Endocrine

Question 1

MOA Canaglifozin

Answer 1

Canagliflozin reversibly inhibits sodium-glucose co-
transporter 2 (SGLT2) in the renal proximal convoluted tubule to reduce glucose
reabsorption and increase urinary glucose excretion.

Question 2

HbA1C

Answer 2

forms when red blood are exposed to glucose in plasma
reflects average plasma glucose over the past 2-3 mths
monitor ev 3-6 mths in T1DM
monitor ev 3-6 initially in T2DM and then ev 6 mths when stable
use with caution in pt with abnormal HB, anaemia, altered red cell lifespan or had a recent blood transfusion.

Question 3

Clinical presentation T1DM

Answer 3

Hyperglycaemia
ketosis
weight loss
BMI under 25
age younger than 25
Hx/family Hx autoimmune disease

Question 4

treatment T2DM - not C/I metformin

Answer 4

1. metformin and aim HbA1C 48
2. if HbA1C above 58, HbA1C of 53
   Metformin and dpp-4 (-gliptin, alogliptin, linagliptin, sitagliptin, saxagliptin, vildagliptin)
   Metformin and pioglitazone
   Metformin and sulphonylurea (glibenclamide, gliclazide, glimepriride, glipizide, tolbutamide)
   Metformin and SGLT-2 (canagliflozin, dapaliflozin, empagliflozin)
3. if HbA1C still/above 58, aim HbA1C 53
   Metformin + DPP-4 + Sulpho
   Metformin + pioglitazone + sulpho
   Metformin + pioglitazone OR sulpho + SGLT-2

Question 5

Mineralocorticoid S/E

Answer 5

hypertension
sodium retention
water retention
potassium loss
calcium loss
fluid retention

Question 6

Mineralcorticoid corticosteroids

Answer 6

Corticotropin
Fludrocortisone v.high mineralocorticoid activity (no equivalence in steroid conversion due to this)
Hydrocortisone high mineralocorticoid activity but equivalent glucocorticoid activity
tetracosactide

Question 7

Glucocorticoid S/E

Answer 7

diabetes
osteoporosis
avascular necrosis of the femoral head
muscle wasting (myopathy) 
peptic ulceration and perforation 
psychiatric reactions

Question 8

glucocorticoid corticosteroids

Answer 8

Dexamethasone and betamethasone - v.high gluco
prednisolone and prednisone - predominant gluco
deflazacort - high gluco (derived from pred)
Triamcinolone - high gluco
methylprednisolone - v.high gluco
Hydrocortisone - equivalent gluocoirticoid and mineralocorticoid activity

Question 9

Withdrawal requirement corticosteroids

Answer 9

Do not abruptly withdraw in patients with:
1. >40mg OD (or equivalent) for >1 week
KIDS: OR 2mg/kg for 1 wk
OR 1mg/kg for 1 mth
2. repeat doses in the evening
3. >3wks treatment
4. recent repeat doses esp if >3wks treatment
5. short-course corticosteroid within one year of stopping long term corticosteroid treatment
6. any other possible causes adrenal supression
Reduce quickly down to physiological dose (= 7.5mg prednisolone OD; KIDS: prednisolone 2-2.5mg/m2 OD) then stop slowly

Question 10

Factors to abruptly stop corticosteroids

Answer 10

not at risk of relapse of disease AND:
+ received treatment for 3 wks or less
+ not included in at risk group

Question 11

Associated risk factors with corticosteroids

Answer 11

ADRENAL SUPPRESSION - if abrupt withdrawal, can happen in 1 year or more after stopping - NEED STEROID CARD
INFECTION - increase susceptibility and severe infections - may have atypical symptoms or delayed symptoms presentation
CHICKENPOX: risk of severe chickenpox infection - avoid people with chickenpox
MEASLES: avoid exposure to measles
PSYCHIATRIC SYMPTOMS: get help if worrying psychological symptoms and suicidal thoughts/ideation

Question 12

corticosteroids C/I

Answer 12

injection containing benzyl alcohol in neonates
live-virus vaccines with immunosuppressive doses
active/dormant systemic infection (unless specific)

