Endocrine System Flashcards
What is diabetes insipidus?
Large amounts of urine (dilute) are produced which causes extreme thirst. Rare form of diabetes where there is hyposecretion of ADH.
Which has a longer duration of action, vasopressin or desmopressin?
Desmopressin (it is also more potent)
How should you counsel patients dosing/drinking water wise with desmopressin and vasopressin?
Limit fluid intake 1 hour before dose and 8 hours after fluid retention
Why would we use carbamazepine in conjunction with treatments of diabetes insipidus?
Increases the sensitivity of renal tubules to ADH
What is it called when you have the opposite condition and have too much ADH?
Syndrome of inappropriate antidiuretic hormone secretion (where the body has kept too much fluid from too much ADH, often after diabetes insipidus treatment.
What do we use to treat the syndrome of inappropriate antidiuretic hormone secretion?
Demeclocycline (as blocks ADH) or tolvaptan (vasopressin antagonist)
Why do we avoid rapid correction of hyponatraemia (correcting Syndrome of inappropriate ADH)?
It can cause osmotic demyelination of neurones
List some examples of glucocorticoids?
Betamethasone, prednisolone, (some hydrocortisone), dexamethasone
What is the main effect of glucocorticoids?
Anti-inflammatory effect (because it mimics cortisol)
List some examples of mineralocorticoids?
Fludrocortisone and hydrocortisone (less than fludrocortisone)
How do mineralocorticoids work?
Mimic aldosterone (sodium and water reabsorption)
What are the main side effects with mineralocorticoids?
Sodium and water retention, potassium and calcium loss
What is the main effect we use mineralocorticoids for?
Water retention
Why would we use dexamethasone or betamethasone over prednisolone?
Because they have the least mineralocorticoid side effects, so would be used for the least fluid retention side effects in patients who it was deemed unsuitable i.e., heart failure
Which medicines would change HbA1c levels? Ramipril, paracetamol, prednisolone or simvastatin
Prednisolone- because glucocorticoids cause hyperglycaemia
What is the concern of using a steroid alongside statins?
Muscle wasting- myopathy
What is the MHRA alert with local and systemic steroid use?
Chorioretinopathy- report visual disturbances and blurred vision
Do corticosteroids cause hyperlipidaemia or hypolipidaemia?
Hyperlipidaemia
What would the interaction be between steroids and beta agonists if one were to happen?
Hypokalaemia- especially if nebulised (same with diuretics not K+ sparing and theophylline)
Who do you offer gradual/weaning doses of corticosteroids to?
1) >3 weeks treatment
2) 40mg pred or more for a week or longer
3) repeat doses in the evening
4) received repeated courses
5) taken a short course within 1 year of stopping long term therapy
What is the MHRA alert with methylprednisolone?
Methylprednisolone injection medicine contains lactose- solumedrone 40mg. Do NOT use in patients with milk allergy, bronchospasm and anaphylaxis reported
When would you issue a steroid card to patients?
> 3 weeks treatment OR if using higher doses than licensed
Which steroid would you use to treat Addison’s disease?
Fludrocortisone and hydrocortisone (Addisons is a disease with adrenal glands not producing enough cortisol or aldosterone- you generally need to urinate a lot and are thirsty)
What is Cushings disease and what are the symptoms?
High cortisol levels, skin thinning, easy bruising, red purple stretch marks, fat deposits in the face, moon face, acne
There is an antifungal which can also be used for its cortisol inhibiting purposes, which is it?
Ketoconazole- therefore inhibits cortisol and is used for treatment in Cushing’s, same as metyrapone
Which type of DM is insulin resistance?
Type 2
Type 1 is insulin deficiency
What are the symptoms of DM?
Thirst (polydipsia)
hunger (polyphagia), polyuria (excessive urination),
weight loss (type 1),
fatigue,
blurred vision
poor wound healing
What do diabetic drivers do before driving?
Check blood glucose no more than 2 hours before driving, and every 2 hours whilst driving
What glucose level is ok for driving?
5mmol/L
If the glucose level falls below 5mmol/L for driving, what you do?
