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Trainee pharmacist > Endocrinology > Flashcards

Endocrinology Flashcards

1
Q

Mr Y is due to undergo planned surgery in two weeks. He has come to see you for advice re metformin..

A

Stop at time of surgery under general, spinal or epidural anaesthesia.

Continue at least 48 hours after surgery when renal function is stable

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2
Q

What is the onset of action of rapid-acting insulin?

A

15 minutes

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3
Q

What are the different rapid-acting insulins?

A

Insulin aspart
Insulin glulisine
Insulin lispro

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4
Q

What is the onset of action of soluble insulin (SC)?

A

30 - 60 minutes

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5
Q

Give an example of an intermediate- acting insulin

A

Isophane insulin

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6
Q

List counselling points with SC insulin administration

A

Inject into abdominal wall, thigh, upper arm or gluteal region

Injection sites should be rotated within the same area to reduce risk of lipodystrophy and cutaneous amyloidosis

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7
Q

What do biphasic insulins contain?

A

A mix of intermediate-acting and short-acting insulin (varying from 15-50%)

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8
Q

Give examples of biphasic insulins (brands)?

A

Humulin M3
Novomix 30
Humalog Mix 50

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9
Q

What is the duration of action of long-acting insulin?

A

Upto 36 hours

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10
Q

What are examples of long-acting insulins?

A

Insulin detemir
Insulin glargine
Insulin degludec

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11
Q

Give examples of brands of long-acting insulin

A

Levemir
Lantus
Tresiba

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12
Q

Give examples of brands of rapid-acting insulins

A

Fiasp
Novorapid
Apidra
Humalog
Lyumjev

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13
Q

Metformin exerts its action by…

A

Decreasing gluconeogenesis
Increasing peripheral utilisation of glucose

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14
Q

Which antidiabetic drug can be used to aid weight reduction, normalise menstrual cycle and improve hirsutism?

A

Metformin

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15
Q

Patients must report symptoms of dysuria or haematuria with which anti-diabetic drug?

A

Pioglitazone - MHRA advice re bladder cancer risk

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16
Q

What is the mechanism of action of sulphonylureas?

A

Stimulates insulin secretion from beta-cells of the islets of Langerhans

This means that residual pancreatic beta-cell activity is required.

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17
Q

Give examples of sulphonyureas?

A

Gliclazide
Glibenclamide
Glimepiride
Glipizide
Tolbutamide

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18
Q

What are the signs and symptoms of hypothyroidism?

A

Weight gain, cold intolerance, constipation

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19
Q

What are the signs and symptoms of hyperthyroidism?

A

Weight loss, heat intolerance, diarrhoea goitre (lump or swelling in front of neck), fine tremor, palpitations

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20
Q

What does high T3 and T4, low TSH mean?

A

primary hyperthyroidism

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21
Q

What does the TFTs of someone with primary hypothyroidism look like?

A

High TSH, low T4 and T3

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22
Q

What are the unlicensed use of metformin

A

PCOS (dose titrated as it is for diabetes)
T2DM in children aged 8-9

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23
Q

When should metformin be avoided ?

A

If eGFR is less than 30ml.min/1.72m2

24
Q

What are common s/e of metformin

A

Lactic acidosis (discontinue treatment)

GI discomfort - can be resolved using modified release preparations, symptoms usually worst on initiation

Vitamin B12 deficiency

25
Q

What dietary interactions are there with levothyroxine?

A

Food, including dietary fibre, milk, soya products, and coffee, might decrease the absorption of levothyroxine.

26
Q

Counselling advice for levothyroxine?

A

-Take before breakfast or the first meal of the day.

-Administration should be of levothyroxine should be at least 4 hours apart if taking antacids, calcium salts, cimetidine, oral iron, sucralfate, colestipol, polystyrene sulphonate resin and cholestyramine.

-Avoid caffeine

27
Q

What is the DVLA advice around glucose monitoring for drivers with diabetes?

A

Blood-glucose concentration should be checked no more than 2 hours before driving and every 2 hours while driving

28
Q

What is the minimum blood-glucose concentration required for driving?

A

Should be at least 5 mmol/litre

29
Q

When is HbA1c target 53mmol/mol?

A

-Patient prescribed a single drug associated with hypoglycaemia (such as a sulfonylurea).
-When two or more antidiabetic drugs are prescribed

30
Q

Which sulfonylureas are long-acting?

A

glibenclamide, chlorpropamide, glimepiride

31
Q

List microvascular complications of T2DM

A

Retinopathy
Neuropathy
Nephropathy

32
Q

List the macrovascular complications of T2DM

A

Stroke
MI
Peripheral arterial disease

33
Q

How do systemic corticosteroids work?

A

2 classes:
Glucocorticoids - reduce inflammatory response

Mineralocorticoids - influence sodium and water retention

34
Q

Diabetes, osteoporosis and psychiatric reastions are side-effects of which class of steroids?

