Endocrine Flashcards
//
What are the two types of diabetes insipidus? (2)
pituitray
nephrogenic
What causes pituitary diabetes insipidus?
insufficient levels of antidiuretic hormone (ADH).
What causes nephrogenic diabetes insipidus?
kidney defects.
(The kidneys do not respond to ADH)
What are the treatment options for pituitary diabetes insipidus? (2)
Vasopressin (ADH)
and its analog Desmopressin
How are doses of Vasopressin or Desmopressin adjusted in the treatment of pituitary diabetes insipidus?
Doses are tailored to produce slight diuresis every 24 hours to avoid water intoxication.
What is the difference between Vasopressin and Desmopressin in terms of potency and duration of action? (2)
Desmopressin is more potent
and has a longer duration of action than vasopressin.
How is Desmopressin used in the differential diagnosis of diabetes insipidus?
If desmopressin fails to produce a respond (i.e no reduction in urine output), it indicated nephrogenic diabetes insipidus
How do both pituitary and nephrogenic diabetes insipidus patients benefit from thiazide diuretics?
Both types of patients can benefit from the paradoxical antidiuretic effect of thiazide diuretics.
(While diuretics typically increase urine output, thiazide diuretics can actually reduce urine volume in individuals with diabetes insipidus)
In what situations is Carbamazepine used in the treatment of diabetes insipidus?
Carbamazepine is sometimes useful
in sensitizing renal tubules to the action of remaining vasopressin
(im guessing this is for nephrogenic diabetes insipidus)
What are some other uses of Desmopressin? (2)
in haemophilia and Von Willebrand’s disease to boost factor VIII concentration
also in nocturnal enuresis.
How is Desmopressin used in the treatment of haemophilia and Von Willebrand’s disease?
it boost factor VIII concentration
What is the recommendation regarding fluid intake when taking Desmopressin? (3)
have minimal fluid intake
1 hour before the dose
until 8 hours after
Why should we not administer intranasal desmopressin for nocturnal enuresis?
increased risk of hyponatraemic convulsions.
Why can vasopressin be used in the treatment of variceal bleeding in portal hypertension?
has vasoconstrictor effects.
What is the role of Oxytocin in medical practice? (2)
another pituitary hormone
used in obstetrics: labour stimulation as increased uterine activity
What are some common side effects associated with desmopressin?(6)
fluid retention
hyponatremia (especially when fluid intake is not restricted)
stomach pain
headache
nausea
vomiting
what risk is increased when taking desmopressin for nocturnal enuresis?
hyponatremic convulsions
How can the risk of hyponatremic convulsions be minimized when using desmopressin for nocturnal enuresis? (4)
by avoiding fluid overload
stopping the medication during vomiting or diarrhea episodes
adhering to recommended doses
avoiding concurrent use of drugs that increase vasopressin secretion (such as paracetamol, nicotine, and tricyclic antidepressants).
Why is there an increased risk of hyponatremic convulsions in elderly patients taking desmopressin?
due to factors such as age-related changes in physiology
What should we measure and monitor in elderly patient taking desmopressin? (1)
When should we discontinue the desmopressin? (1)
measure what their baseline serum sodium is
AND regularly monitor their levels during treatment.
Discontinue treatment if levels fall below baseline.
What is the oxytocic effect of desmopressin during pregnancy?
has a small oxytocic effect in the third trimester of pregnancy
(has the ability to stimulate uterine contractions)
What is the potential risk associated with desmopressin use in pregnancy?
an increased risk of pre-eclampsia
What is pre- eclampsia? (5)
a disorder
characterized by high blood pressure
and significant protein in the urine
can lead to serious comp
can affect both the mother and the unborn baby
What are the normal secretions of the adrenal cortex? (2)
hydrocortisone (cortisol): glucocorticoid activity
aldosterone: mineralocorticoid activity
What are the biological effects exerted by glucocorticoid hormones (glucocorticoid activity)? (5)
regulating metabolism
suppressing inflammation
modulating the immune response
vasoconstrictive effects
maintaining blood sugar levels
responding to stress
What is mineralocorticoid activity? (4)
Mineralocorticoids act on the kidneys
increase the reabsorption of sodium and water
while promoting the excretion of potassium
help regulate blood pressure and maintain proper fluid balance within the body.
What is Addison’s disease?
a disorder
adrenal glands not producing enough hormones
primarily cortisol (a glucocorticoid)
and often aldosterone (a mineralocorticoid)
What are common symptoms of Addison’s disease?(5)
fatigue
weakness
weight loss
low blood pressure
hyperpigmentation of the skin
How is Addison’s disease treated? (4)
lifelong hormone replacement therapy
to replace the deficient hormones
this is a combination of oral hydrocortisone
AND
fludrocortisone acetate
(a glucocorticoid + mineralocorticoid)
Why is a combination of hydrocortisone and fludrocortisone acetate preferred in Addison’s disease?
Hydrocortisone alone does not provide sufficient mineralocorticoid activity for complete replacement in Addison’s disease.
How is replacement therapy dosed throughout the day for mimicking the normal diurnal rhythm of cortisol secretion? (3)
Replacement therapy is given in two doses
with a larger dose in the morning
and a smaller dose in the evening
What is acute adrenocortical insufficiency?
a life-threatening condition
characterized by a sudden and severe deficiency of cortisol and often aldosterone
Who does acute adrenocortical insufficiency typically occur in? (3)
individuals with underlying adrenal insufficiency (such as Addison’s disease)
who experience stress, illness, surgery, or trauma
and thus their body has an INCREASED demand for cortisol
What are symptoms of acute adrenocortical insufficiency? (7)
sudden onset of severe weakness
fatigue
abdominal pain
nausea
vomiting
low blood pressure
electrolyte imbalances.
How is acute adrenocortical insuffiency treated?
IV hydrocortisone every 6 to 8 hours.
