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
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
3
Q
What HbA1c levels are indicative of diabetes?
A
> 47mmol/L
4
Q
What HbA1c levels are indicative of pre-diabetes?
A
42-47mmol/L
5
Q
What HbA1c levels are indicative of NO diabetes present?
A
<42mmol/L
6
Q
Which disease causes hypERthyroidism?
A
Graves disease
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
8
Q
What causes the thickening of skin and bulging eyes in Graves disease?
A
Thyroid Stimulating Immunoglobulin
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.
10
Q
Which pharmacological treatment of Graves disease is preferred in pregnancy?
A
Titration
As ‘Block & Replace’ requires very high levels of antithyroid drugs
11
Q
What are the antithyroid drugs used in pharmacological management of Graves disease?
A
- Carbimazole
- Propylthiouracil
- Propranolol (provides relief of adrenergic symptoms)
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
13
Q
What is the normal duration of carbimazole treatment?
A
12-18 months
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
15
Q
What is an MHRA warning for carbimazole?
A
- Risk of acute pancreatitis
- Increased risk of congenital malformations, strengthened advice on contraception
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
17
Q
What is the usual dosing of propranolol in thyrotoxicosis?
A
10-40mg TDS or QDS
18
Q
What are some cautions for beta-blockers?
A
- Asthma
- Diabetic patients (can mask symptoms of hypoglycaemia)
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
20
Q
What is a drug that can commonly induce hypERthyroidism?
A
Amiodarone
- iodine rich, can cause thyroid dysfunction
Can also causes hypOthyroidism
21
Q
What is a drug that can commonly induce hypOthyroidism?
A
Amiodarone
- iodine rich, can cause thyroid dysfunction
Can also causes hypERthyroidism
22
Q
What is hypOthyroidism?
A
Impaired production of T3 and T3
23
Q
What are some symptoms of hypOthyroidism?
A
- Cold intolerance
- Tiredness
- Constipation
- Depression
- Wt gain
24
Q
What are some symptoms of primary hypOthyroidism?
A
- Iodine deficiency
- Hashimoto’s
- Physical damage
- Drug induced
- Transient
25
What are some symptoms of secondary hypOthyroidism?
- Pituitary/ hypothalamic disorder
- Tumours
- Surgery
26
What is Hashimoto's disease?
Autoimmune disease
Thyroid follicular cells gradually destroyed by lymphocytes
Goitre can form due to thyroid enlargement
27
What is primary hypOthyroidism?
Thyroid gland unable to produce hormones
28
What is secondary hypOthyroidism?
Result of insufficient production of bioactive TSH
29
What is an MHRA warning for levothyroxine?
Patients can react very differently to different brands of levothyroxine
If a patient says they can only take ONE brand, only give that brand
30
What are some monitoring requirements for levothyroxine?
Measure TSH every 3 months until stabilised
31
What are some side-effects of levothyroxine?
SYMPTOMS OF HYPERTHYROIDISM:
- Diarrhoea
- Nervousness
- Rapid pulse
- Insomnia
- Tremors
- Anginal pain (if latent myocardial ischaemia)
32
How should side-effects of levothyroxine be managed?
(1) Reduce dose
(2) Withhold for 1-2 days + restart at lower dose
33
What is the HPA-axis?
Hypothalamic Pituitary Adrenal Axis
Central stress response system
34
What are some short term stress responses of the sympatho-adrenomedulary system?
- 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)
35
Where is ACTH released?
Anterior pituitary
36
What stimulates the production of ACTH?
CRH
37
Where are glucocorticoids produced?
Adrenal cortex (stimulated by ACTH)
38
What is Addisons disease?
Form of adrenal insufficiency
39
What are some long term stress responses of the HPA-axis?
- 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
40
How is Addisons disease managed?
Treatment initiated and monitored by a specialist endocrinologist
- Glucocorticoid: Hydrocortisone (can also use prednisolone/ dexamethasone)
- Mineralocorticoid: Fludrocortisone (50-300micrograms daily)
41
What are the sick day rules for Addisons disease?
- 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:
ø Adrenal crisis
ø Addisons emergency
ø Steroid-dependent patient
- Serious injury: 20mg hydrocortisone (to avoid shock)
42
What should be done for an Addisons patient experiencing diarrhoea/ vomiting OR a serious illness?
(1) Use emergency hydrocortisone 100mg injection immediately
(2) Call doctor
(3) Say: 'adrenal crisis' OR 'Addisons emergency' OR 'steroid-dependent patient'
43
What is Cushing's disease?
Increased secretion of ACTH from pituitary gland
Leads to too much cortisol
44
What most commonly causes Cushing's disease?
