Endocrine Flashcards
1
Q
Treatment of cranial diabetes insipidus
A
Vasopressin
Desmopressin
ADH drugs
2
Q
Treatment of nephrogenic diabetes insipidus
A
Carbamazapine
Thiazide diuretics - paradoxical effects
Oxytocin
3
Q
Side effect of desmopressin
A
HypONatraemic convulsions
due to extreme dilution of water
4
Q
When to inform DVLA of diabetes
A
- All drivers treated with insulin must inform DVLA
- Drivers to notify DVLA if the have episodes of hypoglycaemia
- Drugs with greatest risk of hypoglycaemias: insulin, sulphonylurea, meglitinides
5
Q
DVLA advice with diabetes
Target blood glucose while driving
A
- Avoid hypoglycaemia and know warning signs & actions to take
- Carry glucose meter & test strips when driving
- Check blood glucose at least 2 hours before driving and every 2 hours while driving
- Blood glucose should always be >5 mmol/L while driving
- Take snack if blood glucose falls to or below 5 mmol/L
6
Q
What to do if blood glucose goes below 5 mmol/L while driving
A
- STOP vehicle in safe place
- Switch off engine
- Eat or drink suitable source of sugar
- Wait until 45 minutes after blood glucose is normal
- Continue journey
7
Q
Advice on alcohol consumption with diabetes
A
- Alcohol can mask the signs of hypoglycaemia
- Drink in moderation and with food
8
Q
Symptoms of hypoglycaemia
A
- Confusion, unconsciousness, change of behaviour
- Difficulty concentrating
- Slurring speech & convulsions
- Hunger
- Palpitations (tachycardia)
- Shaking and trembling
- Sweating
- Double vision
- Headache
9
Q
What is the oral glucose tolerance test used to test for?
How is it carried out?
A
- Establish gestational diabetes
- Diagnose impaired glucose tolerance
- Involves measuring blood glucose conc after fasting for 8 hours and then 2 hours after drinking a standard anhydrous glucose drink
Not for testing diabetes
10
Q
What is HbA1c?
What’s it used for?
when is it performed?
A
- Test for red blood cells with glucose linked
- Used to diagnose Type 2 diabetes ONLY
- How well you’ve been controlling blood sugar in the past 2-3 months in type 1 and type 2
- Predict microvascular and macro vascular complications and mortality
Performed at anytime of the day and doesn’t require any special preparation
11
Q
When won’t you use HbA1c in diagnosing diabetes
A
- Type 1 diabetes
- In children
- During pregnancy
- Women up to 2 months postpartum
- Symptoms < 2 months
- Treatment with meds that can cause hyperglycaemia, pancreatic damage, CKD, HIV
12
Q
How often should you monitor HbA1c in diabetics
A
- Type 1: every 3-6 months (more frequently if blood glucose changing rapidly)
- Type 2: every 3-6 months until stable then monitor every 6 months
13
Q
What tests are used in diagnosing type 2 diabetes
A
HbA1c
Fasting blood glucose test
14
Q
What test is used in diagnosing gestational diabetes
A
Oral glucose tolerance test (OGTT)
15
Q
What test is used in diagnosing type 1 diabetes
A
Random blood glucose test
16
Q
Examples of diabetic complications
A
Retinopathy
Nephropathy
Neuropathy (pain, numbness & weakness)
Premature CVD
Peripheral arterial disease
17
Q
Symptoms of Type 1 Diabetes
A
- Polydipsia: excessive thirst
- Polyphagia: excessive hunger
- Pulyuria: excessive urination (especially at night)
- Weight loss
- Irritability and other mood changes
- Fatigue and weakness
- Blurred vision
18
Q
What is the glucose level in random hyperglycaemia
A
> 11 mmol/L
19
Q
Target HbA1c
A
>/= 48mmol/mol (6.5%)
20
Q
What BMI indicates rapid weight loss
A
<25kg/m
21
Q
What is the fasting plasma glucose level on waking
A
5-7 mmol/L
I wake at 5 to 7
22
Q
What is glucose target before meals
A
4-7 mmol/L
Be4 meals
23
Q
What is glucose target after meals
A
5-9 mmol/L
I dine at nine
24
Q
Random plasma glucose concentration target
A
< 11 mmol/L
25
How many times should blood glucose be measured each day
4 times
26
What is the body’s normal insulin regimen?