What is hypopituitarism?
a deficiency in one or more of the hormones produced by the pituitary gland
(note: the pituitary gland regulates cortisol and other hormones however, it has nothing to do directly with mineralocorticoids. That’s the job of the adrenal gland)
How is hypopituitarism treated? (2)
oral hydrocortisone
AND
Additional replacement therapy with levothyroxine sodium and sex hormones should be given (as indicated by the pattern of hormone deficiency)
(a mineralocorticoid is not usually required as adrenal glands produce them and they should be functioning as normal)
(in hypopituitarism, where the pituitary gland fails to produce adequate levels of various hormones, there can be deficiencies in other hormones beyond just cortisol and mineralocorticoids. Additional treatment with levothyroxine sodium (to replace thyroid hormone) and sex hormones may be needed based on the specific hormone deficiencies. Levothyroxine helps with metabolism, while sex hormones address issues like reproductive dysfunction. This therapy aims to balance hormones and relieve symptoms caused by hormone deficiencies.
Why is high glucocorticoid activity alone not advantageous in corticosteroid therapy? (2)
High glucocorticoid activity is only beneficial if accompanied by relatively low mineralocorticoid activity.
Without this balance, the therapeutic effects may not be clinically relevant.
Why is fludrocortisone’s anti-inflammatory activity considered clinically irrelevant? (3)
has such high mineralocorticoid activity
that its anti-inflammatory effects are overshadowed
rendering them clinically insignificant.
Which corticosteroids are particularly suitable for high-dose therapy in conditions where fluid retention is a concern? (4)
Betamethasone and dexamethasone are suitable
as have long duration of very high glucocorticoid activity
and have insignificant mineralocorticoid activity
minimizing the risk of fluid retention.
Which corticosteroid is most commonly used by mouth for long- term disease suppression?
Prednisolone
What activities do prednisolone and prednisone predominately have?
glucocorticoid activity
How does deflazacort compare to prednisolone in terms of glucocorticoid activity? (2)
Deflazacort is derived from prednisolone
so demonstrates high glucocorticoid activity, making it effective for therapeutic use.
Why is hydrocortisone considered unsuitable for long-term disease suppression? (4)
Has significant mineralocorticoid activity
this leads to fluid retention
making it unsuitable for long-term disease suppression
due to associated side effects.
What can hydrocortisone be used to treat? (2)
can be utilized for adrenal replacement therapy
where its mineralocorticoid activity may be beneficial.
What are corticosteroids?
Steroid hormones
Where are corticosteroids produced?
In the adrenal cortex?
What are the two main classes of corticosteroids? (2)
Glucocorticoids
Mineralocorticoids
Which corticosteroid has the MOST mineralocorticoid side effects?
fludrocortisone
Which corticosteroids have significant mineralocorticoid side effects? (3)
hydrocortisone
corticotropin
tetracosactide
Which corticosteroids have negligible mineralocorticoid actions?
high potency glucocorticoids such as betamethasone and dexamethasone
Which corticosteroids have slight mineralocorticoid side effects? (3)
methylprednisolone
prednisolone
and triamcinolone
What are some mineralocorticoid side effects associated with corticosteroid use? (5)
hypertension
sodium retention
water retention
potassium loss
calcium loss.
What are some glucocorticoid side effects associated with corticosteroid use? (9)
diabetes
osteoporosis (particularly in the elderly),
avascular necrosis of the femoral head at high doses
proximal myopathy
weakly linked peptic ulceration
psychiatric reactions
Cushing’s syndrome (with moon face, striae, and acne at high doses)
increased appetite
weight gain
What is the significance of high doses of glucocorticoids in terms of side effects? (3)
High doses of glucocorticoids can lead to severe side effects
such as Cushing’s syndrome
but these side effects are usually reversible upon withdrawal of treatment
What is Cushing’s syndrome?
Disorder resulting from prolonged exposure to high levels of cortisol
What can cause Cushing’s syndrome? (2)
Can be endogenous (excessive natural cortisol production)
or exogenous (due to corticosteroid medication)
What are symptoms of Cushing’s syndrome? (8)
Weight gain (especially in face and upper body)
thinning skin
easy bruising
stretch marks (striae)
high blood pressure
fatigue
muscle weakness
mood changes.
What are patients advised to do if they notice warning signs while undergoing prolonged steroid treatment?
Patients are advised to report all warning signs to their doctor immediately
What should patients undergoing prolonged steroid treatment (>3 weeks) have?
A steroid card
What is paradoxical bronchospasm?
constriction of the airways
What are the symptoms of uncontrolled asthma? (3)
cough
wheezing
tight chest
What is adrenal suppression?
occurs when the adrenal glands do not produce enough cortisol
What are the symptoms of adrenal suppresion? (7)
fever
nausea
vomiting
weight loss
fatigue
headache
muscular weakness
How should prolonged corticosteroid therapy be withdrawn to prevent acute adrenal insufficiency?
must be withdrawn gradually
( as adrenal atrophy can develop and persist for years after stopping treatment)
What are some signs indicating the need for gradual withdrawal of corticosteroid therapy? (3)
a) Receiving more than 40mg prednisolone (or equivalent) daily for more than one week.
b) Being given repeat evening doses.
c) Receiving treatment for more than three weeks.
How does prolonged corticosteroid treatment affect infection risk, and what precautions should patients take? (4)
Prolonged corticosteroid treatment increases the risk of infection
especially severe infections like chickenpox or measles (if the patient is not already immune)
Patients should avoid exposure to chickenpox, shingles, or measles, and more serious infections such as TB and septicaemia
infections may reach an advanced stage before being recognized.
What psychiatric reactions are associated with corticosteroid treatment? (5)
euphoria
suicidal thoughts
nightmares
depression
insomnia
When do psychiatric reactions associated with corticosteroid treatment, and when do they usually subside? (2)
These reactions are usually associated with high doses or treatment withdrawal
they typically subside on reducing the dose.