Pituitary adenoma (~80%)
45
What are some common signs and symptoms of Cushing's disease?
- 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)
46
How is Addisons disease diagnosed?
Short Synthacten Test
47
How is Cushing's disease diagnosed?
DEXAMETHASONE SUPPRESSION TEST:
(1) Overnight test
(2) Two-day, low-dose test
(3) Two-day, high-dose dexamethasone suppression test
48
What are the main treatment options for Cushing's disease?
(1) Endoscopic surgical resection
(2) Pituitary radiation therapy
(3) Bilateral adrenalectomy
49
What are some pharmacological management options for Cushing's disease?
(1) Mifepristone
(2) Ketoconazole
(3) Mitotane
50
What are the parathyroid glands?
Produces parathyroid hormone (PTH)
Four of these glands on the posterior of the thyroid
51
What does parathyroid hormone (PTH) do?
Helps to maintain calcium homeostasis
52
What is hyperparathyroidism?
Autonomous overproduction of parathyroid hormone
Results in hypercalcaemia (pulling calcium out of the bones + into the blood)
53
What are some signs and symptoms of hyperparathyroidism?
- 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
54
When is management of hyperparathyroidism required?
- Thirst
- Excessive urination
- Constipation
- Osteoporosis/ fragility fracture
- Renal stones
55
What is the pharmacological management of hyperparathyroidism?
(1) Bisphosphonates - reduce fracture risk
(2) Cinacalcet - reduce blood plasma levels of Ca2+
56
Why does hypercalcaemia need to be managed effectively?
Can cause coma + increased mortality
57
What is secreted by the adrenal glands?
(1) Mineralocorticoids
(2) Glucocorticoids
(3) Androgens
(4) Stress hormones (adrenaline/ noradrenaline)
58
What does ACTH do?
Stimulates the adrenal cortex
58
What does ACTH do?
Stimulates the adrenal cortex
59
What is the adrenal medulla responsible for?
Short-term stress response
60
What is the adrenal cortex responsible for?
Long-term stress response
61
Which type of endocrine patients should carry a steroid alert card, as per NPSA alerts?
Addisons disease
To support early identification & treatment of adrenal crisis
62
***Endocrine System***
What is diabetes insipidus?
Too little ADH
Excess thirst and excess dilute urine
63
***Endocrine System***
(1) What are the types of diabetes insipidus? (2) What are their treatments?
(1)
- Cranial - pituitary
- Nephrogenic - partial
(2)
Pituitary - vasopressin/ desmopressin
Nephrogenic - thiazide diuretic
64
***Endocrine System***
What are some benefits of desmopressin over vasopressin?
- more potent and longer duration
- no vasoconstrictor effect
65
***Endocrine System***
What are some side effects of desmopressin?
- Hyponatraemia - if given too rapidly - can increase risk of convulsions
- Nausea
66
***Endocrine System***
What is SIADH?
Syndrome of inappropriate antidiuretic hormone secretion
Leads to hyponatraemia, due to reduced urination diluting salt concentration in the blood
67
***Endocrine System***
What is the treatment of SIADH?
(1) Fluid restriction
(2) Demeclocycline - blocks renal tubular effect of ADH
(3) Tolvaptan - vasopressin antagonist
68
***Endocrine System***
Why should rapid correction of hyponatraemia with tolvaptan be avoided?
Causes osmotic demyelination - serious neurological events
69
***Endocrine System***
What are some risk factors for osteoporosis?
- 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
70
***Endocrine System***
What are some lifestyle changes for management of osteoporosis?
- increase exercise
- smoking cessation
- maintaining an ideal BMI
- reduce alcohol intake
- increase intake of vit D and calcium (can use supplements)
71
***Endocrine System***
What HRT can be used peri-menopause?
Oestrogen
72
***Endocrine System***
What HRT can be used post-menopause?
Tibolone/ oestrogen
73
***Endocrine System***
What is the first line treatment for osteoporosis?
Oral bisphosphonates (alendronic/ risedronate)
74
***Endocrine System***
What alternative therapies are available for postmenopausal osteoporosis?
- ibandronic acid - 150mg once a month
- denosumab
- raloxifene
75
***Endocrine System***
What can be used for severe osteoporosis in post-menopausal patients?
- Teriparatide - total of 2yrs
- romosozumab
76
***Endocrine System***
What is the recommendation if a patient experiences one severe or two moderate-low trauma vertebral fractures, for osteoporosis?
Teriparatide/ romosozumab recommended over oral bisphosphonates
77
***Endocrine System***
What are some alternative therapies for osteoporosis in men?
Zoledronic acid/ denosumab/ teriparatide
78
***Endocrine System***
What is the treatment for glucocorticoid-induced osteoporosis?