**Basal-bolus**
- Basal - slow and steady secretion of insulin
- Bolus - insulin excreted when you eat
27
Three types of insulin
- Human insulin
- Human analogue insulin (modified)
- Animal insulin (cows and pigs)
28
How is insulin administered?
**SC route** most ideal - *inactivated by GI enzymes so not orally*
- Inject in area with most fat - *(**Abdomen** fastest absorption rate)* or **outer thigh / buttocks***
- Injecting same area repeatedly can cause **lipohypertrophy** - *(Rotate injection sites)*
- Check injection sites for signs of **infection, swelling, bruising & lipohypertrophy** before administration**
29
Examples of soluble insulin
*Soluble are not rapid but **act-rapid** and all have ‘**S**’* and similar to h**uman** insulin
- **Actrapid**
- Humulin **S**
- In**s**uman
30
Examples of rapid acting insulin and their brand names
**’LAG’**
- **Lispro** *(Humalog)*
- **Aspart** *(Novorapid)*
- **Glulisine** *(apidra)*
31
Examples of intermediate insulin
- **Isophane/NPH** *(Humulin I)*
- **Novimix**
- **Humalogmix**
- **Humulin M3**
32
Examples of long acting insulin and frequency
- Detemir **(*levemir*) OD-BD**
- Glargine **(*lantus, toujeo*) OD**
- Degludec **(*tresiba*) OD**
33
Which long acting insulin can be given twice a day
**Determir (levemir)**
34
When should rapid acting insulin be taken?
- onset of action
- duration
**Inject immediately before meals**
- **15 minutes**
- **2-5 hours**
35
When should soluble insulin be taken?
- onset of action
- duration
**IV best for diabetic emergencies *(eg. Ketoacidosis & pre-operatively)***
- **30-60 mins** *(SC admin)*
- **9 hours**
36
When should intermediate insulin be taken?
- onset of action
- duration
**Inject before meals**
- **1-2 hours**
- **11-25 hours**
37
When should long acting insulin be taken?
- onset of action
- duration
**Once a day except Determir that can be twice a day**
- **2-4 hours**
- **36 hours**
38
Three types of insulin regimens
- **Basal-bolus**
- **Once daily regimen**
- **Mixed/ Biphasic regimen**
39
What is basal-bolus regimen
When is it used?
**Multiple daily injection regimen at each meal**
- Long acting / intermediate + Short acting
- **Basal**: **OD/BD** *(Given at **bedtime**)*
- **Bolus**: Taken specifically **at meal time**
40
Who is basal-bolus regimen good for
- **First line for *NEWLY* diagnosed *TYPE 1* pts**
- Busy work life who need to be **flexible**
- People who have less regular routine
41
Basal-bolus regimen for type 1 vs type 2
**Type 1**: **SA** at meal times + **LA** at bed time
**Type 2**: **SA** + **IM**
42
Who is the once daily regimen for?
