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Pre-reg > Endocrine System > Flashcards

Endocrine System Flashcards

1
Q

what is diabetes insipidus?

A

where large amount of dilute urine are produced which causes extreme thirst

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2
Q

what are the 2 types of diabetes insipudus

A
  1. cranial = vasopressin or desmopressin - the hypothalamus does not make enough ADH
  2. Nephrogenic = thiazide diuretics; paradoxical - the kidneys do not resppond to ADH
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3
Q

what is desmopressin?

A

a more potent analouge of vasopressin with a longer duration of action and no vasoconstrictior effects

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4
Q

in what 2 conditions is desmopression used?

A

diabetes insipidus
nocturnal enuresis

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5
Q

what’s the main SE of desmopressin?

A

hyponatraemic convulsions

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6
Q

what electrolyte disbalance does inappropriate secretion of ADH cause?

A

hypOnatraemia

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7
Q

fluid restriction is used to correct hypOnatraemia - what drugs could you use if fluid restriction doesn’t work?

A

demeclocycline - blocks renal tubular effect of ADH
tolvaptan - vasopressin antagonist

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8
Q

what effects can rapid correction of hypOnatraemia cause?

A

osmotic demyelination of neurons, serious CNS effects - must correct slowly

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9
Q

what does high mineralocorticoid activty do to fluid?

A

causes fluid retention

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10
Q

what mineralocorticoid is the most potent and retaines the most fluid?
In what condition would this be beneficial?

A

fludrocortisone is the most potent
fluid rentention is beneficial in someone who is hypotensive e.g., adrenal insuffiency due to septic shock

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11
Q

How do mineralocorticoids affect electrolytes?
what ones have the most profound effects and what ones have a negligible effect?

A

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

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12
Q

Besides fluid retention, what activity does high glucocorticoid have?
What glucocorticoids are most potent and used if fluid retention is a disadvantage

A

anti-inflammatory
most potent = dexamethasone/betamethasone

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13
Q

what are the side effects of glucocorticoids? ACHING BOSOM

A
  1. Musculoskeletal (osteoporosis, muscle wasting)
  2. 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

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14
Q

what’s the MHRA advice regarding methylprednisolone injectable medicine containing lactose?

A

do not use in patients with cow’s milk allergy - serious allergic reactions such as bronchospasam and anaphlyaxis reported

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15
Q

what are 6 key corticosteorid counselling points?

A
  1. risk of infection
  2. adrenal suppression - carry steroid card
  3. psychiatric reactions
  4. withdrawal of corticosteorids
  5. need for GI protection
  6. taking am to mimic body’s natural cortisol produciton and prevent insomnia
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16
Q

in what scenarios shoulds you avoid abrupy withdrawal of corticosteroids?

A
  1. long erm use >3weeks
  2. > 40mg prednisolone daily or equivalent for more than 1 week
  3. repeated doses taken in the evening
  4. recent repeated courses
  5. short course within 1-yr of stopping long ter, steroids
  6. have other causes of adrenal suppression
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17
Q

when do you need to give someone a steroid card?

A

taking long term steroids for more then 3 weeks
consider for patients using greater than maximum licensed doses of inhaled corticosteroids

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18
Q

are corticosteroids safe in pregnancy and breastfeeding?
what should be monitored?

A

generally safe - monitor fluid retention in pregnant women

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19
Q

what is hypopituitarism?

A

pituitary gland does not stimulate hormone secretion by target glands

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20
Q

what steroid replacement do you give in someone with hypopituitarism?
how is this different to the replacement given for adrenalectomy and Addison’s disease?

A

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

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21
Q

What is Cushing’s syndrome characterised by?
Name some symptoms

A

hypercortisolism (high cortisol)
Symptoms = skin thinning, moon face, acne, buffalo hump, striae (stretch marks)

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22
Q

what are the 2 drugs to treat for Cushing’s syndrome? What’s the safety advice and patient counselling with both options?

A
  1. Ketoconazole
    Safety advice = life-threatening hepatotoxicity
    Counselling = signs of liver toxicity (fatigue, anorexia, N&V, jaundice, dark urine, itching
    counselling = adrenal insufficiency as
  2. Cortisol-inhibiting drugs (Metyrapone)
    Safety advice = adrenal insufficieny
    Counselling = hypotension, hyponatraemia, hyperkalaemia, hypoglycaemia
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23
Q

what is diabetes mellitus characterised by and what are the two types?

A

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

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24
Q

when should you start screening for long term complications in diabetes?

