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Pre-Reg (Trainee) Pharmacy > HIGH WEIGHTING - Endocrine System > Flashcards

HIGH WEIGHTING - Endocrine System Flashcards

1
Q

What is Type 1 Diabetes Mellitus?

A

Autoimmune condition
- destroys beta pancreatic cells
- prevents insulin production

Symptom onset is FAST

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2
Q

What is Type 2 Diabetes Mellitus?

A

Develops over time
- exacerbated by lifestyle factors (wt, diet, exercise)

Body still produces insulin but cells become increasingly resistant to it

Symptom onset is SLOW

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3
Q

What HbA1c levels are indicative of diabetes?

A

> 47mmol/L

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4
Q

What HbA1c levels are indicative of pre-diabetes?

A

42-47mmol/L

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5
Q

What HbA1c levels are indicative of NO diabetes present?

A

<42mmol/L

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6
Q

Which disease causes hypERthyroidism?

A

Graves disease

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7
Q

What are some presenting symptoms of Graves disease?

A
  • Thickening of skin (particularly on shins) - Graves Dermopathy
  • Bulging eyes (retracted eyelids)
  • Eye redness
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8
Q

What causes the thickening of skin and bulging eyes in Graves disease?

A

Thyroid Stimulating Immunoglobulin

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9
Q

What are the pharmacological management options for Graves disease?

A

(1) TITRATION: Start with antithyroid drugs and titrate to lowest effective dose

(2) BLOCK & REPLACE: Start with high dose antithyroid drugs and use levothyroxine to replace thyroid hormones and stop hypothyroidism.

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10
Q

Which pharmacological treatment of Graves disease is preferred in pregnancy?

A

Titration

As ‘Block & Replace’ requires very high levels of antithyroid drugs

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11
Q

What are the antithyroid drugs used in pharmacological management of Graves disease?

A
  • Carbimazole
  • Propylthiouracil
  • Propranolol (provides relief of adrenergic symptoms)
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12
Q

What is the normal dosing of carbimazole?

A

20-60mg in divided doses

Once euthyroid, reduce by 5-15mg gradually

For 12-18 months duration

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13
Q

What is the normal duration of carbimazole treatment?

A

12-18 months

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14
Q

What are the main side-effects of carbimazole?

A
  • Bone marrow disorders (neutropenia & agranulocytosis)
  • Acute pancreatitis (discontinue permanently - MHRA warning)
  • Stomach irritation
  • Rash
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15
Q

What is an MHRA warning for carbimazole?

A
  • Risk of acute pancreatitis
  • Increased risk of congenital malformations, strengthened advice on contraception
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16
Q

What are the counselling points for carbimazole?

A
  • Can reduce number of WBCs in the body
  • Important that they are able to recognise symptoms
  • See GP if experiencing the following:
  • Sore throat
  • Temperature ≥37.5ºC (fever)
  • Unexplained bruising
  • Mouth ulcers
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17
Q

What is the usual dosing of propranolol in thyrotoxicosis?

A

10-40mg TDS or QDS

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18
Q

What are some cautions for beta-blockers?

A
  • Asthma
  • Diabetic patients (can mask symptoms of hypoglycaemia)
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19
Q

What is the STOPP criteria for beta-blockers?

A
  • Combinatory use with verapamil/ diltiazem (risk of heart block)
  • Bradycardia
  • Diabetes mellitus
  • Non-selective beta-blockers in patients with asthma
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20
Q

What is a drug that can commonly induce hypERthyroidism?

A

Amiodarone
- iodine rich, can cause thyroid dysfunction

Can also causes hypOthyroidism

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21
Q

What is a drug that can commonly induce hypOthyroidism?

A

Amiodarone
- iodine rich, can cause thyroid dysfunction

Can also causes hypERthyroidism

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22
Q

What is hypOthyroidism?

A

Impaired production of T3 and T3

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23
Q

What are some symptoms of hypOthyroidism?

A
  • Cold intolerance
  • Tiredness
  • Constipation
  • Depression
  • Wt gain
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24
Q

What are some symptoms of primary hypOthyroidism?

A
  • Iodine deficiency
  • Hashimoto’s
  • Physical damage
  • Drug induced
  • Transient
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25
Q

What are some symptoms of secondary hypOthyroidism?

A
  • Pituitary/ hypothalamic disorder
  • Tumours
  • Surgery
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26
Q

What is Hashimoto’s disease?

A

Autoimmune disease

Thyroid follicular cells gradually destroyed by lymphocytes

Goitre can form due to thyroid enlargement

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27
Q

What is primary hypOthyroidism?

A

Thyroid gland unable to produce hormones

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28
Q

What is secondary hypOthyroidism?

A

Result of insufficient production of bioactive TSH

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29
Q

What is an MHRA warning for levothyroxine?

A

Patients can react very differently to different brands of levothyroxine

If a patient says they can only take ONE brand, only give that brand

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30
Q

What are some monitoring requirements for levothyroxine?

A

Measure TSH every 3 months until stabilised

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31
Q

What are some side-effects of levothyroxine?