A snack should be taken BUT if 4 or less, or warnings of a hypo develops pull over and stop, switch off engine and remove keys and move from driver’s seat, eat/drink suitable source of sugar, wait 45 mins after BMs returned to normal
HbA1c reflects average plasma glucose control over the previous how many months?
2-3 months
At what time of day should HbA1c be performed?
It can be performed at any time of day
What is the normal target HbA1c level for someone on metformin or diet-controlled DM?
48
How often should HbA1c be performed?
Every 3-6 months for both types but with type 2 when meds are stable monitoring can be reduced to 6-monthly
How often do you monitor for long term complications when patients are diabetic?
Annually
What are the two drugs we use to reduce long term cardiovascular complications in diabetes?
Statin and ACE Inhibitors
What are the macrovascular complications and microvascular complications associated with DM?
Macrovascular- cardiovascular.
Microvascular-
1) eyes: retinopathy (treat HTN protects visual acuity)
2) kidneys: nephropathy (treatment ACE/ARB)
3)nerves: painful neuropathy ‘diabetic foot’, autonomic neuropathy, gustatory neuropathy, neuropathic postural hypotension
neuropathy, nephropathy, retinopathy
Why do we get ketosis in diabetes?
The body’s response to low blood glucose is that it uses fat instead, which creates high levels of ketones
How often should type 1 DM patients measure their BMs?
At least four times a day: before each meal and bedtime
What range of BMs should patients aim for on waking?
5-7 (fasting)
What range of BMs should patients aim for at other times of the day before meals?
4-7
What range of BMs should patients aim for after about 90 minutes of eating?
5-9
What range of BMs should patients aim for when driving?
Above 5
What insulin regimen is recommended for patients first line in type 1 diabetics?
Basal bolus regimen
What basal insulin should patients use for basal bolus insulin?
Generally, BD detemir first or OD glargine. NB: detemir can be OD
What insulin type is novorapid?
Rapid acting insulin aspart
What insulin type is Humalog?
Rapid acting insulin lispro
What insulin type is Apidra?
Rapid acting insulin glulisine
In what situations may insulin requirements increase?
Infection and illness, stress, trauma, surgery, pregnancy, puberty, steroids
What situations decrease insulin requirements?
Exercise, intercurrent illness, reduced food intake, impaired renal function and in certain endocrine disorders (Addison’s, hypopituitary)
Why must we be careful of patients monitoring their BMs when also prescribed beta blockers?
Beta blockers blunt hypoglycaemic awareness by reducing warning signs- for example: tremor
What are the blood sugars when patients go into an DKA?
> 14mmol/L
Why do we tell patients to rotate insulin injection sites?
Lipodystrophy
What do ACE inhibitors do to insulin?
ACE inhibitors enhance the effect of insulin (hyperkalaemia linked with hyoglycaemia is linked with insulin and concomitant ACE inhibitors)
When changing insulin brands, how much do we change the dose by when moving from beef to human?
Beef to human: reduce by 10%
When changing insulin brands, how much do we change the dose by when moving from pork to human?
Pork to human: no dose change
What are the MHRA warnings with insulin?
Doses should always be written as units not IU, never give IV syringe for SC injection, check injection technique (SC not IV), always check insulin container, pen and needle size
What do you need to prescribe alongside IV soluble insulin?
Potassium and glucose (check not hyperkalaemic)
What is the duration of action for rapid acting insulins?
2-5 hours
What is the onset of action for rapid acting insulins?
15 minutes
List the types of rapid acting insulins
Novorapid – insulin aspart,
Apidra- glusiline,
Humalog- insulin lispro
List some brands of soluble insulins
Actrapid, Humulin S, Insuman Rapid
What are the two intermediate acting insulins?
Insulin isophane and NPH
Give some examples of these intermediate acting
Isophane: Humulin I, insulatard, insuman basal.
NPH: protamine
What is the onset for intermediate acting insulin?
1-2 hours
What is the duration of action for intermediate acting insulin?
16-25 hours
Give some examples of branded insulins which have an intermediate AND short acting insulin in
Novomix 25, Humulin 30, Humalog mix 25
What is the duration of action for long-acting insulins?
36 hours (Css in 2-4 days)
What type of insulin is Levemir?