A

after 12 years old or 5 years after diagnosis

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25
Q

is a statin given to all diabetes as primary prevention?

A

no:
given to all type 1 diabetes and only type 2 who have CV risk score >10%

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26
Q

what’s one way to protect vision in diabetes?

A

by treating hypertension to protect visual acuity

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27
Q

what is used to help protect kidneys in nephropathy?
what can this do to hypoglycaemic effects of drugs and insulin?

A

ACEi/ARB
can potentiate hypoglycaemia effect

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28
Q

what drugs can be used to manage painful neuropathy?

A

analgesics: strong opiods = oxycodone/morphine (specialist use)
Duloxetine, tricyclic antidepressants: amitriptyline, nortrityline
anti-epileptics: gabapentin, pregabalin, carbamazepine

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29
Q

what are the effects of autonomic neuropathy and what drugs can be used to manage them?

A

diabetic diarrohea: codeine or tetracycline
gastroparesis: erythromycin
Erectile dysfunction: sildenafil

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30
Q

what are the effects of gustatory neuropathy and what can be used to manage them?

A

sweating face, scalp, head, and neck: antimuscarinic/antiperspirant

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31
Q

what can be used to manage neuropathic postural hypotension in diabetes?

A

fludrocortisone and increased salt intake

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32
Q

in pregnancy, when would insulin requirements increase?

A

in 2nd and 3rd trimester

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33
Q

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?

A

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

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34
Q

how should you manage a pregnant lady’s insulin?
what’s the first choice?
another option?
what to do in post natal period?

A
  • 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
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35
Q

what should you in monitor in pregnant women taking corticosteorids?

A

fluid retention

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36
Q

during pregnancy in people with pre-existing diabetes treated with insulin - how should you counsel them in terms of glucose control?

A
  • 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
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37
Q

how would you manage a pregnant patients T2DM medication who is not on insulin?

A

stop all oral antidiabetic drugs except metformin, substitute with insulin

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38
Q

how should you manage medicines in a pregnant patient with T2DM who is breast feeding?

A

continue metformin or resume glbenclamide post birth

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39
Q

how do you manage gestational diabetes in someone with glucose <7 mmol/l at diagnosis?

A

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)

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40
Q

how do you manage gestational diabetes in someone with glucose >7 mmol/l at diagnosis?

A

1st line - insulin, with or without metformin + dietary and exercise measures

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41
Q

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)?

A

1st line = insulin with or without metformin

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42
Q

is DKA more common in T1D or T2D?
what are some of the signs?

A

type 1
signs = severe hyperglycaemia, high blood ketones, ketonuria, pear drop breath, dehydration, drowsiness

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43
Q

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?

A
  1. soluble insulin
  2. fluids (saline)
  3. 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
44
Q

what’s the 1st line in all T2DM?
MoA?
SE? Contraindications?

A
  • metformin
  • decreases liver gluconeogenesis and increases peripheral use
  • SE = lactic acidosis, GI disturbances
  • Contraindications: general anaesthesia, iodidne containing contrast media, renal impairment
45
Q

name 2 short acting sulphonylureas.
is what pt groups might these be used?

A

gliclazide, tolbutamide
used in elderly and renal impairment

46
Q

whats the MoA of sulphonyureas?

A

increases insulin secretion

47
Q

name 2 long acting sulphonyureas

A

glibenclamide (2nd 3rd trimester), glimepride

48
Q

what are the main SE with sulphonyureas?
Whare are the key interactions?

A

hyponatraemia with glipizide, glimepiride
hypoglycaemia
weight gain
skin rashes in first 6 - 8 weeks

Interactions =
warfarin & ACEi = increased hypO
NSAIDs = reduced renal excretion

49
Q

how does poiglitazone work and when does NICE suggest you continue it?

A

reduces peripheral resistance to insulin
NICE states continue if HbA1c reduced by 0.5% in 6 months

50
Q

what are 3 SE of pioglitazone you should counsel patients about?

A
  1. heart failure - increaed incidence when combined with insulin, contraindicated if Hx HF
  2. bladder cancer - contraindicated in history or bladder cancer
  3. Hepatotoxicity - counsel on signs of toxicity
51
Q

how do SGLT2i work?
give some examples

A

inhibit sodium-glucose co-transporter 2 in renal proximal tubule to reduce glucose reabsorption and increase urinary excretion
dapaglifozin, canaglifozin (all the flozins)

52
Q

what are the MHRA warnings/main SE to look out for associated with SGLT2i?