Type 2 diabetes + oral tablets
43
Choice of OD insulin regimen
**LA**: pts who experience hyperglycaemia through the day & night
**IM**: hyperglycaemia at night or morning but fine during the day *(take before bed)*
44
How is mixed/biphasic regimen taken
**Works on assumption that you have 3 meals each day**
- Inject **OD, BD or TDS** before meals
45
What does biphasic contain
**SA** + **IM**
- Premixed or manually mix with syringe
46
Who can use biphasic regimen
**Can be used by type 1 & 2 pts**
***NOT** for **acutely ill** pts or **newly diagnosed type 1** pts*
47
What type of pts use insulin pump
Adults with **disabling hypoglycaemia** or **high HbA1c >69 mmol/mol**
- Specialist
48
What factors affect insulin requirements
- **Adherence**
- Injection **technique / site problems**
- Blood glucose **monitoring skills**
- Lifestyle (diet, alcohol, exercise)
- **Renal disease**
- **Thyroid disorders**
49
What factors **increase** insulin requirements
- Infection
- Stress
- Accidental or surgical trauma
- Pregnancy (2nd & 3rd trimester)
50
What factors **decrease** insulin requirements
- Physical activity
- Vomiting
- Reduced food intake
- Impaired renal function
- **Addisons** - endocrine disease
*Things that use up energy or sugar*
51
Where do you dispose needles, lancets
Yellow bin
52
Sick day rules
Diabetic pts on sick days
**’SICK’**
- **S**ugar; Monitor blood glucose *(blood glucose rise when sick)*. Increase insulin or sulfonylureas
- **I**nsulin; **NEVER** stop insulin or oral diabetes medications. May increase dose of insulin
- **C**arbohydrate; Maintain hydration and carbs intake. Replace meals with sugary fluid if pt can’t eat
- **K**etones; Check for ketones every **2-4 hours** in type 1. Give **extra rapid-insulin** if ketones present.
53
Drugs to stop on sick days until better and able to eat and drink for 24-48 hours
**’SADMAN’**
- **S**GLT2 inh : lead to dehydration, risk of DKA
- **A**CEi: dehydration, AKI
- **D**iuretics: dehydration, AKI
- **M**etformin: dehydration, lactic acidosis
- **A**RBs: dehydration, AKI
- **N**SAIDs: dehydration, AKI
54
Most common insulin errors reported
- Failure to manage insulin resulting in death
- Dosing error
- Wrong frequency
- Omitted or delayed insulin
55
Guidance to prevent errors with insulin
- Confirm insulin pen with pt
- Confirm frequency
- Intermediate usually cloudy
56
What drug can increase risk of DKA when given with insulin
GLP-1 (**Byetta**- exenatide & **Victoza**- liraglutide)
*Reports of DKA with people with **type 2** on GLP + insulin whose insulin dose was **rapidly reduced or discontinued***
57
Pt advice on insulin
- **DO NOT** withdraw insulin from **insulin pen / cartridge devices**, use as it is
- **Units** must not be abbreviated on prescription or label
- **Insulin syringes and pens** should always be used to measure dose
- **Amyloid protein under skin** which interferes with insulin absorption and administration *(rotate injection site)*
58
Patient and carer advice on insulin
- How to avoid hypoglycaemia
- Insulin passport
- Driving and skilled tasks
59
Conversion to human insulin
- Bovine (cow) to human = **reduce by 10%**
- Porcine (pig) to human = **maintain**
60
What are the different drug classes of anti diabetics
- Sulphonylureas
- SGLT-2
- Biguanides *(**Metformin**)*
- DPP4 inh *(gliptins)*
- GLP-1
- **A**lpha glucosidase inh *(**A**crobase)*
- Thiazolidinedi**one**s *(pioglitaz**one**)*
- Meglitinides *(nateglinide)*
61
Examples of sulphonylureas
- Gliclaz**ide**
- Tolbutam**ide**
- Glipiz**ide**
62
Examples of GLP-1 agonists
- Albiglutide
- Liraglutide
- Exenatide
63
Examples of DPP-4 inhibitors
(**Dip**eptidylpeptidase-4 inhibitors)
***Dip** your **liptin** in hot water*
- Alo**gliptin**
- Lina**gliptin**
64
Examples of SGLT-2 inhibitors
- Cana**gliflozin**
- Dapa**gliflozin**
65
Risk factors of Type 2 diabetes
- Obesity
- Physical inactivity
- Raised bp
- Dyslipidaemia and tendency to develop thrombosis
66
Steps in treatment of type 2 diabetes
**Step 1**: Lifestyle for ***3 months***
**Step 2**: Antidiabetic drugs
67
Properties of metformin
- Only available **biguanide**
- **1st choice** for **ALL** type 2 pts
- Does NOT cause **hypoglycaemia**
- Increase dose slowly to prevent GI side effects (OD-BD-TDS)
- Offer MR if standard not tolerated
68
Side effects of Metformin
- **GI** effects : *take with or after food*
- **Lactic acidosis**: discontinue
69
Contraindications of metformin
**Acute metabolic acidosis**
- **Ketoacidosis, renal failure, general anaesthesia** (stop morning of surgery)
- Lactic acidosis, **avoid if eGFR < 30mL/min**
- Renal failure
70
Can you give metformin to pregnant and breast feeding?
