least 11 or 1% reduction in HbA1c and a weight loss of at least 3%
THIAZOLIDINEDIONES
- Pioglitazone
- Cause weight gain
- Avoid in HF, hepatic impairment, diabetic ketoacidosis, bladder cancer, haematuria (uninvestigated)
ALPHA- GLUCOSIDASE INHIBITORS (NOT USED ANYMORE)
- Acarbose causes GI problems
INSULIN
- Intermediate
- Intermediate in combination with shorth acting (biphasic)
- Long acting at night
STEP WISE APPROACH
1) Metformin/MR metformin (GI discomfort)
2) If not enough (HbA1c 58 or 7.5%) add
- SGL2 inhibitor dapagliflozin if there is CV risk/HF or atherosclerosis or high risk of hypos
- Sulfonylurea (if not obese)
- Pioglitazone (if not obese)
- DPP-4 inhibitor
3) If metformin not tolerated/contraindicated
- DPP4-inhibitor + pioglitazone
- DPP4-inhibitor + sulfonylurea
- Pioglitazone + sulfonylurea
4) Triple therapy
- Metformin + DPP4-inhibitor + sulfonylurea
- Metformin + pioglitazone + sulfonylurea
- Metformin + sulfonylurea + SGLT2
- Metformin + sulfonylurea + GLP-1 mimetic (if BMI is 35 or higher or less then 35 but does not accept insulin therapy with significant obesity related co-morbidities)
- Insulin therapy
BLOOD PRESSURE AND DIABETES
- Target bp is 140/90 monitor every 1-2 months
- Give ACEi (nephroprotective) and statin to reduces atherosclerotic risk
HYPOGLYCAEMIA <4
- Fast acting sugar (Lucozade) followed by a snack
- If severe give glucagon injection
- Monitor glucose level for 24-48 hours

Question 2

GLAUCOMA

Answer 2

1ST LINE PROSTAGLANDIN ANALOGUES (PROSTS)
- Lantaprost, travoprost, bimaprost
- Can change eye colour
BETABLOCKERS (OLOLS)
- Timolol, betaxolol
- Contraindicated in heart problems and uncontrolled asthma
- Interacts with verapamil
ALPHA 2 ADRENERGIC AGONISTS (NIDINE)
- brimonidine, apraclonidine used to delay laser surgery and control IOP
CARBONIC ANHYDRASE INHIBITORS (MIDE)
- acetazolamide, dorzolamide
- cause blood disorders and rashes monitor electrolytes
MIOTICS

Question 3

DRY EYE DISEASE

Answer 3

LUBRICANTS 
-	1st choice is hypermelloseis
MUCOLYTICS 
-	Acetylcysteine
CARBOMERS
POLYVINYL ALCOHOL 
SODIUM CHLORIDE
PARAFFIN CONTAINING OINTMENTS
LIPOSOMAL SPRAYS

Question 4

DIABETIC KETOACIDOSIS

Answer 4

• IV insulin

- Fluids and potassium

Question 5

DIABETIC FOOT WITHOUT OSTEOMYELITIS

Answer 5

MILD (1-2 WEEKS) AN MODERATE (2-4 WEEKS FOLLOWED BY A REVIEW)
- Flucloxacillin PO 1g every 6 hours or clarithromycin 500mg every 12 hours if allergic to penicillin
- MRSA in the past: doxycycline 200mg then 100mg od
SEVERE (2 WEEKS THEN REVIEW)
- Flucloxacillin PO 2g every 6 hours or clindamycin 600mg IV/PO every 6 hours if allergic to penicillin
- MRSA in the past: vancomycin IV and flucloxacillin 2g IV every 6 hours