A
  1. fourniers gangrene - necrotizing fascitits of groin
  2. canaglifozin - increased risk of lower limb amputation (mainly toes) - pt to report skin ulceration
  3. diabetic ketoaciosis
  4. volume depletion - postural hypotension, dizziness
53
Q

how do DDP-4 inhibitors work?
give some examples
what SE must you consel patients on?

A

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

54
Q

what DDP-4 inhibitor is associated with liver toxicity?

A

vildagliptin

55
Q

what are the symptoms of DKA?

A

N&V
rapid weight loss
fast, deep breathing
pear drop breath
confusion
fatigue
abdominal pain

56
Q

what are nateglinide and repaglinide examples of?

A

meglitinides - these stimulate insulin secretion
they have rapid onset of action, must be taken 30mins before meal

57
Q

when is acrabose used?

A

when other oral hypoglycaemics cannot be taken

58
Q

how do GLP-1 agonists work?
name some examples
what are the 3 key counselling points?

A

binding to GLP-1 receptor increases insulin secretion, slows gastric emptying, supress glucagon secretion
e.g., dulaglutide, exenatide, liraglutide

  1. pancreatitis - stop in persistent abdo pain
  2. missed doses - do not administer after ameal
  3. use contraception MR exenatide (12 weeks after stopping) lixsenatide, albiglutide
59
Q

in relation to missed doses of GLP-1 agonists, what’s the specific guidance for lixsenaitide, exenatide, dulaglutide and albiglutide?

A

lixisenatide - inject within 1 hour of next meal
exenatide - continue with next dose schedule
dulaglutide, albiglutide - inject with 3 days of next weekly dose

60
Q

what does HbA1c need to be for diagnosis of T2DM?

A

48mmol (6.5%)

61
Q

are oral glucose tests recommended for all patients when diagnoising T2DM?

A

no - not fot patients with severe hyperglycaemic symptoms

62
Q

what monitoring can you do for diabetes?

A
  1. urinanalysis - ketones, albumin, glucose
  2. blood - ketone and glucose
63
Q

when is monitoring recommended for T2DM?

A
  • when treated with insulin or oral hypoglycaemia e.g., sulphonylurea
  • during intercurrent illness, lifestyle or medication changes
  • driving
64
Q

what are the blood glucose targets pre and post prandial?

A

pre-prandial = 4 - 7 mmol/l
post-prandial = 9mmol/l

65
Q

what are the HbA1c targets in both diabetic patients and diabetic patients at high risk of arterial disease?

A

diabetics = 6.5 - 7.5% (48 - 59mmol/l) or less
diabetic pt at high risk of arterial disease <6.5%

66
Q

what are the BP readings targets in diabetes for patients with and without complications?

A

without complications = 140/80
with complications = 130/80

67
Q

what antihypoertensive should diabetic patients receive?

A

ACEi 1st line
African or Caribbean patients sshould receive both an ACEi and diuretic or CCB 1st line

68
Q

what is the cholesterol target in diabetes?

A

normal patients = <5mmol/l
high risk patients e.g., diabetes = <4mmol/l

69
Q

when do you initiate a statin for primary prevention in type 1 and 2 diabetes?

A

always in T1D
give in T2D when pt has a CVD risk >10%

70
Q

what drug class can mask the symptoms of hypoglycaemia?

A

beta blockers

71
Q

what is the risk of having too tight gylcaemic control?

A

this lowers the level needed to trigger hypoglycaemic symptoms

72
Q

how do you manage hypoglycaemic in the comminuty? (medical emergency?
give examples of what you could give
What should be avoided?

A

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

73
Q

can all types of hypoglycaemia be managed in the community?

A

no - sulphonylurea-induced hypoglycaemia is always treated in hospital becasue it can persist for hours

74
Q

do patients need to inform DVLA of diabetes diagnosis no matter what treatment they’re on?

A

only if on insulin or any medicaion for group 2 (lorry, bus, coach) drivers
not if diet-controlled

75
Q

when do diabetics need to tell DVLA about hypoglycaemic episodes?

A
  • if has 2 severe episodes in past 12 months
  • any impaired awareness
  • disabling hypoglycaemia while driving
76
Q

what diabetic patients need to monitor glucose levels before/whilst driving and when should they do this?

A

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)

77
Q

what glucose level would mean someone could not drive?

A

<4 mmol/l = do not drive
5mmol/l - take carbohydrate before driving

78
Q

what should patients do if hypoglycaemia occurs during driving?