A

SYMPTOMS OF HYPERTHYROIDISM:
- Diarrhoea
- Nervousness
- Rapid pulse
- Insomnia
- Tremors
- Anginal pain (if latent myocardial ischaemia)

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32
Q

How should side-effects of levothyroxine be managed?

A

(1) Reduce dose

(2) Withhold for 1-2 days + restart at lower dose

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33
Q

What is the HPA-axis?

A

Hypothalamic Pituitary Adrenal Axis

Central stress response system

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34
Q

What are some short term stress responses of the sympatho-adrenomedulary system?

A
  • Increased HR
  • Increased BP
  • Conversion of glycogen to glucose in the liver
  • Bronchiole dilation
  • Changes in blood flow patterns (increased alertness, increased metabolic rate, decreased urine output, decreased digestive system activity)
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35
Q

Where is ACTH released?

A

Anterior pituitary

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36
Q

What stimulates the production of ACTH?

A

CRH

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37
Q

Where are glucocorticoids produced?

A

Adrenal cortex (stimulated by ACTH)

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38
Q

What is Addisons disease?

A

Form of adrenal insufficiency

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39
Q

What are some long term stress responses of the HPA-axis?

A
  • Retention of Na+ & water by kidneys
  • Increased blood volume & blood pressure
  • INCREASED:
  • Gluconeogenesis
    ø Fat & protein mobilisation
  • DECREASED:
    ø Insulin sensitivity
    ø GH & T3
    ø Immune/ inflammatory response
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40
Q

How is Addisons disease managed?

A

Treatment initiated and monitored by a specialist endocrinologist

  • Glucocorticoid: Hydrocortisone (can also use prednisolone/ dexamethasone)
  • Mineralocorticoid: Fludrocortisone (50-300micrograms daily)
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41
Q

What are the sick day rules for Addisons disease?

A
  • Double normal dose of hydrocortisone for a fever or infection/ sepsis requiring ABx
  • Severe nausea: Take 20mg hydrocortisone & rehydrate using fluids/ electrolytes
  • D + V/ serious illness: Emergency 100mg hydrocortisone injection immediately, then call doctor saying:
    øAdrenal crisis
    ø Addisons emergency
    ø Steroid-dependent patient
  • Serious injury: 20mg hydrocortisone (to avoid shock)
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42
Q

What should be done for an Addisons patient experiencing diarrhoea/ vomiting OR a serious illness?

A

(1) Use emergency hydrocortisone 100mg injection immediately

(2) Call doctor

(3) Say: ‘adrenal crisis’ OR ‘Addisons emergency’ OR ‘steroid-dependent patient’

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43
Q

What is Cushing’s disease?

A

Increased secretion of ACTH from pituitary gland

Leads to too much cortisol

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44
Q

What most commonly causes Cushing’s disease?

A

Pituitary adenoma (~80%)

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45
Q

What are some common signs and symptoms of Cushing’s disease?

A
  • Wt gain
  • High BP
  • Excess hair growth (women)
  • Irritability
  • Poor short-term memory & concentration
  • Impaired immunological function
  • Red face
  • Extra fat around neck
  • Fatigue
  • Moon face
  • Red stretch marks
  • Irregular menstruation (women)
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46
Q

How is Addisons disease diagnosed?

A

Short Synthacten Test

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47
Q

How is Cushing’s disease diagnosed?

A

DEXAMETHASONE SUPPRESSION TEST:

(1) Overnight test
(2) Two-day, low-dose test
(3) Two-day, high-dose dexamethasone suppression test

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48
Q

What are the main treatment options for Cushing’s disease?

A

(1) Endoscopic surgical resection
(2) Pituitary radiation therapy
(3) Bilateral adrenalectomy

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49
Q

What are some pharmacological management options for Cushing’s disease?

A

(1) Mifepristone
(2) Ketoconazole
(3) Mitotane

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50
Q

What are the parathyroid glands?

A

Produces parathyroid hormone (PTH)

Four of these glands on the posterior of the thyroid

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51
Q

What does parathyroid hormone (PTH) do?

A

Helps to maintain calcium homeostasis

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52
Q

What is hyperparathyroidism?

A

Autonomous overproduction of parathyroid hormone

Results in hypercalcaemia (pulling calcium out of the bones + into the blood)

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53
Q

What are some signs and symptoms of hyperparathyroidism?

A
  • Digestive system:
    ø Loss of appetite
    ø Constipation
    ø N + V
  • Nervous system:
    ø Fatigue
    ø Depression
    ø Confusion
  • Musculoskeletal system:
    ø Muscle weakness
    ø Aches + pains
  • Urinary system:
    ø Increased thirst
    ø Increased urination
    ø Kidney stones
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54
Q

When is management of hyperparathyroidism required?

A
  • Thirst
  • Excessive urination
  • Constipation
  • Osteoporosis/ fragility fracture
  • Renal stones
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55
Q

What is the pharmacological management of hyperparathyroidism?

A

(1) Bisphosphonates - reduce fracture risk
(2) Cinacalcet - reduce blood plasma levels of Ca2+

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56
Q

Why does hypercalcaemia need to be managed effectively?

A

Can cause coma + increased mortality

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57
Q

What is secreted by the adrenal glands?