Question 6

DIABETIC FOOT WITH OSTEOMYELITIS

Answer 6

INTIAL IV PHASE (MINMUM 2 WEEKS)
- Co-amoxiclav 1.2g IV every 8 hours or ertapenem 1g IV od if allergic to penicillin
- MRSA in the past: vancomycin IV and co-amoxiclav 1.2g IV every 8 hours
EMPRICAL PO THERAPY (BASED ON CULTURE RESULTS)
- Ciprofloxacin 750mg PO every 12 hours and clindamycin 450mg PO every 6 hours

Question 7

PREMENSTRUAL SYNDROME

Answer 7

• Calcium, magnesium and vitamin B6 supplements

- Primrose oil for breast discomfort

Question 8

DYSMENORRHOEA

Answer 8

1ST LINE NSAIDS
- Ibuprofen 200-400mg qds/tds (max 1200mg per day)
- Diclofenac 12.5-25mg od then increased to qds/tds (max 75mg per day)
- Naproxen 250mg-500mg od after food then increased to 250mg qds/tds (max 750 mg per day for 3 days)
ASPIRIN
- Less commonly used as it causes more GI discomfort than NSAIDS
PARACETAMOL +/- NSAIDS
CAFFEINE 15-65MG
NON-PHARMACOLOGICAL
- Warmth, TENS machine, acupuncture fish oils and herbal remedies
REFER
- Younger than 16 or over 60, 1st occurrence or recurrent, STI (past/partner), irregular vaginal bleeding, ulcers/bisters, dysuria, swelling from treatment, diabetic, pregnant or immunocompromised.

Question 9

VAGINAL THRUSH

Answer 9

FIUCONAZOLE 150MG SINGLE DOSE
- Interacts with warfarin and may be given to partner if also infected
TOPICAL AZOLE
- Clotrimazole, econazole and miconazole pessaries or creams and may be given to partner if also infected for 6 days
- May exacerbate burning
NON-PHARMACOLOGICAL
- Yoghurt/tea tree oil on tampons or adding vinegar/bicarbonate to bath, loose fitting trousers, no perfumed products, cotton underwear and wipe from front to back

Question 10

CYSTITIS

Answer 10

• Resolves on its own within 2 days if not then refer
• Give paracetamol/NSAIDs for pain and fever
• Potassium citrate unless taking K sparing diuretics, ACEi, ARB, hyperkalaemia or kidney disease
  NON-PHARMACOLOGICAL
• Lots of fluids, wiping from front to back, urination after sex
  REFER
• Men, children, elderly, pregnant, undiagnosed diabetes suspected, recurrent, haematuria and vaginal discharge

Question 11

CHLAMDIYA

Answer 11

CLAMELLE TEST KIT AND AZITHROMYCIN 500MG

• Testing service paid by the customer
• OTC azithromycin 500mg for chlamydia treatment only if they show test result/verification tear off slip to verify on the database
• Taken as 1g od ASAP (for 16 and over) and partner should be treated two regardless of test (must show URN/reference number of their partner)
• If contraindicated, doxycycline 100mg bd for 7 days
• No sex for the whole treatment period and 1 week after
• Pharmacist must record any sales on the GLG clamelle database and complete a NHS proforma to the testing site
• Advice the patient to not take another test for at least 6 weeks of positive testtreatmet because there is a high chance of false positives
• It could take 2 weeks for the test to be positive after UPSI

Question 12

MENORRHAGIA OR HEAVY MENSTRUAL BLEEDING

Answer 12

TRANEXAMIC ACID

• OTC 2 x 500mg tds at the start of menstruation for maximum 4 days (max 4g a day)
• Do not give if there is irregular bleeding, thrombotic disease/family history of thrombotic disease, pregnancy, warfarin/anticoagulants, contraceptives or haematuria
• Do not supply (refer) women aged under 18 or over 45, if tranexamic acid did not help for 3 cycles, breastfeeding, diabetic, obese, PCOS, family history of endometrial cancer or taking tamoxifen
• Stop immediately and go to the doctor if there are any visual disturbances
• Reduce dose if there is GI discomfort