What are warning signs of corticosteroids? (6)
paradoxical bronchospasm
uncontrolled asthma
adrenal suppression
frequent courses of antibiotics and/ or corticosteroids
immunosuppression
psychiatric reactions
What parameters should be monitored regularly during corticosteroid treatment? (8)
Blood pressure
blood lipids
serum potassium
body weight and height - in children and adolescents
bone mineral density
blood glucose
eye exams (for intraocular pressure and cataracts)
signs of adrenal suppression
What is the recommendation regarding corticosteroid treatment during pregnancy and breastfeeding? (2)
Benefit of treatment during pregnancy and breastfeeding outweighs the risk.
Pregnant women with fluid retention should be closely monitored, and treatment is required during labor.
What are some drug interactions associated with corticosteroids? (6)
Accelerated metabolism of corticosteroids by carbamazepine, phenobarbital, phenytoin, and rifamycins.
Induction or enhancement of the anticoagulant effect of coumarins by corticosteroids
Impairment of the immune response to vaccines by high-dose corticosteroids, necessitating avoidance of concomitant use with live vaccines.
Masking of gastrointestinal effects of NSAIDs (including aspirin) by corticosteroids, with avoidance of concomitant use if possible and consideration of gastroprotection.
Potential for severe hypokalemia when given with other drugs that lower serum potassium, such as loop and thiazide diuretics.
Antagonism of the effects of antihypertensive and oral hypoglycemic drugs by glucocorticoids.
Why is it important to monitor blood pressure during corticosteroid treatment?
because corticosteroids can cause hypertension as a side effect.
What is the significance of monitoring bone mineral density during corticosteroid treatment?
because corticosteroids can lead to osteoporosis and bone loss
How can corticosteroids affect the immune response to vaccines? (2)
High-dose corticosteroids can impair the immune response to vaccines
necessitating avoidance of concomitant use with live vaccines.
What effect can corticosteroids have on the gastrointestinal effects of NSAIDs? (2)
Corticosteroids can mask the gastrointestinal effects of NSAIDs, including aspirin
carefully consider use
avoid use
if do use, use along with gastroprotection.
Which drugs accelerate the metabolism of corticosteroids? (4)
Carbamazepine
phenobarbital
phenytoin
rifamycins
What effect can corticosteroids have on the anticoagulant effect of coumarins?
Corticosteroids may induce or enhance the anticoagulant effect of coumarins
What risk is associated with combining corticosteroids with loop and thiazide diuretics?
can lead to severe hypokalemia
How do glucocorticoids affect the effects of antihypertensive and oral hypoglycemic drugs?
Glucocorticoids antagonize the effects of antihypertensive and oral hypoglycemic drugs.
when glucocorticoids are taken concurrently with antihypertensive or oral hypoglycemic medications, they can reduce the effectiveness of these drugs, potentially leading to less control over blood pressure or blood sugar levels
What is the treatment approach for patients with type 1 diabetes?
Patients with type 1 diabetes require administration of insulin
How can patients with type 2 diabetes be controlled? (2)
Patients with type 2 diabetes may be controlled on diet alone
but may also require oral antidiabetics and/or insulin
What is the main aim of diabetes treatment? (2)
alleviate symptoms
minimize the risk of long-term complications, particularly cardiovascular disease.
How can the risk of cardiovascular disease in diabetic patients be reduced? (2)
risk of cardiovascular disease can be reduced by using an ACE inhibitor (which also provides kidney protection to diabetics)
and a lipid-regulating drug.
What are the long-term complications associated with diabetes? (3)
neuropathy
retinopathy
nephropathy.
How often should HbA1c levels be measured?
HbA1c (glycosylated hemoglobin) should be measured every 3-6 months
What are HbA1c levels a good indication?
glycemic control over the previous 2-3 months.
What is the ideal target for HbA1c concentration, and why may it not always be achievable? (3)
The ideal target for HbA1c concentration is 59mmol/mol or less.
However, the reference range is 20-42mmol/mol, which may not always be achievable
Moreover, aiming for very low HbA1c levels increases the risk of severe hypoglycemic episodes in diabetics.
How is diabetic nephropathy tested for? (3)
urinary microalbuminuria
annual tests for urinary protein
serum creatinine
What risk is associated with the presence of nephropathy in diabetic patients?
increases the risk of hyperkalemia.
What is the recommended treatment for diabetic patients with nephropathy, regardless of blood pressure?
All diabetic patients with nephropathy should be treated with ACE inhibitors or ARBs, regardless of blood pressure.
How can ACE inhibitors affect the hypoglycemic effect of anti-diabetic drugs and insulin? When is this especially true? (2)
ACE inhibitors can potentiate the hypoglycemic effect of anti-diabetic drugs and insulin
especially during initial treatment and if renal impairment is present.
How is mild to moderate pain associated with diabetic neuropathy treated? (2)
Paracetamol
Ibuprofen.
What medication is effective for PAINFUL neuropathy in diabetic patients?
Duloxetine
What alternatives can be considered if Duloxetine is ineffective for painful neuropathy? (3)
Amitriptyline
Nortriptyline (unlicensed)
Gabapentin
What other medications are supported by evidence for the treatment of neuropathic pain in diabetic patients? (5)
Tramadol
morphine
oxycodone (under specialist supervision)
Carbamazepine
Capsaicin cream
What are the symptoms of hypoglycemia (blood sugar level < 3.5mmol/L)? (8)
pale skin
feeling sweaty
tremor
rapid heart rate
confusion
aggression
fits
impaired consciousness
How should blood glucose be restored in a conscious individual experiencing hypoglycemia?
oral glucose should be administered
How should blood glucose be restored in an UNconscious individual experiencing hypoglycemia? (2)
IV dextrose should be given.
If this is not available, Glucagon can be administered via an intramuscular injection.
What are the symptoms of Diabetic Ketoacidosis (DKA) or HyperOsmolar Non-Ketosis (HONK)? (9)
dehydration
acute hunger
thirst
abdominal pain
fruity smelling breath and urine if ketotic
rapid breathing
confusion
decreased consciousness
and arrhythmias due to hyper/hypokalemia.