Yes
71
Monitoring requirements for metformin
Renal function
72
Symptoms of lactic acidosis
- Dysponea (difficulty breathing)
- Muscle cramps
- Abdominal pain
- Hypothermia (low temp)
- Asthenia (weakness/lack of energy)
73
Properties of solphonylureas
- **Hypoglycaemia**
- **Weight gain**
- **Avoid in pregnancy/ breastfeeding**
- Given when **metformin is CI or not overweight**
74
Can sulphonylureas be taken before surgery
No,
Change to insulin
75
Can sulphonylureas be given in pregnancy
No, Avoid
76
What are the long acting sulphonylureas
Glimepiride
Chloropropamide
*Greatest risk of hypoglycaemia, **Avoid in elderly***
77
What are the short acting sulphonylureas
Gliclazide
Tolbutamide
78
Side effects of sulphonylureas
- **GI**
- **Hepatic impairment** (jaundice, hepatitis, hepatic failure)
- **Allergic skin reaction in first 6-8 weeks**
79
Cautions and CI of sulphonylureas
*All start with **‘Gli’***
- Caution in **elderly**
- Acute **porphyria and Ketoacidosis**
- Avoid / reduce dose in **renal & hepatic impairment**
80
Which anti diabetic affects absorption of sucrose
**Acarbose**
Give glucose
**GI side effects**
81
Side effects of Pioglitazone
- Associated with **Heart failure** - *risk increased when giving with **insilin***
- Risk of **bladder cancer**
82
When to continue tx with Pioglitazone
Only when **HbA1c decreased by atleast 0.5% within 6 months** of starting tx
83
Side effects of Pioglitazone
- **Bone fracture**
- **Weight gain**
- **Visual impairment**
- Increased risk of **infections and numbness**
84
Monitoring requirements for Pioglitazone
Liver function
*Report signs of liver toxicity*
85
Pt diagnosed with heart failure has also been diagnosed with type 2 diabetes
What drug can worsen pts condition?