Question 13

PREGNANCY SUPPLEMENTS

Answer 13

FOLIC ACID
- 400mcg od if first pregnancy or 5mg od (to prevent neural tube damage recurrence or taking antifolates) for at least 12 weeks of pregnancy
VITAMIN D
- 10mcg od or 20mcg od (for Asian women) during pregnancy and breastfeeding
ESSENTIAL FATTY ACIDS (MUMOMEGA)
- Docosahxanoic acid DHA for eye & brain development
AVOID/REDUCE
- Vitamin A found in liver and its products (fetotoxic)
- Listeria containing foods such as unpasteurised cheese, milk, lightly cooked/chilled meals (miscarriage and still birth)
- Salmonella and other bacteria containing foods such as raw eggs, undercooked meats and poultry, raw shell fish and swordfish (miscarriage and dehydration)
- Fish with high Hg levels like shark, swordfish, merlin and tuna (neurotoxicity)
- Caffeine max 200mg/day (low birth weight and miscarriage)
- Toxoplasma in meat, soil and cat faeces (miscarriage, stillbirth, hydrocephalus, epilepsy, mental problems and blindness)
- Rubella causes mental problems, blindness and deafness
- Opioids, beta blockers, diazepam, ACEi
- Herbal remedies

Question 14

MORNING SICKNESS AND DYSPEPSIA

Answer 14

• Adequate fluid intake
• Ginger
• Smaller more frequent meals
• Rest
• Avoid trigger foods
• Good posture
• Raise bedhead
• Use alginates or if severe ask GP for ranitidine/omeprazole

Question 15

CONSTIPATION DURING PREGNANCY

Answer 15

• Increase fluid intake
• Increase dietary fibre intake
• Exercise
• Fybogel or if severe ask the GP for lactulose or docusate

Question 16

CYSTITIS, HAYFEVER AND THRUSH DURING PREGNANCY

Answer 16

REFER

Question 17

PAIN KILLERS DURING PREGNANCY

Answer 17

• Paracetamol no NSAIDS

- Avoid caffeine analgesics

Question 18

MALE HYPOGONADISM

Answer 18

ANDROPAUSE
- Pharmacological doses of testosterone
- Increase muscle mass, cognition and well-being unfortunately also increase LDL, prostate size and urinary symptoms
ANDROGEN REPLACEMENT THERAPY ART
- Testosterone derivatives using IM/implant/capsules or patches effect seen within 1-2 months
- Examples are histerone, methyltestosterone, testosterone propanoate/ethanoate/undecanoate

Question 19

EHC

Answer 19

LEVONGESTEROL / LEVONELLE 1.5MG
ULIPRISTAL ACETATE / ELLAONE
COPPER IUD

Question 20

PCOS AND AMENORRHOEA

Answer 20

• Treat underlying cause and replace hormones!
• Weight gain / exercise reduction for hypothalamic disorders
• Replace steroids for pituitary or ovarian failure
• Block prolactin – dopamine agonists e.g. cabergoline / bromocriptine
• Treat symptoms PCOS
• Relieve physical obstruction - surgery

Question 21

HYPOTHYROIDISM

Answer 21

LEVOTHYROXINE
- Initially 100 mcg od 30-60 mins before breakfast (max 200mcg od)
- Initial dose for elderly is 25mcg for at least 4 weeks to 50-200mcg
- Assess thyroid function after al least 6 weeks
LIOTHYRONINE SODIUM ORAL/IV
- 20mcg of this = 100 mcg mcg of levothyroxine
- Intially 10-20mcg od increased gradually to 60 mcg (20 mcg tds or 30 mcg bd)