Detemir (OD or BD)
What long-acting insulins are there?
Levemir (insulin detemir), Lantus (insulin glargine), Tresiba (insulin degludec)
What is the patient safety alert for insulin?
Risk of severe harm or death due to withdrawing insulin from pen devices, and to not use part pens
What is first line for type 2 diabetes?
Metformin
What is the target HbA1c in patients taking DPP-4 inhibitor and metformin and pioglitazone?
53
What is the first intensification in antidiabetic treatment for type 2 diabetics?
Metformin + DPP4i/pioglitazone/sulfonylurea/SGLT2i
Why doesn’t metformin cause hypoglycaemic?
It does not stimulate insulin secretion
Why do we gradually increase metformin doses when initiating patients on it?
To reduce GI side effects
What else can you do with metformin if GI side effects occur?
Offer the slow release/controlled release metformin
What class of drug is glipizide?
Sulfonylurea
Which class of antidiabetic is associated with the most weight gain?
Sulfonylurea
What class of drug is repaglinide?
A metglinide
What is the MHRA alert with pioglitazone?
Bladder cancer and Heart Failure
What is associated with long term pioglitazone?
Heart failure (esp when combined with insulin and predisposing factors)
Why might gliptins (DPP4i) be preferred over sulfonylureas?
Reduced incidence of hypoglycaemia and weight gain
Give an example of SGL2 inhibitors
Canagliflozin, dapagliflozin and empagliflozin
Give examples of GLP-1 agonists
dulaglutide, exenatide, liraglutide, lixisenatide
What class of drug is sitagliptin?
DPP4 inhibitor
Which drug other than metformin in safe in breast feeding?
Glibenclamide (2nd and 3rd trimester)
If a patient has fasting <7mmol/L blood glucose results when diagnosed with gestational DM, how do you manage them?
Dietary measures, although if BMs are not within range start metformin (if targets aren’t met in 1-2 weeks)
If a patient has fasting >7mmol/L blood glucose results when diagnosed with gestational DM, how do you manage them?
First line- insulin (with or without metformin) and dietary and exercise measures
If a patient has 6-6.9 mmol/L blood glucose results when diagnosed with gestational DM, WITH hydramnios or macrosomia how do you manage them?
Insulin with or without metformin
What treatment can be given to gestational DM ladies who are intolerant of metformin and don’t want insulin?
Glibenclamide – but from 11 weeks’ gestation
What is the first choice long-acting insulin analogue in pregnancy?
Insulin isophane – although if a pregnant female had good control with long-acting analogues prenatally they can continue with insulin detemir (Levemir) or glargine (Lantus)
What is the oral glucose tolerance test?
Measure glucose levels after fasting and 2 hours after drinking a standard glucose drink
What antihypertensives can you use in pregnancy?
Labetalol, nifedipine or methyldopa (NO ACE!!)
List some symptoms of Diabetic ketoacidosis (DKA)?
Pear drop breath, severe hyperglycaemia, ketonuria, high blood ketones, dehydration, excessive thirst, polyuria, abdominal pain, difficulty breathing, convulsions etc
How do you treat DKA?
Soluble insulin,
fluids (saline- restore circulating volume if BP below 90mmHg,
give 500ml NaCl 0.9% over 10-15 mins, when BP over 90, provide fluids at a rate that is sufficient to provide replacement for deficit), potassium.
Ensure you CONTINUE the long-acting insulin (i.e. detemir or glargine), add glucose to infusion when below 14mmol/L,
continue until the patient is able to eat and drink and blood pH above 7.3, then give SC fast acting insulin and a meal, stop the infusion one hour later.
What class of drug is metformin?
Biguanide
MOA of metformin
decrease liver gluconeogenesis
What is the MHRA alert with SGLT2 transporters?
risk of lower limb amputation – especially canaglifozin.
Also: DKA at euglycemia,
also: genital necrotising fasciitis.
AND DKA RISK- monitor ketones for perioperative period
Give some example of SGLT2 inhibtors
canaglifozin, dapaglifozin, empaglifozin
Why is there a higher risk of UTIs with SGLT2 transporters?
Because they work by increasing the amount of glucose output in the urine, increased glucose in urine= increased chance of infection
Who uses GLP-1 agonists?
