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PharmEducate Notes > Endocrine > Flashcards

Endocrine Flashcards

1
Q

Effects of mineralocorticoids?

A

Fluid and Na+ retention

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2
Q

Effects of glucocorticoids?

A

Anti inflammatory

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3
Q

Most potent mineralocorticoids?

A

Fludrocortisone (most potent)
Hydrocortisone (significant)

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4
Q

Most potent glucocorticoids?

A

Dexamethasone (highest potency)
Betamethasone (highest potency)
Prednisolone (significant)

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5
Q

Does hydrocortisone have mineralocorticoids or glucocorticoid activity?

A

Both, higher mineralocorticoid activity but still significant glucocorticoid activity

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6
Q

When would a mineralocorticoid be preferred?

A

Neuropathic postural hypotension
Septic shock

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7
Q

When would a glucocorticoid be preferred?

A

When fluid retention is considered a disadvantage e.g. in HF PTs

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8
Q

Which condition should be particularly avoided with steroid treatment?

A

Chicken pox or shingles

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9
Q

What should be done if a patient taking steroids or up to 3 months after taking steroids, contracts Chicken pox or shingles?

A

Require passive immunisation with the varicella-zoster vaccine

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10
Q

When does a steroid need to be stopped gradually rather than abruptly?

A

> 3 weeks use
7 days of >40mg dose

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11
Q

What is adrenal suppression?

A

Condition where the adrenal cortex stops making corticosteroids

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12
Q

Symptoms of adrenal suppression?

A

Opposite to aching bosoms

Fatigue, anorexia, N&V, hyponatraemia, hypotension, hyperkalaemia, hypoglycaemia, itchiness and weight loss

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13
Q

What are the sick day rules with steroid use?

A

Dose needs to be increased to mimic normal cortisol levels
Vomiting once = retake dose
Persistent vomiting = go to the hospital

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14
Q

Side effects of corticosteroids?

A

“ACHING BOSOM”

A = adrenal suppression
C = Cushing’s syndrome / cataracts
H = hyperglycaemia / hyperlipidaemia
I = infections / insomnia
N = nervous system - psychiatric reactions
G = glaucoma / GI ulcers

B = (mineralocorticoid SEs) increased BP / oedema / hypokalaemia
O = osteoporosis
S = skin thinning
O = obesity
M = muscle wasting

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15
Q

MHRA alert for buccal corticosteroids?

A

Not to be used for adrenal insufficiency in children

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16
Q

MHRA alert for hydrocortisone?

A

Adrenal insufficiency caused in children when switching from tablets to granules

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17
Q

MHRA alert about methyl prednisolone injections?

A

Contains lactulose so caution with allergies

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18
Q

What is Addison’s disease?

A

Adrenal insufficiency caused by damage to the adrenal gland

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19
Q

How is adrenal insufficiency treated?

A

2 doses of hydrocortisone (larger OM to mimic cortisol levels) + fludrocortisone

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20
Q

What is hypopituitarism?

A

When the pituitary glands do not stimulate hormone secretion (including in the adrenal glands)

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21
Q

Symptoms of adrenal crisis?

A

Low BP
Dizziness
Fever
N, V & D
Tiredness
Confusion
Aching muscles and joints
Stomach pains

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22
Q

Treatment of adrenal crisis?

A

IV hydrocortisone

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23
Q

Sick day rules for PTs with adrenal insufficiency?

A

Fever / infection requiring antibiotics = double hydrocortisone dose and switch to SA preparation

Persistent vomiting or diarrhoea = switch to IV/IM hydrocortisone and go to hospital if persistent

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24
Q

What is diabetes insipidus?

A

Low antidiuretic hormone (ADH)

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25
Q

What are the 2 types of diabetes insipidus?

A

Cranial and nephrogenic

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26
Q

What is cranial diabetes insipidus?

A

Hypothalamus/pituitary gland doesn’t make enough ADH

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27
Q

What is the treatment of cranial diabetes insipidus?

A

Desmopressin

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28
Q

What is nephrogenic diabetes insipidus?

A

Kidneys no longer respond to ADH

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29
Q

Treatment of nephrogenic diabetes insipidus?

