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GPhC BNF > ENDOCRINE > Flashcards

ENDOCRINE Flashcards

1
Q

ANTIDIURETIC HORMONES

DIABETES INSIPIDUS

EXCESS DILUTE URINE=?

A

EXTREME THIRST

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2
Q

NORMAL PERSON? ADH, hypothalamus

A

Hypothalamus produces vasporessin (ADH)->stored in pituitary gland
ADH released when water in the body becomes too low
ADH retains water in the body by reducing amount of water lost through the kidneys

Therefore, more CONCENTRATED urine

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3
Q

DIABETES INSIPIDUS?

A

Reduced production of ADH
Kidneys do NOT retain much water, so too much water passed from body
Causing extreme thirst/polyuria

Therefore, more DILUTE urine

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4
Q

2 TYPES OF DIABETS INSIPIDUS?

A

PITUITARY (CRANIAL)- lack of ADH production

NEPHROGENIC (PARTIAL)- NO response to ADH

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5
Q

DIABETES INSIPIDUS

PITUITARY (CRANIAL) TREATMENT?

A

VASOPRESSIN/DESMOPRESSIN

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6
Q

DIABETES INSIPIDUS

NEPRHOGENIC (PARTIAL) TREATMENT?

A

THIAZIDE-DIURETIC (paradoxical effect)

HOW DOES THIS WORK? UNDERSTANDING!

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7
Q

DESMOPRESSIN x3 FEATUERS?

A

More potent+longer duration of action than vasopressin

No vasoconstrictor effect->avoid bp conditions?

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8
Q

DESMOPRESSIN- SIDE-EFFECTS?

A

Hyponatraemia

Nausea

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9
Q

INAPPROPRIATE ADH SECRETION

Hyponatraemia explained?

A

Increased ADH-> body stores too much water-> dilutes the salt conc. in the blood-> hyponatraemia

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10
Q

HYPONATRAEMIA TREATMENT? FDT

A

FLUID RESTRICTION
DEMECLOCYCLINE (blocks renal tubular effect of ADH)
TOLVAPTAN (vasopressin antagonist)

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11
Q

Why do we AVOID rapid correction of hyponatraemia w/ Tolvaptan?

A

Causes osmotic demyelination-> serious neurological events

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12
Q

CORTICOSTEROIDS

2 TYPES?

A

MINERALCORTICOIDS

GLUCOCORTICOIDS

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13
Q

x2 FEATURES OF MINERALCORTICOID STEROIDS? Bottle of water

A

HIGH FLUID retention

LOW anti-inflammatory effect

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14
Q

MINERALCORTICOID STEROID ACTIVITY? high to low

A

FLUDROCORTISONE

HYDROCORTISONE

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15
Q

FLUDROCORTISONE ALSO USED TO TREAT?

A

POSTURAL HYPOTENSION

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16
Q

MINERALCORTICOID SIDE-EFFECTS?

A

Oedema
Hypertension-> soidum+water retention
Potassium loss-> hypokalaemia
Calcium loss-> hypocalcaemia

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17
Q

Mineralocorticoid actions are negligible with the high potency…? GBD

A

GLUCOCORTICOIDS
BETAMETHASONE
DEXAMETHASONE

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18
Q

X2 FEATURES OF GLUCORTICOID STEROIDS?

A

HIGH ANTI-INFLAMMATORY EFFECT

LOW FLUID RETENTION

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19
Q

HIGHEST GLUCOCORTICOID STEROID ACTIVITY?

A

DEXAMETHASONE/BETAMETHASONE

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20
Q

GLUCOCORTCOID SIDE-EFFECTS? DOAG

A

DIABETES
OSTEROPOROSIS-> fractures
AVASCULAR NECROSIS OF FEMORAL HEAD+ MUSCLE WASTING
GASTRIC ULCERATION+PERFORATION

Clopi+Lans, NOT Omep

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21
Q

CORTICOSTEROID SIDE-EFFECTS? MHRA

A

CENTRAL SEROUS CHORIORETINOPATHY->report blurred vision/other visual disturbances

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22
Q

CORTICOSTEROID PSYCHIATRIC REACTIONS?

A

INSOMNIA, IRRITABILITY, MOOD CHANGE, ETC

SEEK ADVICE+STOP TEATMENT

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23
Q

STEROID EMERGENCY CARD? For patients with…

A 
ADRENAL INSUFFICIENCY
STEROID DEPENDENCE (risk of adrenal crisis)
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24
Q

CORTCOISTEROID SIDE-EFFECTS

ADRENAL SUPPRESSION?

A

Prolonged use can lead to adrenal atrophy (years)

DON’T STOP ABRUPTLY (acute adrenal insufficiency/hypotension/death)

Significant illness/trauma/surgery-> temporary increase in corticosteroid dose OR temporary reintroduction if already stopped

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25
Q

CORTICOSTEROID SIDE-EFFECTS? I->CM

A

INFECTIONS (immunocompromised, can’t clock on)
|
CHICKEN POX-> passive immunisation w/ varicella-zoster immunoglobin if unimmune (+if taken steroid in past 3 months)
|
MEASLES-> prophylaxis w/ IM normal immunoglobulin if needed

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26
Q

CORTICOSTEROID SIDE-EFFECTS? ICS

A

INSOMNIA-> take OM (cortisol produced then)
CHILDREN-> stunted growth, even w/ inhaled
SKIN THINNING-> most common in topical (apply thinly!)

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27
Q

CORTICOSTEROID PROLONGED USE SIDE-EFFECT?
Manage?
Treat?

A 
CUSHING'S SYNDROME
|
Moon face/striae/hirsutism/acne
|
Manage? w/ Metyrapone
Treat? w/ Ketoconazole
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28
Q 
CORTICOSTEROID SIDE-EFFECTS ROUND UP
C
O
R
T
I
C
O
S
t
E
R
O
I
D
u
S
e
A 
Cushing's
Osteroporosis
Retardation of growth
Thin skin
Immunocompromised+Insomnia
Chorioretinopathy
Oedema (water retention)
Striae
T?
Emotional
Rise in BP (Hypertension)
Obestity (truncal)
Increased hair growth (hirsutism)
Diabetes mellitus (hyperglycaemia)
u
SUPPRESSION (adrenal)
Electrolyte imbalance (hypokalaemia
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29
Q

HOW DO WE MANAGE STEROID SIDE-EFFECTS?

A 
LOWEST EFFECTIVE DOSE, MINIMUM PERIOD
SINGLE DOSE OM
2 DAYS DOSE? GIVE ON ALTERNATE DAYS
SHORT COURSES? INTERMITTENT THERAPY
LOCAL>SYSTEMIC
e.g. creams, inhalations, eye-drops, enemas
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30
Q

WHEN DO YOU GRADUALLY WITHDRAW FROM STEROIDS?

GIVE ALL?

A

> 40MG PREDNISOLONE FOR >1 WEEK

REPEAT EVENING DOSES

> 3 WEEKS TREATMENT, ANY DOSE

RECEIVED RECEIVED REPEATED COURSES/TAKEN SHOURT COURSE WITHIN 1 YEAR OF STOPPING LONG-TERM THERAPY

OTHER CAUSES OF ADRENAL SUPPRESSION

GIVE ALL? STEROID CARD

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31
Q

TOPIC STEROID POTENCIES

MILD?

MODERATE?

POTENT?

VERY POTENT?

A

MILD? Hydrocortisone

MODERATE? Clobetasone

POTENT? Betamethasone

VERY POTENT? Clobetasol

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32
Q

WHAT IS ADRENAL INSUFFICIENCY CAUSED BY?

A

ADDISON’S DISEASE

CONGENITAL ADRENAL HYPERPLASIA

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33
Q

ADRENAL INSUFFICIENCY TREATMENT?

PRIMARY?

A

TREAT WITH HYDROCORTISONE

PRIMARY? +FLUDROCORTISONE (mineralcorticoid replacement- aldosterone deficiency)

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34
Q

ADRENAL INSUFFICIENCY CAN LEAD TO…?