A

(1) Mineralocorticoids
(2) Glucocorticoids
(3) Androgens
(4) Stress hormones (adrenaline/ noradrenaline)

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58
Q

What does ACTH do?

A

Stimulates the adrenal cortex

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58
Q

What does ACTH do?

A

Stimulates the adrenal cortex

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59
Q

What is the adrenal medulla responsible for?

A

Short-term stress response

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60
Q

What is the adrenal cortex responsible for?

A

Long-term stress response

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61
Q

Which type of endocrine patients should carry a steroid alert card, as per NPSA alerts?

A

Addisons disease

To support early identification & treatment of adrenal crisis

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62
Q

Endocrine System

What is diabetes insipidus?

A

Too little ADH

Excess thirst and excess dilute urine

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63
Q

Endocrine System

(1) What are the types of diabetes insipidus? (2) What are their treatments?

A

(1)
- Cranial - pituitary
- Nephrogenic - partial

(2)
Pituitary - vasopressin/ desmopressin
Nephrogenic - thiazide diuretic

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64
Q

Endocrine System

What are some benefits of desmopressin over vasopressin?

A
  • more potent and longer duration
  • no vasoconstrictor effect
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65
Q

Endocrine System

What are some side effects of desmopressin?

A
  • Hyponatraemia - if given too rapidly - can increase risk of convulsions
  • Nausea
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66
Q

Endocrine System

What is SIADH?

A

Syndrome of inappropriate antidiuretic hormone secretion

Leads to hyponatraemia, due to reduced urination diluting salt concentration in the blood

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67
Q

Endocrine System

What is the treatment of SIADH?

A

(1) Fluid restriction
(2) Demeclocycline - blocks renal tubular effect of ADH
(3) Tolvaptan - vasopressin antagonist

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68
Q

Endocrine System

Why should rapid correction of hyponatraemia with tolvaptan be avoided?

A

Causes osmotic demyelination - serious neurological events

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69
Q

Endocrine System

What are some risk factors for osteoporosis?

A
  • postmenopausal women
  • men over 50yrs
  • patients taking long term corticosteroids
  • age increase
  • lack of exercise
  • vit D/ calcium deficiency
  • low BMI (underweight)
  • smoking/ drinking
  • Hx of fractures
  • early menopause
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70
Q

Endocrine System

What are some lifestyle changes for management of osteoporosis?

A
  • increase exercise
  • smoking cessation
  • maintaining an ideal BMI
  • reduce alcohol intake
  • increase intake of vit D and calcium (can use supplements)
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71
Q

Endocrine System

What HRT can be used peri-menopause?

A

Oestrogen

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72
Q

Endocrine System

What HRT can be used post-menopause?

A

Tibolone/ oestrogen

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73
Q

Endocrine System

What is the first line treatment for osteoporosis?

A

Oral bisphosphonates (alendronic/ risedronate)

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74
Q

Endocrine System

What alternative therapies are available for postmenopausal osteoporosis?

A
  • ibandronic acid - 150mg once a month
  • denosumab
  • raloxifene
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75
Q

Endocrine System

What can be used for severe osteoporosis in post-menopausal patients?

A
  • Teriparatide - total of 2yrs
  • romosozumab
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76
Q

Endocrine System

What is the recommendation if a patient experiences one severe or two moderate-low trauma vertebral fractures, for osteoporosis?

A

Teriparatide/ romosozumab recommended over oral bisphosphonates

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77
Q

Endocrine System

What are some alternative therapies for osteoporosis in men?

A

Zoledronic acid/ denosumab/ teriparatide

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78
Q

Endocrine System

What is the treatment for glucocorticoid-induced osteoporosis?

A
  • zoledronic acid
  • denosumab
  • teriparatide
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79
Q

Endocrine System

When is a treatment review for osteoporosis required?

A

5yrs

3yrs for zoledronic acid

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80
Q

Endocrine System

When should prophylaxis of osteoporosis at glucocorticoid treatment onset be started?

A

(1) Women:
- 70yrs or older
- previous fragility fracture
- large doses of glucocorticoid (e.g. >7.5mg prednisolone daily - or equivalent)

(2) Men >70yrs AND previous fragility fracture OR large doses of glucocorticoids

(3) Large dose corticosteroids for >3 months

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81
Q

Endocrine System

What are some MHRA warnings for bisphosphonates?

A

(1) Atypical femoral fracture

(2) ONJ - osteonecrosis of the jaw

(3) Osteonecrosis of the external auditory canal

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82
Q

Endocrine System

What are some side effects of bisphosphonates?

A
  • oesophageal reactions
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83
Q

Endocrine System

What is the administration advice for alendronic acid?

A

Take 30 minutes before breakfast/ other oral medications

Take with a full glass of water while standing

Remain upright for 30 minutes after

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84
Q

Endocrine System

How does the administration advice for risedronate sodium differ to that of alendronic acid?

A

Is still to take 30 mins before breakfast

BUT also to leave 2hrs before and after food/ drink - if taken at any other time of day

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85
Q

Endocrine System

What is Strontium?

A

Bone formation stimulant and reduces bone resorption

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86
Q

Endocrine System

What are some side effects of Strontium?