A

Thiazide diuretics as these can help retain water

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30
Q

Side effects of desmopressin?

A

Hyponatraemia - can lead to convulsions so should be used in caution in epilepsy

Oedema - caution in HF, HTN, migraine

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31
Q

What is the main drug interaction for desmopressin?

A

TCAs which also increase ADH secretion

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32
Q

Mechanism of action of desmopressin?

A

Makes urine more concentrated which decreases the number of times you need to go

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33
Q

What is SIADH?

A

“Syndrome of inappropriate ADH secretion”

Too much ADH secretion

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34
Q

Electrolyte disturbance caused by SIADH?

A

Increased fluid retention causing reduced concentrations of Na+ therefore causing hyponatraemia

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35
Q

1st line treatment of SIADH?

A

Fluid retention

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36
Q

2nd line treatment of SIADH?

A

Demeclocycline - blocks renal effects of ADH
Or tolvaptan - ADH antagonist

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37
Q

Why can’t hyponatraemia be corrected rapidly?

A

Can cause osmotic demyelination of neurones causing serious CNS effects

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38
Q

What is Cushing’s syndrome?

A

Condition where cortisol levels are too high

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39
Q

What are the distinguishing symptoms of Cushing’s syndrome?

A

Fat deposits on the face and back of the neck causing a moon face and buffalo hump

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40
Q

Treatment of Cushing’s caused by steroid use?

A

Reduce/review dose

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41
Q

Treatment of Cushing’s caused by tumours?

A

Surgery / Ketoconazole (cortisol inhibiting drug reserved for only this purpose due to SEs)

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42
Q

Ketoconazole side effects?

A

Report signs of liver disorder E.g. vomiting, abdomen pain and jaundice

Can also cause adrenal insufficiency

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43
Q

What are the diabetes sick day rules?

A

“SICK”

S = sugar - check blood glucose every 3-4H until normal including ON

I = insulin - never stop

C = carbs - maintain normal meal pattern and replace meals with high carb drinks if necessary. Drink 3L of fluid a day. Seek medical help for persistent N&V

K = ketones - check blood and urine ketones every 3-4 hours. Seek medical help if urine ketones > 2 or blood ketones > 3

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44
Q

Symptoms of diabetes?

A

Polyuria, polydipsia (thirst), polyphagia (hunger), poor wound healing, fatigue, weight loss, blurred vision

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45
Q

Pre-diabetes levels?

A

5.7 - 6.4

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46
Q

Diabetes levels?

A

6.5 +
(48mmol/L)

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47
Q

Treatment of type 1 diabetes?

A

Insulins

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48
Q

Treatment of type 2 diabetes?

A

Diet and lifestyle advice
Anti diabetic drugs
Insulin

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49
Q

Different types of diabetic complications?

A

Microvascular
Macrovascular
Diabetic foot

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50
Q

Types of microvascular complications in diabetes and treatment?

A

Retinopathy - treat hypertension

Nephropathy - treat hypertension, low dose ACE/ARB to treat protein urea

Peripheral neuropathy- treat neuropathic pain using analgesics/ TCAs and anti-epileptics

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51
Q

Types of macrovascular complications in diabetes?

A

CVD = Stroke, heart attack and atherosclerosis

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52
Q

Prevention of macrovascualr complications?

A

CVD prevention with low dose high intensity statin E.g. atorvastatin 20mg or low-dose aspirin for secondary prevention

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53
Q

When is a low dose statin given to a diabetic patient for primary prevention of CVD?

A

Over 40, type 1 > 10 years, type 2 > 20 years, target organ damage, QRISK > 10%

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54
Q

What is diabetic ketoacidosis?

A

When blood glucose levels are too high

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55
Q

Symptoms of diabetic ketoacidosis?

A

Pear drop breath
Polyuria
Abdominal pain
Dehydration and excessive thirst
Ketonuria
Anorexia
Difficulty breathing

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56
Q

Treatment of ketoacidosis?

A

Soluble (human) insulin + fluids + electrolytes E.g. potassium (only if the patient is urinating) until ketones < 0.3mmol/L

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57
Q

Do you continue LA insulin while undergoing treatment for ketoacidosis?