For patients taking triple therapy with metformin and a sulfonylurea. It is for patients >35 who have psychological or medical problems associated with obesity OR patients <35 and on insulin who have occupational implications
When do you review patients who are on GLP1 agonists?
Review at 6 months and continue if an 11 mmol reduction is seen in HbA1c and 3% weight loss
What is one of the more severe side effects that should be monitored with GLP – 1 agonist?
For pancreatitis, especially exenatide
If a GLP 1 agonist dose is missed (weekly), when can you give/change doses?
Within 3 days
How would you treat diabetic neuropathy (pain)?
Optimise diabetic control to reduce it, monotherapy with tricyclics although pregabalin and gabapentin can be used second line
How would you treat neuropathic postural hypotension?
Increase salt intake, fludrocortisone (unlicensed) to increase plasma volume. Midodrine may also be used
How would you treat gustatory sweating in diabetics?
Antimuscarinics: Propantheline
How do you treat hypoglycaemia?
(<4mmol/L): if conscious and able to swallow: glucose 15-20g fast acting carb i.e. 3tsp or 4 lumps of sugar, 4-7 glucose tabs, 150-200ml fruit juice and repeat in 10-15 mins if needed. MAX 3 TIMES, then have a snack/meal to restore liver glycogen.
If this hasn’t worked and still hypoglycaemic- glucagon injection of glucose 10% IV.
If a hypoglycaemic emergency and patient unconscious, glucagon use initially, if no response then give IV glucose 10% (or 20%)
If patients are going in for an elective minor surgery, how would you manage their insulin?
Use the usual regimen but on the day before surgery give normal insulin except OD long-acting dose given 80% of dose
How would you manage it in major elective surgery or poor glycaemic control?
Requires IV variable rate insulin, aim for 6-10 mmol/L, the day before give 80% of LA insulin,
on day of surgery use 80% of LA insulin and stop all others until patient is eating and drinking. Use a sliding scale: K+, NaCl etc.
Give IV glucose 20% if BMs drop below 6,
if BMs rise about 12, check ketones and other signs of DKA
How often do you check BMs during sliding scale?
Hourly
For non-insulin drugs, which do you keep during surgery?
Pioglitazone, DPP4i (gliptins), GLP1 agonists BUT NB: if patient is having variable insulin, stop ALL drugs except GLP1 agonists
For non-insulin drugs, which do you stop during perioperative period
SGLT2i and sulfonylureas, restart when eating/drinking
For non-insulin drugs, which meds do you omit the morning dose for day of surgery?
Acarbose, nateglinide and repaglinide
List some risk factors for osteoporosis
Men over 50,
post-menopausal women,
low BMI,
long term corticosteroids,
lack of physical activity,
vitamin D deficiency,
low calcium intake,
family history,
previous fractures,
early menopause,
excess alcohol,
What is the general treatment for osteoporosis?
Lifestyle changes, calcium and vitamin D supplementation, drug treatment
Of the drug treatment, what is first line for osteoporosis for all groups of people?
Bisphosphonates PO or IV
What is the treatment for osteoporosis in post-menopausal women?
First: bisphosphonates, second: denosumab third: raloxifene etc
What is the treatment for osteoporosis in men?
First: Bisphosphonates, second: teriparatide (max 24 months) third: denosumab,
What is the treatment for glucocorticoid induced osteoporosis?
Bisphosphonates, then teriparatide (max 24 months)
What are the lifestyle recommendations for people with osteoporosis?
Reduce alcohol, increase activity, stop smoking, BMI 20-25, diet with calcium/vitamin D then supplement if cannot incorporate into diet
When do you review bisphosphonate treatments?
After 5 years with alendronic acid, risedronate and ibandronic acid.
Review 3 years with zoledronic acid. But patients over 75 with history of hip/vertebral fracture or had fragility fractures during treatment can continue beyond these periods
What are the bisphosphonates of choice?
Alendronic acid and risedronate sodium
Which bisphosphonate has the highest risk of osteonecrosis of the jaw?
Zoledronic acid
What is the creatinine clearance for bisphosphonates to be avoided in?