Question 22

HYPERTHYROIDISM

Answer 22

CARBIMAZOLE
- 15-40 mg od until euthyroid (after 4-8 weeks) then reduced to a maintenance dose of 5-15mg
- Given for 12-18 months
- Patients must report sore throat (agranulocytosis)
PROPYLTHIOURACIL
- 200-400 mg od until euthyroid
BLOCKING-REPLACEMENT REGIMEN
- Carbimazole 40-60mg od for 18 months with thyroxine 50-150mcg od
- Less risk of under or over treatment
RADIOACTIVE IODINE
- Contraindicated in pregnancy/breast feeding
- Takes several months for full effect (4-12 months until euthyroid)
- One dose to destroy gland, sometimes a second dose is given (increases risk of hypothyroidism)
BETA BLOCKERS (PROPRANOLOL)
- For symptomatic relief or adjunct to radioactive iodine (before thyroidectomy) /antithyroid drugs
- Useful for hyperthyroid arrhythmias and neonatal thyrotoxicosis
SURGERY – SUBTOTAL THYROIDECTOMY
- Stop antithyroid drugs 10-14 days before and replace with oral potassium iodide
- Complications include hypocalcaemia, hypothyroidism and hypoparathyroidism
- Measure TFTs at 2 and 6 months then every year
• Measure TSH, T3 and T4 every 6 weeks until TSH is normal then only TSH every 3 months for all drugs
• Monitor TFTs after 8 weeks once a course is completed and then every 3 months for a year then annually (to avoid relapse)

Question 23

THYROID CRISIS

Answer 23

• Large doses of carbimazole, propranolol and iodine

- Dexamethasone or hydrocortisone as sodium succinate

Question 24

OSTEOPOROSIS

Answer 24

LIFESTYLE CHANGES
- Regular weight bearing exercise
- Adequate calcium intake and normal calcium/vitamin D levels
- Smoking cessation
- Lower alcohol intake
- Daily supplements of 200-1200mg calcium or 800 IU of cholecalciferol post menopause/ older men
- Adjust glucocorticoid dose and/or take bone protective treatment with them
- Maintain good oral hygiene
PHARMACOLOGICAL MANAGEMENT
1. ORAL BISPHOSPHONATES: (10-year fracture risk at least 1%) alendronic acid, risedonate sodium and ibandronic acid
- ALENDRONIC ACID: 10mg daily or 70 mg once a week
Take on an empty stomach (30 mins before breakfast) with plenty of water while sitting/standing and stand/sit upright for at least 30 mins after
Beware from dysphagia, new heartburn and pain on swallowing
- RISEDONATE SODIUM: 5 mg od or 35 mg once a week
Swallow with plenty of water on an empty stomach (after rising and do not take at bedtime) or avoid food 2 hours before/after and stand/sit upright for at least 30 mins after
- Treatment is reviewed after 5 years of treatment with oral bisphosphonates. Holiday period is 2 years for alendronic acid and 1 year for risedonate
2. IV BISPHOSPHONATES: (10-year fracture risk at least 10% or cannot swallow) ibandronic acid and zolendronic acid
- Treatment is reviewed after 3 years for zolendronic acid and the holiday period is 3 years
• Long term bisphosphonate use increases the risk of atypical femoral fractures (reassess after 3-5 years) so patients must report thigh, hip or groin pain
• Long term bisphosphonate use increases the risk of osteonecrosis of the external auditory canal (more common with IV) so patients must report ear symptoms, discharge (including infections) especially if they use steroids, chemotherapy, had infections, had an ear operation or use cotton buds
3. Denosumab: 60mg SC injection every 6 months (Prolia) and for cancer patients 120mg SC injection every 4 months (XGEVA)
- Must have normal calcium and vitamin D before starting
• Increases risk of osteonecrosis of the jaw so the patient has to have regular dental check-ups and good oral hygiene and must report any dental pain or welling, non-healing sores
• Increases risk of hypocalcaemia so calcium levels should be monitored before each dose, within 2 weeks after the intial dose (if the patient has impaired renal function Cr clearance less than 30) and should report muscle spasms, twitches, cramps, numbness or fingers/toes or around the mouth
• Increases risk of atypical femoral fractures (reassess after 3-5 years) so patients must report thigh, hip or groin pain
4. HRT only until the age of 50 in premenopausal women with adequate calcium intake
5. SELECTIVE OESTROGEN RECEPTOR MODULATOR (SERM): RALOXIFENE if bisphosphonates not tolerated or contraindicated and T-score 2.5 or below in post-menopausal women aged 55 and above or have other risk factors
6. STRONTIUM RANELATE granules 2g od in 30 ml water at bedtime
- Avoid food for 2. Hours before and after taking
- Avoid antacids containing Al and Mg for 2 hours after
- Causes DRESS (rash with eosinophilia and systemic symptoms) so the patient must report rash, fever, swollen glands and increased WBC
- Stop if rash develops and do not restart
- Assess cardiovascular risk before and during treatment every 6-12 months
7. TERIPARATIDE 20mcg SC injection od for 24 months max
- Only given if all the above are not tolerated, contraindicated or not effective after a whole year of treatment with evidence of BMD decline
- Given if patient is 65 or over with T-score of -4 or below or T-score of -3.5 or below with history of fractures
- Also given to patients aged 55-64 with T-score of -4 or below and a history of 2 or more fractures
- Initiated by specialist and will not be repeated after the course finishes