A

Yes

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58
Q

Which area of the body has the fastest absorption rates for insulin?

A

The abdomen

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59
Q

Is it safe to miss meals or do strenuous exercise before injecting insulin?

A

No

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60
Q

Which insulins are considered a bolus insulin?

A

Short acting and rapid acting

These mimic prandial insulin released after a meal

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61
Q

Which insulins are considered basal insulins?

A

Long and intermediate acting insulins

Mimics insulin secretion throughout the day

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62
Q

Can beta blockers be given in diabetes? And why?

A

No, because they mask symptoms of hypoglycaemia

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63
Q

Examples of short acting (soluble) insulins?

A

Human / animal

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64
Q

What routes can SA insulin be given?

A

SC / IM
IV in emergencies / surgery

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65
Q

When should SA insulins be injected?

A

15-30mins before food

Max 30mins to avoid hypos

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66
Q

Examples of rapid acting insulins?

A

“LAG”
Lispro, Aspart, Glulisine

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67
Q

What routes can RA insulin be given?

A

SC or IV in emergencies

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68
Q

When should RA insulins be injected?

A

Just before food
(Can be after but not recommended due to poor glycemic control)

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69
Q

Example of intermediate acting insulin?

A

Isophane

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70
Q

Which route can isophane never be given?

A

IV due to risk of VTE

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71
Q

Caution with isophane?

A

Contains protamine which can cause allergic reactions

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72
Q

How often is isophane injected?

A

BD

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73
Q

Onset and duration of isophane?

A

Onset = 1-2 hours
Duration = 11-24 hours

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74
Q

Examples of long acting insulins?

A

“DDG (David DeGea is long)”

Detemir, degludec (OD/BD), glargine (brand specific)

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75
Q

Onset of LA insulins?

A

2-4 hours

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76
Q

Which LA insulin should be prescribed by brand?

A

Glargine

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77
Q

What are the three types of insulin regimens for type 1 diabetes?

A
  1. Multiple injections AKA basal-bolus
  2. Biphasic injections
  3. Subcutaneous infusion
78
Q

What is a multiple injection regiment?

A

SA/RA before meals + intermediate or LA OD/BD

E.g. RA + detemir BD

79
Q

What is a biphasic injection regiment?

A

SA/RA mixed with isophane (typically 30:70)

80
Q

How often is biphasic regimens injected?

A

BD before meals
Match carb intake to dose

81
Q

When are biphasic regimens contraindicated?

A

In inter current illness due to changing insulin requirements

82
Q

What is a subcutaneous insulin infusion regimen?

A

SA/RA continuously through the day via an insulin pump

83
Q

When can a SC insulin infusion regimen be used?

A

In severely poor control or children < 12 (must be trialled on MIR once they turn 12)

84
Q

Which insulin regimens are used in T2DM?

A

Biphasic or MIR

85
Q

What should be done to the dose of insulin when undergoing a minor surgery?

A

Adjust dose

86
Q

What anti diabetic medications should be stopped when undergoing minor surgery?

A

SGLT - risk of ketoacidosis
SU - risk of hypo
Metformin - risk of renal impairment

87
Q

What anti diabetic medications should be stopped when undergoing major surgery?

A

All of them

88
Q

What should be done to the dose of insulin when undergoing a major surgery?

A

Stop all insulins except LA (give 80% dose) and start sliding scale soluble human insulin until patient is eating and drinking and established on normal meds.

89
Q

What are the mechanisms of action of anti diabetic medications?

A

All hypoglycaemics except metformin and pioglitazone which increase insulin sensitivity

90
Q

1st line anti diabetic drug?

A

Metformin
(Also used in poly cystic ovary syndrome - PCOS)

91
Q

What are the main side effects of metformin?

A

GI disturbances - take with food or switch to MR
Lactic acidosis
Low vit b12
Taste disturbances

92
Q

Symptoms of lactic acidosis?

A

Dyspnoea, cramps, abdominal pain, hypothermia, asthenia (muscle weakness)

93
Q

Contraindications of metformin?

