Endocrine System Flashcards
what is diabetes insipidus?
where large amount of dilute urine are produced which causes extreme thirst
what are the 2 types of diabetes insipudus
- cranial = vasopressin or desmopressin - the hypothalamus does not make enough ADH
- Nephrogenic = thiazide diuretics; paradoxical - the kidneys do not resppond to ADH
what is desmopressin?
a more potent analouge of vasopressin with a longer duration of action and no vasoconstrictior effects
in what 2 conditions is desmopression used?
diabetes insipidus
nocturnal enuresis
what’s the main SE of desmopressin?
hyponatraemic convulsions
what electrolyte disbalance does inappropriate secretion of ADH cause?
hypOnatraemia
fluid restriction is used to correct hypOnatraemia - what drugs could you use if fluid restriction doesn’t work?
demeclocycline - blocks renal tubular effect of ADH
tolvaptan - vasopressin antagonist
what effects can rapid correction of hypOnatraemia cause?
osmotic demyelination of neurons, serious CNS effects - must correct slowly
what does high mineralocorticoid activty do to fluid?
causes fluid retention
what mineralocorticoid is the most potent and retaines the most fluid?
In what condition would this be beneficial?
fludrocortisone is the most potent
fluid rentention is beneficial in someone who is hypotensive e.g., adrenal insuffiency due to septic shock
How do mineralocorticoids affect electrolytes?
what ones have the most profound effects and what ones have a negligible effect?
Na+ and water retention = HTN
K+ and Ca2+ loss
most profound effect with fludrocortisone
significant effect with hydrocortisone, corticotrophin, tetracosacitide
negligible with beclometasone and dexamethasone
Besides fluid retention, what activity does high glucocorticoid have?
What glucocorticoids are most potent and used if fluid retention is a disadvantage
anti-inflammatory
most potent = dexamethasone/betamethasone
what are the side effects of glucocorticoids? ACHING BOSOM
- Musculoskeletal (osteoporosis, muscle wasting)
- Gastro-intestinal (peptic ulcers, dyspepsia) - cousel to take with ot after food
A - drenal suppression
C- ushing’s syndrome with high doses
H - yperglycaemia - diabetes
I - infections (immunospuuression), insomnia
N - ervous system; psychiatric reactions
G - laucoma, GI ulcers
B - lood pressure increase (HTN)
O - steoporosis
S - skin thinning
O - besity
M - uscle wasting
what’s the MHRA advice regarding methylprednisolone injectable medicine containing lactose?
do not use in patients with cow’s milk allergy - serious allergic reactions such as bronchospasam and anaphlyaxis reported
what are 6 key corticosteorid counselling points?
- risk of infection
- adrenal suppression - carry steroid card
- psychiatric reactions
- withdrawal of corticosteorids
- need for GI protection
- taking am to mimic body’s natural cortisol produciton and prevent insomnia
in what scenarios shoulds you avoid abrupy withdrawal of corticosteroids?
- long erm use >3weeks
- > 40mg prednisolone daily or equivalent for more than 1 week
- repeated doses taken in the evening
- recent repeated courses
- short course within 1-yr of stopping long ter, steroids
- have other causes of adrenal suppression
when do you need to give someone a steroid card?
taking long term steroids for more then 3 weeks
consider for patients using greater than maximum licensed doses of inhaled corticosteroids
are corticosteroids safe in pregnancy and breastfeeding?
what should be monitored?
generally safe - monitor fluid retention in pregnant women
what is hypopituitarism?
pituitary gland does not stimulate hormone secretion by target glands
what steroid replacement do you give in someone with hypopituitarism?
how is this different to the replacement given for adrenalectomy and Addison’s disease?
Hypopituitarism - replace with hydrocortisone NOT fludrocortisone (renin-angiotensin system will regular aldosterone) so just need to replace cortisol and other hormones e.g., sex. thyroid
Adrenalectomy/Addison’s:
Have both low cortisol and aldosterone so need to replace with hydrocortisone and fludrocortisone
What is Cushing’s syndrome characterised by?
