Endocrine Flashcards
what is the treatment choice for diabetes insipidus?
desmopressin - causes you to pee less but more concentrated
(can cause hyponatraemia, nausea)
what are the treatment options for SIADH?
tolvaptan, demeclocycline
what happens when you correct sodium too quickly?
osmotic demyelination syndrome
what are the risk factors for osteoporosis?
postmenopausal women, men over 50, smoking, excess alcohol, vitamin D deficiency, low calcium intake, low BMI
what treatments are first line for patients with osteoporosis?
-alendronic acid
-risedronate
** ibandronic acid may also be appropriate
for patients with osteoporosis who cannot tolerate oral bisphosphonates, what would be a suitable alternative?
-parenteral bisphosphonates (zolendronic acid)
-denosumab
when would tibolone be recommended for treatment of osteoporosis?
younger postmenopausal women women with menopausal symptoms
how long after treatment with alendronic acid, should it be reviewed to possibly stop?
5 years
what are the three MHRA alerts for all bisphosphonates?
osteonecrosis of the jaw
osteonecrosis of the auditory canal
atypical femoral fracture
what are the counselling points for alendronic acid?
-take with a full glass of water
-swallowed whole
-taken on an empty stomach
-taken while sitting upright or standing - and continue for 30 minutes after
-taken once a week (women) - same day each week
how often is zolendronic acid given for osteoporosis?
IV - once yearly
how long is denosumab given for osteoporosis?
SC - every 6 months
What are the MHRA alerts for denosumab?
-osteonecrosis of the jaw
-osteonecrosis of the auditory canal
-atypical femoral fracture
-rebound hypercalcaemia
-multiple vertebral fractures
which corticosteroid has the highest mineralocorticoid (aldosterone) activity?
fludrocortisone
which corticosteroids have the highest glucocorticoid (cortisol) activity?
dexamethasone, betamethasone
what effect do mineralocorticoids have on the body?
fluid retention, increase BP, hypokalaemia, hypocalcaemia
what effects do glucocorticoids have on the body?
anti-inflammatory, osteoporosis, diabetes, muscle wasting, gastric ulceration
what are the side effects of corticosteroids?
chorioretinopathy, psychiatric reactions, adrenal suppression, immunosuppression, insomnia, stunted growth, skin thinning, cushingoid symptoms
what are the causes of adrenal insufficiency?
addison’s disease, congenital adrenal hyperplasia, secondary causes
list the potency of topical corticosteroids?
Mild: hydrocortisone
Moderate: clobetasone
Potent: betamethasone
Very Potent: clobetasol
when should you do a reducing course of steroids?
40mg + prednisolone > 1 week
repeat evening doses
> 3 weeks treatment
repeated courses
short course within 1 year of stopping long term therapy
adrenal suppression
patients who are diabetic and driving, should check their blood glucose levels how regularly?
2 hourly
for patients with diabetes, blood glucose levels should always be above what to drive?
5
if between 4-5, a snack should be taken
if below 4, pull over
what are the sick day rules for type 1 diabetics?
monitor sugar levels regularly
continue insulin
eat and keep hydrated
test ketones regularly
SEEK HELP IF:
pregnant
high BG levels
drowsy/ breathless
vomiting/ diarrhoea
abdo pain
What is the advice for managing T1DM patients during surgery?
MINOR SURGERY: reduce long acting insulin by 20%
MAJOR SURGERY:
reduce long acting insulin by 20%
and on day of surgery:
stop until pt eating
IV KCl + glucose + NaCl
IV insulin in NaCl (soluble insulin)
hourly BG measurements
IV glucose 20% if > 6mmol/L
POST SURGERY:
SC insulin when eating
restart with first meal
long acting 20% reduced until patient discharged
what are the features of diagnosis in T1DM?
hyperglycaemia (>11mmol/L)
ketosis
weight loss
BMI < 25
age < 50
family history
how often should blood glucose be monitored in T1DM?