A
  • serious cardiovascular diseases (inc. MI, VTE)
  • severe allergic reaction - DRESS: drug rash with eosinophilia and systemic symptoms
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87
Q

Sex Hormone Responsive Conditions

What are some natural oestrogens?

A
  • estradiol
  • estrone
  • estriol
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88
Q

Sex Hormone Responsive Conditions

What are some examples of progesterones?

A
  • norethisterone
  • levonorgestrel
  • desogestrel
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89
Q

Sex Hormone Responsive Conditions

What are some examples of synthetic oestrogens?

A
  • ethinylestradiol
  • mestranol
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90
Q

Sex Hormone Responsive Conditions

What are some examples of tibolones?

A
  • estrogenic
  • progestogenic
  • weakly androgenic
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91
Q

Sex Hormone Responsive Conditions

What menopausal symptoms can estrogens alleviate?

A
  • vaginal atrophy (vaginal dryness)
  • vasomotor instability (hot flushes, night sweats)
  • postmenopausal osteoporosis
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92
Q

Sex Hormone Responsive Conditions

What are the differences in HRT between women with a uterus and those without?

A

1) Without:
- continuous oestrogen use
- consider addition of progesterone IF endometriosis occurs

2) With:
- oestrogen with cyclical progestogen

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93
Q

Sex Hormone Responsive Conditions

What are the risks of HRT?

A

1) Breast cancer
2) Endometrial cancer
3) Ovarian cancer
4) VTE
5) Stroke
6) Coronary heart disease

94
Q

Sex Hormone Responsive Conditions

What are some reasons to stop HRT?

A
  • sudden severe chest pain/ breathlessness (PE)
  • unexplained swelling/ severe pain in calf (DVT)
  • severe stomach pain (hepatotoxicity)
  • jaundice/ hepatitis (liver dysfunction)
  • serious neurological defects
  • very high BP
  • prolonged immobility
95
Q

Sex Hormone Responsive Conditions

What should be done for HRT for an elective surgery?

A

Stop 4-6 weeks before surgery

Re-initiate when FULLY mobile

96
Q

Sex Hormone Responsive Conditions

What should be done for a patient taking HRT during a non-elective surgery?

A

Prophylactic heparin

Graduated compression stockings

97
Q

Sex Hormone Responsive Conditions

What are some contraindications for HRT?

A
  • prolonged immobility after surgery
  • thrombophlebitis
  • angina/ MI
  • VTE
  • thrombophillic disorder (tendency to form blood clots)
  • liver disease
  • untreated endometrial hyperplasia
  • oestrogen dependent cancer
  • history of breast cancer
98
Q

Sex Hormone Responsive Conditions

Name an anti-oestrogen.

A

Clomifene

99
Q

Sex Hormone Responsive Conditions

What is the main side effect of clomifene?

A

Multiple pregnancies

100
Q

Thyroid Disorders

What do thyroid hormones regulate?

A
  • metabolic rate
  • heart rate
  • digestive function
  • muscle control
  • brain development
101
Q

Thyroid Disorders

What are the signs and symptoms of hypERthyroidism?

A

INCREASED METABOLISM AND ACTIVITY
- hyperactivity/ excitability
- tachycardia/ arrhythmias
- insomnia
- heat intolerance
- increased appetite
- weight loss
- diarrhoea
- goitre
- tremors
- angina pain

102
Q

Thyroid Disorders

What is the treatment for hypERthyroidism?

A

Carbimazole

OR

Propylthiouracil

103
Q

Thyroid Disorders

What are some MHRA warnings for carbimazole?

A
  • acute pancreatitis
  • congenital malformations
  • bone marrow suppression (neutropenia & agranulocytosis)
104
Q

Thyroid Disorders

What drug can be given in hypERthyroidism for symptomatic relief?

A

Propranolol

105
Q

Thyroid Disorders

What is the treatment for Graves’ disease?

A

Radioactive iodine

Can consider carbimazole if remission is likely

106
Q

Thyroid Disorders

What is the treatment for hypERthyroidism in pregnancy?

A

1st trimester: Propylthiouracil
2nd & 3rd trimesters: Carbimazole

107
Q

Thyroid Disorders

What are the signs and symptoms of thyrotoxicosis?

A
  • HR >140 (tachycardia)
  • heat intolerance
  • diarrhoea/ N&V
  • seizures/ delirium/ confusion/ psychosis
108
Q

Thyroid Disorders

What are the signs and symptoms of hypOthyroidism?

A

DECREASED METABOLISM AND ACTIVITY
- fatigue
- weight gain
- constipation
- depression
- dry skin
- intolerance to cold
- menstrual irregularities

109
Q

Thyroid Disorders

What is the treatment for hypOthyroidism?

A

Levothyroxine

110
Q

Thyroid Disorders

What monitoring is required for levothyroxine?

A

TSH - every 3 months until stable, then yearly

111
Q

Thyroid Disorders

When should levothyroxine be taken?

A

At least 30 minutes before food/ caffeinated drinks

112
Q

Thyroid Disorders

What is an MHRA warning for levothyroxine?

A

Small proportion of patients can feel symptoms if alternating between brands

113
Q

Thyroid Disorders

When should levothyroxine doses be questioned?

