Endocrine Flashcards
Sulfonylureas
Sulfonylurea- increase pancreatic insulin secreation
I- T2DM
D-
Glibenclamide (AKA glyburide)- 2.5-20mg daily in 1-2 doses (max single dose 10mg)
Gliclazide- IR 40-320mg d in one or two doses (up to 160mg in single dose), MR 30-120mg once daily
Glimepiride- 1-4mg daily
Glipizide- 2.5-40mg daily in 1-2 doses (doses >15mg should be divided)
M- blood glucose, HbA1C, weight gain, hypoglycaemia (highest risk with glibenclamide and glimepiride), renal (dose reduction may be required in impairment),
AE- nausea, dysppepsia, weight gain, headaches, hypoglycaemia
C- take with food to avoid hypoglycaemia (MR-swallow whole do not crush or chew), more likely to experience hypos- ensure you have a plan and know the signs, diabetes lifestyle advice, avoid alcohol- increased risk of hypoglycaemia, causes weight gain- maintain healthy balanced diet,
CAL- 10a, B
Metformin
Biguanide antidiabetic agent
I- T2DM, PCOS
D- IR 500-1000mg d in 1-3 doses (max 3000mg/d) CR-500-2000mg od
M- BG, HbA1C, renal function (requires dose reduction when CrCl 60-90 max 2g, 30-60 max 1g, 15-30 max 500mg, Serum vit B12, lactic acidosis
AE- D, N, loss of appetite- often disappear with use, vomiting, lactic acidosis, acute hepatitis
C- take with or soon after food, XR swallow whole do not crush or chew, see dr ASAP weight loss, NV, abdo pain, cramps, fatigue, D, weight loss, 2 weeks to obtain BG control, diabetes lifestyle advice, usually stopped before surgery and restarted when diet and renal function recovers, avoid alcohol due to risk of hypoglycaemia
CAL-10a, B (A for CR)
Rosiglitazone
Thiazolidinediones
I- T2DM
D- 4-8mg d in one or two doses
M- BG, BMI (can cause weight gain), oedema, anaemia, LFT, blood lipids, BMD
AE- weight gain, headache, dizziness, arthralgia
C- see dr ASAP swollen feet, ankles, breathlessness, jaundice, diabetes lifestyle advice and monitoring
others- pioglitazone, lobeglitazone
DPP-4 Inhibitors
DPP-4 inhibitor- dipeptidyl peptidase-4 inhibitors- reduces incretin GLP-1 breakdown which increases glucose dependent insulin secretion
I- T2DM
D- Alogliptin- 25mg od Linagliptin- 5mg od Saxagliptin- 5mg od Sitagliptin- 100mg d in 1-2 doses Vildagliptin- 50mg od-bd
M- BG, HbA1c, renal function (linagliptin is the only hepatically cleared), ACE-I treatment (increased risk of ACE-I angioedema), pancreatitis, weight neutral, HF (saxagliptin used in people with HF found increased hospitalisations), LFTs (for vildagliptin)
AE- hypoglycaemia (low risk alone- more likely with insulin or SU), headache, musculoskeletal pain, constipation, nausea
C- take irrespective of food (if combo with metformin take with food)If BG is not controlled see dr, see dr ASAP and stop taking if you get a rash (steven johnsons), hypo action plan, impact of alcohol, diet and exercise, tell all HCP youre taking,
GLP-1 analogues
Glucagon-like peptide-1 analogues- (incretin analogue)- increase glucose dependent insulin secretion and suppress inappropriate glucagon secreation. slow gastric emptying which slows glucose absorption and decreases appetite.