Pioglitazone
86
Which anti diabetic drug can increase risk of infection
Pioglitazone
87
Signs of liver toxicity
- jaundice
- nausea and vomiting
- dark urine
88
When are Dipepridylpeptidase-4 inhibitors contraindicated
Diabetic Ketoacidosis
89
Side effect of gliptins
- GI
- Skin reactions
*Discontinue if symptoms of **acute pancreatitis***
90
Sign of acute pancreatitis
Persistent severe abdominal pain
91
MHRA warning with SGLT-2
(Flozins)
Risk of **Diabetic Ketoacidosis**
92
MHRA warning with Canagliflozin
Increased risk of **lower limb amputation *(mainly toes)***
93
Which flozin should be stopped when eGFR < 15ml/min
Dapagliflozin
94
What drugs require dose adjustments when given with SGLT-2
Insulin and Sulphonylureas
95
Side effects of SGLT-2
- Weight loss
- DKA
- **Increased risk of infection risk**
- **Urinary disorders**
96
Which anti diabetic drugs require effective contraception
Glucagon-like peptide 1 receptor agonist ( GLP1)
*(Liraglutide, exenatide, lixisenatide)*
97
What class of antidiabetic have no effect on weight
*’**Metformin** with **liptin** doesn’t affect weight’*
Metformin
Gliptins
98
What class of antidiabetic cause weight gain
Sulphonylureas
Pioglitazone
99
What class of antidiabetic cause weight loss
*’The **G**ir**L**s like to **lose weight**’*
SGLT2i (flozins)
GLP-1(tide)
100
What antdiabetic causes heart failure
Pioglitazone
101
Which SGLT-2 is no longer used in **Type 1**
**Dapagliflozin**
*(Forxiga 5mg)*
102
What is a severe side effect associated with GLP-1
*which one is excluded*
Sever GI disease
*Semaglutide*
103
Mechanism of action of acarbose
**Delays digestion** and absorption of **starch and sucrose**
104
Mechanism of action of metformin
**Decreases gluconegenesis**
Increases peripheral utilisation of glucose
*Acts only in the presence of insulin so only effective when there is some functioning pancreas cells*
105
Mechanism of action of dipeptidylpeptidase-4 inhibitor
Increase insulin secretion
Lower glucagon secretion
106
Mechanism of Sulphonylureas
Increase insulin secretion
107
Mechanism of action of pioglitazone
Reduce peripheral resistance
Reduces blood glucose concentration
108
Mechanism of SGLT2 (flozins)
Reduce glucose reabsorption
Increase urinary glucose excretion
109
Mechanism of action of GLP-1 receptor agonists (semaglutide)
Augments glucose dependent insulin secretion
Slows gastric emptying
110
What does HbA1c have to be before adding a second antidiabetic to Metformin?
58 mmol/mol
111
What anti diabetic is not indicated for triple therapy
Pioglitazone + **Dapagliflozin**
112
When is insulin introduced in type 2 diabetes
When multiple drugs not effective
**HbA1c > 75 mmol/mol**
113
What to do if pt has glucose >4 mmol/L but with hypoglycaemia symptoms
**Small carb snack** eg. Bread/ normal meal
114
What to do if pt has blood glucose <4 mmol/L and is **conscious and can swallow**
**oral glucose** - *for 3 cycles with 15 minutes intervals*
Eg. Glucogel 40%
115
What to do if pt with glucose < 4mmol/L has been given 3 cycles of oral glucose but still has blood glucose <4
**IM glucagon** or
**IV glucose 10%** infusion
*Give **thiamine** to alcohol patients*
116
What to do if pt has blood glucose <4 mmol/L and is **unconscious** or in **emergency**
**IM glucagon** or
**IV glucose 10% / *20%*** infusion
117
When do you give IV glucose in hypoglycaemia
When IM glucagon is not effective after 10 minutes
118
When is IV glucose **20%** infusion used
Only in **emergency** or if **unconscious**
119
What to avoid in hypoglycaemia
- **Orange juice** : high potassium
- **Chocolates and biscuits** : low in sugar but high in fat which can delay gastric emptying
120
Examples of long acting carb
- two biscuits
- one slice of bread
- 200-300ml of milk (not alternative)
121
When to avoid glucagon
- Prolonged fasting
- Adrenal insufficiency
- Chronic hypoglycaemia
- Alcohol- induced hypoglycaemia
- **Pt taking sulfonylurea** (give IV glucose)
122
CVD drugs beneficial in diabetes
- ACEi
- low dose aspirin
- lipid regulating drugs eg. Statin
123
What is used in diabetic nephropathy?