- zoledronic acid
- denosumab
- teriparatide
79
***Endocrine System***
When is a treatment review for osteoporosis required?
5yrs
3yrs for zoledronic acid
80
***Endocrine System***
When should prophylaxis of osteoporosis at glucocorticoid treatment onset be started?
(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
81
***Endocrine System***
What are some MHRA warnings for bisphosphonates?
(1) Atypical femoral fracture
(2) ONJ - osteonecrosis of the jaw
(3) Osteonecrosis of the external auditory canal
82
***Endocrine System***
What are some side effects of bisphosphonates?
- oesophageal reactions
83
***Endocrine System***
What is the administration advice for alendronic acid?
Take 30 minutes before breakfast/ other oral medications
Take with a full glass of water while standing
Remain upright for 30 minutes after
84
***Endocrine System***
How does the administration advice for risedronate sodium differ to that of alendronic acid?
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
85
***Endocrine System***
What is Strontium?
Bone formation stimulant and reduces bone resorption
86
***Endocrine System***
What are some side effects of Strontium?
- serious cardiovascular diseases (inc. MI, VTE)
- severe allergic reaction - DRESS: drug rash with eosinophilia and systemic symptoms
87
***Sex Hormone Responsive Conditions***
What are some natural oestrogens?
- estradiol
- estrone
- estriol
88
***Sex Hormone Responsive Conditions***
What are some examples of progesterones?
- norethisterone
- levonorgestrel
- desogestrel
89
***Sex Hormone Responsive Conditions***
What are some examples of synthetic oestrogens?
- ethinylestradiol
- mestranol
90
***Sex Hormone Responsive Conditions***
What are some examples of tibolones?
- estrogenic
- progestogenic
- weakly androgenic
91
***Sex Hormone Responsive Conditions***
What menopausal symptoms can estrogens alleviate?
- vaginal atrophy (vaginal dryness)
- vasomotor instability (hot flushes, night sweats)
- postmenopausal osteoporosis
92
***Sex Hormone Responsive Conditions***
What are the differences in HRT between women with a uterus and those without?
1) Without:
- continuous oestrogen use
- consider addition of progesterone IF endometriosis occurs
2) With:
- oestrogen with cyclical progestogen
93
***Sex Hormone Responsive Conditions***
What are the risks of HRT?
1) Breast cancer
2) Endometrial cancer
3) Ovarian cancer
4) VTE
5) Stroke
6) Coronary heart disease
94
***Sex Hormone Responsive Conditions***
What are some reasons to stop HRT?
- 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
***Sex Hormone Responsive Conditions***
What should be done for HRT for an elective surgery?
Stop 4-6 weeks before surgery
Re-initiate when FULLY mobile
96
***Sex Hormone Responsive Conditions***
What should be done for a patient taking HRT during a non-elective surgery?
Prophylactic heparin
Graduated compression stockings
97
***Sex Hormone Responsive Conditions***
What are some contraindications for HRT?
- 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
***Sex Hormone Responsive Conditions***
Name an anti-oestrogen.
Clomifene
99
***Sex Hormone Responsive Conditions***
What is the main side effect of clomifene?
Multiple pregnancies
100
***Thyroid Disorders***
What do thyroid hormones regulate?
- metabolic rate
- heart rate
- digestive function
- muscle control
- brain development
101
***Thyroid Disorders***
What are the signs and symptoms of hypERthyroidism?
INCREASED METABOLISM AND ACTIVITY
- hyperactivity/ excitability
- tachycardia/ arrhythmias
- insomnia
- heat intolerance
- increased appetite
- weight loss
- diarrhoea
- goitre
- tremors
- angina pain
102
***Thyroid Disorders***
What is the treatment for hypERthyroidism?
Carbimazole
OR
Propylthiouracil
103
***Thyroid Disorders***
What are some MHRA warnings for carbimazole?
- acute pancreatitis
- congenital malformations
- bone marrow suppression (neutropenia & agranulocytosis)
104
***Thyroid Disorders***
What drug can be given in hypERthyroidism for symptomatic relief?
Propranolol
105
***Thyroid Disorders***
What is the treatment for Graves’ disease?
Radioactive iodine
Can consider carbimazole if remission is likely
106
***Thyroid Disorders***
What is the treatment for hypERthyroidism in pregnancy?
1st trimester: Propylthiouracil
2nd & 3rd trimesters: Carbimazole
107
***Thyroid Disorders***
What are the signs and symptoms of thyrotoxicosis?