I- T2DM
D Exenatide: -Byetta- 5-10microg SC bd within 60min prior to meals -Bydureon- SC 2mg once weekly Liraglutide: -Victoza (T2DM)- SC 0.6-1.8mg od -Saxenda (obesity)- 0.6-3mg od Dulaglutide: -Trulicity- 1.5mg SC once weekly
M-hypoglycaemia (esp with SU or insulin), GIT AE (avoid in gastroparesis)- NV occur in 50% of patients dyspepsia GORD, pancreatitis, gall bladder disease (increased risk of cholecystectomy), HbA1c, blood glucose, weight (weight loss), constipation (slowed GIT), injection site reactions (most common with exenatide), antidrug antibodies (most common with exenatide ~50% of patients- usually clinically unimportant but in high levels can decrease response and increase injection site reactions)
C- inject at the same time each day/week irrespective of meals (for byetta inject within 60min before of 2 main meals at least 6 hours apart- do not give post meal), AE- NVD especially when starting but reduces with use- drink plenty of fluids to avoid dehydration, tell Dr of any severe unexplained abdominal pain , byetta- take antibiotics 1h before or 4h after exentide due to decreased gastric emptying, bydureon- get out of fridge 15min prior, check sliquid is clear and free of particles, attach needle, twist until green disppears and a click is heard, hold pen at orange end and tap 80+ times rotating pen to mix, check window for uniform cloudy suspension (no clumps), clean injection site on thigh or abdomen, twist until orange disappears and button appears, remove needle cover, inject straight after mixing (dont leave) and hold for 10sec, monitor BG, know how to treat hypoglycaemia, avoid alcohol- risk of hypoglycaemia, healthy balanced diet and exercise,
SGLT-2 inhibitor
Sodium glucose co-transporter 2 inhibitors- inhibit glucose reabsorption in the kidneys increasing glucose excreation in urine
I-T2DM
Dose
Dapagliflozin- 10mg od
Empagliflozin- 10-25mg daily (metformin combinations may split the dose across bd)
Ertugliflozin- 5-15mg daily in one or two doses
M- BSL, HbA1c, renal function (requires dose reduction in renal impairment- not effective in poor renal function), surgery- stop at least 3 days prior due to risk of DKA, gential infections (increase sugar in urine), blood lipids (causes dyslipidaemia), hypoglycaemia (esp with insulin or SU), volume status/diuretic use (SGLT2 inhibitors have diuretic effect and hypovolaemia increases risk of DKA), BP (hypotensive effect), weight (weight loss)
C- urine will test positive for glucose whilst taking, make sure you drink enough water to control thirst and avoid dehydration, increases risk of genital infections- if you notice burning discharge fever etc see dr, monitor BSLs, diabetes healthy diet and exercise, take irrespective of meals, dizziness on standing- get up slowly (empagliflozin- hypotensive effect)
CAL-10a, 16 (empa), 21, A
Anti-thyroid drugs
C- Anti-thyroid drugs: block thyroid hormone synthesis, propothyluracil also blocks peripheral conversion of T4 to T3
I-Graves, disease, short term treatment around thyroid surgery or radioactive iodine treatment, thyroid storm
D
Carbimazole- 2.5-60mg daily in 1-3 doses (up to 80mg daily divided in thyroid storm)
Propylthiouracil- 25-400mg daily in 2-4 doses (up to 600-1200mg daily in divided doses in thyroid storm)
M-TSH, T4, T3, FBC (risk of agranularcytosis WCC), LFTs (risk of hepatocellular hepatitis with propothyluracil and risk of cholestatic jaundice with carbimazole), Pregnancy (propylthiouracil is preferred in first trimester due to risk of aplasia cutis with carbimazole, carbimazole is preferred in 2nd and 3rd trimester)
C- tell dr if you develop fever, mouth ulcers, sore throat, rash, severe fatigue, abdo pain, jaundice, dark urine or pale stools, itch commonly occurs in first 8 weeks- can be treated with antihistamine, monitor for signs of hypothyroid- constipation, fatigue, weight gain, sensitivity to cold, monitor for signs of hyperthyroid- diarrhoea, weight loss, irregular heart beat
no CALs
Bisphosphonates
C- Bisphosphonates- prevent bone resorption by inhibiting osteoclasts
Alendronate
I-Osteoporosis (including related to corticosteroid use), pagets disease of bone
D- 70mg once weekly
Risedronate
I-Osteoporosis, pagets disease of the bone, treatment and prevention of corticosteroid induced osteoporosis
D- osteoporosis- 5mg daily or 35mg once weekly or 150mg monthly. pagets- 30mg once daily for 2 months
M- BMD t score and z score, calcium and vitamin D levels, Gastr-oesophageal AE-pain on swallowing dysphagia new or worsening heart burn, osteonecrosis of the jaw (complete dental work prior to starting treatment), fractures, duration of treatment- generally 5 year blocks, falls risk, renal function (avoid CrCl <35ml/min), use of other GIT irritants- eg NSAIDs,
C- take on the same day each week/month, swallow whole with a full glass of plain water in the morning at least 30min before food and drink. Remain upright for 30min, Eat after 30min and remain upright until you have eaten, don’t take antacids, calcium iron or minerals within 2 hours of dose, stop and see dr asap for dysphagia, pain on swallowing or new/worsened heart burn or severe pain in bones/joints/muscles, tell dr and dentist you are taking this medication before any dental work due to ONJ, for monthly risendonate if forgoten- if >7 days until next dose- take dose and continue normal dosing date but if <7 days wait until next dose- do not take 2 tablets in 1 week.