CrCl <35
MHRA alerts for bisphosphonates
Osteonecrosis of jaw (pre dental check up), osteonecrosis of external auditory ear canal, atypical femoral fractures (report thigh, hip and groin pain)
MHRA alerts for denosumab (monoclonal antibody)
Osteonecrosis of jaw (higher risk with IV administration in malignancy), osteonecrosis of ear canal, hypocalcaemia, atypical femoral fractures, increased risk of multiple vertebral fractures,
What is the dose for risedronate?
35 mg weekly or 5mg daily
How would you counsel a patient on risedronate?
To sit upright for 30 mins,
do not take any milk (calcium containing foods or drinks) or antacids within 2 hours of risedronate.
Patient reminder card and inform patients of risk for any bisphosphonate IV
How would you counsel a patient on alendronic acid?
1) Swallow whole with plenty of water
2) While standing or sitting upright
3) On an empty stomach 30 minutes before breakfast or another oral medicine
4) Remain upright 30 minutes after
List some natural oestrogens and synthetic oestrogens
Natural: oestriol, estradiol. Synthetic: ethinylestradiol and tibolone
If long term therapy oestrogen is needed in women WITH a uterus, we give progestogen also, why is this?
To reduce the risk of endometrial cystic hyperplasia (reduces endometrial cancer risk)
What option is given to women who have vasomotor symptoms in menopause but can’t use oestrogen?
Clonidine (drowsy = SE)
What is used in vaginal atrophy? (vaginal dryness)
Topical oestrogens such as vaginal creams, tablets and rings
What is the MHRA warning with HRT treatment?
Should only be prescribed to relieve post-menopausal symptoms that are adversely affecting QOL and treatment should be reviewed regularly to ensure minimum effective doses for shortest duration
In what age do we stop prescribing HRT?
Over 65’s as experience is limited
How do we treat vasomotor symptoms with HRT in women who can have oestrogen?
Systemic oestrogens in either patches or tablet form (apply patch below waistline away from waist band or breast) NB: with progestogen for patients with uterus but weigh up with breast cancer risk with progestogen
With combined HRT, you can have cyclical or continuous treatment. Who is continuous combined unsuitable for?
Patients in perimenopause or <12 after last period
When do you stop HRT before elective surgery?
4-6 weeks before surgery, restart when fully mobile. NB: if emergency surgery use a parenteral anticoagulant
You are fertile for 2 years after stopping your period when below 50 and fertile for 1 year when above 50. Does HRT provide contraception?
No, it does not provide contraception, use a low oestogen combined oral contraception if under 50 y/o or use barrier method if over 50
HRT must be discontinued when blood pressure is raised past a certain point, what measurement is this?
Systolic >160 or >95 diastolic
What is clomifene used for?
In infertility in women- it can be used for 6 cycles max as increased risk of ovarian cancer
What are the symptoms of hyperthyroidism?
Weight loss, heat intolerance, diarrhoea, tachycardia, excitability, arrhythmias
Which thyroid hormone is levothyroxine?
Weight loss, heat intolerance, diarrhoea, tachycardia, excitability, arrhythmias
What treatment is first line in Hashimoto’s?
Levothyroxine
What is the drug of choice in hyperthyroidism?
Carbimazole (can use propylthiouracil as an alternative)
What is the side effect to watch out for with propylthiouracil?
Hepatotoxicity- stop and report signs of liver failure
How do you treat thyrotoxicosis? (tachy, diarrhoea, seizures etc)
Propranolol, anti-thyroid drugs, fluids, hydrocortisone and radioactive sodium iodide solution
What do you use to treat hyperthyroidism in pregnancy?
Propylthiouracil in first trimester and carbimazole in second trimester
What are the symptoms of hypothyroidism?
Cold intolerance, weight gain, bradycardic, constipation, lethargy
What is used for hypothyroid emergencies?
Liothyronine rather than thyroxine because it is more potent and more rapid effect
When taking levothyroxine, how is it taken?
In the morning, 30 mins before breakfast, caffeine containing liquids or other medication
What is the MHRA alert with carbimazole?
Bone marrow suppression- report signs AND congenital malformations in 1st trimester AND pancreatitis