Name some symptoms
hypercortisolism (high cortisol)
Symptoms = skin thinning, moon face, acne, buffalo hump, striae (stretch marks)
what are the 2 drugs to treat for Cushing’s syndrome? What’s the safety advice and patient counselling with both options?
- Ketoconazole
Safety advice = life-threatening hepatotoxicity
Counselling = signs of liver toxicity (fatigue, anorexia, N&V, jaundice, dark urine, itching
counselling = adrenal insufficiency as - Cortisol-inhibiting drugs (Metyrapone)
Safety advice = adrenal insufficieny
Counselling = hypotension, hyponatraemia, hyperkalaemia, hypoglycaemia
what is diabetes mellitus characterised by and what are the two types?
characterised by hyperglycaemia
Type 1 = insulin deficiency: pancreatic beta cells destroyed causing insufficient insulin
Type 2 = insulin resistance: reduced insulin secretion/peripheral resistance to insulin
when should you start screening for long term complications in diabetes?
after 12 years old or 5 years after diagnosis
is a statin given to all diabetes as primary prevention?
no:
given to all type 1 diabetes and only type 2 who have CV risk score >10%
what’s one way to protect vision in diabetes?
by treating hypertension to protect visual acuity
what is used to help protect kidneys in nephropathy?
what can this do to hypoglycaemic effects of drugs and insulin?
ACEi/ARB
can potentiate hypoglycaemia effect
what drugs can be used to manage painful neuropathy?
analgesics: strong opiods = oxycodone/morphine (specialist use)
Duloxetine, tricyclic antidepressants: amitriptyline, nortrityline
anti-epileptics: gabapentin, pregabalin, carbamazepine
what are the effects of autonomic neuropathy and what drugs can be used to manage them?
diabetic diarrohea: codeine or tetracycline
gastroparesis: erythromycin
Erectile dysfunction: sildenafil
what are the effects of gustatory neuropathy and what can be used to manage them?
sweating face, scalp, head, and neck: antimuscarinic/antiperspirant
what can be used to manage neuropathic postural hypotension in diabetes?
fludrocortisone and increased salt intake
in pregnancy, when would insulin requirements increase?
in 2nd and 3rd trimester
in people with pre-existing diabetes planning to get pregnant, what HbA1c should you aim for and what drug should you give?
what is the purpose behind this?
HbA1c - 48mmol/l
5mg folic acid (diabetes is high risk group for neural tube defects)
do these things to reduce the risk of congenital malformations
how should you manage a pregnant lady’s insulin?
what’s the first choice?
another option?
what to do in post natal period?
- longer acting first choice (Isophane): may be appropriate to continue using long-acting analouges: glargine or detemir if good glycaemic control before pregnant
- option: continuous subcutaneous infusion pump: women with difficulty achieving glycaemia control with multiple daily injections without significant disabling hypoglycaemia
- reduce insulin immediately after birth due to increased risk of hypoglycaemia, need to monitor blood glucose to determine dose
what should you in monitor in pregnant women taking corticosteorids?
fluid retention
during pregnancy in people with pre-existing diabetes treated with insulin - how should you counsel them in terms of glucose control?
- explain hypoglycaemic risk in all pregnant women treated with insulin (especially in 1st trimester)
- carry fast acting form og glucose
- for type 1, pescribe glucagon if needed
how would you manage a pregnant patients T2DM medication who is not on insulin?
stop all oral antidiabetic drugs except metformin, substitute with insulin
how should you manage medicines in a pregnant patient with T2DM who is breast feeding?
continue metformin or resume glbenclamide post birth
how do you manage gestational diabetes in someone with glucose <7 mmol/l at diagnosis?
1st line = dietary and exercise advice
2nd line - metformin if blood glucose target not met in 1 - 2 weeks OR insulin (can be added if metformin not effective alone)
how do you manage gestational diabetes in someone with glucose >7 mmol/l at diagnosis?