A

When higher than 200micrograms

114
Q

Thyroid Disorders

How does the dosing of liothyronine compare to levothyroxine?

A

2-25micrograms = 100micrograms of levothyroxine

115
Q

Corticosteroid Responsive Conditions

Which patients on corticosteroid treatment receive a PIL?

A

Those on systemic corticosteroids

116
Q

Corticosteroid Responsive Conditions

What counselling should patients on corticosteroids receive?

A
  • risk of infections
  • adrenal suppression
  • psychiatric reactions
  • withdrawal of corticosteroids
117
Q

Corticosteroid Responsive Conditions

What are the types of corticosteroid?

A

1: mineralocorticoid
2: glucocorticoid

118
Q

Corticosteroid Responsive Conditions

Which type of corticosteroid causes high fluid retention?

A

Mineralocorticoids

119
Q

Corticosteroid Responsive Conditions

Which type of corticosteroid causes a high anti-inflammatory effect?

A

Glucocorticoids

120
Q

Corticosteroid Responsive Conditions

Which drug has the highest mineralocorticoid steroid activity?

A

Fludrocortisone

121
Q

Corticosteroid Responsive Conditions

Which type of corticosteroid is hydrocortisone?

A

Mineralocorticoid

122
Q

Corticosteroid Responsive Conditions

What is fludrocortisone used to treat?

A

Postural hypotension

123
Q

Corticosteroid Responsive Conditions

When are glucocorticoids preferred?

A

When fluid retention is a disadvantage, e.g. heart failure

124
Q

Corticosteroid Responsive Conditions

Which drugs have the highest glucocorticoid activity?

A
  • dexamethasone
  • betamethasone
125
Q

Corticosteroid Responsive Conditions

What are some side effects of mineralocorticoids?

A
  • HTN - due to sodium + water retention
  • hypOkalaemia - due to potassium loss
  • hypOcalcaemia - due to calcium loss
126
Q

Corticosteroid Responsive Conditions

What are some side effects of glucocorticoids?

A
  • hyperglycaemia - can lead to diabetes
  • osteoporosis
  • avascular necrosis of the femoral head and muscle wasting
  • gastric ulceration and perforation, irritation and dyspepsia
127
Q

Corticosteroid Responsive Conditions

(1) Which type of corticosteroid requires addition of a PPI during treatment? (2) Why?

A

(1) Glucocorticoid

(2) Can cause gastric ulceration and perforation

128
Q

Corticosteroid Responsive Conditions

What is required in glucocorticoid treatment lasting longer than three months?

A

Prophylaxis of osteoporosis with bisphosphonates

129
Q

Corticosteroid Responsive Conditions

What are the MHRA warnings for corticosteroids?

A
  • central serous chorioretinopathy (degradation of retina)
  • psychiatric reactions
  • adrenal suppression
  • infections (due to immunosuppression)
  • insomnia
  • skin thinning
  • Cushing’s syndrome (in prolonged usage)
130
Q

Corticosteroid Responsive Conditions

What are some symptoms of adrenal suppression?

A
  • fatigue
  • anorexia
  • nausea + vomiting
  • hypOnatraemia
  • hypOglycaemia
  • hypOtension
  • hypErkalaemia
131
Q

Corticosteroid Responsive Conditions

(1) What effect can anaesthesia have on a patient taking corticosteroids? (2) How is this managed?

A

(1) Dangerous fall in BP

(2) Supply adrenal replacement with IV hydrocortisone

132
Q

Corticosteroid Responsive Conditions

Why do corticosteroids cause increased risk of infections?

A

They cause immunosuppression

133
Q

Corticosteroid Responsive Conditions

Why should corticosteroids be given in the morning?

A

That is when cortisol is produced

It reduce risk of insomnia

134
Q

Corticosteroid Responsive Conditions

How can risk of side effects of corticosteroids be minimised?

A
  • lowest effective dose for minimum period
  • given as a single dose in the morning
  • total dose for 2 days can be taken as a single dose on alternate days
  • intermittent therapy with short courses
  • local treatment, rather than systemic
135
Q

Corticosteroid Responsive Conditions

When is gradual withdrawal necessary for corticosteroids?

A
  • > 3 weeks of treatment
  • > 40mg daily (or equivalent) for >1 week
  • recently received repeated courses
  • repeat evening doses
  • taken a short course within 1 year of stopping long-term therapy
  • other possible causes of adrenal suppression
136
Q

Corticosteroid Responsive Conditions

What effect can corticosteroids have with prolonged/ repeated use in pregnancy?

A

Risk of intra-uterine growth restriction

137
Q

Corticosteroid Responsive Conditions

What should be monitored in corticosteroid treatment of pregnant women?

A

Monitor fluid retention

138
Q

Corticosteroid Responsive Conditions

Describe the potency of topical hydrocortisone.

A

Mild

139
Q

Corticosteroid Responsive Conditions

Describe the potency of topical clobetasone.

A

Moderate

140
Q

Corticosteroid Responsive Conditions

Describe the potency of topical betamethasone 0.025%.

A

Moderate

141
Q

Corticosteroid Responsive Conditions

Describe the potency of topical betamethasone 0.1%.

A

Potent

142
Q

Corticosteroid Responsive Conditions

Describe the potency of topical mometasone.