How do DKA and HHS differ, and which type is usually associated with Type 1 diabetes?
DKA is usually associated with Type 1 diabetes and is characterized by hyperglycemia (>20mM) with ketones present.
HHS mainly occurs in Type 2 diabetes and is characterized by severe dehydration due to hyperglycemia (>50mM) with minimal ketones present.
How are DKA and HHS managed? (9)
nasogastric tube to remove stomach contents
IV insulin and fluids
LMWH to prevent clotting
urinary catheter for fluid monitoring
sliding scale insulin for tight glucose control
fluid, potassium
phosphate replacement for rehydration and electrolyte balance maintenance
consideration of antibiotics if infection caused hyperglycemia.
What are the characteristics of rapid-acting insulins? (3)
they are used as needed (PRN)
have a faster onset and shorter duration of action compared to “short” insulins
should be injected immediately before or after eating.
Can you provide examples of rapid-acting insulins? (3)
Insulin Aspart (Novorapid)
Insulin Glulisine (Apidra)
Insulin Lispro (Humalog)
How should short (neutral or soluble) insulins be administered? (2)
used PRN
should be injected 30 minutes before eating
Can you name some examples of short (neutral or soluble) insulins? (3)
Actrapid
Humulin S
Insuman Rapid
What is the administration frequency and duration of action for intermediate insulins? (2)
usually administered twice daily (BD)
have a duration of action of up to 16 hours
What precaution should be taken before injecting intermediate insulins? (2)
Before injecting intermediate insulins, it’s necessary to resuspend zinc-insulin particulate.
also important to never use these insulins intravenously (as the particulate may block a capillary)
Can you give examples of intermediate insulins?
Humulin I
Detemir (Levemir)
Deglubec (Tresiba).
What is the purpose of long acting insulins and how often are they used in a day? (2)
They provide 24-hour coverage
used OD at the same time each day
Name some examples of long-acting insulins
Glargine (Absaglar, Lantus)
What are biphasic insulins, and what is their composition?
They are a combination of shorter- and longer-acting insulins
They offer more convenience but less control
They need to be re- suspended before giving
Can you provide examples of biphasic insulins? (3)
Novomix 30
Humalog Mix 25
Humulin M3.
What are some warning signs associated with insulin therapy? (6)
recurring episodes of hypoglycemia (e.g., sweating, palpitations, confusion, drowsiness)
signs of diabetic ketoacidosis (e.g., nausea, vomiting, drowsiness)
symptoms of liver toxicity
heart failure
pancreatitis (e.g., jaundice, abdominal pain)
ulceration of foot tissue.
What interactions should be considered with insulin therapy? (2)
Interactions may include substances that INCREASE blood-glucose-lowering activity (reducing insulin requirements) and INCREASE RISK OF HYPOGLYCAEMIA
such as:
oral antidiabetics, ACE inhibitors, MAOIs, salicylates, and sulphonamide antibiotics.
Additionally, substances that REDUCE blood-glucose-lowering activity (increasing insulin requirements) include:
corticosteroids, diuretics, sympathomimetics (e.g., epinephrine, salbutamol, terbutaline), thyroid hormones, and oral contraceptives (oestrogens, progestogens)
Beta-blockers or alcohol may also potentiate and/or weaken the blood-glucose-lowering activity of insulin.
How can we resuspend the zinc- insulin particulate in intermediate insulin?
need to gently roll or invert the insulin vial between your palms until the solution appears uniformly cloudy or milky
helps ensure that the insulin is properly mixed before administration
It’s important not to shake the vial vigorously, as this can cause foaming or denaturation of the insulin.
What substances INCREASE blood-glucose-lowering activity and increase the risk of hypoglycemia when interacting with insulin? (5)
Oral antidiabetics
ACE inhibitors
MAOIs
salicylates
sulphonamide antibiotics
Which substances may REDUCE blood-glucose-lowering activity and increase insulin requirements when interacting with insulin? (5)
Corticosteroids
diuretics
sympathomimetics (e.g., epinephrine, salbutamol, terbutaline)
thyroid hormones
oral contraceptives (oestrogens, progestogens)
beta- blockers and alcohol MAY also reduce blood- glucose lowering activity
What is the brand- name of the long- acting Insulin Detemir? (1)
Levemir
What are two brand names of Insulin Glargine? (2)
Absaglar
Lantus
What is the brand- name of the long- acting Insulin Degludec? (1)
Tresiba
What is the brand- name of the rapid- acting Insulin Aspart?
Novorapid
What is the brand- name of the rapid- acting Insulin Glulisine?
Apidra
What is the brand- name of the rapid- acting Insulin Lispro?
Humalog
What is the mechanism of action of Alpha glucosidase inhibitor (Acarbose)? (2)
inhibits the breakdown of starch and sucrose to glucose
thus delaying the absorption of sugar.
What is a common side effect associated with Acarbose, and how does it typically change over time? (2)
Flatulence
but it tends to decrease with time, potentially improving adherence
How should acarbose be taken?
With food
What is the primary mechanism of action of Biguanide (Metformin)? (2)
decreases gluconeogenesis
and increases the peripheral utilization of glucose.
What is the current recommendation regarding the use of Metformin in diabetes treatment?
Metformin is now considered first-line treatment for all patients with type 2 diabetes.
What precaution should be taken regarding Metformin use in patients undergoing surgery with general anesthesia? (3)
Metformin should be suspended on the morning of surgery if general anesthesia is used
as it can cause ketoacidosis
It should be restarted when renal function returns to baseline.
How should Metformin use be managed in patients undergoing procedures involving iodinated contrast agents such as in X- rays? (3)
Metformin should be suspended prior to such procedures
and restarted after 48 hours IF renal function returns to baseline
to prevent renal failure and lactic acidosis.
What are some common side effects of Metformin, particularly when initiating treatment? (3)
GI disturbances are initially common with Metformin use
Especially at high doses.
