Endocrine Pharmacotherapeutics

Question 1

What are the HbA1c, FBG, and PPG targets for T2DM?

Answer 1

HbA1c < 7%
FBG 4-7
PPG <10

Question 2

What is the dosing regimen for metformin IR?

Answer 2

initiate: 500-850mg OD
increase dose by 500-850mg every 1-2 weeks
max: 2500-2550

Question 3

What is the dosing regimen for metformin ER?

Answer 3

initiate: 500mg OD
increase by 500mg every week
max: 2g

Question 4

What is the CrCL cut off for metformin?

Answer 4

30

Question 5

When is metformin contraindicated?

Answer 5

heart failure, sepsis, hepatic impairment, alcoholism, >= 80yo

Question 6

What is the sulfonylurea preferred in renal impairment?

Answer 6

glipizide

Question 7

What is the dosing regimen of glipizide?

Answer 7

5mg BD –> 40mg/day

Question 8

What diabetes drugs are not recommended to be given in pt with acute pancreatitis?

Answer 8

DPP4i, GLP-1 agonists

Question 9

What is the dosing regimen for sitagliptin (inc. renal dosing)?

Answer 9

100mg OD
CrCL 30-45 50mg OD
CrCL <30 25mg OD

Question 10

What is the eGFR cut off when SGLT2i is initiated for glycemic control only?

Answer 10

eGFR < 45

Question 11

What is the eGFR cut off when SGLT2i is initiated for cardiorenal benefit? When should it be discont?

Answer 11

dapag 25
empag 20
discont on dialysis

Question 12

What is the dosing regimen for empag and dapag?

Answer 12

empag 10mg - 25mg OD
dapag 5mg - 10mg OD

Question 13

Which types of insulin can be mixed?

Answer 13

NPH + regular
NPH + rapid acting

Question 14

How much time before meal should rapid-acting insulin be administerd?

Answer 14

5 mins

Question 15

What oral medications can be continued / discontinued upon insulin initiation?

Answer 15

Continue: metformin, SGLT2i
Discont: TZD
SU: discont / reduce dose by 50% if basal insulin is started, discont completely if PPG started

Question 16

Outline the 15-15-15 rule for hypoglycaemia

Answer 16

15g of fast acting carbs - 15 mins - test, if still under, then 15g of carbs again

Question 17

When converting from NPH BD to glargine/determir OD, how much should insulin dose be reduced?

Answer 17

20%

Question 18

How is insulin usually initiated?

Answer 18

10u NPH at bedtime / 0.1-0.2/kg/day

Question 19

How is basal insulin usually titrated?

Answer 19

increase by 2u every 3 days until target
increase by 4u every 3 days if FBG consistently >10
decrease by 10-20% if hypoG

Question 20

What is the maximum basal insulin to be given?

Answer 20

0.5/kg/day

Question 21

If A1c is above target after basal insulin has reached maximum, what should be done?

Answer 21

1. add mealtime glucose
   - 4u or 10% of basal
   also reduce basal by 4u or 10% if a1c < 8%
2. split NPH insulin (1/3 bedtime, 2/3 morning)

Question 22

When should insulin be considered in a patient?

Answer 22

• ongoing weight loss
• hyperG symptoms
• A1c > 10% / BG > 16.7

Question 23

SC GLP-1 agonists are given ________.

Answer 23

once weekly

Question 24

What should be done if a patient is discovered to be experiencing the somogyi effect?

Answer 24

reduce dose of bedtime basal insulin

Question 25

When should ulipristal 30mg be taken for prevention of preg?

Answer 25

within 5 days

Question 26

When should levonorgestrel be taken for prevention of preg?

Answer 26

best within 12 hours, max 72h

Question 27

When should a copper IUD be inserted for emergency contraception?

Answer 27

within 5 days

Question 28

What are the goals of therapy for both hypo and hyperthyroidism?

Answer 28

1. improve symptoms, improve QoL 2. prevent long-term damage of organs 3. normalise T4 and TSH

Question 29

What is firstline in the treatment of hypothyroidism?

Answer 29

Levothyroxine

Question 30

Outline the dosing regimen of levothyroxine

Answer 30

initial: adults < 60 (w/o CVD): 1.6mcg/kg/day adults > 60 (w/o CVD): 50mcg/kg/day with CVD: 12.5-25mcg/day titrate to desired TSH

Question 31

How should levothyroxine be taken?

Answer 31

30-60mins before breakfast or 4 hours after last meal

Question 32

What are the safety monitoring parameters for levothyroxine (inc SE)?

Answer 32

BP. HR, cardiac abnormalities, chest pain, fractures (bone mineral density), hyperthyroidism

Question 33

What is the TSH target for pregnant women with hypothyroidism in the respective trimesters?

Answer 33

1st: <2.5 2nd: <3 3rd: <3.5

Question 34

How should the dose of levothyroxine be adjusted in women who are pregnant?

Answer 34

increase dose by 30-50%

Question 35

What is the TSH target for non-pregnant adults?

Answer 35

0.4 - 4

Question 36

How does lithium affect the thyroid?

Answer 36

can increase or decrease thyroid function

Question 37

What is the first line treatment for hyperthyroidism?

Answer 37

radioactive iodine ablative therapy

Question 38

Radioactive iodine ablative therapy can be used in pregnant women

Answer 38

no

Question 39

How long do thionamides take to work?

Answer 39

4-6 months

Question 40

What thionamides should be used in the various trimesters of pregnancy for hyperthyroidism?

Answer 40

1st: PTU 2nd/3rd: Carbimazole

Question 41

Which is the preferred thionamide for Graves disease?

Answer 41

Carbimazole

Question 42

Outline the dosing regimen of propylthiouracil.

Answer 42

initiate: 50-150mg TDS 50mg BD/TDS once euthyroid

Question 43

Outline the dosing regimen for carbimazole

Answer 43

initiate 15-60mg OD in 2-3 divided doses 5-15mg OD once euthyroid

Question 44

What are the adverse effects to watch out for in thionamide therapy?

Answer 44

Hepatotoxicity (PTU) Rash - risk of SJS agranulocytosis (early in treatment, within first 3m) - watch out for fever

Question 45

What is the role of non-selective beta blockers in hyperthyroidism?

Question 46

What is the role of iodides in hyperthyroidism? (inc duration)

Question 47

At what duration do iodides have limited efficacy?

Question 48

When should liothyronine be used?

Question 49

What is the dose of liothyronine?