A

Potent

143
Q

Corticosteroid Responsive Conditions

Describe the potency of topical clobetasol.

A

Very potent

144
Q

Corticosteroid Responsive Conditions

Why should topical corticosteroids be applied thinly?

A

To prevent skin thinning

145
Q

Corticosteroid Responsive Conditions

Why should topical corticosteroids not be applied to broken skin?

A

Increased risk of infection

146
Q

Corticosteroid Responsive Conditions

What are the potential causes of adrenal insufficiency?

A
  • Addison’s disease
  • congenital adrenal hyperplasia
147
Q

Corticosteroid Responsive Conditions

What is the treatment for adrenal insufficiency?

A

Hydrocortisone

Can be treated with fludrocortisone as well

148
Q

Corticosteroid Responsive Conditions

What can adrenal insufficiency lead to?

A

Adrenal crisis

149
Q

Corticosteroid Responsive Conditions

What are some symptoms of adrenal crisis?

A
  • severe dehydration
  • hypovolaemic shock
  • altered consciousness
  • seizures
  • stroke
  • cardiac arrest
  • death (if left untreated)
150
Q

Corticosteroid Responsive Conditions

What is the treatment of adrenal crisis?

A

Medical EMERGENCY- treat rapidly with hydrocortisone

151
Q

Corticosteroid Responsive Conditions

What is the treatment for low cortisol and low aldosterone?

A

Hydrocortisone and fludrocortisone

152
Q

Corticosteroid Responsive Conditions

What is the treatment for hypopituitarism?

A

Replacement hydrocortisone

153
Q

Corticosteroid Responsive Conditions

What is Cushing’s syndrome characterised by?

A

Hypercortisolism

154
Q

Corticosteroid Responsive Conditions

What are some symptoms of Cushing’s syndrome?

A
  • skin thinning
  • easy bruising
  • reddish-purple stretch marks
  • striae
  • fat deposits in the face
  • moon face
  • acne
  • amenorrhoea (absence of periods)
  • hirsutism (excessive growth of dark/ coarse hair)
155
Q

Corticosteroid Responsive Conditions

(1) What are some causes of Cushing’s syndrome? (2) How can they be resolved?

A
  • corticosteroids: reduce dose/ withdraw
  • tumour: surgery/ cortisol-inhibiting drugs
156
Q

Corticosteroid Responsive Conditions

What is the treatment for Cushing’s syndrome?

A

Ketoconazole

157
Q

Corticosteroid Responsive Conditions

What is the required patient counselling for treatment of Cushing’s syndrome with ketoconazole?

A
  • report signs of liver toxicity
  • anorexia
  • abdo pain
  • dark urine
  • jaundice
  • itching
  • pale stools
  • N+V
158
Q

Corticosteroid Responsive Conditions

What effects can adrenal suppression have on electrolytes?

A
  • hypOnatraemia
  • hypOglycaemia
  • hypERkalaemia
159
Q

Corticosteroid Responsive Conditions

What is the dosing of prednisolone for an asthma exacerbation?

A

40mg for at least 5 days

160
Q

Corticosteroid Responsive Conditions

What is the dosing of prednisolone for treatment of COPD exacerbation?

A

30mg for 7-14 days

161
Q

Diabetes in Pregnancy and Breastfeeding

Describe the insulin requirements for diabetes in pregnancy?

A

Insulin requirements increase in 2nd and 3rd trimester

162
Q

Diabetes in Pregnancy and Breastfeeding

(1) Why should folic acid be taken during pregnancy? (2) At what dose?

A

(1) Reduce risk of neural tube defects

(2) 5mg OD

163
Q

Diabetes in Pregnancy and Breastfeeding

Which oral antidiabetics should be stopped for treatment of diabetes during pregnancy?

A

All except metformin should be stopped and changed to insulin

164
Q

Diabetes in Pregnancy and Breastfeeding

Which oral antidiabetics should be avoided during breastfeeding?

A

All except metformin

165
Q

Diabetes in Pregnancy and Breastfeeding

Which type of insulin is first choice for a long-acting insulin during pregnancy?

A

Insulin isophane

166
Q

Diabetes in Pregnancy and Breastfeeding

(1) Which patients are at increased risk of hypOglycaemia during the postnatal period? (2) How should this risk be reduced?

A

(1) Women with pre-existing diabetes

(2) Reduce their insulin immediately after birth

167
Q

Diabetes in Pregnancy and Breastfeeding

(1) What should women taking insulin during pregnancy always carry with them? (2) Why? (3) How does this differ if the patient is a type 1 diabetic?

A

(1) Dextrose tablets/ glucose-containing drink

(2) HypOglycaemia risk

(3) Carry a glucagon injection

168
Q

Diabetes in Pregnancy and Breastfeeding

What should be done if a pregnant diabetic patient is taking statins?

A

Discontinue during pregnancy

169
Q

Diabetes in Pregnancy and Breastfeeding

What should be done if a pregnant diabetic patient is taking ACEis/ ARBs?

A

Discontinue

Replace with alternative antihypertensives suitable for use in pregnancy

170
Q

Diabetes in Pregnancy and Breastfeeding

When should treatment for gestational diabetes be stopped?