Question 25

RHEUMATOID ARTHRITIS

Answer 25

PARACETAMOL +/- WEAK OPIOIDS
- For analgesia with no anti-inflammatory effect
NSAIDS/COX-2 INHIBITORS
- Reliefs joint pain and stiffness but do not slow disease progression
- Full analgesic effect within a week while anti-inflammatory effect within 3 weeks
- Only use selective COX-2 inhibitors in patients with high risk of GI ulceration and bleeding (assess cardiovascular risk)
- Lowest effective dose prescribed for a short period
CORTICOSTEROIDS
- Exhibit rapid anti-inflammatory effect
- Large doses can supress disease progression (long term risk/toxicity)
- Can be given with DMARD or bridging before DMARD shows any effect
- Used for RA flares
- Increase the risk of osteoporosis (consider prophylaxis if treatment is long term)
- Methylprednisolone (1g max) for 3 days used to suppress active inflammation
- Prednisolone 7.5mg od used to reduce joint destruction in moderate-severe RA of less than 2 years onset
- Given as intra-articular injections (hydrocortisone acetate injections are often used for no more than 4 times/year for each inflamed joint)
DMARDS
- Used within 3-6 months of onset to prevent irreversible joint damage (max effect seen within 6 months)
- They reduce ESR, C-RP & rheumatoid factor levels to prevent further disease manifestations

SULFASALAZINE (can be taken during pregnancy)

• Used for mild-moderate RA full response in 8-12 weeks
• Initial dose is 500mg od then titrated up to 2-3 g od (divided doses) at 1-week intervals
• Monitor FBC initially and monthly during first 3 months and monitor LFTS every month for the first 3 months
• The patient must report any unexplained bleeding, bruising, sore throat or fever and stop immediately if there is blood dyscrasia

METHOTREXATE 1st line (not given if pregnant)

• Used for moderate-severe RA and effect seen after 6-8 weeks
• 7.5mg (3x 2.5mg tablets) once a week max 20mg weekly
• Monitor FBC, renal and liver functions
• Folic acid 5mg every week co-administered the day after MTX tablet to reduce side effects
• Avoid using aspirin and NSAIDS
• The patient must report sore throat, bruising and mouth ulcers (signs of blood disorders)
• The patient must report nausea, vomiting, abdominal discomfort and dark urine (signs of liver toxicity)
• The patient should report shortness of breath (sign of respiratory problems)

HYDROXYCHLOROQUINE

• Lowest efficacy and causes ocular toxicity/retinopathy
• Used for mild RA or in combination with other DMARDs
• Monitor FBC, urea, electrolytes, LFTs and eye sight