A

ADRENAL CRISIS

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35
Q

SYMPTOMS OF ADRENAL CRISIS? SHAS^2 CD

A 
SHAS^2 CD
SEVERE DEHYDRATION
HYPOVOLAEMIC SHOCK
ALTERED CONSCIOUSNESS
SEIZURES
STROKE
CARDIAC ARREST
|
DEATH
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36
Q

ADRENAL CRISIS TREATMENT?

A

hydrocortisone+Rehydration using a crystalloid fluid (e.g. sodium chloride 0.9%).

For patients usually on fludrocortisone, high-dose hydrocortisone has sufficient mineralocorticoid effect to cover this

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37
Q

DIABETES MELLITUS is…?

A

PERSISTENT HYPERGLYCAEMIA

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38
Q

DIABETES CAN BE CAUSED BY…?

A

DEFICIENT INSULIN SECRETION (TYPE 10
RESISTANCE TO ACTION OF INSULIN (TYPE 2)
PREGNANCY (GESTATIONAL)
MEDICATIONS (SECONDARY) e.g. STEROIDS!

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39
Q

DIABETES MELLITUS- DRIVING

All drivers w/ insulin must notify the DVLA.

What is awareness of hypoglycaemia?

A

The capability of bringing their vehicle to a safe controlled stop

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40
Q

GROUP 1 DRIVERS?

A

ADEQUATE AWARENESS OF HYPOGLYCAEMIA

NO MORE THAN 1 EPISODE OF SEVERE HYPOGLYCAEMIA WHILST AWAKE IN THE PRECEDING 12 MONTHS

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41
Q

GROUP 2 DRIVERS? (HGV, bus, etc)

A

FULL AWARENESS OF HYPOGLYCEAMIA
MUST REPORT ALL EPISODES, INCLUDING IN SLEEP
NO EPISODES OF SEVERE HYPOGLYCAEMIA IN THE PRECEDIG 12 MONTHS
MUST USE A BG meter with sufficient memory- store 3 months of readings
VUSUAL COMPLICATIONS- holla DVLA+do not drive

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42
Q

ADVICE FROM THE DVLA?

<5?

<4?

A

Insulin treatment? Carry a GM+BGS
Check BGC no >2hrs before driving+/2hours whilst driving
B-G should always be>5mmol/L whilst driving
<5mmol/L? Lickle snack
Ensure supply of FAST-ACTING carb in the whip

<5? lickle snack

<4? stop the whip

wait until 45 minutes after blood-glucose has returned to normal, before continuing journey

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43
Q

HYPOGLYCEAMIA WHILST DRIVING?

A

<4mmol/L

SAFELY STOP VEHICLE
OFF THE ENGINE, REMOVE KEYS FROM IGNITIONS, MOVE FROM DRIVER’S SEAT
EAT/DRINK SUITABLE SOURCE OF SUGAR
WAIT TILL 45MINS AFTER B-G BACK TONORMAL

DO NOT DRIVE IF HYPOGLYCAEMIA AWARENESS L+NOTIFY DVLA

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44
Q

TPYE 1 DIABETES

INSULIN DEFICIENCY?

A

DESTRUCTION OF INSULIN-PRODUCING BETA-CELLS IN THE PANCREATIC ISLETS OF LANGERHANS

Most common before adulthood

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45
Q

FEATURES OF TYPE 1 DIABETES?

A 
HYPERGLYCAEMIA (>11mmol/L)
KETOSIS
RAPID WEIGHT LOSS
BMI<25
AGE<50
FAMILY HISTORY OF AUTOIMMUNE DISEASE
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46
Q

TYPE 1 DIABETES- BLOOD GLUCOSE MONITORING

HOW MANY TIMES?

A

MONITOR AT LEAST 4 TIMES A DAY (including before each meal+before bed)

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47
Q

TYPE 1 DIABETES- BLOOD GLUCOSE MONITORING

TARGETS?

A

5-7 mmol/L on WAKING (fasting)
4-7 mmol/L fasting BG BEFORE meals at other times of the day
5-9 mmol/L 90mins AFTER eating
>5 mmol/L when driving

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48
Q

TYPE 1 DIABETES- INSULIN REGIMENS

HOW MANY TYPES?

A

MULTIPLE DAILY INJECTION BASAL-BOLUS (1st LINE)

BIPHASIC (mixture)

CONTINUOUS SC INFUSION (insulin pump)

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49
Q

TYPE 1 DIABETES- MULTIPLE DAILY INJECTION BASAL-BOLUS REGIMEN

BASAL?
AND
BOLUS?

A 
BASAL (long/intermediate acting) OD or BD
AND
BOLUS (short/rapid acting) before meals
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50
Q

BASAL
1st LINE?
2nd LINE?

A

1st LINE? Insulin detemir BD

2nd LINE? Insulin glargine OD

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51
Q

TYPE 1 DIABETES- BIPHASIC MIXTURES?

A

SHORT-ACTING mixed with INTERMEDIATE insulin injected 1-3 TIMES A DAY

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52
Q

TYPE 1 DIABETES- CONTINOUS SC INFUSION (insulin pump) for..?

A

Adults who suffer w/ disabling hypoglycaemia/uncontrolled hyperglycaemia

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53
Q

WHAT FACTORS INCREASE INSULIN REQUIREMENTS? SIT DOWN BRO!

A

IST
Infection
Stress
Trauma

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54
Q

WHAT FACTORS DECREASE INSULIN REQUIREMENTS? EIRIE

A 
EIRIE
Exercise
Intercurrent illness
Reduced food intake
Impaired renal function
Endocrine disorders (thyroid, coeliac, addison's)
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55
Q

INSULIN ADMINISTRATION ADVICE?

A

Inactivated by GI enzymes- so SC

Injected into body area with plenty of SC fat:
abdomen (fast)
outer thighs/buttocks (slow)

Rotate injection sites:
Lipohypertrophy happens due to repeato injection sites into same suto area
Cutaneous amyloidosis (amyloid protein under skin)
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56
Q

2 TYPES OF SHORT-ACTING INSULIN?

A

SOLUBLE

RAPID-ACTING

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57
Q

SHORT-ACTING- SOLUBLE INSULIN

EXAMPLE?
INJECT?
ONSET?
DURATION?

A

EXAMPLE? HUMAN+BOVINE/PORCINE

INJECT? 15-30mins BEFORE MEALS

ONSET? 30-60mis, peak 1-4hrs

DURATION? Up to 9hrs

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58
Q

SHORT-ACTING- RAPID-ACTING INSULIN
NO LAGing

EXAMPLE?
INJECT?
ONSET?
DURATION?

A

EXAMPLE? Lispror/Aspart/Glulisine

INJECT? Immediately before meal

ONSET? <15mins (NO LAG!)

DURATION? 2-5hrs

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59
Q

INTERMEDIATE-ACTING INSULIN/BIPHASIC

EXAMPLE?
ONSET?
DURATION?

A

EXAMPLE? Biphasic isophane/biphasic aspart/biphasic lispro (isophane mixed with SA)

ONSET? 1-2hr, peak 3-12hrs

DURATION? 11-24hrs

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60
Q 
LONG-ACTING INSULIN
DDG
EXAMPLE?
INJECT?
ONSET?
DURATION?
A

DDG
EXAMPLE? Detemir/Degludec/Glargine

INJECT? OD (Detemir= BD)

ONSET? 2-4days to reach steady state

DURATION? 36hrs

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61
Q

TYPE 2 DIABETES is characterised by…?

A

Insulin resistance, later in life

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62
Q

Prediabetic HBA1c?

A

42-47mmol/mol

Can try prevent diabetes with lifestyle advice

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63
Q

Diabetes HbA1c?

A

48mmol/mol

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64
Q

DIABETES TREATMENT- LOW CVD RISK

What do you need to assess first?

A

HbA1c
Kidney function
Cardiovascular risk

ALL INDIIVDUALLY AGREED THRESHOLDS!

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65
Q

DIABETES TREATMENT- LOW CVD RISK

1st LINE?

A

METFORMIN

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66
Q

DIABETES TREATMENT- LOW CVD RISK

Metformin L,
HBA1C> individually agreed threshold?

A 
DUAL THERAPY
ADD IN...
DPP-4i (gliptin) 
OR
Pioglitazone
OR
SU (Sulphonylurea- glic, glim, tolb)
OR
SGLT-2i (Flozins)
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67
Q

DIABETES TREATMENT- LOW CVD RISK

DUAL THERAPY L..
HBA1C> individually agreed threshold?