A

renal impairment <30 eGFR
AKI
Tissue hypoxia - e.g. acute HF, respiratory failure, MI or liver dysfunction

94
Q

When is triple therapy an option in T2DM?

A

When dual therapy including metformin is not effective. Cannot be given without metformin

95
Q

When is a GLP1 switched in during triple therapy?

A

When normal triple therapy is in effective and the patient has a BMI>35 or having occupational implications with insulin.

96
Q

When can an SGLT2 be added to treatment?

A

At any stage if a PT has a QRISK > 10%

97
Q

Examples of sulphonylureas?

A

LA = Glimepiride
SA = gliclizide, Tolbutamide

98
Q

Which SU is used in renal impairment or in the elderly?

A

Gliclazide

99
Q

Side effects of SUs?

A

Hypoglycaemia - treated in hospital with glucose
HypoNa+
Weight gain
Jaundice
Allergic dermatitis

100
Q

Main interaction with sulphonylureas?

A

ACE/ARB = increased risk of hypo

101
Q

Side effects of pioglitazone?

A

Heart failure (particularly with insulins)
Bladder cancer (CI in uninvestigated haematuria)
Hepatotoxicity
Vision impairment
Weight gain

102
Q

Example of an SGLT2?

A

“Flozins”
Canagliflozin, Empagliflozin, Dapagliflozin

103
Q

Which SGLT2s are beneficial in CVD?

A

Canagliflozin and empagliflozin

104
Q

Side effects of SGLT2s?

A

Atypical ketoacidosis (HbA1c only slightly rises)

Volume depletion - hydrate and report dizziness and postural hypotension

Increased glucose secretion which also leads to increased risk of infections

Fournier’s gangrene - report severely painful, red and swollen genitals with fever and malaise

Weight loss

105
Q

Which SGLT2 should not be used in T1DM?

A

Dapagliflozin

106
Q

Which SGLT2 increases risk of lower limb amputation?

A

Canagliflozin
- report ulcers and skin colour change

107
Q

Examples of DPP4 inhibitors?

A

“Gliptins”
Linagliptin
Sitagliptin
Vidagliptin

108
Q

Which DPP4 can be given in renal impairment?

A

Linagliptin

109
Q

Side effects of DPP4s?

A

Pancreatitis - report persistent, severe abdominal pain
Vidagliptin can cause hepatotoxicity

110
Q

Examples of GLP1s?

A

“Tide”
Exenatide
Lixisenatide
Dulaglutide

111
Q

When should GLPs be injected?

A

Before food

112
Q

Which GLP1s do not need to be kept in the fridge?

A

Lixisenatide
Exenatide

113
Q

What route are GLP1s given?

A

SC

114
Q

Side effects of GLP1s?

A

GI disturbances and decreased gastric emptying
Pancreatitis
DKA when insulin stopped
Weight loss

115
Q

Which GLP1s increase risk of infections?

A

“The Ls”
Liraglutide
Lixisenatide

116
Q

What is acarbose?

A

Last line treatment for diabetes which decreases sucrose absorption

117
Q

Side effects of acarbose?

A

Flatulance - improves with time, antacids won’t help
Diarrhoea- reduce dose or withdraw

118
Q

Patient counselling for acarbose?

A

Chew with 1st mouthful of food
Carry glucose not sucrose for hypo

119
Q

Side effects of Meglitinide “glinides”?

A

Hypoglycaemia
Diarrhoea

120
Q

Counselling for meglitinides?

A

Take 30mins before main meal

121
Q

What blood glucose range is considered hypoglycaemic?

A

<4mmol/L

122
Q

Symptoms of hypoglycaemia?

A

Palpitations
Tingling lips
Pale/clammy skin

123
Q

Should a patient take their next insulin dose if they are experiencing hypoglycaemia?

A

Yes but it must be reviewed

124
Q

What should be done if blood glucose is >4 in hypoglycaemia?

A

Give a long acting carb snack

125
Q

What should be done if blood glucose is <4 in hypoglycaemia?

A

15-20g of fast acting sugar, repeat after 15mins (max 3 times)
+ Give a long acting carb

126
Q

How is gestational diabetes diagnosed?