A
  1. stop vehicle in safe place and switch engine off
  2. eat or drink fast acting sugar and then long acting carbohydrate e.g., sandwich to maintain levels
  3. wait 45 mins after blood glucose levels reeturn to normal
79
Q

in what situations should you increase insulin requirements?

A
  1. infections or intercurent illness
  2. stress or accidental surgical tramua
  3. puberty
  4. pregnancy (2nd 3rd trimester)
80
Q

in what situations should insulin requireemnts be decreased?

A
  1. endocrine disorders e.g., Addison’s disease, hypopituitarism
  2. coeliac disease
81
Q

how should insulin be stored?

A
  • 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
82
Q

what do you need to change the insulin dose to if you are switching from beef or port to human?

A

beef = reduce dose by 10%
pork = no dose change

83
Q

name some risk factor for osteoporosis?

A
  • low body weight
  • elderly
  • smoking
  • lack of exercise
  • menopause
  • long term oral corticosteroids
  • family Hx
84
Q

what’s a counselling point risedronate have that alendronic acid doesn’t have?

A

need a 2 hour gap between risedronate and food, drink, antacids, calcium-containing products

85
Q

what are the 4 main SE of bisphosphonates?

A
  1. oesophageal reactions: pts to stop and report dysphagisa, new heartburn or retrosternal pain
  2. atypical femoral fractures: pts to report hip, thigh or groin pain
  3. osteonecrosis of the jaw: pt to report any oral symptoms, non-healing sores
  4. osteonecrosis of external auditory canal: pt to repoty ear pain, ear discharge
86
Q

what are the natrial oestrogens used in HRT?

A

estrone
estradiol
estriol

87
Q

what are the synthetic oestrogens used in HRT?

A

ethinylestradiol
mestranol

88
Q

what type of HRT is used for vaginal atrophy (dryness)?

A

topical oestrogens (vaginal creams, tablets and rings)

89
Q

what type of HRT is used for vasomotor symptoms in HRT?
What is these options are contraindicated?

A

systemic oestrogens (tablets or patches )

if contraindicated give clonidine (vasodilator antihypertensive but has unacceptable side effects)

90
Q

where should HRT patches be applied?

A

below the waistline away from waist band or breast

91
Q

what type of HRT should you give women without a uterus?

A

oestrogen alone continuously

92
Q

what HRT should you give to someone with a uterus?

A

oestrogen and progesterone cyclically or continuously to avoid withdrawal bleed

93
Q

in what type of patients is combined HRT unsuitable in?

A

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

94
Q

when should patients stop HRT in relation to elective surgery?

A

4 - 6 weeks

95
Q

when do patients on HRT need contraception after last period?

A

under 50 = fertile 2 years after last period - use low oestrogen combined contraceptive
over 50 = fertile 1 year after last period - use condoms

96
Q

what cancers do HRT increase the risk of?

A

ovarian, breat, cervical, endometrial

97
Q

alongside increased cancer risk, what other side do they have?

A

increased risk coronary heart disease

98
Q

what can you do to reduce the risk of endometrial cancer with HRT?

A

add progesterone - this reduced additional risk (at least 10/28 day cycle or given continuously eliminates additional risk)

99
Q

what are the reasons to stop HRT?

A
  1. VTE - sudden severe chest pain, sudden breathlessness (PE), swelling or severe leg pain (DVT_
  2. Stroke - serious neurological effects: proglonged headache, visual disturbances
  3. Liver dysfunction - jaundice, stomach pain
  4. Blood pressure - systolic >160mmHg or diastolic 95 mmHg
100
Q

what type of drug is clomifene and when would it be used?
Can it be used long term?

A

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

101
Q

are you meant to apply testosterone gels to genital area?

A

no

102
Q

what would TSH, T4 and T3 levels look like in someone with hyperthyroidism?

A

T4 = high
TSH = low
T3 = high

103
Q

what are the 2 main drugs for hyperthyroidism?
what are their main SE?

A
  1. carbimazole - bone marrow suppression, rashes/itching
  2. propylthiouracol - hepatotoxicity
104
Q

what drug can be used for rapid symptom relief in thyrotoxicosis?

A

propranolol

105
Q

what do you need to give prior to thyroidectomy?

A

iodine 10 - 14 days before
adjunct to anti-thyroid drugs

106
Q

what can you give in 1st and 2nd trimester in pregnancy for hypoerthyroidism as blocking-replacement therapy and radioactive iodine is contraindicated?

A

1st = propylyhiouralcil
2nd = carbimazole

Pre-reg (47 decks)

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