1st line - insulin, with or without metformin + dietary and exercise measures
how do you manage gestational diabetes in someone with glucose 6 - 6.9mmol/l at diagnosis with hydroaminos (too much amniotic fluids) or macrosomia (big baby)?
1st line = insulin with or without metformin
is DKA more common in T1D or T2D?
what are some of the signs?
type 1
signs = severe hyperglycaemia, high blood ketones, ketonuria, pear drop breath, dehydration, drowsiness
what 3 elements are used to manage DKA?
what should you do with the patients established long acting insulin?
how long do you continue the infusion?
at what point do you add glucose to the infusion?
- soluble insulin
- fluids (saline)
- potassium (do not give if anuria - lack of urine)
- continue patients established long acting insulin
- continue infusion until pt able to eat and drink an glood pH above 7.3
- add glucose to infusion when below 14mmol/l
what’s the 1st line in all T2DM?
MoA?
SE? Contraindications?
- metformin
- decreases liver gluconeogenesis and increases peripheral use
- SE = lactic acidosis, GI disturbances
- Contraindications: general anaesthesia, iodidne containing contrast media, renal impairment
name 2 short acting sulphonylureas.
is what pt groups might these be used?
gliclazide, tolbutamide
used in elderly and renal impairment
whats the MoA of sulphonyureas?
increases insulin secretion
name 2 long acting sulphonyureas
glibenclamide (2nd 3rd trimester), glimepride
what are the main SE with sulphonyureas?
Whare are the key interactions?
hyponatraemia with glipizide, glimepiride
hypoglycaemia
weight gain
skin rashes in first 6 - 8 weeks
Interactions =
warfarin & ACEi = increased hypO
NSAIDs = reduced renal excretion
how does poiglitazone work and when does NICE suggest you continue it?
reduces peripheral resistance to insulin
NICE states continue if HbA1c reduced by 0.5% in 6 months
what are 3 SE of pioglitazone you should counsel patients about?
- heart failure - increaed incidence when combined with insulin, contraindicated if Hx HF
- bladder cancer - contraindicated in history or bladder cancer
- Hepatotoxicity - counsel on signs of toxicity
how do SGLT2i work?
give some examples
inhibit sodium-glucose co-transporter 2 in renal proximal tubule to reduce glucose reabsorption and increase urinary excretion
dapaglifozin, canaglifozin (all the flozins)
what are the MHRA warnings/main SE to look out for associated with SGLT2i?
- fourniers gangrene - necrotizing fascitits of groin
- canaglifozin - increased risk of lower limb amputation (mainly toes) - pt to report skin ulceration
- diabetic ketoaciosis
- volume depletion - postural hypotension, dizziness
how do DDP-4 inhibitors work?
give some examples
what SE must you consel patients on?
DDP-4 breaks down hormone incretin. Incretin is made my the gut in response to food to increase insulin secretion and lower glucagon secretion.
linagliptin, sitagliptin (all the gliptins)
counsel on pancreatitis - abdominal pain
what DDP-4 inhibitor is associated with liver toxicity?
vildagliptin
what are the symptoms of DKA?
N&V
rapid weight loss
fast, deep breathing
pear drop breath
confusion
fatigue
abdominal pain
what are nateglinide and repaglinide examples of?
meglitinides - these stimulate insulin secretion
they have rapid onset of action, must be taken 30mins before meal
when is acrabose used?
when other oral hypoglycaemics cannot be taken
how do GLP-1 agonists work?
name some examples
what are the 3 key counselling points?
binding to GLP-1 receptor increases insulin secretion, slows gastric emptying, supress glucagon secretion
e.g., dulaglutide, exenatide, liraglutide
- pancreatitis - stop in persistent abdo pain
- missed doses - do not administer after ameal
- use contraception MR exenatide (12 weeks after stopping) lixsenatide, albiglutide
in relation to missed doses of GLP-1 agonists, what’s the specific guidance for lixsenaitide, exenatide, dulaglutide and albiglutide?
lixisenatide - inject within 1 hour of next meal
exenatide - continue with next dose schedule
dulaglutide, albiglutide - inject with 3 days of next weekly dose
what does HbA1c need to be for diagnosis of T2DM?