A

Oral glucose tolerance test

127
Q

What is the 1st line treatment is gestational diabetes when the PTs fasting blood glucose < 7mmol/L?

A

Diet and exercise

128
Q

What is the 2nd line treatment is gestational diabetes when the PTs fasting blood glucose < 7mmol/L?

A

When blood glucose levels not met in 1-2 weeks give Metformin / insulin

129
Q

What is the 1st line treatment is gestational diabetes when the PTs fasting blood glucose > 7mmol/L?

A

Insulin +/- Metformin

130
Q

Which diabetic medications are safe in breastfeeding and pregnancy?

A

Metformin and insulin

131
Q

When should treatment of gestational diabetes be stopped?

A

At term

132
Q

What is the blood glucose target in pre-existing diabetes in pregnancy?

A

< 6.5% (48mmol)

133
Q

What is the treatment of pre-existing diabetes in pregnancy?

A

RA insulin + isophane
Doses increase during pregnancy but must be decreased straight after birth

134
Q

What is the blood glucose target in type 1 diabetes?

A

< 6.5% (48mmol)

135
Q

What is the blood glucose target for type 2 diabetics controlled with diet or monotherapy?

A

< 6.5% (48mmol)

136
Q

What is the blood glucose target for type 2 diabetics controlled with monotherapy with a hypoglycaemic drug or combo therapy?

A

< 7% (53mmol)

137
Q

When does diabetic treatment need to be stepped up?

A

When blood glucose >7.5% (58mmol)

138
Q

Which anti diabetic medications can cause weight gain?

A

Pioglitazone
Sulphonylureas

139
Q

Which anti diabetic medications can cause weight loss?

A

“The GLs”
SGLT2
GLP1

140
Q

Which anti diabetic medications can cause pancreatitis?

A

“The ones with P (except pioglitazone)”
DPP4
GLP1

141
Q

Which anti diabetic medications are cardio protective?

A

SGLTs - Canagliflozin and empagliflozin

142
Q

Risk factors for osteoporosis?

A

Menopause
50+ men
Prolonged steroid use
Elderly
Low BMI
Smoking
Diabetes
Rheumatoid arthritis
Low vit D/C levels

143
Q

First line treatment of osteoporosis?

A

Bisphosphonates e.g. alendeonic acid, risendronate, Ibadronic (IV or PO), Zolendronic acid (IV, most potent)

Also used for prophylaxis in LT glucocorticoid Tx

144
Q

What dose of glucocorticoids are considered a high risk for osteoporosis?

A

7.5mg + of prednisolone

145
Q

What is the alternative option for menopausal women at high risk of osteoporosis?

A

HRT if < 60 years old and has menopausal symptoms

146
Q

Which bisphosphonates can be given for 5 years before needing to be reviewed?

A

Alendronic acid and risendronate

147
Q

Alendronic acid counselling?

A

Take 30mins before food
Swallow whole with plenty of water while sitting upright or standing
Stand or sit upright for another 30mins

148
Q

Alendronic acid dose?

A

10mg OD (can give 70mg once weekly for women)

149
Q

MHRA alerts for bisphosphonates?

A

Atypical femoral fractures
Osteonecrosis of the jaw
Osteonecrosis of the external auditory canal

150
Q

Risedronate dose?

A

Women = 5mg OD (can give 35mg weekly)
Men = 35mg weekly

151
Q

Risedronate counselling?

A

Do not have food, drink, calcium products, antacids, iron or minerals 2 hours before or after taking.

Stand or sit upright for 30mins after taking each dose

152
Q

What is menopause?

A

A decrease in oestrogen levels in ages 45-55

153
Q

What is vaginal atrophy?

A

Vaginal dryness

154
Q

Treatment of vaginal atrophy?

A

Topical oestrogens (creams, tablets, rings)

155
Q

What are the vasomotor symptoms of menopause?

A

Hot flushes and night sweats

156
Q

Treatment of vasomotor symptoms in menopause?

A

Systemic oestrogens or Tibolone tablets or patches (when the patient has an intact uterus to avoid endometrial cancer)

157
Q

Patient counselling for topical oestrogen patches?