A 
TRIPLE THERAPY by...
adding/swapping class of anti-diabetic

NOTE: DAPAG with PIOG not recommended, OTHER SGLT-2is calm

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68
Q

DIABETES TREATMENT- HIGH CVD RISK

When is it high risk?

A

Established atherosclerotic CVD
HF
QRISK2>10%

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69
Q

DIABETES TREATMENT- HIGH CVD RISK

1ST LINE?
ONCE TOLERATED?
IF NOT TOLERATED?

A

1ST LINE? METFORMIN

ONCE TOLERATED? ADD SLGT-2i

IF NOT TOLERATED? ALONE SLGT-2i

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70
Q

DIABETES TREATMENT- HIGH CVD RISK

HBA1C> individually agreed threshold?

A

SAME AS DUAL+TRIPLE THERAPY FLASHCARDS!

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71
Q

Patient w/ diabetes develops high risk CVD?

A

Consider SLGT-2i first.

EU marketing agency, recent approval for flozins in HF, draining effect. Lotta hype!

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72
Q

TREATMENT OF DIABETES- METFORMIN RESISTANCE

Patient can’t tolerate metformin due to side-effects?

A

Use MR preparations

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73
Q

TREATMENT OF DIABETES- METFORMIN RESISTANCE

Patient can’t tolerate metformin MR? Treat w/…

BUT
When high risk of CVD?

A

Treat w/ DPP-4I/Pioglitazone/SU/SLGLT-2I
(SU first choice heeh)

BUT
When high risk of CVD? SGLT-2i

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74
Q

TREATMENT OF DIABETES- METFORMIN RESISTANCE

HbA1c above individually agreed threshold& Monotherapy an L?
Treat w/…

A 
Treat w/...
DPP-4i+Piogltiazone
OR
DPP-4i+SU
OR
Pioglitazone+SU
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75
Q

TREATMENT OF DIABETES- METFORMIN RESISTANCE

HbA1c STILL not controlled..?

A

INSULIN THERAPY!

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76
Q

METFORMIN (biguanide)

MOA?

A

Decreases gluconeogenesis+increases peripheral utilisation of glucose
mad

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77
Q

METFORMIN SIDE-EFFECTS? LGV

A

LGV
Lactic acidosis (avoid if eGFR<30)
GI side-effects (increase dose slowly/give MR prep)
Can reduce vitamin B12

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78
Q

PATIENT ON METFORMIN w/ AKI?

A

STOP!

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79
Q

SULPHONYLUREAS
MOA?

S for secretion!

A

STILMULATES insulin secretio

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80
Q

SULPHONYLUREAS

MOA?

A

Stimulates insulin secretion from pancreatic beta cell

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81
Q

2 TYPES OF SULPHONYLUREAS?

A

SHORT-ACTING- GT- gliclazide, tolbutamide, glipizide

LONG-ACTING- GG- glibenclamide, glimepiride

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82
Q

What is LONG-ACTING sulphonylureas associated with?

A

Associated with prolonged/sometimes fatal cases of hypoglycaemia
AVOID IN ELDERLY

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83
Q

SULPHONYLUREAS- SIDE-EFFECTS? AH(R)F, not KHF

A 
High risk of hypoglycaemia
AVOID in: 
Acute porphyria (GTGTGTGTGTGTGTGT)
Hepatic/Renal
FAILURE
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84
Q

PIOGLITAZONE
MOA?

P for less peripheral!

A

Reduces peripheral insulin resistance

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85
Q

PIOGLITAZONE

AVOID IN…?

A

Patients with history of HF

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86
Q

PIOGLTAZONE

There’s an increase risk of…?

Report what..?

A

-Bladder cancer
review safety+efficacy after 3-6months
stop treatment if patient responds inadequately

REPORT…
Haematuria (blood in urine)
Dysuria (painful urination)
Urinary urgency

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87
Q

PIOGLITAZONE

Increase risk of…? continued

A

BONE FRACTURES

LIVER TOXICITY- report N&V, abdominal pain, fatigue & dark urine

PIOGLITAZONE IS MOSTLY ASSOCIATED WITH...
HF
BLADDER CANCER
BONE FRACTURES
LIVER TOXICITY
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88
Q

DPP-4i
MOA?

increases one, decreases the other

A

Increases insulin secretion+lowers glucagon secretion

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89
Q

DPP-4i

Can cause..?

A

Pancreatitis
Discontinue if symptoms of acute pancreatitis occur…
- persistent, severe abdominal pain

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90
Q

DPP-4i EXAMPLES?

A 
ALLOGLIPTIN
LINAGLIPTIN
SAXAGLIPTIN
SITAGLIPTIN
VILDAGLIPTIN (hepatotoxic)
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91
Q

SLGT-2iS

MOA?

A

Inhibits SLGT2 in renal proximal convoluted tubule (more urine, glucose, infection)

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92
Q

SGLT-2iS

MHRA WARNINGS? DKAKFaGLLA

MONITOR RENAL FUNCTION!

A

DIABETIC KETOACIDOSIS
MONITOR KETONES if treatment interruped-> surgery/illness
FOURNIER’S GANGRENE
CANAGLIFLOZIN only: risk of lower-limb amputation (mainly toes)

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93
Q

SGLT-2iS

Volume depletion?

A

Due to lots of urination, loss of water

Correct hypovolaemia (reduced volume of circulating blood in body) before starting treatment

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94
Q

SGLT-2iS EXAMPLES?

A

CANAGLIFLOZIN
DAPAGLIFLOZIN
EMPAGLIFLOZIN

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95
Q

GLP-1 AGONIST
MOA?

GLP-1 receptor

A

BINDS TO GLP-1 RECEPTOR
Increases insulin secretion,
suppresses glucagon secretion
slows gastric emptying

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96
Q

GLP-1 AGONIST

EXAMPLES? -tides

A

DULAGLUTIDE
EXENATIDE
LIRAGLUTIDE
LIXISENATIDE

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97
Q

GLP-1 AGONIST SIDE-EFFECTS?

A

DULAGLUTIDE!!!
ACUTE PANCREATITIS- persistent, severe abdominal pain

DEHYDRATION- risk, due to GI side-effects, take precautions to avoid fluid depletion?

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98
Q

OTHER ANTIDIABETICS

ACARBOSE?

A

Delays digestion+absorption of starch+sucrose

Risk of GI side-effects- reduce dose?

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99
Q

OTHER ANTIDIABETICS

MEGLITIDES (Nataglinide/Repaglinide)?

A

Stimulates insulin secretion

Stressed? Change to treatment to insulin to maintain glycaemia control? :/

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100
Q

DIABETICS, PANCREATITIS ASSOCIATION? G^2

A

GLIPTINS

GLP-1 AGONIST, -tides-> PERSISTENT, ABDOMINAL SEVERE PAIN

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101
Q

ANTIDIABETIC EFFECT ON WEIGHT

WEIGHT GAIN?

NEUTRAL?

WEIGHT LOSS?

A

WEIGHT GAIN? Pioglitazone+Sulphonylureas+Insulin

NEUTRAL? Metformin+DPP-4i

WEIGHT LOSS? GLP-1+SGLT-2i

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102
Q

DIABETIC COMPLICATIONS

CARDIOVASCULAR DISEASE? Diabetes strong rf

WHAT DRUG IS CONSIDERED IN ALL TYPE 1 PATIENTS?

WHAT DRUG REDUCES CVD RISK?

A

WHAT DRUG IS CONSIDERED IN ALL TYPE 1 PATIENTS? Low-dose atorvastatin, offer to:
40+years
diabetic 10+years
nephropathy/other CVD factors

WHAT DRUG REDUCES CVD RISK?
ACEi, regardless of ethnicity

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103
Q

DIABETIC COMPLICATIONS

DIABETIC NEPHROPATHY, proteinuria (protein in urine)
TREATMENT?

WHAT DRUG CAN POTENTIATE HYPOGLYCAEMIA EFFECT OF ANTIDIABETIC DRUGS/INSULIN?