A

Immediately after birth

171
Q

Diabetes in Pregnancy and Breastfeeding

What is the management for a patient with gestational diabetes with blood glucose of <7mmol/L?

A

Diet and exercise
- metformin if requirement not met within 2 weeks
- insulin if metformin contraindicated or not effective

172
Q

Diabetes in Pregnancy and Breastfeeding

What is the management for a patient with gestational diabetes with blood glucose of >7mmol/L?

A

Diet and exercise

AND

insulin immediately +/- metformin

173
Q

Diabetes in Pregnancy and Breastfeeding

What is the management for a patient with gestational diabetes with blood glucose of 6-6.9mmol/L with complications?

A

Insulin immediately +/- metformin

174
Q

Diabetes & Driving

Which diabetic patients should notify the DVLA?

A

Those on insulin

175
Q

Diabetes & Driving

What are the hypo requirements to be a Group 1 driver?

A

No more than 1 episode of severe hypoglycaemia while awake in the previous 12 months

176
Q

Diabetes & Driving

What are the hypo requirements to be a Group 2 driver?

A

Must report ALL episodes of severe hypoglycaemia (including sleep)

No episodes of severe hypoglycaemia in the preceding 12 months

177
Q

Diabetes & Driving

What is the advice from the DVLA for diabetic drivers?

A
  • drivers on insulin should always carry a glucose meter and blood glucose test strips
  • check CBGs every 2 hours
  • CBGs should always be above 5 while driving
  • if CBGs <5, have a snack
  • if CBGs <4, stop driving
178
Q

Diabetes & Driving

What CBG range is considered as hypoglycaemic when driving?

A

<4mmol/L

179
Q

Diabetes

How frequently should HbA1c be monitored in diabetes?

A

Every 3-6 months

180
Q

Diabetes

What are some of the typical features of type 1 diabetes?

A
  • hyperglycaemia
  • ketosis
  • rapid weight loss
  • BMI <25
  • age <50
  • FHx of autoimmune disease
181
Q

Diabetes & Driving

How often should CBGs be monitored in type 1 diabetic patients?

A

Four times a day

(Before each meal and before bed)

182
Q

Diabetes & Driving

For type 1 diabetes, what is the blood glucose target on waking?

A

5-7mmol/L

183
Q

Diabetes & Driving

For type 1 diabetes, what is the blood glucose target when fasted during the day?

A

4-7mmol/L

184
Q

Diabetes & Driving

For type 1 diabetes, what is the blood glucose target 90mins after eating?

A

5-9mmol/L

185
Q

Diabetes & Driving

For type 1 diabetes, what is the blood glucose target while driving?

A

> 5mmol/L

186
Q

Diabetes

What regimen should all insulin patients be on?

A

1) Basal bonus - (long-acting AND multiple doses of short-acting)

2) Mixed biphasic regimen - (short-acting mixed with intermediate-acting)

3) Insulin pump - (initiated by specialist team only)

187
Q

Diabetes

What is the first line generic basal insulin?

A

Insulin detemir BD

188
Q

Diabetes

What is the second line generic basal insulin?

A

Insulin glargine OD

189
Q

Diabetes

What is an alternative generic basal insulin if first and second line are not suitable?

A

Insulin degludec OD

190
Q

Diabetes

What are some factors that increase insulin requirements?

A
  • infection
  • stress
  • trauma
191
Q

Diabetes

What are some factors that decrease insulin requirements?

A
  • physical activity
  • reduced food intake
  • impaired renal/ hepatic function
  • certain endocrine disorders (thyroid, coeliac, Addison’s)
192
Q

Diabetes

Which injection site for insulin has the fastest absorption rate?

A

Abdomen

193
Q

Diabetes

Why must injection site of insulins be rotated?

A

Lipohypertrophy can occur

Leads to erratic absorption of insulin

194
Q

Diabetes

What is some important safety information for insulins?

A
  • risk of severe harm and death due to withdrawing insulin from pen devices
  • overdose of insulin due to abbreviations or incorrect device
  • risk of cutaneous amyloidosis at injection site
195
Q

Diabetes

Name the rapid-acting insulins (generic).

A
  • lispro
  • aspartame
  • glulisine
196
Q

Diabetes

Name the intermediate-acting insulins (generic).

A
  • bisphasic isophane
  • biphasic aspart/ lispro
197
Q

Diabetes

Name the long-acting insulins (generic).

A
  • detemir
  • degludec
  • glargine
198
Q

Diabetes

Which long-acting insulin requires a BD regime?

A

Detemir

199
Q

Diabetes

Which antidiabetics cause weight LOSS?

A
  • GLP-1 analogues
  • SGLT2i
200
Q

Diabetes

Which antidiabetics cause weight gain?

A
  • sulfonylureas
  • pioglitazone
  • insulin
201
Q

Diabetes

Which antidiabetics have no effect on weight?

A
  • DPP4i
  • metformin
202
Q

Diabetes

What is the first line diabetes treatment in patients with low CVD risk?

A

Metformin

203
Q

Diabetes

What is the second line diabetes treatment in patients with low CVD risk?