AZATHIOPRINE

• Used for severe RA. Monitor FBC
• Report GI problems

GOLD (NOT USED ANYMORE)

• Sodium aurothiomalate IM injections used for progressive disease but have severe ADRs
• Auranofin also has many ADRs and has low efficacy

PENICILLAMINE similar to gold but is better tolerated
- Low efficacy and hardly used

CICLOSPORIN used for severe active RA when other agents are inappropriate

CYCLOPHOSPHAMIDE used for RA with severe manifestations but is toxic and regular blood tests should be carried out

LEFLUNOMIDE

• Rapid onset of action effect starts after 4-6 weeks
• Same efficacy as MTX and sulfasalazine (can be used if they are not tolerated/contraindicated)
• Need a procedure to wash out (metabolite stays for a long time) if there are severe ADRs or before starting another agent or before conception
• Patients require effective contraception during treatment and for at least 2 years after in women (at least 3 months after in men)

BIOLOGICALS – CYTOKINE INHIBITORS
a) TNF-alpha inhibitors: adalimumab, certolizumab pegol, etanercept, golimumab and infliximab
b) IL-6 inhibitors: tocilizumab and sarilumab
c) IL-1 inhibitors: anakinra
d) T cell deactivator: abatacept
e) Causes B cell lysis: rituximab
- Adalimumab, etanercept +/- MTX and infliximab + MTX for active RA in adults whose disease has responded inadequately to intensive therapy with 2 cDMARDs DAS28 3.2 – 5.1 with commercial arrangement to lower price
- Adalimumab, etanercept, infliximab, certolizumab pegol, golimumab, tocilizumab and abatacept, sarilumab + MTX for active RA in adults whose disease has responded inadequately to intensive therapy with 2 cDMARDs DAS28 > 5.1
- Rituximab + MTX if other TNF-alpha inhibitors did not work DAS28 > 5.1
- Assess response after 6 months using EULAR before continuation
- Certolizumab pegol, Abatacept, golimumab, tocilizumab, Sarilumab - the manufacturers provide as agreed in the patient access schemes (PAS).
JANUS KINASE INHIBITORS (JAK)
- Inhibit tyrosine kinase: baricitinib, tofacitinib, upadacitinib and filgotinib
- Upadacitinib or Filgotinib +/- methotrexate for active RA in adults whose disease has responded inadequately to intensive therapy with 2 cDMARDs DAS28 3.2 – 5.1 with commercial arrangement to lower price
- Filgotinib, Upadacitinib, Tofacitinib, Baricitinib, or Sarilumab, Adalimumab, etanercept, infliximab and abatacept, Certolizumab pegol or Tocilizumab MTX for active RA in adults whose disease has responded inadequately to intensive therapy with 2 cDMARDs DAS28 > 5.1 with commercial arrangement to lower price
- Anakinra + MTX in controlled long-term clinical studies
- Assess response after 6 months using EULAR before continuation
SURGERY
Joint replacement and arthroplasty
PHYSIOTHERAPY

STEP WISE APPROACH

1) Monotherapy with conventional DMARD MTX, leflunomide, hydroxychloroquine or sulfasalazine +/- corticosteroid bridging
2) Combination of 2 DMARDs or change DMARD +/- corticosteroid bridging
3) cDMARD + biological DMARD
4) cDMARD + JAK inhibitor