A

DIABETIC NEPHROPATHY, proteinuria (protein in urine)
TREATMENT? ACE-i/ARB

WHAT DRUG CAN POTENTIATE HYPOGLYCAEMIA EFFECT OF ANTIDIABETIC DRUGS/INSULIN? ACE-i (risk of HYPERkalaemia)

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104
Q

DIABETIC COMPLICATIONS

DIABETIC NEUROPATHY TREATMENTS

PAINFUL PERIPHERAL NEUROPATHY?
Diabetic foot?

AUTONOMIC NEUROPATHY?

NEUROPATHIC POSTURAL HYPOTENSION?

GUSTATORY SWEATING?

ERECTILE DYSFUNCTION?

VISUAL IMPAIRMENT?

A

PAINFUL PERIPHERAL NEUROPATHY? antidepressants/gabapentin/pregabalin
Diabetic foot? treat pain+manage infection

AUTONOMIC NEUROPATHY? treat diarrhoea w/ codeine/tetracyclines

NEUROPATHIC POSTURAL HYPOTENSION? increase salt intake/fludrocortisone

GUSTATORY SWEATING? antimuscarinic- propantheline bromide

ERECTILE DYSFUNCTION? Sildenafil

VISUAL IMPAIRMENT? Yearly eye tests

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105
Q

DIABETEIC KETOACIDOSIS- SEVERE HYPERGLYCAEMIA

SYMPTOMS? PTP(B)DLC

A 
PTPDLC
Polyurea
Thirsty
Pear drop breath smells (ketones)
(B) Deep breathing
Lethargic
Confusion

LUC, DKA or just drunk?

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106
Q

DKA- checking blood sugar levels

What do you do if…

PATIENT DISPLAYS SYMPTOMS OF DKA?

BLOOD SUGAR LEVELS >11mol/L?

A

PATIENT DISPLAYS SYMPTOMS OF DKA? Check blood sugar levels

BLOOD SUGAR LEVELS >11mol/L? Check ketone levels

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107
Q

DKA- ketone levels

  1. 6-1.5mmol?
  2. 6-2.9mmol?

3mmol?

A
  1. 6-1.5mmol? slight risk (retest in 2hrs)
  2. 6-2.9mmol? increased risk (contact GP)

3mmol? medical emergency

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108
Q

DKA- TREATMENT

BP<90?

Once BP>90? Give…

Start IV insulin mixed w/ NaCl, administer at a rate so that
ketone conc. falls at?
blood glucose conc. falls at?

A

BP<90? RESTORE VOLUME W/ 500ml IV NaCl 0.9%

Once BP>90? GIVE MAINTENANCE IV NaCl 0.9%

Start IV soluble human insulin! mixed w/ NaCl, administer at a rate so that…?

  • ketone conc. falls at 0.5mmol/L/hr
  • Blood glucose conc/ falls at 3mmol/L/hr
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109
Q

DKA- TREATMENT

What do you do when blood glucose <14mmol/L?

Continue insulin till..
ketone<
ph>?

When patient is able to eat, give…?

Finally, stop treatment…?

A

What do you do when blood glucose <14mmol/L? Give IV glucose 10%

Continue insulin till..
ketone <3 mmol/L
&
pH>7.3

When patient is able to eat, give fast-acting insulin w/ meal

Finally, stop treatment 1hr after food

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110
Q

INSULIN DURING SURGERY

ELECTIVE (minor w/ good glycaemic control) day before?

A

ELECTIVE (minor w/ good glycaemic control) day before? Reduce OD long-acting dose by 20%, rest as usual

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111
Q

INSULIN DURING SURGERY

ELECTIVE (major/poor glycaemia control)

DAY BEFORE?

ON THE DAY?

A

DAY BEFORE?
Reduce long-acting dose by 20%- rest as usual

ON THE DAY?

  • Reduce long-acting dose by 20%- stop other insulin till patient eating
  • IV infusion of KCL+Glucose+NaCl
  • Variable rate IV insulin (soluble human)
  • Hourly blood glucose measurements for first 12hrs
  • Give IV glucose 20% if blood glucose dips <6mmol/L
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112
Q

INSULIN- POST SURGERY

When do you convert back to SC insulin?

BASAL-BOLUS REGIMEN?

A

CONVERT BACK TO SC INSULIN when patient can eat/drink

Restart B-B with the first meal- IV insulin infusions carried on till 30-60mins after first meal-time short-acting insulin dose

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113
Q

INSULIN- POST SURGERY

LONG-ACTING REGIMEN?

A

Carry on at 80% until patient leaves hospital

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114
Q

INSULIN- POST SURGERY

BD REGIMEN?

A

Restart before breakfast/evening meal- IV insulin infusion carried on for 30-60mins after first SC insulin dose

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115
Q

SICK DAY RULES

SUGAR LEVELS?

INSULIN?

CARBOHYDRATES?

KETONES?

A

SUGAR LEVELS? Check regularly

INSULIN? Carry on taking

CARBOHYDRATES? Keep eating+stay hydrated

KETONES? Check regularly

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116
Q

DIABETES- PREGNANCY/BREASTFEEDING

Risks to woman+foetus, risk reduced by effective blood-glucose control

117
Q

DIABETES- PREGNANCY/BREASTFEEDING

PLANNING FOR PREGNANCY?

A

Aim for HbA1c< 48mmol/mol

Take folic acid 5mg

118
Q

FOLIC ACID

HIIGH RISK OF NEURAL TUBULE DEFECTS?

A

diabetes, antiepileptics, previous yute, smoking is just at risk factor, relax

5MG OD
BEFORE CONCEPTION+TILL WEEK 12 PREGNANCY

SICKLE CELL THROUGHOUT

119
Q

FOLIC ACID

LOW RISK OF NEURAL TUBULE DEFECTS?

A

400MCG OD

BEFORE CONEPTION+TILL WEEK 12 PREGNANCY

120
Q

WOMEN TAKING INSULIN MUST BE AWARE OF..?

A

HYPOGLYCAEMIA RISK
+
ALWAYS CARRY FAST-ACTING GLUCOSE

121
Q

DIABETES- PREGNANCY/BREASTFEEDING

x3 MEDICATION KEY POINTS?

A
  • Stop all antidiabetics, bar metformin.
  • 1st line long-acting insulin: isophane insulin*
  • Statins/ACE-i/ARBs-> discontinue

*Good blood glucose control before pregnancy w/ long-acting insulin analogues (detemir/glargine) calm to continue

122
Q

GESTATIONAL DIABETES

Developed during pregnancy, STOP treatment after birth

123
Q

GESTATIONAL DIABETES

Fasting BG<7mmol/L?

A
  1. Diet+Exercise. L?
  2. Metformin (unlicensed). L?
  3. Insulin

IF REQUIREMENTS NOT MET IN 1-2 WEEKS!

124
Q

GESTATIONAL DIABETES

Fasting BG>7mmol/L?

A

diet, exercise, insulin and MAYBE metformin

no longer glinbeclamide!

125
Q

GESTATIONAL DIABETES

Fasting BG 6-6.9mmol/L w/ complications?

macrosomia- newborn»»> than average
hydramnios-&raquo_space;»>amniotic fluid build up

A

Insulin

with/without Metformin

126
Q

HYPOGLYCAEMIA- mmol/L?

127
Q

HYPOGLYCAEMIA- SYMPTOMS?

A 
SWEATING
LETHARGIC
DIZZINESS
HUNGER
TREMOR
TINGLING LIPS
PALPITATIONS
EXTREME MOODS
PALE
128
Q

HYPOGLYCAEMIA- TREATMENT (conscious+can swallow)
with/without symptoms!

What 3 things could you give?

A

FAST-ACTING CARBS:

  • 4-5 glucose tablets
  • 3-4 heaped teaspoonfuls of sugar
  • 150-200mL fruit juice
  • Repeat/ 15mins for 3 cycles
129
Q

HYPOGLYCAEMIA- TREATMENT (patient unconscious/swallow L)

What do you do now?

A

IV glucagon
unresponsive after 10mins?
IV glucose

130
Q

Why be careful with b-blockers?

A

Can mask the effects of hypoglycaemia

131
Q

OSTEOPOROSIS

What is it?

A

Progressive bone disease- reduction of bone mass+density, causing increased risk of fractures

132
Q

RISK FACTORS FOR OSTEOPOROSIS?