CALs- 4a, 20, A, C (C=take at least 30min prior to food)
Others- Clodronate, Ibandronic acid, Pamidronate, Zolendronic acid
Denosumab
Osteoporosis drug- human monoclonal antibody that binds RANKL preventing binding to the RANK receptor which decreases formation and activity of osteoclasts and reducing bone resorption
I-osteoporosis, increase BMD in pts taking long term steroids, osteopenia in men on androgen deprivation therapy for prostate cancer, hypercalcaemia of malignancy, giant cell tumour of bone, prevention of fracture in multiple myloma or with bone metasteses from solid tumours
D- SC 60mg every 6 months (SC 120mg every 4 weeks in oncology type indications)
M-BMD, z score, t score, calcium (CI in hypocalcaemia), vit D level, dental hygeine (risk of ONJ), renal function (increased risk of hypocalcaemia), contraception for women for 5 months post dose, blood cholesterol (risk of hypercholesterolaemia), fractures, fall risk
C- injected by dr every 6 months, tell dr/pharm/dentist youre taking denosumab before any dental work (risk of ONJ), tell dr if symptoms of low calcium (muscle spasms, twitches, cramps, tingling of fingers toes around mouth), ensure to take calcium and vit D as recommended
CALs- 6, 21
Fludrocortisone
Corticosteroid- mineralocorticoid
I- mineralocorticoid replacement in primary adrenal insufficency, salt losing cogenital adrenal hyperplasia, orthostatic hypotension
D-adrenal conditions- 50-300microg mane. Orthostatic hypotension- 100-200microg mane
M- electrolytes (potassium (hypokaelaemia) and sodium), fluid balance, oedema, blood pressure, heart failure
C- take with food, dont stop taking suddenly, see dr if you notice swelling of feet or ankle, headaches or weakness, caution with falls (for orthostatic hypotension), once open can be stored out of the fridge for 3 months
CAL- 6, 9, B
Insulins
Insulin- restore ability to metabolise glucose enhancing cellular glucose uptake and inhibit endogenous glucose output and lipolysis
I-T1DM, T2DM, gestational diabetes
Ultra-short acting- 15min for onset, peak 1h, duration 4-5h. Give immediately before meal, clear solution
- Insulin aspart (Novorapid)
- Insulin lispro (Humalog)
- Insulin glulisine (Apidra)
Short acting- 30min onset, 2-3h peak, 6-8h duration. Give 30min prior to food, soluble, clear solution
-Neutral insulin (Actrapid, Humulin R)
Long Acting- 1-2.5h onset, 4-12h peak, 16-24 duration. AKA intermediate acting, given once or twice daily, cloudy solution
-Isophane insulin (Humulin NPH, Protaphane)
Long Acting (analogues)
-Insulin Detemir (levemir)- 1-2h onset, 6-8h peak, 12-24h duration. once or twice daily (usually twice because wears off before 24h), clear solution, inject seperately- do not mix with other insulins
Insulin Glargine- once daily, basal, inject seperately- dont mix with other insulins, clear solution, lantus and toujeo are not directly interchangable
-Lantus 100U/mL- onset 1-2h, no peak, 24h duration
-Toujeo 300U/mL)- onset 1-6h, no peak, 24-36h duration
Mixed Insulins (AKA biphasic insulins) Neutral insulin with Isophane (short acting + long acting)- give 30min before meal, once or twice daily, cloudy solution -Humulin 30/70 -Mixtard 30/70 -Mixtard 50/50
Ultra short acting + Long acting
Insulin aspart with aspart protamine (Novomix 30)- once or twice daily, immediately before food, cloudy
Insulin lispro with lispro protamine (Humalog mix25, mix50)-once or twice daily, immediately before food, cloudy
Insulin aspart with degludec (Ryzodeg 70/30)- once or twice daily, immediately before meal, clear solution
M- blood glucose, HbA1c, injection technique, hypoglycaemia, weight gain, ketones
C- SC injection in abdo, thigh, upper arm, buttocks, rotate injection site, allow to stand for 30min after taking from fridge before injecting to reduce pain, know how to take insulin in relation to meal (30min before for short acting, immediately before for ultra-short acting), make sure you and family know how to try hypo (eg 7 jelly beans then sandwich) and know the signs of hypo, alcohol can decrease BG and mask hypos- avoid binge drinking and eat when drinking, refrigerate- keep 1 pen out for 28 days, roll/invert cloudy insulins to ensure even mixing, consider medic-alert bracelet
CAL- 6, 7b (28 day expiry out of fridge), 10a
Levothyroxine
Thyroid hormone. AKA thyroxine or T4
I-Hypothyroidism, block-replacement regimen in hyperthyroid, suppressive regimen in thyroid cancer and euthyroid goitre, replacement in thyroidectomy
D- 1.6microg/kg ideal body weight once daily
Usual doses: 50-200microg once daily. For elderly or IHD- 25-50microg daily initially increase by 25microg increments. Assess TFTs after 6-8 weeks
M-TFTs (TSH and T4), symptoms of hypo or hyperthryoid, worsening of CV disorders, BG in diabetes- pt may require insulin adjustment, pregnancy (dose increase required in pregnancy 25-40% increase), BMD, calcium and vit D (can lead to decrease BMD), storage (14 days out of fridge)
C- take on empty stomach before breakfast, avoid dairy/calcium/antacids within 2 hours of dose, see dr for hyperthyroid symptoms- palpitations excitability insomnia flushing sweating or weightloss, refrigerate- 14 day expiry once out of fridge, takes 6-8 weeks to work- doctor will monitor blood tests to get the right dose, see dr asap if you become pregnant (dose increase required)
Eltroxin and eutroxig/oroxine are not bio-equivalent
CAL- 3b, 4a, 6