ACEi / ARB
124
Signs of DKA
- Dehydration; *polydipsia & polyuria*
- Weight loss
- Excessive tiredness
- Nausea & vomiting
- Abdominal pain
- **Sweet smell to breath**
- **Sweet and metallic taste in mouth**
125
Symptoms of hyperosmolar hyperglycaemic state (HHS)
- Dehydration; *polydipsia & polyuria*
- Weight loss
- Weakness
- **Poor skin turgor**
- **Acute cognitive impairment**
126
Which has a faster onset of action between DKA and HHS
**DKA faster**
HHS takes days and more severe
127
Treatment of DKA
- **IV fluid replacement**
- Followed by **IV soluble insulin** *(continue **LA** insulin)*
- Add **K & glucose** if required
128
Treatment of HHS
- **IV fluid replacement**
- Followed by **IV insulin**
- *K omitted of replaced if required*
129
What to monitor in DKA
**Blood glucose**
**Blood ketone**
*Every 1 hour*
130
What to do to insulin during surgery
- Have emergency tx of hypoglycaemia on chart
- **Day before** : insulin given as normal BUT ***reduce dose of LA to 80%***
- **Day of surgery** : Stop all other insulins and continue with **80% LA** until pt can eat and drink again
131
What is given throughout surgery with diabetic pts
**IV Glucose + Soluble insulin**
*Give until 30-60 min after 1st meal*
132
What two drugs can be continued during surgery
Metformin
GLP-1
133
What is the anti diabetic drug that can be used in pregnancy?
Metformin
134
What insulin is preferred in pregnancy/ breastfeeding
- **Rapid acting**
- **Intermediate acting**
- **Long acting**
135
What is giving to diabetic women planning to get pregnant
**Folic acid 5mg** until 12 weeks gestation
136
Tx of gestational diabetes
Step 1: **Diet and exercise**
Step 2: **Metformin**
Step 3: **Insulin** *if metformin ineffective*
137
MHRA advice for corticosteroids
**Chorioretinopathy**
- Blurred vision
- Refer to ophthalmologist
138
Difference between mineralcorticoid and glucocorticoid
**Mineralcorticoid** - work on electrolytes and water *(used in hypotension)*
**Glucocorticoid** - Inflammation/ reduced immunoresponse
139
Examples of Mineralcorticoid
Fludrocortisone
Hydrocortisone (cortisol)
140
Examples of glucocorticoid
Betamethasone
Dexamethasone
Methyl prednisolone
Prednisolone
Triamcinolone
141
Side effects of glucocorticoid
*’**Diabetic bodybuilders** are **psychos** and get **stomach ulcers** from eating **broken bones**’*
- Diabetes
- Osteoporosis (esp in elderly)
- Muscle wasting (myopathy)
- Psychiatric reactions
- Peptic ulceration & perforation
- Cushing’s syndrome
142
Side effects of mineralcorticoids
- Hypertension
- Sodium retention
- Water retention
- Potassium loss
- Calicum loss
143
What steroids have the highest potency for glucocorticoid
Betamethasone
Dexamethasone
144
What hormones are secreted by adrenal glands
**Cortisol**- glucocorticoid
**Aldosterone**- Mineralcorticoid
145
What is adrenal suppression and example
Insufficient steroid
80% due to **Addisons disease**
146
Difference between Addisons disease and Cushing’s disease
**Addisons**- insufficient steroids
**Cushing’s**- too much steroids
147
Symptoms of adrenal suppression
- **HypONatraemia**
- Hyp**O**tension
- Hyp**ERK**alaemia
- Hyp**OG**lycaemia
- **Salt craving**
- Weight loss / Anorexia
- Fatigue
- Nausea & vomiting
148
How to minimise corticosteroid side effects
- Use **lowest dose for shortest time**
- Give as **single dose in the morning**
- Use **local tx** over **systemic**
- Give **short course**
- Use **large volume spacer devices** of high doses required to increase **airway deposition & reduce oropharyngeal deposition**
149
What is used in adrenal deficiency state
**Hydrocortisone & Fludrocortisone**
150
General side effects of corticosteroids
- **Blurred vision**
- Adrenal suppression (Addisons)
- Increase risk of infection
- Psychiatric reactions
- **Chicken pox** - *varicella zoster immunoglobulin vaccine*
- Measles
151
Is it okay to give steroids in pregnancy
Yes
Benefits outweigh risk
152
When to titrate steroid down?