Question 26

GOUT

Answer 26

ACUTE ATTACKS:
- NSAIDS: 50-100mg indomethacin od gradually reduced to 25mg tds over 5-7 days as attack subsides (used for 7-14 days)
- COLCHICINE: 1mg initially then 500mcg max qds (max 6 mg per course and not repeated within days) the dose is reduced for elderly/renally impaired patients
- CORTICOSTEROIDS: if 1 or few joints inflamed joints, oral/IM methyl-prednisolone 4-10mg for small joints and 20-80mg for bigger ones
- MONOCLONAL ANTIBODIES: canakinumab only used for frequent attacks (min 3 in 12 months) or if other treatments not tolerated/effective
LONG TERM MANAGEMENT AT LEAST 2 WEEKS AFTEER ATTACK WITH 3 MONTHS PROPHYLAXIS
- ALLOPURINOL: initially 100mg od after food, can be increased up to 900mg (300mg tds) according to urate levels
Dose reduced in renal failure. Ensure adequate fluid intake. Prophylactic NSAID/colchicine co-administered for at least 1 month to avoid future attacks (after correcting urate levels).
Can cause rash (exfoliative dermatitis), if it occurs withdraw and reintroduce and if it happens again stop immediately
- FEBUXOSTAT: 80mg od and 120mg od can be given if urate above 6mg/100ml 2-4 weeks following treatment
Given if allopurinol is not tolerated or contraindicated
Stop immediately if hypersensitivity or anaphylaxis occurs
- URICOSURIC: SULPHINPYRAZONE 100-200mg od with food initially increasing to 600mg od over 2-3 weeks and continued until urate level is normal (then educe gradually to 200mg od)
Avoid aspirin and salicylates when taking it
Contraindicated in renal failure (risk of urate crystals) and uric acid stones history
Not given within 3 weeks of acute attack
Prophylactic NSAID/colchicine co-administered for at least 1 month to avoid future attacks (after correcting urate levels).
- Special orders of probenecid (to prevent nephrotoxicity) and benzbromarone (for mild renal impairment) are also available
- Rasburicase is licensed for chemotherapy induced acute hyperuricaemia
LIFESTYLE CHANGES
- Weight reduction
- Lower alcohol consumption
- Lower purine intake
- Increase water intake
- Adjust dose/stop inducing drugs (thiazide diuretics and aspirin

Question 27

OSTEOARTHRITIS

Answer 27

LIFESTYLE CHANGES
- Weight reduction
- Hot press on affected joint
- Physiotherapy to preserve joint function
- Hydrotherapy/ swimming
- Suitable footwear
- TENS machine
PHARMACOLOGICAL MANAGEMENT
1- PARACETAMOL
1 g qds max regularly for 2 weeks (trial)
2- TOPICAL NSAIDS
3- ORAL NSAIDS
Start with ½ max dose and increase according to need
Diclofenac max 150mg od, ibuprofen max 2.4 g od or naproxen max 1g od
For acute inflammation but avoid if the patient is older than 65, smoker, takes anticoagulants/antiplatelets or has a history of GI problems
Avoid alcohol to prevent kidney injury
4- OPIOIDS
5- INTRA-ARTICULAR CORTICOSTEROIDS
6- CHONDROPROTECTIVE AGENTS
Chondroitin, glucosamine and vitamin E
Hyaluronic acid and its derivatives for the knee (injected into synovial fluid)
7- SURGERY IF ALL TREATMENTS FAIL

Question 28

RENAL ANAEMIA

Answer 28

ERYTHROPOIESIS STIMULATING AGENTS
- Increase RBC production
- IV (during dialysis) or SC
- Epoetin alpha, beta, theta or zeta and methoxy polyethylene glycol-epoetin beta
- Monitor haemoglobin levels, blood pressure, RBC and beware of seizures and allergic reactions
- Increases risk of stroke and VTE and pure red cell aplasia
IRON
- Oral or IV supplement given to reach target of 200-500mcg/L
- Examples are iron sucrose and iron dextran
- Higher iron level (up to 700) reduces ESA requirement, blood transfusion and mortality risk