Dose titration may improve tolerability and MR
E.G. DIARRHOEA
What are examples of sulphonylureas? (5)
Gliclazide
Glipizide
Glibenclamide
Glimepiride
Tolbutamide
What is the primary mechanism of action of Sulphonylureas?
increase insulin secretion from the pancreas
How should sulphonylureas be taken?
With food
What are potential side effects associated with Sulphonylureas?
may cause hypoglycemia and weight gain
hypersensitivity (common within the first 6-8 weeks of therapy)
What is the primary mechanism of action of Thiazolidinedione (Pioglitazone)?
Pioglitazone reduces peripheral insulin resistance
What are some common side effects of Pioglitazone? (11)
GI upset
weight gain
edema
hypoglycemia
anaemia
headache
visual disturbances
arthralgia (joint pain)
hematuria (blood in urine)
impotence
liver toxicity
What action should be taken if symptoms of liver dysfunction occur in a patient taking Pioglitazone? (2)
If symptoms such as severe GI upset, fatigue, jaundice, or dark urine occur
discontinue pioglitazone treatment
What risk increases when pioglitazone is combined with insulin? How should patients be monitored? (2)
risk of heart failure increases
monitor and if signs such as shortness of breath, fatigue, irregular heartbeat, edema occur; DISCONTINUE treatment
What risk is associated with the use of Pioglitazone regarding bladder health? (5)
a small increased risk of bladder cancer
However, the benefits of Pioglitazone outweigh the risks.
Patients should be assessed for risk factors before treatment
Treatment should be reviewed after
3–6 month
If patient develops urinary symptoms during treatment should be reported promptly for review (such as haematuria, dysuria, or urinary urgency)
What are risk factors that would put patients on pioglitazone at a higher risk of bladder cancer? (4)
un-investigated macroscopic haematuria
age
smoking status
exposure to chemotherapy agents
What is the mechanism of action of Meglitinides, including Nateglinide and Repaglinide?
stimulate insulin secretion
When should Meglitinides be taken in relation to main meals?
30 minutes before main meals
What are potential side effects associated with Meglitinides? (3)
may cause hypoglycemia
hypersensitivity
GI upset.
What is the mechanism of action of DPP 4 inhibitors, including Alogliptin, Linagliptin, Saxagliptin, Sitagliptin, and Vidagliptin?
(3)
DPP 4 inhibitors inhibit DPP4 enzymes that break down incretins,
which are produced by the gut in response to food
Incretins trigger insulin secretion and lower glucagon secretion
Therefore;increase in incretion= increased insulin secretion and decreased glucagon secretion
What are some common side effects of DPP 4 inhibitors? (5
hypoglycemia
upper respiratory tract infections (URTI)
GI upset
peripheral edema,
pancreatitis.
(Vildagliptin has rare reports of liver dysfunction)
When should treatment with DPP 4 inhibitors be discontinued in the case of pancreatitis? (2)
if severe abdominal pain, nausea, and vomiting persist
as these indicate pancreatitis.
What action should be taken if symptoms of liver dysfunction occur in a patient taking DPP 4 inhibitors?
discontinue treatment
What is the mechanism of action of SGLT2 inhibitors, including Canagliflozin, Empagliflozin, and Dapagliflozin? (3)
SGLT2 inhibitors inhibit SGLT2 in the renal tubules
to reduce glucose reabsorption
and increase glucose excretion.
What precaution should be taken regarding volume depletion before starting treatment with SGLT2 inhibitors? (2)
Any hypovolemia needs to be corrected before starting treatment with SGLT2 inhibitors
due to their associated risk of volume depletion.
When should treatment with SGLT2 inhibitors be considered for interruption?
if symptoms of hypovolemia occur
(such as postural hypotension and dizziness)
What factors may increase the risk associated with SGLT2 inhibitor use? (5)
being elderly
concomitant use of antihypertensive medications
cardiovascular disease
gastrointestinal illness
complicated urinary tract infections (UTI)
What are some common side effects of SGLT2 inhibitors? (6)
constipation
thirst
nausea
lower UTIs
hypoglycemia
polyuria.
What serious complication has been associated with the use of SGLT2 inhibitors, and what action should be taken if suspected? (3)
Serious and potentially life-threatening cases of diabetic ketoacidosis (DKA)s.
Treatment should be discontinued if DKA is suspected
and prompt medical attention must be sought.
What specific risk has been associated with Canagliflozin use regarding lower limbs, and what preventive measures are advised?
Canagliflozin may increase the risk of lower-limb amputation, mainly affecting toes.
Preventive foot care is important for all patients with diabetes.
Patients are advised to stay well hydrated, carry out routine preventive foot care
They should seek medical advice promptly if they develop skin ulceration, discoloration, or new pain or tenderness.
What are examples of GLP-1 like agonists? (5)
Exenatide
Albiglutide
Dulaglutide
Liraglutide
Lixisenatide
What is the mechanism of action of GLP-1 like receptor agonists? (3)
bind to and activate the GLP-1 receptor
mimicking the activity of normal incretins.
They increase insulin secretion and slow gastric emptying.
What are some common side effects associated with Glucagon-like peptide receptor agonists? (4)
gastrointestinal (GI) upset
headaches
weight loss
pancreatitis.
What action should be taken if severe abdominal pain, nausea, and vomiting persist in a patient taking Exenatide?
Treatment should be discontinued permanently
as these symptoms could indicate pancreatitis.
How should missed doses be managed of the Glucagon-like peptide receptor agonists: Abliglutide, Liraglutide and Dulaglutide
Administer the missed dose only if there are at least three days until the next scheduled dose.
How should missed doses be managed of the Glucagon-like peptide receptor agonist: Exenatide
Leave the missed dose and continue with the next scheduled dose.
How should missed doses be managed of the Glucagon-like peptide receptor agonist: Lixisenatide?
Administer the missed dose 1 hour before the next meal
According to the NICE 2017 guidelines for treating type 2 diabetes, what is the recommended initial treatment if metformin monotherapy is contraindicated or not tolerated? (3)
DPP4 inhibitor (gliptin)
Pioglitazone
sulfonylurea.