4 times daily
what are the BG targets for T1DM?
waking (fasting) 5 -7 mmol/L
before meals 4 - 7 mmol/L
after eating 5 - 9 mmol/L
driving > 5 mmol/L
what are first line options for insulin for a basal-bolus regime in T1DM?
1st detemir
2nd glargine
name the short acting insulin?
soluble insulin (human OR bovine/porcine)
BRANDS: humulin S, insuman, hypurin soluble, actrapid
when should you administer short acting insulins?
15-30 minutes before food
onset: 30-60 minutes
peak: 1-4 hours
duration: up to 9 hours
name the rapid acting insulins?
lispro
aspart
glulisine
BRANDS: apidra, novorapid, lispro, aspart, fiasp
when should you administer rapid acting insulins?
immediately before meals
onset: <15 mins
duration: 2-5 hours
name the intermediate acting insulins?
isophane
BRANDS: insulatard, humulin I, insuman basal, hypurin isophane
when should you administer intermediate acting insuin?
onset: 1-2 hours
peak: 3-12 hours
duration: 11-24 hours
name the long acting insulins?
detemir
degludec
glargine
BRANDS: tresiba, lantus, toujeo, levemir
when should you administer long acting insulins?
once daily
(twice daily for detemir)
onset: 2-4 days for steady state
duration: 36 hours
what are the symptoms of DKA?
polyurea
thirst
fruity breathe
deep, fast breathing
lethargy
confusion
how is DKA diagnosed?
if BG > 11mmol/L test ketones:
0.6-1.5 retest in 24 hours
1.6-2.9 GP
>3 medical emergency
how do you manage DKA?
BP < 90 restore volume (500ml NaCl)
BP > 90 maintenance IV NaCl
start IV insulin (soluble) in NaCl at rate so that:
ketones fall at 0.5mmol/L/hr
BG falls at 3mmol/L/hr
when BG <14 start IV glucose 10%
continue insulin until:
ketones < 0.3
pH > 7.3
STOP treatment 1 hour after first meal
what are the symptoms of a hypo?
sweating
lethargic
dizziness
hunger
tremor
palpitations
pale
extreme moods
how do you diagnose a hypo?
BG < 4 mmol/L
How do you treat a hypo in patients who can swallow?
fast-acting carbohydrate:
4-5 glucose tablets
3-4 teaspoons of sugar
200ml fruit juice
glucose 40% gels
Can repeat after 15 minutes up to 3 times
Once BG > 4, give a longer acting carbohydrate
How do you manage a patient who has been treated 3 times with short acting carbohydrates and whose BG are still below 4?
IM glucagon
IV glucose 10%
what are the medications for type 2 diabetes?
metformin (biguanides)
sulfonylureas
DPP-4 inhibitors
SGLT 2 inhibitors
GLP 1 agonists
Pioglitazone
what is the mechanism of action of metformin?
reduced gluconeogenesis and increase the peripheral use of glucose
what is the max daily dose of metformin
2g
what are the side effects of metformin?
lactic acidosis
GI
reduced B12
what is the renal cut off for metformin?
30ml/min
what are the benefits of treatment with metformin?
weight loss and cardiovascular benefit
name the sulfonylureas?
glibenclamide, gliclazide, glimepiride, tolbutamide, glipizide
which of the sulfonylureas has the longest duration of action and is therefore associated with he greatest hypo risk?
glibenclamide
what is the mechanism of action of the sulfonylureas?
stimulate beta cell insulin secretion in the pancreas
what are the side effects of the sulfonylureas?
hypos
acute porphryia
what are the side effects of the sulfonylureas?
hypos
acute porphyria
hepatic and renal failure
what effect do sulfonylureas have on weight?
weight gain
name the DPP-4 inhibitors?
alogliptin, linagliptin, sitagliptin, saxagliptin, vildagliptin
which of the DPP-4 inhibitors is associated with hepatotoxicity?
