Endocrine

Question 1

what is appropriate advice to give to a patient who takes hydrocortisone and fludocortisone for addisons disease when they have concurrent illness e.g. infection?

Answer 1

Increase CCS dose during illness to prevent adrenal crisis

Question 2

What medication is used for hyperthyroidism in 1st trimester of pregnancy

Answer 2

Propylthiouracil

Question 3

A patient is on: levothyroxine and initiated on ferrous fumarate and now blood tests show low T4, Low T3, and high TSH, what is the issue here?

Answer 3

Ferrous fumarate (iron) reduces absorption of levo so no control - should wait 4 hours before taking - take levo on empty stomach 30 min before any food /caffeine

Question 4

what is an MHRA warning for corticoteroids relating to the eyes

Answer 4

rare risk of central serous chorioretinopathy with local and systemic use - counsel pts to report blurred vision and visual disturbances

Question 5

What situations should you NOT withdraw steroids abruptly?

Answer 5

• Recent repeated courses
• long term>3wks
• > 40mg pred daily >1 week or equiv
• repeated doses in evening
• addisons
• short course within 1 year of stopping

Question 6

What is ketoconazole used for in endocrine?

Answer 6

Cushings disease caused by a tumour - only used in this situation now - risk of hepatotoxicity so no longeer sused for other things

Question 7

what is 1st line for treatment of post menopausal osteoporosis

Answer 7

Alendronic acid

Question 8

State key counselling points for bisphosphonates

Answer 8

Swallow whole plenty of water
sitting upright or standing
remain upright or ~30 mins
on empty stomach 30mins before any breakfast/oral meds

Question 9

What would blood tests show if patient has hyperthyroidism?

Answer 9

High T3/T4

Low TSH

Question 10

What would blood tests show if patient has hypothyroidism?

Answer 10

Low T3/T4 
High TSH (because its a feedback loop-senses low and hormone stimulated to produce more hormones but hormones aren't produced) - needs to be replaced

Question 11

What are the symptom of hyperthyroidism?

Answer 11

Hyper e.g.

• sweating/heat intolerance
• weight loss
• tachycardia
• diarrhoea
• excitable, tremors, arrhythmias, angina

Question 12

What are the symptoms of hypothyroidism?

Answer 12

HYPO
lethargy/tiredness
weight gain
bradycardia
constipation
cold intolerance
muscle cramps, slow movement, slow thoughts, depression
hair thinning

Question 13

What are the 2 main treatments for hyperthyroidism?

Answer 13

1. Carbimazole

2. Propylthiouracil

Question 14

What is key side effect of propylthiouracil?

Answer 14

Hepatotoxicity - counsel patients

3x UPPER LIMIT

Question 15

What are 4 key side effects of carbimazole?

Answer 15

1. neutropenia and agranulocytosis-counsel pts
2. congenital malformations in pregnancy esp 1st trimester. Childbearing potential should be on effective contraception. (MHRA)
3. Acute pancreatitis- counsel pts to report severe abdominal pain
4. Rash/itch - antihistamine or switch

Question 16

what medications are used for hyperthyroidism in pregnancy?

Answer 16

1st trimester: propylthiouracil

2nd trim: carbimazole

Question 17

What regimens are contraindicated in pregnancy for hyperthyroidism?

Answer 17

Blocking replacement regimen and radioactive iodine

Question 18

Describe symptoms of thyrotoxicosis?

Answer 18

High HR >140bpm 
tachycardia, arrhythmias 
heat intolerance (high temp)
diarrhoea, N&V, dehydration
sizures, delirium, psychosis

Question 19

What is treatment for thyrotoxicosis?

Answer 19

propranolol beta blocker for symptoms
antithyroid medication 
fluids
hydrocortisone 
radioactive iodide

Question 20

What is the mainstay treatment for hypothyroidism?

Answer 20

Levothyroxine 1st line

or liothyronine but not used much

Question 21

If a patient experiences hyperthyroid symptoms e.g. irritability, diarrhoea when on levothyroxine (e.g.dose too high) what is done?