A 
POSTMENOPAUSAL WOMEN
MEN>50
LONG-TERM ORAL CORTICOSTEROIDS (glucocorticoids)
Age increase
Vitamin D+Calcium deficiency
Lack of exercise
Low BMI
Smoking+drinking
History of fractures
Early menopause
133
Q

LIFESTYLE CHANGES?

A 
Increase exercise
Smoking cessation
Maintain an ideal BMI
Reduce alcohol intake
Increase intake of vitamin D+calcium (supplement if need be)
134
Q

OSTEOPOROSIS- TREATMENT

Review need for medication after how many years?

A

After 5 years for most meds, 3 years for Zoledronic

135
Q

OSTEOPOROSIS- TREATMENT

1st LINE?

A

ORAL BISPHOSPHONATES (alendronic acid/risedronate sodium)

136
Q

OSTEOPOROSIS- TREATMENT

POSTMENOPAUSAL?

A

POSTMENOPAUSAL? ibandronic acid/denosumab/raloxifene/strontium

137
Q

OSTEOPOROSIS- TREATMENT

YOUNGER MENOPAUSAL WOMEN?

A

USE HRT/TIBOLONE

138
Q

OSTEOPOROSIS- TREATMENT

A

TERIPARATIDE- used in severe osteoporosis

139
Q

OSTEOPOROSIS TREATMENT

MEN?

A

ZOLENDRONIC ACID
DENOSUMAB
TERIPARATIDE
STRONITUM

140
Q

OSTEOPOROSIS TREATMENT

GLUCOCORTICOID-INDUCED?

A

FIRST LINE
ALENDRONIC ACID/RISEDRONATE

ZOLEDRONIC ACID
DENOSUMAB
TERIPARATIDE

141
Q

GLUCOCORTICOID-INDUCED OSTEOPOROSIS

Bone-protection treatment, considered in everyone on large dose corticosteroids for how many months?

A

> 3 months

142
Q

GLUCOCORTICOID-INDUCED OSTEOPOROSIS

WOMEN- RISK FACTORS?

A

> /= 70 years
Previous fragility fracture
Large doses of glucocorticoids (>/= prednisolone 7.5mg OD)

143
Q

GLUCOCORTICOID-INDUCED OSTEOPOROSIS

MEN- RISK FACTORS?

A

> /= 70 years AND either:
Previous fragility fracture
OR
Large doses of glucocorticoids

144
Q

BISPHOSPHONATES- MHRA WARNINGS?

A

ATYPICAL FEMORAL FRACTURES- thigh/hip/groin pain

OSTEONECROSIS OF THE JAW- dental pain/swelling/non-healing sores/discharge

OSTEONECROSIS OF THE EXTERNAL AUDTIORY CANAL- report ear pain/discharge/ear infection

145
Q

BISPHOSPHONATES- SIDE-EFFECTS

OSEOPHAGEAL REACTIONS,
REPORT & STOP?

How do you avoid oesophageal reactions?

A

REPORT & STOP for: oesophageal irritation, dysphagia & heartburn

How do you avoid oesophageal reactions?
Take w/
FULL GLASS OF WATER
SITTING/STANDING
EMPTY STOMACH AT LEAST 30MINS BEFORE BREAKFAST
SIT UP RIGHT/STAND 30MINS AFTER

ALENDRONIC ACID^

146
Q

RISEDRONATE COUNSELLING?

A

TAKE 30MINS BEFORE BREAKFAST
OR
LEAVE 2 HOURS BEFORE & AFTER FOOD/DRINK AT OTHER TIME OF DAY

147
Q

SEX HORMONE RESPONSIVE CONDITIONS

2 TYPES OF OESTROGENS?

A

NATURAL- estradiol, estrone & estriol

SYNTHETIC- ethinylestradiol & mestranol

148
Q

PROGESTOGENS? NLD

A

NORETHISTERONE
LEVONORGESTREL
DESOGESTREL

149
Q

TIBOLONE ACTIVITY?

A

OESTROGENIC
PROGESTOGENIC
WEAKLY ANDROGENIC

150
Q

HORMONE REPLACEMENT THERAPY

What menopausal symptoms can oestrogen alleviate?

A

itching, flushing, burning

can reduce postmenopausal osteoporosis

151
Q

HORMONE REPLACEMENT THERAPY

Issue with Clonidine?

A

Can be used for vasomotor symptoms, BUT

large side-effect profile

152
Q

HORMONE REPLACEMENT THERAPY- RISKS

BREAST CANCER?

A

Increased risk after 1 year
Risk higher in combined HRT over oestrogen-only
Excess risk persists for >10 years after stopping
but risk lowers after stopping

153
Q

HORMONE REPLACEMENT THERAPY- RISKS

ENDOMETRIAL CANCER?

A

Women with uterus-
Lower risk in combined HRT than oestrogen-only

Tibolone also increases risk

154
Q

HORMONE REPLACEMENT THERAPY- RISKS

OVARIAN CANCER?

A

Small increase which disappears a few years after stopping

155
Q

HORMONE REPLACEMENT THERAPY- RISKS

VTE?

A

Increased risk of DVT with both oestrogen-only & combined HRT

Increased risk with prolonged bed rest, obesity, trauma & family history

156
Q

HORMONE REPLACEMENT THERAPY- RISKS

STROKE?

A

Slight increase w/ both oestrogen-only & combined HRT

Tibolone increases risk by x2.2 in first year of treatment

157
Q

HORMONE REPLACEMENT THERAPY- RISKS

CORONARY HEART DISEASE?

A

Increased risk in combined HRT when started >10 years after menopause

158
Q

CHOOSING HRT

WOMEN W/ UTERUS?

A

Oestrogen w/ cyclical progestogen for last 12-14 days of the cycle
OR
Continuous administration of an oestrogen+progestogen (from day 1)

NOTE: Continuous combined+tibolone, avoid in perimenopausal phase(just before menopause)/within 12months of last menstrual period

159
Q

CHOOSING HRT

WOMEN WITHOUT UTERUS?

WHAT DO YOU DO IF ENDOMETRIOSIS OCCURS?

A

CONTINUOUS OESTROGEN USE

Endometriosis? Add progesterone

160
Q

HRT- SURGERY

ELECTIVE
When do you stop HRT?
When do you reinitiate?

A

STOP HRT 4-6 WEEKS BEFORE SURGERY

REINITIATE WHEN FULLY MOBILE

161
Q

HRT- SURGERY

NON-ELECTIVE?

A

PROPHYLACTIC HEPARIN

GRADUATED COMPRESSION STOCKINGS

162
Q

REASONS TO STOP HRT?

A 
SUDDEN CHEST PAIN/BREATHLESSNESS (pe?)
SWELLING/SEVERE PAIN IN CALF (dvt)
SEVERE STOMACH PAIN (hepatoxicity)
NEUROLOGICAL: prolonged headache, fainting, seizures
HEPATITIS/JAUNDICE
BP> 160mmHg systolic OR 95mmHg diastolic
PROLONGED IMMOBILITY
163
Q

THYROID HORMONES- negative feedback loop?

High levels of T3+T4->low levels of TSH->inhibits own production

A

High levels of T3+T4->low levels of TSH->inhibits own production

164
Q

HYPERTHYROIDISM LEVELS?

A

LOW TSH-> HIGH T3+T4, too much thyroid hormone

165
Q

HYPERTHYROIDISM

SYMPTOMS?

A 
HYPERACTIVITY
INSOMNIA
HEAT INTOLERANCE
INCREASED APPETITE
WEIGHT LOSS
DIARRHOEA
GOITRE
166
Q

HYPERTHYROIDISM- TREATMENT

1st LINE?

2nd LINE?

A

1st LINE? CARBIMAZOLE

2nd LINE? PROPYLTHIOURACIL

167
Q

HYPERTHYROIDISM

CARBIMAZOLE MHRA WARNINGS? CM-NAP

A

Neutropenia+Agranulocytosis-> sore throat, malaise, fever
Congenital Malformations-> use effective contraception
Acute Pancreatitis-> report & stop ASAP (severe abdominal pain, GLP-1s & flozins ;) )

Note: B-blockers can be used for symptomatic relief in primary hyperthyroidism

168
Q

HYPERTHYROIDISM

PROPYLTHIOURACIL cautioned in..?