48mmol (6.5%)
are oral glucose tests recommended for all patients when diagnoising T2DM?
no - not fot patients with severe hyperglycaemic symptoms
what monitoring can you do for diabetes?
- urinanalysis - ketones, albumin, glucose
- blood - ketone and glucose
when is monitoring recommended for T2DM?
- when treated with insulin or oral hypoglycaemia e.g., sulphonylurea
- during intercurrent illness, lifestyle or medication changes
- driving
what are the blood glucose targets pre and post prandial?
pre-prandial = 4 - 7 mmol/l
post-prandial = 9mmol/l
what are the HbA1c targets in both diabetic patients and diabetic patients at high risk of arterial disease?
diabetics = 6.5 - 7.5% (48 - 59mmol/l) or less
diabetic pt at high risk of arterial disease <6.5%
what are the BP readings targets in diabetes for patients with and without complications?
without complications = 140/80
with complications = 130/80
what antihypoertensive should diabetic patients receive?
ACEi 1st line
African or Caribbean patients sshould receive both an ACEi and diuretic or CCB 1st line
what is the cholesterol target in diabetes?
normal patients = <5mmol/l
high risk patients e.g., diabetes = <4mmol/l
when do you initiate a statin for primary prevention in type 1 and 2 diabetes?
always in T1D
give in T2D when pt has a CVD risk >10%
what drug class can mask the symptoms of hypoglycaemia?
beta blockers
what is the risk of having too tight gylcaemic control?
this lowers the level needed to trigger hypoglycaemic symptoms
how do you manage hypoglycaemic in the comminuty? (medical emergency?
give examples of what you could give
What should be avoided?
10 - 20g glucose/sucrose - repeat after 10 - 15 mins if needed
e.g.,
- coco-cola 100 - 200ml
- lucozade oringinal 55 - 100ml
- sugar lumps 3 - 6
- sugar 2 - 4 tsp
and provide long-acting carbohydrate or next meal if due to sustain
- avoid chocolate/biscuits; fat delays glucose absorption
If hypoglycaemia unresponsive or unconscious then give SC/IM glucagon
if still unreposponsive after 10 mins give IV glucose
can all types of hypoglycaemia be managed in the community?
no - sulphonylurea-induced hypoglycaemia is always treated in hospital becasue it can persist for hours
do patients need to inform DVLA of diabetes diagnosis no matter what treatment they’re on?
only if on insulin or any medicaion for group 2 (lorry, bus, coach) drivers
not if diet-controlled
when do diabetics need to tell DVLA about hypoglycaemic episodes?
- if has 2 severe episodes in past 12 months
- any impaired awareness
- disabling hypoglycaemia while driving
what diabetic patients need to monitor glucose levels before/whilst driving and when should they do this?
only patients on insulin, andgroup 2 drivers on sulphonyureas or glinides
chec blood glucose no more than 2 hours before driving and every 2 hours for long journerys
(record readings at least twice a day when when not driving to avoid hypoglycaemia)
what glucose level would mean someone could not drive?
<4 mmol/l = do not drive
5mmol/l - take carbohydrate before driving
what should patients do if hypoglycaemia occurs during driving?
- stop vehicle in safe place and switch engine off
- eat or drink fast acting sugar and then long acting carbohydrate e.g., sandwich to maintain levels
- wait 45 mins after blood glucose levels reeturn to normal
in what situations should you increase insulin requirements?
- infections or intercurent illness
- stress or accidental surgical tramua
- puberty
- pregnancy (2nd 3rd trimester)
in what situations should insulin requireemnts be decreased?
