Endocrine

Question 1

Which bisphosphonate needs to be discontinued if a skin rash develops?

Answer 1

Strontium ranelate

Severe allergic reaction:
Symptoms known as DRESS ‘Drug rash with eosinophilia and systemic symptoms’
Starts with: fever, rash, swollen glands, high WCC

Question 2

What is the side effect we need to be vigilant about with Bisphosphonate treatment?

Answer 2

Osteonecrosis of the Jaw

The risk is higher with IV therapy for cancer treatment than it is with oral.

Patients have a dental check up before starting and need to maintain good oral hygiene and attend regular check ups.

They should report any oral symptoms: Pain, inflammation, difficulty swallowing

Question 3

If patients taking Alendronic acid experience dysphagia, heartburn, pain on swallowing or retrosternal pain what should they do?

Answer 3

Stop taking and Report it- may be an oesophageal reaction: can be serious

Question 4

Desmopressin, used for diabetes insipidous and first line for nocturnal enuresis, can cause electrolyte disturbance: hyponatreamia. What can this lead to, and what can be done to stop this?

Answer 4

Hyponatreamic convulsions mentioned in the BNF.

This can be minimised by sticking to the recommended start dose and avoiding drugs that increase secretion of vasopressin such as TCA’s.

Question 5

Clomifene is a drug used to treat female infertility as it is anti-oestrogen. The CSM have advised that it should not be used for more than __ cycles, due to increased risk of _____ cancer.

Answer 5

Not for more than 6 cycles

Increased risk of ovarian cancer with clomifene use.

Question 6

Which drug used in thyroid therapy can cause agranulocytosis and neutropenia? what is this drug used for?

Answer 6

Carbimazole

Used for Hyperthyroidism
Used in the 18 month blocking-replacement regimen together with levothyroxine.

Question 7

What test is indicated prior to therapy with levothyroxine and Liothyronine?

Answer 7

Baseline ECG- this is because we want to check we haven’t mistaken hypothyroidism with ischaemia/ cardiovascular disease.

Question 8

Which antithyroid drug is used if carbimazole is contraindicated?
What do we need to monitor with this drug?

Answer 8

Propylthiouracil

Liver function- severe hepatic reactions have taken place.

Question 9

What drugs are used for management of thyrotoxic symptoms (when too much thyroid hormone has been given)?

Answer 9

Beta blockers- propranolol
IV fluids
hydrocortisone

Question 10

What side effect of carbimazole is common and can be treated with antihistamines without the need to discontinue?

Answer 10

Rashes and pruritis- don’t say ‘discontinue’ in exam cause you’ve mistaken it for neutropenia/agran

Question 11

Sick day rule for patients on a systemic steroid and fall mildly ill?

Answer 11

Double dose for 2 days

Question 12

Sick day rule for patients on a systemic steroid and severely ill?

Answer 12

Double dose until symptoms improve

Question 13

If a patients has severe diarrhoea or vomiting and can’t keep their steroid down?

Answer 13

Hydrocortisone emergency injection may be needed from GP

Question 14

Difference between Addisons and Cushings (hint: they are opposites)?

Answer 14

Addisons is a deficiency of ACTH- (adrenocorticotropic hormone) because the immune system has turned against the adrenal glands. Symptoms: anorexia, Nausea and vomiting, weightloss- treat with glucocorticoids

Cushings- too much ACTH, caused by long term glucocorticoid therapy or tumour. Moon face, buffalo hump, mood swings, weight gain. Treatment- withdraw the steroid

Question 15

Symptoms of DKA?(8)

Answer 15

Rapid weight loss
Abdominal pain
Nausea and vomiting
Rapid and deep breathing?
Sweet smelling breath
Sweet/metallic tasting breath
Altered odour of urine/sweat
Sleepiness

Question 16

In adults:
Gradual withdrawal of systematic corticosteroids is considered in those where the disease is unlikely to relapse and have….? (6)

Answer 16

Received more than 40mg of prednisolone (or equiv) daily in the last week

Given repeated doses in the evening

Received more than 3 weeks treatment

Recently received repeated courses (particularly for longer than 3 weeks)

Taken short-course within a 1 year of stopping long-term treatment

Other possible causes of adrenal suppression

Question 17

How to withdraw corticosteroids from adults and children?

Answer 17

Adult:
Dose may be reduced rapidly down to physiological dose (equivalent to 7.5mg prednisolone daily) and then reduced more slowly

Child:
Dose may be reduced rapidly down to physiological dose (equivalent to 2-2.5 mg/m2 prednisolone daily) and then reduced more slowly

Question 18

When can systemic steroids be stopped abruptly?

Answer 18

When disease is unlikely to relapse and those who have received less than 3-weeks treatment (and those not included in the patient groups described on page 659)

Question 19

How long can corticosteroid-induced adrenal suppression last for after stopping drug

Answer 19

1 year or more

Question 20

What is the duration of dexamethasone and betamethasone?

Answer 20

Long duration of action

Makes it good for suppression of corticotrophin secretion (e.g. congenital adrenal hyperplasia)

Question 21

Steroid with high mineralocorticoid activity

Answer 21

Fludrocortisone acetate

Can be used to treat postural hypotension

Question 22

Steroid with very high glucocorticoid activity and insignificant mineralocorticoid activity?

Answer 22

Betamethasone

and

Dexamethasone

Question 23

Corticosteroid with moderate glucocorticoid activity and high mineralocorticoid activity - good for topical use because side-effects are less marked?

Answer 23

HYDROCORTISONE

Question 24

What are prednisolone and prednisones predominant activity on?

Answer 24

Glucocorticoids

Question 25

Side effects of glucocorticoids? (6)

Answer 25

Diabetes
Osteoporosis (particularly in elderly)
At high doses - avascular necrosis of femoral head
Muscle wasting
Weekly linked with peptic ulcer/perforations
Psychiatric reactions

Question 26

Side effects of mineralocorticoids (5)

Think minerals

2 increase, 2 decrease

Answer 26

Hypertension (hence why it can tx postural hypo)

Sodium retention
Water retention

Potassium loss
Calcium loss

Question 27

What is Deflazacort?

Answer 27

Derived from prednisolone

Has high glucocorticoid activity

Question 28

What happens to prednisolone when it crosses the placenta in pregnancy?

Answer 28

88% is inactivated

Question 29

What is the advise with ketoconazole and hepatic inpairment?

In treating Cushing syndrome

Answer 29

Avoid in acute or chronic impairment

Do not initiate the drug if liver enzymes are greater than 2X the normal upper limit

Question 30

Symptoms suggestive of adrenal Insufficiency?

Answer 30

Fatigue
Anorexia
Nausea and vomiting
Hypotension
Hyponatraemia 
Hypoglycaemia
Hyperkalaemia