A

Glucocorticoids

35
Q

Give examples of corticosteroids with primarily glucocorticoid activity

A

Betamethasone
Dexamethasone
Prednisolone
Deflazacort

  • these are all more suitable for long-term use for disease suppression as less likely to cause fluid retention
36
Q

Give examples of corticosteroids with primarily mineralocorticoid activity

A

Fludrocortisone
Hydrocortisone (equal activity)

37
Q

Important counselling points for GLP-1 agonists?

A

Patients should recongise and report symptoms of acute pancreatitis

38
Q

At what HbA1c value should treatment be intensified?

A

58mmol/mol or greater (if single antidiabetic agent used)

39
Q

What class of medication is repaglinide in and explain briefly its pharmacokinetics.

A

Meglitinide

Have a rapid onset of action and short duration of activity (ideal for use around mealtimes)

40
Q

Which sulphonylureas are safer in elderly patients?

A

Short-acting such as gliclazide and tolbutamide

41
Q

How can you use repaglinide for the management of diabetes?

A

By itself (monotherapy) or in combination with metformin ONLY.

41
Q

What is the target HbA1c for T1DM?

A

48mmol/mol or less

42
Q

What should blood glucose levels be for T1DM before meals

A

4–7 mmol/litre

43
Q

What are common signs and symptoms of DKA?

A

Palpitations
Nausea and vomiting
Sweating
Thirst
Blurred vision
Leg cramps
Fruity smell on breath

44
Q

How do you manage hypoglycaemia?

A

symptoms of hypo with blood-glucose greater than 4mmol/L - give normal meal or small carbohydrate snack

blood-glucose <4mmol/L, with or without symptoms and who is conscious and able to swallow - give glucose 40% gels, Lift glucose liquid, pure fruit juice. Repeat after 15 mins (max 3 times).

hypoglycaemia where patient is unconscious should be treated with glucagon IM or glucose 10% IV infusion

Long-acting carboyhdrate should be given when patient has recovered in all cases.

45
Q

When is glucagon ineffective?

A

In patients whos liver glycogen is depleted e.g. anyone who has fasted for a prolonged time or has adrenal insufficiency.

Glucagone may be ineffective in alcohol-induced hypos.

46
Q

How do you manage hypos caused by sulphonylureas?

A

Glucagon may be less effective, use IV glucose instead.

monitor blood glucose levels for at least 24-48hours.

hypoglycaemia caused by a sulphonylurea may persist for 24-36hours following last dose.

47
Q

Which GLP-1 agonist has a special contraindication?

A

Liraglutide - contraindicated in IBD, and diabetic gastroparesis

48
Q

Which SGLT2i has an additional MHRA warning that others in the same class dont have? What is the warning??

A

canagliflozin - increased risk of lower limb amputation (toes).

Consider stopping canagliflozin if patient develops a significant lower limb complication (skin ulcer, osteomyelitis or gangrene)

49
Q

What should drivers with diabetes do if their blood glucose is less than 4mmol/L or they have symptoms of hypo?

A

Stop the car. Do not drive.

Resolve hypoglycaemia, then wait at least 45 minutes after blood glucose is 5mmol/L to start driving again.

50
Q

What are the risks associated with abrupt withdrawal of systemic corticosteroids

A

Abrupt withdrawal can lead to acute adrenal insufficiency, hypotension or death.

Withdrawal can also be associated with:
Fever
Myalgia
Arthralgia
Rhinitis
Conjunctivitis
Painful itchy skin nodules
Weight loss.

51
Q

When should you consider gradual withdrawal of corticosteroids?

A

When patients disease is unlikely to relapse and have:
(i) received more than 40 mg prednisolone (or equivalent) daily for more than 1 week

(ii) been given repeat doses in the evening

(iii) received more than 3 weeks’ treatment

(iv) recently received repeated courses (particularly if taken for longer than 3 weeks)

(v) taken a short course within 1 year of stopping long-term therapy

(vi) other possible causes of adrenal suppression.

51
Q

What sort of symptoms should patients be advised to report with vildagliptin?

(THIS APPLIES ONLY TO VILDAGLIPTIN, not other gliptins)

A

signs of liver toxicity:

Dark urine, nausea, vomiting, abdominal pain, fatigue, jaundice

52
Q

Which antidiabetic drugs carry risk of acute pancreatitis?

A

Gliptins (DPP4 inhibitors)
GLP-1 agonists

53
Q

What are the two MHRA alerts around the use of pioglitazone?

A

Bladder cancer

Cardiovascular safety - pioglitazone should not be used in HF or history of HF (the drug increases water retention which worsens HF). Should be avoided in patients with previous MI

54
Q

What are the symptoms of rapid metabolism of levothyroxine?

What can be done to help this?

A

Rapid metabolism causes: diarrhoea, nervousness, rapid pulse, insomnia, tremors and sometimes anginal pain where there is latent myocardial ischaemia.

Reduce dose or withhold for 1–2 days and start again at a lower dose.

Trainee pharmacist (5 decks)

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