A

Cautioned in liver disorder-> jaundice, dark urine, nausea

169
Q

Note: B-blockers can be used for symptomatic relief in…

A

PRIMARY HYPERTHYROIDISM

170
Q

HYPERTHYROIDISM- TREATMENT

GRAVE’S DISEASE
1st LINE?

A

RADIOACTIVE IODINE
But if remission is likely with anti-thyroids, consider carbimazole

Iodine/surgery unsuitable? Consider carbimazole
Given as a block & replace regimen in combo w/ levyothyroxine for 12-18 months

171
Q

HYPERTHYROIDISM- TREATMENT

PREGNANCY
1st TRIMESTER?
2nd+3rd TRIMESTER?

A

1st TRIMESTER? Propylthiouracil (>carbimazole’s congenital defects)

2nd+3rd TRIMESTER? Carbimazole (>propylthiouracil’s hepatotoxicity)

172
Q

HYPOTHYROIDISM LEVELS?

A

HIGH TSH->LOW T3+T4

173
Q

HYPOTHYROIDISM

SYMPTOMS?

A 
FATIGUE
WEIGHT GAIN
CONSTIPATION
DEPRESSION
DRY SKIN
INTOLERANCE TO COLD
MENSTRUAL IRREGULARITIES

REDUCED METABOLIC ACTIVITY!

174
Q

HYPOTHYROIDISM- TREATMENT

1st LINE?

A

LEVOTHYROXINE

175
Q

HYPOTHYROIDISM- TREATMENT

LEVOTHYROXINE
Monitor TSH/?
How to take it?
Brands?

A

Monitor TSH/? /3 months till stable, then yearly thereafter

How to take it? Take medicine in AM, at least 30mins before brekky/red bull

Brands? Some patients can feel symptoms if alternating between brands

176
Q

HYPOTHYROIDISM TREATMENT

LIOTHYRONINE?

A

Rare
More rapid+potent (20-25mcg= 100mcg levo)
Non-UK brands may not be bioqeuivalent

177
Q

INTERMEDIATE INSULIN EXAMPLES?

A

ISOPHANE
INSULTARD
HUMULIN I

178
Q

NOT INTERMEDIATE?

A

TRESIBA- DEGLUDEC- LONG-ACTING

179
Q

METFORMIN

AVOID IF eGFR is LESS THAN?

A

30 mL/minute/1.73 m2

180
Q

POTASSIUM LOSS
HYPERTENSION
WATER RETENTION
?

A

MINERALCORTICOIDS

181
Q

DIABETES
OSTEOPOROSIS
PEPTIC ULCERATION
?

A

GLUCOCORTICOIDS

182
Q

Miss A is 27 years old and has type 1 diabetes. Her PMR shows that she uses NovoRapid (insulin aspart) and Lantus (insulin glargine). Which of the following is/are appropriate if she experiences severe diarrhoea and is unable to eat solid foods? She should

A

Increase the frequency of blood glucose monitoring, Take oral rehydration therapy

183
Q

FASTING BLOOD GLUCOSE ON WAKING?

184
Q

DIABETIC MEDICATION CONTRAINDICATED IN
HEART FAILURE
BLADDER CANCER?

A

PIOGLITAZONE

185
Q

DIABETIC KETOACIDOSIS RISK?

A

FLOZINs
GLIPTINs (not lina or saxo!)

GLP-1 (NOT dulaglutide)
Absolute L when insulin abruptly stopped

186
Q

GLICLAZIDE/SULPHONYLUREA ELDERLY?

A

Elderly
Prescription potentially inappropriate (STOPP criteria) if prescribed a long-acting sulfonylurea (e.g. glibenclamide, chlorpropamide, glimepiride) in type 2 diabetes mellitus (risk of prolonged hypoglycaemia).

187
Q

SICK DAY RULES?

A

Just because the patient is ill and not eating does not mean they should stop injecting their insulin

ill/ infection= stress hormones/ steroids released
steroids increase blood glucose
stay well hydrated to avoid DKA
patient should monitor their BG and urine ketones more frequently and be prepared to inject accordingly

188
Q

A trainee pharmacist asks you to go through the different types of studies conducted in research in order to
produce reliable evidence.
Which of the following studies is most likely to produce reliable results?

A

o Systematic Reviews

189
Q

Patient, flushing, face, what med?

A

CCB, amlodipine

190
Q

A 2-month-old boy has been admitted to hospital with suspected bacterial meningitis
Which is the most appropriate treatment for this patient?

A

BENZYL-CEFOTAXIME-CHLORAMPHENICOL

191
Q

SITAGLIPTIN DOSE ADJUSTMENT RENAL?

A

50mg OD if eGFR 30–45 mL/minute/1.73 m2.

25mg OD if eGFR less than 30 mL/minute/1.73 m2.

192
Q

CUTANEOUS DD LIPOHYERP

193
Q

INSULIN TYPE 1 FIRST LINE?

A

insulin detemir twice daily and insulin aspart before meals

BASAL-BOLUS!

194
Q

chlorhexidine, gingivitis?

A

taste disturbance

195
Q

METFORMIN PATIENT ADVICE?

A

risk of lactic acidosis and told to seek immediate medical attention if symptoms such as dyspnoea, muscle cramps, abdominal pain, hypothermia, or asthenia occur.

196
Q

METRONIDAZOLE BV DOSING?

A

400–500 mg twice daily for 5–7 days, alternatively 2 g for 1 dose

197
Q

DIABETIC CHOC, NOT ENOUGH SUGAR!

198
Q

CO-AMOX HEPATOXIC!

199
Q

monitor insulin more when meal times changed

200
Q

One week after his hospital admission, the patient develops diarrhoea. A stool sample confirms
the presence of Clostridium difficile infection. Doctors decide to stop the lansoprazole and review
the antibiotic for his infection.
Which ONE of this patient͛s medications listed below is MOST likely to require temporary
discontinuation in view of his Clostridium difficile infection?

A

stop ibu he’s sick

201
Q

BISPHOSPHONATES COUNSELLING

ALENDRONIC ACID?

RISEDRONATE?

A

alen- avoid if crcl<35

rised- avoid if crcl<30

202
Q

type 1 diabetes, high sugars, too much ketones- abdominal pain!

A

not flatulence? hm

203
Q

VILDGALIPTIN, HEPATOTOXIC!!

204
Q

ABRUPT INSULIN STOP- DKA risk?

A

ALL THE GLP1s

but dulalglutide not contraindicated in ketoacidosis, don’t get it twisted!

205
Q

PIOGLITAZONE AVOID IN?

A 
BONE FRACTURES
LIVER TOXICITY- report N&V, abdominal pain, fatigue & dark urine
HF
BLADDER CANCER
BONE FRACTURES
206
Q

HOW OFTEN DO YOU MEASURE HBA1C?

A

type 1 diabetes- 3 to 6 months, and more frequently if blood-glucose control is thought to be changing rapidly.
type 2 diabetes- 3 to 6 months until HbA1c and medication are stable when monitoring can be reduced to every 6 months. STABLE 6 MONTHS

207
Q

what is exenatide?

A

GLP-1 mate
Binds to, and activates, the GLP-1 (glucagon-like peptide-1) receptor to increase insulin
secretion, suppresses glucagon secretion, and slows gastric emptying.

208
Q

DIARRHOEA IN HRT?

209
Q

MINERALCORTICOID SIDE-EFFECTS?

A 
hypertension
sodium retention
water retention
hypokalaemia
hypocalcaemia
210
Q

BG TARGET WHILST DRIVING?

A

> 5 AT LEAST

211
Q

Mr rue Licitiy is a new patient at your practice. You are conducting a new patient meds
reconciliation and review with the patient. From his previous practice records you note that
he is a Type 2 Diabetic, who is stable on Metformin, Gliclazide and Dapagliflozin. You have a
look at his previous HbA1cs and can see that it is stable, around 52mmol/mol.
How often should Mr Prue Licitiy get his HbA1c checked?

A

Every 6 months

212
Q

trulicity drug?

A

dulaglutide

213
Q

cvd DIABETES COMPLICATION?