- Tx more than **3 weeks**
- Disease unlikely to relapse
- Received **> 40mg prednisolone (or equivalent), daily for *>1 week***
- Recently received repeat courses
- Taken **short course within 1 year** of stopping *long term therapy*
- Other causes of adrenal suppression
- Had repeat doses **in the evening**
153
What are the clinical markers for hyperthyroidism
**LOW TSH**
**HIGH Thyroxine [T4]**
154
Symptoms of hypothyroidism
- Weight loss
- A goitre
- Disturbed sleep
- Hyperactivity
- Heat intolerance
- Complications
155
Drugs used in hyperthyroidism
**Carbimazole**
Propylthiouracil
156
What is blocking replacement regimen
Maintains optimal hormone level
Carbimazole + Levothyroxine
157
When to avoid blocking replacement therapy
Pregnancy
158
When to avoid carbimazole
Pregnancy 1st trimester
159
Other drugs that can be used In hyperthyroidism
Iodine
Radioactive sodium ion
Propanalol
160
What is thyrotoxic crisis
How to tx
Too much thyroid hormone
- IV fluids
- Propranolol
- Hydrocortisone
- Oral iodine solution, carbimazole/ propylthiouracil
161
Which anti thyroid drug is safe in pregnancy
**Propylthiouracil** - *1st trimester*
**Carbimazole** - *2nd and 3rd trimester*
162
Side effects of Carbimazole
- **Neutropenia**
- **Agranulocytosis**
- Susceptible to infection
- **Acute pancreatitis**
163
Warning signs of Carbimazole
- **Stop** if *bone marrow suppression*
- Report signs of infection especially **sore throat**
- Perform white blood cell count if sign of infection
- **Stop promptly** if any clinical or laboratory evidence of *neutropenia*
164
Patient and carer advice with carbimazole
Tell doctor **immediately** if **sore throat, mouth ulcers, bruising, fever, malaise or non specific illness develops**
165
Monitoring requirements for Propylthiouracil
- **Hepatotoxicity**
- **Discontinue** if sever liver-enzyme abnormalities develop
166
What biological marker is used in pregnancy
TSH levels
167
Symptoms of hypothyroidism
- Fatigue
- Weight gain
- Constipation
- Menstrual irregularities
- Depression, dry skin
- Intolerance to the cold
168
Tx of hypothyroidism
**Levothyroxine**
Liothyronine IV - emergency or coma
169
Risk factors of osteoporosis
- Age
- Low BMI
- Cigarette smoking
- Excessive alcohol
- Lack of physical activity
- **Vit D deficiency**
- **Low calcium**
- **Early menopause**
170
What deficiencies can put you at risk of osteoporosis
Calcium
Vitamin D
171
Tx of osteoporosis
1st line: Bisphosphonate (**Alendronic acid or Risedronate**)
2nd line: **Ibrandronic acid, denosumab or raloxifene**
3rd line: **HRT** - *younger post menopausal women*
172
MHRA advice for bisphosphonate
- **Osteonecrosis of the jaw** *(more common in IV)*
- **Pain in thigh, hip or groin** - report
- Ear pain
*Common in tx >2 years*
173
Side effects of alendronic acid
**Oesophageal reactions**
*STOP and seek medical advice if; **dysphasia, new or worsening heartburn, pain on swallowing or retrosternal pain***
174
Dose of alendronic acid in men
10mg OD - **7days**
175
Dose of alendronic acid in women
10mg OD - 7 days
OR
70mg OW
176
Counselling for alendronic acid
- **Swallow whole**
- Take doses with **plenty of water while sitting or standing**
- Take on an **empty stomach** at least **30 minutes before breakfast *or any oral med***
- Stand or sit upright for atleast **30 minutes after administration**
177
At what eGFR is bisphosphonate CI
<30
178
What is used in HRT
Oestrogen
Progestogens
179
Symptoms of menopause
- Hot flushes
- **Vaginal atrophy**
- Accelerated skin aging
- **Vaginal dryness**
- Decreased muscle mass
- **Sexual dysfunction**
- **Bone loss** (osteoporosis)
180
What age is early menopause?