Question 13

Betamethasone BNF

Answer 13

for suppression of allergic disorder/congenital adrenal hyperplasia
S/E: hiccups
steven-johnson syndrome
STEROID CARD

Question 14

deflazacort BNF

Answer 14

suppression of inflammatory and allergic disorder
S/E: oedema
STEROID CARD

Question 15

Dexamethasone

Answer 15

suppression of inflammatory and allergic disorder
mild - severe croup
congenital adrenal hyperplasia
adjunct bacterial meningitis (unlicensed)
palliative care symptoms control
cerebral oedema
S/E: hiccups, hyperglycaemia, myocardial rupture (following recent MI), protein catabolism, perineal irritation (if IV given at large doses)

Question 16

Fludrocortisone acetate

Answer 16

neuropathic postural hypotension (unlicensed)
mineralocorticoid replacement in adrenocortical insufficiency
S/E: conjunctivitis, idiopathic intracranial hypertension., muscle weakness, thrombophlebitis
MONITORING: monitor closely in hepatic impairment

Question 17

Hydrocortison BNF

Answer 17

equal glucocorticoid and mineralocorticoid activity
thyrotoxic crisis
adrenal insufficiency
acute hypersensitive reactions
corticosteroid replacement in pt who take corticosteroid and where abrupt withdrawal = adrenal suppression
UC/ proctitis
severe/life-threatening acute asthma
C/I: X with rectal use if local/abdominal infections, perforation, obstruction
S/E: dyslipidemia, MI rupture (after recent MI), oedema, hiccups (parenteral), kaposi’s sarcoma
ABLE TO USE POM IF LIFE-THREATENING EMERGENCY - restriction don’t apply

Question 18

methylprednisolone BNF

Answer 18

suppression inflammatory and allergic disorder
treatment graft rejection
relapse multiple sclerosis
MHRA: CONTAINS LACTOSE, DO NOT USE IN PT WITH COW’S MILK ALLERGY
!rapid IV injection = CV collapse
S/E: hiccups
MONITORING: BP and creatinine in pt with systemic sclerosis

Question 19

Prednisolone BNF

Answer 19

exacerbation COPD/Asthma
mild-severe croup
suppression inflammatory and allergic response
idiopathic thrombocytopenic purpura
UC/Chron’s/Proctitis
Neuropathic pain
myasthenia gravis
Rheumatoid arthirtis or osteoarthritis, giant cell arteritis
C/I: X with rectal use if local/abdominal infections, perforation, obstruction
!Duchene’s muscular dystrophy - transient rhabdomyolysis and myoglobinuria following sternous activity.
S/E: hiccups
MONITORING: pregnant women with fluid retention
infants for adrenal suppression in breastfeeding mothers on pred higher than 40mg OD
BP and creatinine in pt with systemic sclerosis

Question 20

Triamcinolone BNF

Answer 20

suprresion of inflammatory and allergic disorder
!high dosages = proximal myopathy
!avoid in chronic therapy
S/E: dizziness, flushing, hyperglycaemia

Question 21

Biphosphonates in renal impairment

Answer 21

risedronate C/I eGFR < 30

Alendronic acid C/I in eGFR < 35

Question 22

conditions causing hypoglycaemia

Answer 22

sport 
decrease food intake 
renal impairment 
endocrine impairment
intercurrent illness

Question 23

conditions causing hyperglycaemia

Answer 23

stress
infection
trauma accidental or surgical

Question 24

stages of CKD

Answer 24

above 90: stage 1, kidney functions are normal but urine findings suggest kidney disease
60-89 ml/min: stage 2, mild kidney impairment
30-59 ml/min: stage 3, moderate kidney impairment
15-29 ml/min: stage 4 severe kidney impairment
under 15 ml/min: stage 5, kidney failure

Question 25

risk factor AKI

Answer 25

age over 65
liver disease
CKD 
HF 
Diabetes
hx AKI 
oliguria (decrease urine output)
sepsis
neurological or cognitive impairment (esp when reliant on carer)
hyvoloaemia
drug that can exacerbate AKI - ACEI/ARB, Metformin, NSAID, diuretics, aminoglycoside, contrast media
symptoms or hx of urlogical impairment 
deteriorating early warning signs