214
Q

AWARENESS OF HYPOGLYCAEMIA SYMPTOM?

A

GOLD SCORE

215
Q

MONITORING TSH LEVELS?

A

/3 months till stable, then yearly thereafter

YEARLY ONCE STABLE

216
Q

You are discussing anti-diabetic treatment regimes for type 2 diabetes with a fellow
colleague. Your colleague has a question regarding ongoing use of GLP-1 mimetics once
initiated in a patient.
Which one of the following statements below is an accurate representation of when
GLP-1 mimetics should be continued to treat Type 2 diabetes?

A

Patient has a reduction of at least 3% initial body weight and 1% reduction of Hb1Ac
within 6 months

217
Q

GLP1 FACT

A

If triple therapy with metformin and 2 other oral drugs is not effective, not tolerated or contraindicated,
consider triple therapy by switching one drug for a GLP-1 mimetic for adults with type 2 diabetes who:
• have a body mass index (BMI) of 35 kg/m2 or higher (adjust accordingly for people from Black,
Asian and other minority ethnic groups) and specific psychological or other medical problems
associated with obesity or
• have a BMI lower than 35 kg/m2 and:
– for whom insulin therapy would have significant occupational implications or
– weight loss would benefit other significant obesity related comorbidities.

218
Q

You are reviewing a clinic letter from the consultant endocrinologist for Mr P 29-years-old.
The consultant has recommended initiating a “block and replace” treatment regimen to help
treat his hyperthyroidism.

Usually how long would you expect this “block and replace” regimen to be given?

A

18 months, thought it was 12-18?

219
Q

AKI likely presentation? Mad word

A

Oliguria

Oliguria is the production of abnormally small amounts of urine. It is one of the symptoms of AKI
alongside oedema (legs, ankles and around the eyes), fatigue, shortness of breath, confusion,
nausea, seizures, chest pain or pressure and coma (severe)

220
Q

Mr H has a diagnosis of Type 2 diabetes from a few months ago. He has been finding it very
difficult to control his glucose levels. The doctor has decided to start him on a new antidiabetic drug. Mr H is a bus driver and is concerned that this new medication will affect his
ability to drive. When counselling Mr H, you tell him that he can drive but should be wary of
hypoglycaemia and should try and avoid it.
Which of the following medications has Mr H most likely been started on?

A

Glipizide is a sulfonylurea and they are known to cause hypoglycaemia. They act mainly by
augmenting insulin secretion and consequently are effective only when some residual pancreatic
beta-cell activity is present

221
Q

Mrs N is a 52year old woman who is suffering from the symptoms of menopause. She also
has asthma and hyperthyroidism. She is on the following medication:
● Carbimazole 5mg OD
● Alendronic acid 70mg weekly
● Adcal D3, TWO tablets TWICE daily
● Salbutamol 100mcg, TWO puffs when required
● Seretide 125 evohaler, TWO puffs BD
Mrs N presents at the pharmacy with symptoms of heartburn and difficulty swallowing.
Which one of Mrs S’ medications is the most likely cause of her symptoms?

A

ALENDRONIC ACID
Severe oesophageal reactions are a side effect of oral bisphosphonates. 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.

222
Q

diabetic neuropathy

foot infection?

A

refer to foot protection service, not gp

223
Q

ciprofloxacin+ibuprofen?

IV meropenem L too

A

reduces seizure threshold!!

224
Q

A patient has suspected unstable angina and a glyceryl trinitrate spray is ineffective.

Manage?

A

ASPIRIN 300MG P

225
Q

ORLISTAT+LEVOTHYROXINE?

A

THYROID, INTERACTION, CHECK

Signs of meningitis. 1st line is benzylpenicillin but unsuitable due to penicillin allergy.
Cefotaxime can be used as no history of immediate anaphylactic reaction to penicillins.

See a doctor first

226
Q

WHAT DRUG RISK OF LOWER LIMB AMPUTATION?

A

CANAGLIFLOZIN!

227
Q

INSULIN PEN

228
Q

METFORMIN, LESS B12, AVOID IF CRCL IS

229
Q

SULPHONYLUREAS should be avoided in?

A

Hepatic and renal failure

230
Q

PIOGLITAZONE avoid in?

A

HF
bladder cancer
bone fractures
liver toxicity

231
Q

DPPis

Pancreatitis?
Hepatotoxic?

A

DPPis

Pancreatitis?
Alogliptin
Linagliptin
Sitagliptin
Saxagliptin
Vildagliptin

Hepatotoxic?
Vildagliptin

232
Q

SGLT2s monitor renal function?

A

CANAGLIFLOZIN- ‘LLA’ ;)
DAPAGLIFLOZIN
EMPAGLIFLOZIN

233
Q

GLP-1 AGONIST

PANCREATITIS?

A

DULAGLUTIDE
EXENATIDE
LIRAGLUTIDE
LIXISENATIDE

234
Q

SC INSULIN REGIMEN, SURGERY, doesn’t require?

A

IV infusion continued 1hr later?

235
Q

SIDE-EFFECTS OF INSULIN?

A

WEIGHT GAIN
OEDEMA (reabsorption of soidum, water, etc)
LIPODYSTROPHY- body storing fat,
SKIN REACTIONS

NOT WEIGHT LOSS

(hypertrophy- lump of fat tissue under skin, repeated injection)

236
Q

Patient w/ lipodystrophy/cutaneous amyloidosis?

A

NO NEED TO REFER

Just rotate injection sites

237
Q

gluconeogenesis?

A

the production of glucose

238
Q

DRUG TO PRESCRIBE BY BRAND?

A

NIFEDIPINE MR

239
Q

medication hyperglycaemia risk?

A

thiazide, bendro

240
Q

Novorapid advice?

A

Generally taken before a meal.

Taken immediately before a meal due to risk of hypo, onset of action is <15mins!

241
Q

NOVORAPID ADMINISTRATION?

A

Rapid acting, immediately at/before

but also after eating, wow

242
Q

ultra rapid acting insulin?

A

Fiasp, right at meal, woi

243
Q

15mins before meal insulin?

A 
short-acting insulins
bovine
porcine
insuman rapid
humulin s
actrapid
244
Q 
INSULATARD?
LYUMJEV?
TOUJEO?
TRESIBA?
ACTRAPID?
A 
INSULATARD? isophane, intermediate
LYUMJEV? lispro, rapid-acting
TOUJEO? glargine, long-acting
TRESIBA? degludec, long-acting
ACTRAPID? short-acting
245
Q

RAPID-ACTING INSULINS?

A

LISPRO- HUMALOG
ASPART- NOVORAPID
GLULISINE- APIDRA

246
Q

SHORT-ACTING INSULINS? SOLUBLE/NEUTRAL

A 
ACTRAPID
HUMULIN S
INSUMAN RAPID
BOVINE NEUTRAL
PORCINE NEUTRAL
247
Q

INTERMEDIATE-ACTING INSULINS? ISOPHANE

A 
BOVINE ISOPHANE
PORCINE ISOPHANE
INSULATARD
HUMULIN I
INSUMAN BASAL
248
Q

LONG-ACTING INSULINS?

A

DETEMIR- LEVEMIR
DEGLUDEC- TRESIBA
GLARGINE- LANTUS

249
Q

BIPHASIC INSULINS- BIPHASIC INSULIN ASPART?

A

NOVOMIX 30

250
Q

WHAT IS USED TO TREAT ADDISON’S DISEASE/ADRENAL INSUFFICIENCY?

A

HYDROCORTISONE… PRIMARY+FLUDROCORTISONE

251
Q

SIDE-EFFECTS OF CORTICOSTEROID USE?

A

DIABETES
OSTEOPOROSIS
WEIGHT GAIN
MUSCLE WASTAGE

NOT ADDISON’S DISEASE, IT TREATS IT!

252
Q

FIASP?

A

insulin aspart+nicotinamide- vitamin b3

253
Q

BIPHASIC INSULINS- BIPHASIC INSULIN LISPRO?

A

HUMALOG MIX25

HUMALOG MIX50

254
Q

BIPHASIC INSULINS- BIPHASIC ISOPHANE?