What are the dual therapy options recommended by NICE 2017 for people in whom metformin is contraindicated or not tolerated? (3)
DDP4 inhibitor plus pioglitazone
DDP4 inhibitor plus a sulfonylurea
Pioglitazone plus a sulfonylurea.
Who does osteoporosis commonly occur in? (2)
postmenopausal women
individuals taking long-term oral corticosteroids
What are other risk factors for osteoporosis? (6)
low body weight
cigarette smoking
excess alcohol intake
lack of physical activity
family history of osteoporosis
early menopause.
How can individuals at risk for osteoporosis reduce their risk? (2)
should maintain an adequate intake of calcium and vitamin D
doses of oral corticosteroids should be kept as low as possible, and courses as short as possible
What is the role of calcitonin in the regulation of bone turnover and calcium balance? (2)
Calcitonin decreases blood calcium concentrations
and is involved with parathyroid hormone (PTH) in the regulation of bone turnover and the maintenance of calcium balance.
What is the mechanism of action of Teriparatide in treating osteoporosis? (3)
Teriparatide is a recombinant form of PTH
Intermittent use activates osteoblasts
which leads to an overall increase in bone.
How does Cinacalcet reduce the risk of osteoporosis? (2)
Cinacalcet sensitizes Ca2+ receptors of the parathyroid gland to reduce PTH levels
thereby indirectly reducing the risk of osteoporosis.
What is the mechanism of action of Denosumab in treating osteoporosis? (2)
Denosumab is a human monoclonal antibody that inhibits osteoclast formation, function, and survival
thereby decreasing bone resorption.
What are examples of bisphosphonates commonly used in clinical practice? (2)
alendronate
risedronate
What is the mechanism of action of bisphosphonates?
Bisphosphonates are absorbed onto bone crystals and slow down the rate of bone turnover.
What precautionary measures should be taken regarding osteonecrosis of the jaw in patients receiving bisphosphonates? (5)
Patients receiving bisphosphonates, especially intravenous ones, should have a:
dental check-up before treatment
receive routine dental check-ups
maintain good oral hygiene
report any oral symptoms such as dental mobility, pain, swelling, non-healing sores, or discharge to both a doctor and dentist during treatment.
What is the risk associated with atypical femoral fractures in patients receiving bisphosphonates (3)
Atypical femoral fractures are a rare risk
mainly occurring in patients receiving long-term treatment with bisphosphonates.
Patients should be advised to report any thigh, hip, or groin pain during treatment with a bisphosphonate.
What is the very rare risk associated with the external auditory canal in patients receiving bisphosphonates?
There is a very rare risk of benign idiopathic osteonecrosis of the external auditory canal
mainly in patients receiving long-term therapy with bisphosphonates
Patients should be advised to report any ear pain, discharge from the ear, or ear infection
(a condition where the bone tissue in the external ear canal has died)
What is the mechanism of action of Strontium ranelate? (2)
stimulates bone formation
reduces bone resorption.
What risk is increaed with strontium ranelate?
serious cardiovascular disease, including myocardial infarction
This risk should be assessed before treatment and monitored regularly during treatment.
What severe allergic reaction has been reported with the use of Strontium ranelate, and what are its symptoms? (2)
eosinophilia
systemic symptoms (such as DRESS syndrome)
What is DRESS syndrome?
a delayed hypersensitivity reaction
it can be fatal
What are the symptoms of DRESS syndrome? (4)
rash
fever
swollen glands
increased white cell count
it can affect the liver, kidneys, and lungs.
What action should be taken if a patient experiences severe allergic reactions such as DRESS while taking Strontium ranelate?
Treatment should be discontinued immediately, and the patient should consult their GP immediately.
What advice should be given regarding food intake when taking Strontium ranelate granules? (3)
Patients should avoid food for 2 hours before and after taking Strontium ranelate granules
particularly calcium-containing products like milk
and antacids containing aluminium and magnesium hydroxide.
What is hormone replacement therapy (HRT) and when is it appropriate? (4)
HRT involves small doses of estrogen
sometimes combined with a progestogen in women with a uterus.
It is suitable for alleviating menopausal symptoms like vaginal atrophy or vasomotor instability
It can also help reduce postmenopausal osteoporosis.
Vaginal atrophy= thinning, drying and inflammation of the vaginal walls
How can vasomotor symptoms be managed in women who cannot take estrogen?
Clonidine can be used to reduce vasomotor symptoms (hot flashes and night sweats)
in women who are unable to take estrogen.
What are the risks associated with hormone replacement therapy (HRT)? (5)
increased risk of venous thromboembolism
stroke
endometrial cancer (although reduced by progestogen use)
breast cancer
ovarian cancer
What is the timeframe for increased risk of breast cancer with HRT? (3)
The risk of breast cancer increases within 1-2 years of starting HRT
but it is related to the duration of use
and disappears within 5 years of stopping.
Which HRT has a risk of endometrial cancer?
estrogen-only HRT
How does the risk of endometrial cancer relate to HRT? (2)
The risk of endometrial cancer depends on the dose and duration of estrogen-only HRT
however, this risk is eliminated if a progestogen is given continuously.
What is the association between long-term HRT use and ovarian cancer risk? (2)
Long-term HRT use is associated with an increased risk of ovarian cancer
but this excess risk disappears within a few years of stopping treatment.
What is the increased risk of venous thromboembolism with HRT? (2)
HRT is associated with an increased risk of deep vein thrombosis (DVT) and pulmonary embolism
especially in the first year of use.
Which pre- disposing factors increase the risk of venous thromboembolism with HRT?
a family history of DVT or obesity may further increase this risk.
How can the risk of deep vein thrombosis during travel be managed for women on HRT? (3)
Travel involving prolonged immobility increases the risk of DVT.
This risk can be reduced with exercise or compression hosiery.
It’s also recommended to review the need for HRT in women with predisposing factors.
What factors contribute to the risk of stroke in women on hormone replacement therapy (HRT)?