Answer 21

Refer to GP: Reduce dose or withhold for 1-2 days and start again at a lower dose

Question 22

What is counselling point for levothyroxine?

Answer 22

Take in morning at least 30 min before breakfast / caffeine containing liquids or other medicines

Question 23

What is the MHRA alert regarding levothyroxine?

Answer 23

Prescribing advice for patients who experience symptoms when switching between different products - consider TFT
consider specific tablet known to be well tolerated by patient
If still symptoms or poor control despite this: have oral solution

Question 24

In patients with existing CVD - what is recommended when initiating levothyroxine?

Answer 24

baseline ECG because changes induced by levo can be confused with ischaemia

Question 25

What is the importance of levothyroxine and diabetics?

Answer 25

Levo increases thyroid hormone levels which can increase BG levels - may need to increase doses of anti-diabetic drugs and insulin

Question 26

Why is liothyronine not used? what situations is it more beneficially used?

Answer 26

Very potent and rapid effects but rapidly metabolised by liver and may cause toxicity More use in hypothyroid emergencies - effects last 24-48hrs

Question 27

Are brands of liothyronine bioequivalent?

Answer 27

No

Question 28

What are risk factors for osteoporosis

Answer 28

``` Elderly,65+ women,75+ men Family history smoking Females menopause esp early long term CCS including inhaled high dos ```

Question 29

What is 1st line prophylaxis and treatment of osteoporosis

Answer 29

Bisphosphonates (oral-alendronic, risedronate), (IV=ibandronicacid, zoledronic acid)

Question 30

What are other 2nd line options in prophylaxis and treatment of osteoporosis?

Answer 30

Denosumab Raloxifene Teriparatide pamidronate

Question 31

What drugs are induced for prophylaxis/treatment post menopausal OP?

Answer 31

bisphosphonates calcitrol HRT e.g. tibolone Raloxifene

Question 32

When is HRT used in post menopausal OP?

Answer 32

Where others C/I or not tolerated | in women who are high risk esp early onset menopause

Question 33

When would HRT not be used?

Answer 33

In women >50 due to CV and cancer risk

Question 34

For treating osteporosis, what is the length of time bisphosphonates are used

Answer 34

3 years - no benefit if more

Question 35

What is the dosing for alendronic acid and risedronate

Answer 35

AA: 70mg week or 10mg day Risedronate: 35mg week (or 5mg day)

Question 36

What is the administration counselling for risedronate

Answer 36

Can be taken at any time of day but leave a 2 hour gap with food/drink/antacids/calcium products/iron/milk Remain upright for 30 mins

Question 37

What are MHRA warnings for bisphosphonates (4)

Answer 37

1. Osteonecrosis of jaw 2. osteonecrosis of auditory canal 3. Atypical femoral fractures 4. Oesophageal reactions

Question 38

What are the counselling points for osteonecrosis of jaw for bisphosphonates?

Answer 38

Oral symptoms (dr and dentist) - mobility, pain, swelling, sores Dental check ups and any work done Oral hygeine Appropriate denture fit

Question 39

Which bisphosphonate has highest risk of osteonecrosis of jaw?

Answer 39

IV zolendronic acid - potent

Question 40

What are the counselling points for osteonecrosis of auditory canal for bisphosphonates?

Answer 40

report ear pain, discharge, infection | Mainly in >2 yrs

Question 41

What are the counselling points for atypical femoral fractures for bisphosphonates?

Answer 41

Reporting any thigh, hip or groin pain

Question 42

What are the counselling points for oesophageal irritation in bisphosphonates?

Answer 42

Dysphagia, new or worsening heartburn or retrosternal pain - report Be aware of people purchasing gaviscon etc

Question 43

Which drug used in osteoporosis is not recommended due to long term risk of malignancy?

Answer 43

Calcitonin /calcitrol

Question 44

Name 3 key side effects of denosumab (60mg use in osteoporosis) ?

Answer 44

1. Atypical femoral fractures long term after discontinuation 2. hypocalcaemia 3. osteonecrosis of auditory canal and jaw