vildagliptin
what is the mechanism of action of the DPP-4 inhibitors?
increase insulin secretion, and decrease glucagon
what effect do DPP-4 inhibitors have on weight?
weight neutral
which DPP-4 inhibitors do not need dose reductions in renal impairment?
linagliptin
what are the side effects of he DPP-4 inhibitors?
pancreatitis
name the SGLT-2 inhibitors?
canagliflozin
dapagliflozin
empagliflozin
what is the mechanism of action of the SGLT-2 inhibitors?
inhibits SGLT-2 in renal proximal convoluted tubule
(excrete more glucose in urine)
what is the renal cut off for the SGLT-2 inhibitors?
60 (when used for diabetes)
what effect does SGLT-2 inhibitors have on weight?
weight loss
what is the MHRA alert specific to canagliflozin?
lower limb amputation
what are the MHRA alerts for all SGLT-2 inhibitors?
DKA risk
Fourniers gangrene
name the GLP-1 agonists?
dulaglutide, exenatide, liraglutide, lixisenatide, semaglutide
what is the mechanism of action of the GLP-1 agonists?
increase insulin secretion and reduced glucagon secretion, slows gastric emptying
what effect for the GLP-1 agonists have on weight?
weight loss
what is the mechanism of action of pioglitazone?
reduces peripheral insulin resistance
what effect does pioglitazone have on weight?
weight gain
what are the MHRA alerts for pioglitazone?
bladder cancer
heart failure
what should pioglitazone not be used alongside in triple therapy?
dapagliflozin
how do you manage diabetes in pregnancy?
stop oral antidiabetics except metformin
replace with insulin
folic acid 5mg daily
aim for HbA1c < 48
what is defined as pre-diabetic?
HbA1c 42-47 mmol/mol
what is defined as diabetic?
HbA1c > 48 mmol/mol
what is the HbA1c target for a patient who is at risk of a hypo?
53mmol/L
define a hypo?
< 4mmol/L
what type of HRT has an increased risk of breast cancer?
combined HRT (oestrogen and progesterone)
greater than oestrogen alone
why is progesterone given alongside oestrogen in HRT?
reduces the risk of endometrial cancer when given cyclically (eg 10 days out of 28 day cycle)
which HRT is not suitable for women in the perimenopausal period or up to 1 year after their last period?
combined and tibolone
what options are available for patients with menorrhagia?
levonorgestrel releasing IUD
tranexamic acid
NSAID
cyclical progesterone
what are the symptoms oh hyperthyroidism?
goitre
hyperactivity
disturbed sleep
fatigue
palpitations
anxiety
heat intolerance
increased appetite
weight loss
diarrhoea
what is the main cause of primary hyperthyroidism?
graves disease
define hyperthyroidism?
Low TSH
High T4
Subclinical hyperthyroidism:
Low TSH
Normal T4
what is first line for hyperthyroidism?
carbimazole
what is second line for hyperthyroidism?
propylthiouracil
when carbimazole not tolerated
what are the three MHRA alerts for carbimazole?
neutropenia and agranulocytosis
congenital malformations
acute pancreatitis
which anti-thyroid medication is not suitable for the block and replace regime?
propylthiouracil
what are the symptoms of hypothyroidism?
fatigue
weight gain
constipation
menstrual irregularities
depression
dry skin
cold intolerance
reduced body and scalp hair
define hypothyroidism?
High TSH
Low T4
Subclinical hypothyroidism:
High TSH
Normal T4
what is the drug of choice for hypothyroidism?
levothyroxine
how regularly should TSH levels be monitored in hypothyroidism?
3 monthly until stable
annually thereafter
what is the MHRA alert for levothyroxine?
some patients experience symptoms when switching between levothyroxine products
what are the counselling points for administration of levothyroxine?
take in the morning
30-60 minutes before food, caffeine containing liquids and other medications