The risk of stroke increases with age
meaning older women have a greater absolute risk of stroke.
Does hormone replacement therapy (HRT) prevent coronary heart disease?
No, HRT does not prevent coronary heart disease. In fact, there is an increased risk of coronary heart disease in women who start combined HRT more than 10 years after menopause.
What are the immediate reasons to stop combined hormonal contraceptives or HRT? (8)
Sudden severe chest pain
Sudden breathlessness (or cough with blood)
Unexplained swelling or severe pain in one leg
Severe stomach pain
Serious neurological effects including severe, prolonged headache, sudden partial or complete loss of vision, sudden disturbance of hearing, bad fainting attack, unexplained epileptic seizure or weakness, motor disturbances, very marked numbness suddenly affecting one side or one part of the body
Hepatitis, jaundice, liver enlargement
Blood pressure above systolic 160 mmHg or diastolic 95 mmHg
Prolonged immobility after surgery or leg injury
Detection of a risk factor which contraindicates treatment
What is the purpose of using Clomifene (anti-oestrogen) in medical treatment? (2)
Clomifene is used to stimulate ovulation
used in the treatment of female infertility.
Why should Clomifene not typically be used for longer than 6 cycles?
due to an increased risk of ovarian cancer
How do androgens (testosterone) affect the body?
Androgens, such as testosterone, cause masculinization.
They may be used as replacement therapy in castrated adults and in individuals who are hypogonadal due to either pituitary or testicular disease.
What is the function of anti-androgens?
inhibit the effects of testosterone in the body.
In what circumstances is cyproterone acetate used?
Cyproterone acetate is used in the treatment of severe hypersexuality and sexual deviation in men.
How are dutasteride and finasteride utilized in medical treatment? (2)
Dutasteride and finasteride are used in benign prostatic hyperplasia
to reduce prostate size.
What are the primary antithyroid drugs used in the treatment of thyroid disorders? (2)
Carbimazole is the most commonly used drug
while propylthiouracil is reserved for patients intolerant/ sensitive of carbimazole
How do Carbimazole and Propylthiouracil primarily act in the body?
interfere with the synthesis of thyroid hormones.
What precautionary measures should be taken regarding neutropenia and agranulocytosis in patients taking Carbimazole (3)
should report symptoms and signs suggestive of infection, especially sore throat.
A white blood cell count should be performed if there is any clinical evidence of infection.
Carbimazole should be stopped promptly if there is clinical or laboratory evidence of neutropenia.
Is radioactive iodine contraindicated in pregnancy?
Yes
What considerations are important for the initial dosing of Levothyroxine and Liothyronine? (3)
a baseline ECG is valuable
can assess the electrical activity of the heart
to ensure that symptoms related to hypothyroidism are not being mistaken for symptoms of heart ischemia
What symptoms may indicate a need for dose adjustment or temporary withholding of Levothyroxine or Liothyronine? (6)
diarrhea
nervousness
rapid pulse
insomnia
tremors
and sometimes anginal pain
THESE may ALL indicate a need to reduce the dose or withhold it for 1-2 days.
How does liothyronine compare to levothyroxine? (2)
Liothyronine is used in severe hypothyroid states where a rapid response is required
it is faster acting but has a shorter duration compared to levothyroxine
Why should steroids be used with cuation in children?
possible growth restrictions
What is the target HbA1C concentration for patients with type 1 diabetes?
48mmol/ mol (6.5%)
How often should type 1 diabetes monitor their blood- glucose concentration?
atleast 4 times a day: including before each meal and before bed
What should the blood-glucose concentration of a type 1 diabetic be: on waking
5-7mmol/L
What should the blood-glucose concentration of a type 1 diabetic be: before meals and throughout the day
4-7mmol/L
What should the blood-glucose concentration of a type 1 diabetic be: after eating?
5-9mmol/L atleast 90 minutes after eating
What should the blood-glucose concentration of a type 1 diabetic be: when driving?
atleast 5mmol/L
How does an insulin pump work? (4)
contains short-acting or rapid acting insulin
The pump infuses the insulin into the patient s/c slowly
this provides basal control
When patient is about to eat, they will press the button and get a bolus dose of soluble insulin as well
Who are insulin pumps given to? (2)
only used in adults who suffer disabling hypoglycaemia
or have high HbA1C concentrations.
Where should insulin be injected? (3)
into a body area with plenty of SC fat
usually the abdomen (fastest absorption rate)
or outer thighs/buttocks (slower absorption rate).
What is lipohypertrophy? (3)
lump of fatty tissue
it can occur due to repeatedly injecting the insulin into the same area
can cause erratic absorption of insulin resulting in poor glycaemic control.
Lipohypertrophy can be minimised by using different injection sites in rotation.
What is an alternative to gliclizide whent here is a risk of hypoglycaemia?
sitagliptin
why is metformin a good choice for overweight patients?
it does not cause weight gain
How often is metformin taken?
TDS
with meals
if metformin alone, was not adequately controlled diabetes, what canw e add on?
add a Sulphonylurea/DPP4i/Pioglitazone
Why can we not give sulphonylureas e.g. gliclizide to overweight patients?
cause weight gain
can we give sulphonylureas in pregnancy?
no, avoid
can pioglitazone cause weight gain?
yes
what are two advantages of DPP4 inhibitors compared to sulphonylureas?
do not cause weight gain
have less incidence of hypoglycaemia
what must diabetic patients do to reduce their risk of hypoglycaemia when driving?
Drivers treated with insulin must carry a glucose meter with blood-glucose strips and fast- acting snacks
must check their blood-glucose concentration 2 hours BEFORE driving and every 2 hours WHILE driving.
Blood-glucose levels should always be above 5mmol/litre while driving.
But if blood-glucose falls to 5mmol/litre or below, a snack should be taken (fast-acting carbohydrate).
What should diabetic drivers do if blood glucose is less than 4mmol/L or symptoms of hypoglycaemia appear? (3)
the driver should not drive.