What age is natural menopause?
**Early** - <45
**Natural** - >50
181
Examples of natural oestrogen
Estradiol
Estrone
Estriol
182
What oestrogen has three different activities
Tibolone
- Oestrogenic
- Progestogenic
- Weak androgenic
183
What is the dose of denosumab
60mg every **6 months**
184
Do progesterone cause thromboembolism?
No
Only oestrogen
185
What is given to women **with uterus** on long term therapy of HRT and why?
Progesterone
*Reduces risk of cancer and cystic hyperplasia*
186
What type of pts are progesterone used?
Women with uterus
**Tibolone**
187
Risks of HRT?
**’OBE’**
- **Breast cancer**
- **Endometrial cancer**
- **Ovarian cancer**
- VTE
- Stroke
- Coronary heart disease
188
What type of cancer does progesterone reduce risk of
Endometrial cancer
189
How often should HRT be reviewed
Annually
190
How long is the progesterone cyclically
**10 days** per 28 day cycle
191
Which HRT drug has highest risk of stroke
Tibolone
192
When to stop HRT before surgery
4-6 weeks
Continue after surgery when mobile
193
Symptoms to stop HRT
- Signs of DVT
- Signs of liver toxicity
- SOB
- Severe stomach pain
194
Examples of testosterone analogues
- **Nor**ethisterone
- **Nor**gestrel (Levonorgestrel)
195
Examples of progesterone analogues
Dydro**gesetrone**
Medroxy**progesterone**
196
What is used in severe hyper sexuality in men
**Cyproterone**
(Dutasteride & Finasteride)
197
Warning with finasteride
Women of childbearing age should not handle crushed or broken tablets
198
If pt can’t take HRT what can they have instead
Clonidine
199
Target HbA1c when two or more anti diabetics are prescribed
53 mmol/mol
200
Side effect of ticagrelor
- **Haemorrhage**
- **Bruising**
- **Dyspnoea**
- vertigo
- abdominal pain
201
Nature of interaction between ferrous sulphate and levothyroxine
**Decreases absorption of levothyroxine**
Separate administration by atleast **4 hours**
202
Nature of interaction between beta blockers and levothyroxine
BB decrease effect of levothyroxine
203
What to do if bisphosphonate is not tolerated or contraindicated in osteoporosis
Refer for specialist treatment with
- Zoledronic acid
- Strontium ranelate
- Raloxifene
- Denosumab
- Teriparatide
204
What electrolyte counteracts blood acidity in DKA
Bicarbonate
205
Patient advice with desmopressin
Restrict fluid from 1 hour before until 8 hours after taking
206
What class of anti diabetic is most associated with DKA
SGLT2 (flozins)
207
Pre diabetic blood glucose target
**6-7 mmol/L**
**7.9 to 11** - 2 hours after drink
208
Strongest topical corticosteroids
1. Clobetasol
2. Beclomethasone
3. Clobetasone
4. Hydrocortisone - weakest
All at 1%
209
How to treat adrenal insufficiency (Addisons)
Hydrocortisone IV
Fludrocortisone
210
How do we treat adrenal crisis
Hydrocortisone IM
211
How to give Levo
30-60 mins before food / caffeine
**SAME BRAND**
212
Main side effects of carbimazole
- **Neutropenia**
- Sore throat/ fever/ malaise
- Congenital malformation
- pancreatitis
213
What is used for symptoms of hyperthyroidism
**Propranolol** - tachycardia