A

DPP4i, pioglitazone, sulfonylurea or SGLT2i

204
Q

Diabetes

What is the third line diabetes treatment in patients with low CVD risk?

A

Triple therapy

205
Q

Diabetes

What is the first line diabetes treatment in patients with high CVD risk?

A

Metformin

Consider addition of SGLTi as soon as diabetes is controlled

206
Q

Diabetes

What is the second line diabetes treatment in patients with high CVD risk?

A

DPP4i, pioglitazone, sulfonylurea or SGLT2i

207
Q

Antidiabetics

Name a biguanide.

A

Metformin

208
Q

Antidiabetics

Describe the MoA of biguanides.

A

Decrease gluconeogenesis

Increase peripheral utilisation of glucose

209
Q

Antidiabetics

What are some side effects of metformin?

A
  • lactic acidosis
  • GI side effects
  • can reduce vitamin b12
210
Q

Antidiabetics

What are some side effects of sulfonylureas?

A
  • high risk of hypoglycaemia
  • weight gain
211
Q

Antidiabetics

Can sulfonylureas be used in hepatic or renal failure?

A

No. Avoid.

212
Q

Antidiabetics

Describe the MoA of pioglitazone.

A

Reduces peripheral resistance to insulin

213
Q

Antidiabetics

What are some cautions for pioglitazone?

A
  • increased risk of bladder cancer
  • avoid in Hx of HF
  • increased risk of bone fractures
  • increased risk of liver toxicity
214
Q

Antidiabetics

Name a side effect of DPP4i.

A

Pancreatitis

215
Q

Antidiabetics

What are the MHRA warnings for SGLT2is?

A
  • life-threatening and fatal cases of DKA
  • Fournier’s gangrene
  • lower limb amputation - canagliflozin ONLY
  • increased risk of UTIs
216
Q

Antidiabetics

What are some MHRA warnings for GLP1 analogues?

A
  • risk of DKA when given with insulin
  • acute pancreatitis
  • dehydration due to GI side effects
217
Q

Antidiabetics

How often are eye tests required for diabetic patients, to monitor for retinopathy?

A

Yearly

218
Q

Antidiabetics

(1) What antihypertensive can have an effect on glycaemic control from antidiabetic drugs/ insulin? (2) What is this effect?

A

(1) ACEi

(2) Potentiates hypoglycaemic effects

219
Q

Diabetes

In which type of diabetes is DKA more common?

A

Type 1

220
Q

Diabetes

Name some risk factors for DKA.

A
  • discontinuation/ inadequate insulin therapy
  • acute illness, e.g. MI/ pancreatitis
  • new onset diabetes
  • stress (trauma/ diabetes)
221
Q

Diabetes

How is DKA diagnosed?

A

1) hyperglycaemia: >11mmol/L
2) plasma ketones >3mmol/L
3) acidosis

222
Q

Diabetes

What are some symptoms of DKA?

A
  • polyurea
  • polydipsia
  • weight loss
  • nausea/ vomiting
  • pear drop breath
  • kussmaul respiration (deep/ fast breathing)
  • excessive tiredness
  • confusion
223
Q

Diabetes

What is HHS?

A

Hyperosmolar hyperglycaemic state

224
Q

Diabetes

How is HHS diagnosed?

A

Marked hyperglycaemia (>30mmol/L)

Hypovolaemia

225
Q

Diabetes

What are symptoms of HHS?

A
  • dehydration
  • weakness
  • weight loss
  • tachycardia
  • dry mucous membranes
  • poor skin turgor
  • hypotension
  • acute cognitive impairment
  • shock (in severe cases only)
226
Q

Diabetes

What dose adjustments are required for insulin for elective surgery for minor procedures?

A

Day before: Reduce OD long-acting dose by 20%

227
Q

Diabetes

What dose adjustments are required for insulin for elective surgery for major procedures?

A

Day before: Reduce OD long-acting dose by 20%

On day:
- reduce OD long-acting dose by 20%
- IV infusion of KCl, glucose, and NaCl

228
Q

Diabetes

What are the insulin changes following surgery?

A

Convert back to SC when patient is eating/ drinking without vomiting

  • Basal bonus regimen: restarted with first meal
  • Long-acting regimen: continues at 20% dose reduction until patient leaves hospital
  • BD regimen: restart at breakfast or evening meal
229
Q

Diabetes

How should patients’ understanding of hypoglycaemia be tested?

A

Gold score or Clarke score

230
Q

Diabetes

What blood glucose range is considered to be hypoglycaemic?

A

<4mmol/L

231
Q

Diabetes

What are some symptoms of hypoglycaemia?

A
  • sweating
  • dizziness
  • lethargy
  • hunger
  • tremor
  • tingling lips
  • palpitations
  • extreme moods
  • pale
232
Q

Diabetes

(1) What effect can beta blockers have on glycaemic control observation? (2) How?

A

(1) Can mask signs of hypoglycaemia

(2) Preventing warning signs such as tremors

233
Q

Diabetes

(1) Which snacks should be avoided for correction of hypoglycaemia? (2) Why?

A

(1) Chocolate and biscuits

(2) Likely to have low sugar content and high fat content - can delay gastric emptying

Pre-Reg (Trainee) Pharmacy (31 decks)

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