If the driver is driving then stop driving, eat/drink some sugar
and wait until 45 minutes after blood-glucose has returned to normal.
What is the earliest sign of nephropathy? (2)
Microalbuminuria
so patients should have an annual test for urinary protein
Why should patients with diabetic nephropathy not be given BOTH an ACEi and ARB?
they are susceptible to developing hyperkalaemia
How is diabetic ketoacidosis treated?
have to rehydrate the patient without giving glucose
Initial management involves rehydrating the patient with 0.9% saline via IV infusion
To replenish potassium levels, potassium chloride fluid is administered
IV insulin infusion is then given to reduce blood glucose and ketone production
(the Insulin should be mixed with 0.9 % saline and titrated to lower glucose by at least 3 mmol/l/hr)
When blood glucose drops below 14 mmol/l, IV glucose 10% is added to prevent hypoglycemia.
Insulin infusion continues until blood ketone concentration is <0.3 mmol/l and the patient can eat
then shifted to SC fast-acting insulin with a meal, discontinuing the infusion after 1 hour.
What should be done for patients on insulin before surgery?
On the day BEFORE surgery, continue usual insulin regimen except for once-daily long-acting analogues, which are reduced by 20%.
On the day OF surgery and THROUGHOUT the intra-operative period, once-daily long-acting analogues are also reduced by 20%, while all other insulin is halted until the patient resumes eating and drinking post-surgery.
What medications should be stopped once insulin infusion is initiated during surgery? (6)
Acarbose
meglitinides
sulfonylureas
pioglitazone
DPP4i
SGLT2i
Which medications can be taken as normal during the entire peri-operative period? (2)
Pioglitazone
DPP4i
What should be done with SGLT2 inhibitors on the day of surgery? (2)
SGLT2 inhibitors should be omitted on the day of surgery and not restarted until the patient is stable
due to the increased risk of ketoacidosis during periods of dehydration and acute illness.
Why should sulfonylureas be omitted on the day of surgery? (3)
Sulfonylureas are associated with hypoglycemia in the fasted state
so they should be omitted on the day of surgery
and not restarted until the patient is eating and drinking again.
What risks are associated with diabetes in pregnancy? (2)
increases risks to both the woman and the developing fetus
such as pre-eclampsia and adverse outcomes like stillbirth, miscarriage, and neonatal death.
What HbA1c level should women with pre-existing diabetes aim for before conception?
HbA1c level below 6.5%
to reduce the risk of congenital malformations in the newborn
What should women with pre-existing diabetes take before pregnancy to reduce the risk of neural tube defects in the newborn?
should take folic acid
at the dose recommended for women at high risk of conceiving a child with a neural tube defect.
Which antidiabetic drug should be continued during pregnancy? (2)
Metformin should be continued during pregnancy
while all other oral antidiabetic drugs should be discontinued and SUBSTITUTED with INSULIN therapy.
Which antidiabetic drug can be used during breastfeeding?
Metformin can be used
while all OTHER antidiabetic drugs should be AVOIDED
What is the treatment approach for gestational diabetes if fasting blood glucose is >7mmol/L? (3)
Initially, diet and exercise are recommended.
If blood glucose targets are not met after 1-2 weeks, Metformin can be started.
If fasting blood glucose is over 7mmol/L, immediate treatment with insulin is advised, with or without Metformin.
How is hypoglycemia initially treated? (3)
Initially, 10-20g of oral glucose is given, such as cola, sugar, or Lucozade.
This may be repeated if necessary after 10-15 minutes.
After initial treatment, consuming carbohydrates like a sandwich, fruit, milk, or biscuits can prevent blood glucose from falling again.
What emergency measures are taken for hypoglycemia causing unconsciousness?
Glucagon is administered to increase plasma glucose concentration by releasing glycogen from the liver.
If not effective after 10 minutes, , intravenous glucose 20% can be administered.
Diazoxide administered orally is useful for managing chronic hypoglycemia only.
What should be done if a patient taking liothyronine develops diarrhoea?
its a sign metabolism occurs too rapidly
reduce dose or whithold for 1-2 days and start again at a lower dose
(same is true if pt is experiencing any of these symtoms: nervousness, insomnia, tremors etc)
What fractures have both alendronic acid and risedronate sodium been shown to reduce?
have been shown to reduce the occurrence of vertebral, non-vertebral, and hip fractures
What is an additional option for osteoporosis treatment, particularly for younger postmenopausal women at high risk of fractures?
Hormone replacement therapy (HRT)
Why is hormone replacement therapy generally restricted for older postmenopausal women?
due to the risk of adverse effects such as cardiovascular disease and cancer.
What are the second-line options for those who are intolerant of or contraindicated to oral bisphosphonates?
Intravenous bisphosphonates, such as denosumab and zoledronic acid
How should alendronic acid be taken? (4)
Alendronic acid should be taken once weekly in women and once daily in men
with a full glass of water while sitting or standing.
It should be taken at least 30 minutes before breakfast and other medicines
and the patient should remain upright for a further 30 minutes after taking it
Can alendronic acid be given in pregnancy?
No, avoid
What is tetracosactide used for, and how does its administration help diagnose adrenocortical function? (4)
Tetracosactide
an analogue of corticotropin (ACTH)
is used to test adrenocortical function
FAILURE of the plasma cortisol concentration to RISE after ADMINISTRATION of tetracosactide INDICATED adrenocortical insufficiency.
What are gonadotropins used for in the treatment of infertility in women? (4)
Gonadotropins
are used in the treatment of infertility in women with hypopituitarism
or those who have not responded to clomifene citrate
or for assisted conception such as in-vitro fertilisation (IVF).
Gonadotrophins include: follicle-stimulating hormone (FSH), luteinising hormone (LH), FSH alone (as in follitropin), or chorionic gonadotrophin
What is an example of growth hormone used for treating deficiency in children and adults?
Somatotropin (which has been replaced by somatropin)
What is hypoglycaemia?
a clinical state
where the blood glucose levels fall below 3.5mmol/L.