A

Apply below the waistline as oestrogens can cause breast cancer

158
Q

What is the mechanism of action of tibolone?

A

Oestrogenic, prostogenic and weak androgenic activity

159
Q

What is HRT?

A

Oestrogen replacement given continuously

160
Q

What is combined HRT E.g. Tibolone?

A

The addition of progestogen for women with an intact uterus to help prevent endometrial cancer caused by oestrogens alone

161
Q

Is progestogen given continuously or cyclically?

A

Either
Cyclically lasts 12-14 days of cycle
Continuous avoids withdrawal bleeding (if bleeding occurs rule out endometrial cancer)

162
Q

When can continuous combined HRT not be given?

A

Peri-menopausal women or women who have had a period in the last 12 months

163
Q

What could bleeding during continuous combined HRT a sign of?

A

Endometrial cancer

164
Q

HRT side effects?

A

Breast, cervical, ovarian cancer
VTE
CVD - CI in angina or MI

165
Q

Reasons to stop HRT?

A

VTE (including both PE and DVT)?
Stroke?
Liver dysfunction?
BP > 160/90

166
Q

How long before major surgery should HRT be stopped?

A

4-6 weeks before

167
Q

What can be offered if HRT can not be stopped in time before surgery?

A

Anticoagulant + stockings

168
Q

Does HRT provide contraception?

A

No

169
Q

How long after their last period is a woman under 50 fertile for?

A

2 years

170
Q

How long after their last period is a woman over 50 fertile for?

A

1 year

171
Q

What form of contraception should a woman on HRT who is under 50 use?

A

Low oestrogen COC if VTE risk free

172
Q

What form of contraception should a woman on HRT who is over 50 use?

A

Condoms

173
Q

What is clomifene used for?

A

Infertility treatment in women

174
Q

Side effects of clomifene?

A

Ovarian cancer (max use = 6 cycles)
Multiple pregnancies in one go E.g. triplets

175
Q

Symptoms of hyperthyroidism?

A

Heat intolerance
Weight loss
Tachycardia
Diarrhoea
Bulging eyes
Lump on the front of the neck

176
Q

Lab test results for hyperthyroidism?

A

Low TSH
High T3
High T4

177
Q

Treatment of hyperthyroidism?

A

Carbimazole / propylthiouracil

178
Q

Side effects of carbimazole?

A

Acute pancreatitis

Bone marrow suppression (agranulocytosis and neutropenia) - report signs of infection

Rashes / itching - give antihistamine or switch

Teratogenic

179
Q

Propylthiouracil side effects?

A

Hepatotoxicity - discontinue if ALT/AST 3x normal range

180
Q

Which thyroid reducing drug should be used during pregnancy?

A

Propylthiouracil for 1st trimester
Then switch to carbimazole in the 2nd trimester

181
Q

Hypothyroidism symptoms?

A

Cold intolerance
Weight gain
Constipation
Bradycardia
Depression
Loss of eyebrows

182
Q

Lab test results that suggest hypothyroidism?

A

High TSH
Low T3
Low T4

183
Q

Which drugs commonly cause hypothyroidism?

A

Amiodarone (can cause hypo/hyper) and Lithium

184
Q

Treatment of hypothyroidism?

A

Levothyroxine or Liothyronine

185
Q

Patient counselling for levothyroxine?

A

Take OM 30mins before food of caffeine contains drinks or medications. If other meds needed before food space out by 2 hours

186
Q

Side effects of levothyroxine?

A

Increase thyroid levels which in turn increases blood glucose therefore cautioned in diabetes. Also cautioned in CVD due to hyperthyroidism related heart activity.

187
Q

What dose of levothyroxine should be questioned?

A

> 200micrograms

188
Q

Is liothyronine brand specific?

A

Yes

189
Q

What dose of insulin lantus would be equivalent to insulin toujeo?

A

Lantus dose = 80% of toujeo dose

190
Q

What is grave’s disease?

A

Autoimmune disorder causing hyperthyroidism

191
Q

Treatment of grave’s disease?

A

Radioactive iodine = 1st line

PharmEducate Notes (8 decks)

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