A

HUMULIN M3
INSUMAN COMB 15
INSUMAN COMB 25
INSUMAN COMB 50

255
Q

An 82-year-old patient has been newly diagnosed with type 2 diabetes mellitus. Their past
medical history includes atrial fibrillation, previous bladder cancer and hypertension. Recent
blood results show an eGFR of 25 mL/min.
Which Of the following would be the most appropriate initial drug therapy for this patient?
A. Dapagliflozin
B. Glibenclamide
C. Metformin
D. Pioglitazone
E. Sitagliptin

A

Dapagliflozin- consider additional antidiabetic if egfr <45

Sitagliptin- 25mg OD egfr<30

256
Q

HRT RISKS?

A

BREAST CANCER

NOT? OSTEOPOROSIS

257
Q

METFORMIN MAX./DAY?

258
Q

Metformin is available in a selection of strengths and formulations. Which Of the following is NOT an
appropriate dose of metformin?
A. Metformin 500mg tablets. ONE tablet taken each day with breakfast for at least one week for an
adult newly diagnosed with type 2 diabetes
B. Glugophage SR 1000mg tablets. TWO tablets taken daily with evening meal for an adult male
with type 2 diabetes
C. Metformin 500mg tablets. TWO tablets taken with breakfast and TWO with evening meal for an
adult female with polycystic Ovary Syndrome
D. Metformin hydrochloride 100mg/ml oral solution sugar free. ONE 5ml spoonful taken three
times a day for a 13-year-old child with type 2 diabetes
E. Metformin 500mg tablets. TWO tablets taken three times a day for a 29-year-Old pregnant
woman with gestational diabetes

A

E- too much relax

259
Q

A diabetic patient is having his insulin regime reviewed with his diabetic nurse. He is prescribed an
insulin he has never used before. He presents in your pharmacy with a prescription for Insulin lispro.
Which Of the following products is correct?
A. Lantus
B. Levemir
C. Novorapid
D. Apidra
E. Humalog

A

Humalog- insulin lispro

260
Q

A patient has a review at the diabetes clinic and a decision is made to begin a basal insulin
regime. Due to his current social situation, it is decided that the prescribed insulin should be
chosen in order that the carer can remind the patient to administer the insulin once daily around
breakfast time. Which of the below insulins would be the most appropriate to prescribe?
A. Apidra (insulin glulisine)
B. Humulin S (soluble insulin)
C. Humalog (insulin lispro)
D. Novomix 30 (biphasic insulin aspart)
E. Tresiba (insulin degludec)

A

Tresiba, insulin degludec

261
Q

Mr R, aged 76, is diagnosed with type 2 diabetes and osteoarthritis and has been prescribed
the medicines listed below. He lives alone but has a carer visit twice a day to help around the
house.
Mr R’s carer visits your pharmacy to ask for advice. She tells you he is suffering from “sickness
and diarrhoea and hasn’t been able to keep anything down”. You are worried about these
symptoms and decide to advise the patient to withhold one of his regular medications. Which
one of the following would it be most appropriate for Mr R to withhold?
A. Atorvastatin
B. Codeine
C. Lantus Solostar (insulin glargine)
D. Metformin
E. Paracetamol

A

D, METFORMIN
SICK DAYS

SADMAN, stop, come on

262
Q 
The diabetes clinic counsels Mr R regarding recognising the symptoms of hypoglycaemia and
diabetic ketoacidosis. Which one of the following is least likely to be a symptom of
hypoglycaemia?
A. Blurred vision
B. Bradycardia
C. Mood changes
D. Sweating
E. Tremor
A

NOT BRADYCARDIA

263
Q

After a recent HbA1c test, a diabetes nurse decides to prescribe canagliflozin for Mr
R. He comes into the pharmacy two weeks later, with conjunctivitis in one of his eyes and
wonders if his new rnedication may increase the risk of eye infections. Which is the most
appropriate response?
A. Canagliflozin is a black triangle drug and all adverse effects should be reported via
the Yellow Card Scheme
B. Eye infections are not a known side effect of canagliflozin. Mr R could treat his
conjunctivitis with chloramphenicol eye drops
C. Eye infections are a known side effect of canagliflozin. Mr R should continue taking
the canagliflozin but if the eye infections become recurrent, he could return to his
diabetes nurse for an alternative
D. Eye infections are a known side effect of canagliflozin. Mr R should continue taking
the canagliflozin and see his GP
E. Eye infections are a known side effect of canagliflozin. Mr R should stop taking the
canagliflozin and see his GP

A

B, unknown, chloramphenicol myna

264
Q

side-effects of glucocorticoids?

A 
growth retardation
hypertension
hyperglycaemia
osteoporosis
weight gain

not hypoglycaemia,silly, read Q, eliminate and execute

265
Q

STEROID WITHDRAWAL, KEY TERM

more than PREDNISOLONE 40MG OR EQUIVALENT AND….?

A

MORE THAN 40MG OD FOR MORE THAN A WEEK, SO 7 DAYS IS FINE, key details

268
Q

A drug, hypocalcaemia risk?

A

Denosumab

MHRA/CHM advice: Denosumab: minimising the risk of osteonecrosis of the jaw; monitoring for hypocalcaemia

269
Q

HYPOGLYCAEMIA YOU ARE TACHYCARDIC

271
Q

Driving 45 mins after?

A

Blood glucose level is normal, NOT after eating

273
Q

Informing DVLA, gestational?

A

Need insulin for >3 months after birth

274
Q

Acne, lowest photosensitivitiy risk? highest?

A

Lowest- Minocycline

Highest- Doxy/Oxy

276
Q

hba1c monitoring?

A

3-6 months

type 2 stable, 6 months

HbA1c should usually be measured in patients with type 1 diabetes every 3 to 6 months, and more frequently if blood-glucose control is thought to be changing rapidly. Patients with type 2 diabetes should be monitored every 3 to 6 months until HbA1c and medication are stable when monitoring can be reduced to every 6 months.

277
Q

osteoporosis+prednisolone L

A

osteoporosis+prednisolone L

278
Q

SITALGLIPTIN INTERSTITIAL LUGN DISEASE? OK

279
Q

HBA1C TARGETS?

A

48 IF NO hypoyglycaemia drugs

53 IF HYPOYGLYCAEMIA DRUGS

280
Q

Mr H, a 45-year old patient at your community pharmacy, brings in a new prescription for linagliptin
5 mg tablets once daily. You notice that he was previously prescribed sitagliptin 100 mg tablets once
daily, which he had been taking for 2 years. Mr H has type 2 diabetes mellitus which is currently well
controlled. Mr H’s only Other regular medication is ibuprofen 400 mg tds for back pain.
Which of the following is the most likely reason for the switch to linagliptin?

A

The patient’s renal function has deteriorated and so linagliptin is more appropriate

281
Q

A diabetic patient is having his insulin regime reviewed with his diabetic nurse. He is prescribed an
insulin he has never used before. He presents in your pharmacy with a prescription for Insulin lispro.
Which Of the following products is correct?

A

HUMALOG LISPRO!!!

NOVORAPID ASPART!!!!

GLULISINE APIDRA!!

282
Q

FLOZIN, REDUCED RENAL?

A

CONSIDER ADDITIONAL DRUG

GLIPTIN BEST

283
Q

BRADYCARDIA NOT A SYMPTOM OF?

A

HYPOYGLYCAEMIA!

284
Q

SUGAR HYPO?

A

DISSOLVED IN WATER!

285
Q

Mr. AJ is a 19-year-old newly diagnosed with type-1 diabetes. Which of the
following is recommended as first-line therapy?

A

BASAL-BOLUS FIRST LINE!

BD INSULIN DETEMIR

INSULIN DEGLUDEC- nocturnal hypoglycaemia

DEGLUDEC/GLARGINE- once daily, carer/ etc

286
Q

levothyroxine dose?

A

25mcg before food

287
Q

Anaemia can exacerbate heart failure!!

288
Q

WHAT IS NOT RECOMMENDED IN TRIPLE THERAPY?

A

DAPAGLIFLOZIN+PIOGLITAZONE

289
Q

In type 1 diabetes, aim for a clinic blood pressure of 135/85 mmHg or less unless the adult with type 1 diabetes has albuminuria or 2 or more features of metabolic syndrome, in which case it should be 130/80 mmHg or less

GPhC BNF (48 decks)

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