Question 29

RENAL BONE DISEASE

Answer 29

VITAMIN D SUPPLEMENTS
- Cholecalciferol (inactive form) or calcitriol (active form) can be given with calcium
- If calcium level is normal then pulse dosing (3 times a week) is used
- If calcium level is low than 0.25-1mcg od (max 5mcg od)
- Monitor phosphate and calcium level
CALCIMIMETICS
CINACALCET
- reduces PTH release only licensed in dialysis patients but used in stage 4 CKD or post-transplant
- Monitor calcium level within 1 week of initiation and after dose changes, PTH level during the day, PTH level 12 hours post dose when PTH peaks then every 2-4 weeks
- Taken with food (in the evening) to increase bioavailability and reduce N&V
ETELCALCETIDE
- Given 3 times a week IV on dialysis days
- Initially 5mg (range 2.5-15mg)
- Used when cinacalcet not tolerated or contraindicated
- Monitor calcium and PTH levels
PHOSPHATE BINDERS
- Bind to phosphate forming insoluble compounds that are excreted. Taken with meals.
- Available as tablets, chewable tablets and sachets
- Include calcium acetate, magnesium and lanthanum cations
- Also include sevelamer, sucroferric oxyhydroxide (colours stool) and aluminium binders
- Sevelamer and calcium acetate most commonly used
- Cause GI side effects and reduce the absorption of levothyroxine, doxycycline and ciprofloxacin
PARATHYROIDECTOMY
- Indicated in calciphylaxis, pathological fractures, severe hypercalcaemia and hyperphosphatemia (PTH >85)
- Can be total or subtotal
- The patient is given calcium and active vitamin D post surgery
DIETARY RESTRICTION
- Avoid food that is high in phosphate and triggers parathyroid hormone increase

Question 30

CALCIPHYLAXIS

Answer 30

SODIUM THIOSULFATE IV

• During dialysis sessions to increase calcium solubility
• Avoid calcium and vitamin D products

Question 31

PAIN MANAGEMENT

Answer 31

WHO PAIN LADDER
1- Paracetamol +/- NSAID
2- Paracetamol +/- NSAID + weak opioid (dihydrocodeine, tramadol, paracetamol combinations or codeine)
3- Paracetamol +/- NSAID + a strong opioid (morphine, diamorphine or fentanyl)
TRAMADOL
- Weak opioid so less constipation and respiratory depression but can cause convulsions (serotonin syndrome)
- Tramacet (paracetamol+ tramadol) stronger than paracetamol but weaker than paracetamol
MORPHINE
- 5-10mg every 4 hours for normal release or every 12 hours for modified release initially (20-30mg daily or 40-60mg if switched from another opioid) can go up to 200mg every 4 hours or 600mg every 12 hours in severe pain
- If converting to SC/IM, give half oral dose
- For breakthrough pain, give 1/10 – 1/6 total daily dose or the same as the regular dose if recently initiated (not more than 1/3 – 1/2 total. Daily dose)
DIAMORPHINE
- Usually given SC/IM/IV
- To convert from morphine to diamorphine, divide by 3 (1/3 morphine dose)
- For breakthrough pain, give 1/10 – 1/6 daily total dose
- To convert from diamorphine to oral (MR) morphine, multiply total daily diamorphine dose by 2 (if pain is stable) or by 3 (if the pain is too much)
FENTANYL
- If switching from MR morphine, apply fentanyl patch after last morphine dose
- 30mg morphine per day = ‘12’ fentanyl patch for 72 hours
- Give 1/6 equivalent daily morphine dose for breakthrough pain
- If switching to another opioid, the initial dose should be low and gradually increased
BUPRENORPHINE
- Used in step 2
- If the patient is opioid naïve, then 35mcg/h patch for 4 days (moderate to severe pain)
- Full effect after 24 hours usually assessed after 72 hours
- For breakthrough pain, give 200-400mcg sublingually
- Maximum 2 patches to be worn at the same time
- Wait for 24 hours before administering another opioid (t1/2 is 30 hours)
- Available strengths are 5, 10 and 20 patches for 7 days
• For opioid induced nausea & vomiting, give metoclopramide 10mg tds or haloperidol 1.5mg om
• Usually, 2 laxatives are used while the patient is on opioids (senna and Dulcolax)