- endocrine disorders e.g., Addison’s disease, hypopituitarism
- coeliac disease
how should insulin be stored?
- in the frdige between 2 - 8 oC
- once opend store at room temp and use by 28 days
- if left outside fridge at 15 - 30oC >48hrs, discard
- if frozen must discard
what do you need to change the insulin dose to if you are switching from beef or port to human?
beef = reduce dose by 10%
pork = no dose change
name some risk factor for osteoporosis?
- low body weight
- elderly
- smoking
- lack of exercise
- menopause
- long term oral corticosteroids
- family Hx
what’s a counselling point risedronate have that alendronic acid doesn’t have?
need a 2 hour gap between risedronate and food, drink, antacids, calcium-containing products
what are the 4 main SE of bisphosphonates?
- oesophageal reactions: pts to stop and report dysphagisa, new heartburn or retrosternal pain
- atypical femoral fractures: pts to report hip, thigh or groin pain
- osteonecrosis of the jaw: pt to report any oral symptoms, non-healing sores
- osteonecrosis of external auditory canal: pt to repoty ear pain, ear discharge
what are the natrial oestrogens used in HRT?
estrone
estradiol
estriol
what are the synthetic oestrogens used in HRT?
ethinylestradiol
mestranol
what type of HRT is used for vaginal atrophy (dryness)?
topical oestrogens (vaginal creams, tablets and rings)
what type of HRT is used for vasomotor symptoms in HRT?
What is these options are contraindicated?
systemic oestrogens (tablets or patches )
if contraindicated give clonidine (vasodilator antihypertensive but has unacceptable side effects)
where should HRT patches be applied?
below the waistline away from waist band or breast
what type of HRT should you give women without a uterus?
oestrogen alone continuously
what HRT should you give to someone with a uterus?
oestrogen and progesterone cyclically or continuously to avoid withdrawal bleed
in what type of patients is combined HRT unsuitable in?
pero-menopause or <12 months after last periods = irregualr bleeding - need to rule out endometerial cancer if irregular bleeding continues after stopping continous-combined HRT
when should patients stop HRT in relation to elective surgery?
4 - 6 weeks
when do patients on HRT need contraception after last period?
under 50 = fertile 2 years after last period - use low oestrogen combined contraceptive
over 50 = fertile 1 year after last period - use condoms
what cancers do HRT increase the risk of?
ovarian, breat, cervical, endometrial
alongside increased cancer risk, what other side do they have?
increased risk coronary heart disease
what can you do to reduce the risk of endometrial cancer with HRT?
add progesterone - this reduced additional risk (at least 10/28 day cycle or given continuously eliminates additional risk)
what are the reasons to stop HRT?
- VTE - sudden severe chest pain, sudden breathlessness (PE), swelling or severe leg pain (DVT_
- Stroke - serious neurological effects: proglonged headache, visual disturbances
- Liver dysfunction - jaundice, stomach pain
- Blood pressure - systolic >160mmHg or diastolic 95 mmHg
what type of drug is clomifene and when would it be used?
Can it be used long term?
anti-oestogen
useds in infertility in women due to oligomenorrhoea
secondary amenorrhoea e.g., PCOS
use for up to 6 cycles only due to increased risk of ovarian cancer
are you meant to apply testosterone gels to genital area?
no
what would TSH, T4 and T3 levels look like in someone with hyperthyroidism?
T4 = high
TSH = low
T3 = high
what are the 2 main drugs for hyperthyroidism?
what are their main SE?
- carbimazole - bone marrow suppression, rashes/itching
- propylthiouracol - hepatotoxicity
what drug can be used for rapid symptom relief in thyrotoxicosis?
propranolol
what do you need to give prior to thyroidectomy?
iodine 10 - 14 days before
adjunct to anti-thyroid drugs
what can you give in 1st and 2nd trimester in pregnancy for hypoerthyroidism as blocking-replacement therapy and radioactive iodine is contraindicated?
1st = propylyhiouralcil
2nd = carbimazole