- HR >140 (tachycardia)
- heat intolerance
- diarrhoea/ N&V
- seizures/ delirium/ confusion/ psychosis
108
***Thyroid Disorders***
What are the signs and symptoms of hypOthyroidism?
DECREASED METABOLISM AND ACTIVITY
- fatigue
- weight gain
- constipation
- depression
- dry skin
- intolerance to cold
- menstrual irregularities
109
***Thyroid Disorders***
What is the treatment for hypOthyroidism?
Levothyroxine
110
***Thyroid Disorders***
What monitoring is required for levothyroxine?
TSH - every 3 months until stable, then yearly
111
***Thyroid Disorders***
When should levothyroxine be taken?
At least 30 minutes before food/ caffeinated drinks
112
***Thyroid Disorders***
What is an MHRA warning for levothyroxine?
Small proportion of patients can feel symptoms if alternating between brands
113
***Thyroid Disorders***
When should levothyroxine doses be questioned?
When higher than 200micrograms
114
***Thyroid Disorders***
How does the dosing of liothyronine compare to levothyroxine?
2-25micrograms = 100micrograms of levothyroxine
115
***Corticosteroid Responsive Conditions***
Which patients on corticosteroid treatment receive a PIL?
Those on systemic corticosteroids
116
***Corticosteroid Responsive Conditions***
What counselling should patients on corticosteroids receive?
- risk of infections
- adrenal suppression
- psychiatric reactions
- withdrawal of corticosteroids
117
***Corticosteroid Responsive Conditions***
What are the types of corticosteroid?
1: mineralocorticoid
2: glucocorticoid
118
***Corticosteroid Responsive Conditions***
Which type of corticosteroid causes high fluid retention?
Mineralocorticoids
119
***Corticosteroid Responsive Conditions***
Which type of corticosteroid causes a high anti-inflammatory effect?
Glucocorticoids
120
***Corticosteroid Responsive Conditions***
Which drug has the highest mineralocorticoid steroid activity?
Fludrocortisone
121
***Corticosteroid Responsive Conditions***
Which type of corticosteroid is hydrocortisone?
Mineralocorticoid
122
***Corticosteroid Responsive Conditions***
What is fludrocortisone used to treat?
Postural hypotension
123
***Corticosteroid Responsive Conditions***
When are glucocorticoids preferred?
When fluid retention is a disadvantage, e.g. heart failure
124
***Corticosteroid Responsive Conditions***
Which drugs have the highest glucocorticoid activity?
- dexamethasone
- betamethasone
125
***Corticosteroid Responsive Conditions***
What are some side effects of mineralocorticoids?
- HTN - due to sodium + water retention
- hypOkalaemia - due to potassium loss
- hypOcalcaemia - due to calcium loss
126
***Corticosteroid Responsive Conditions***
What are some side effects of glucocorticoids?
- hyperglycaemia - can lead to diabetes
- osteoporosis
- avascular necrosis of the femoral head and muscle wasting
- gastric ulceration and perforation, irritation and dyspepsia
127
***Corticosteroid Responsive Conditions***
(1) Which type of corticosteroid requires addition of a PPI during treatment? (2) Why?
(1) Glucocorticoid
(2) Can cause gastric ulceration and perforation
128
***Corticosteroid Responsive Conditions***
What is required in glucocorticoid treatment lasting longer than three months?
Prophylaxis of osteoporosis with bisphosphonates
129
***Corticosteroid Responsive Conditions***
What are the MHRA warnings for corticosteroids?
- central serous chorioretinopathy (degradation of retina)
- psychiatric reactions
- adrenal suppression
- infections (due to immunosuppression)
- insomnia
- skin thinning
- Cushing’s syndrome (in prolonged usage)
130
***Corticosteroid Responsive Conditions***
What are some symptoms of adrenal suppression?
- fatigue
- anorexia
- nausea + vomiting
- hypOnatraemia
- hypOglycaemia
- hypOtension
- hypErkalaemia
131
***Corticosteroid Responsive Conditions***
(1) What effect can anaesthesia have on a patient taking corticosteroids? (2) How is this managed?
(1) Dangerous fall in BP
(2) Supply adrenal replacement with IV hydrocortisone
132
***Corticosteroid Responsive Conditions***
Why do corticosteroids cause increased risk of infections?
They cause immunosuppression
133
***Corticosteroid Responsive Conditions***
Why should corticosteroids be given in the morning?
That is when cortisol is produced
It reduce risk of insomnia
134
***Corticosteroid Responsive Conditions***
How can risk of side effects of corticosteroids be minimised?
- 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
***Corticosteroid Responsive Conditions***
When is gradual withdrawal necessary for corticosteroids?
- >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
***Corticosteroid Responsive Conditions***
What effect can corticosteroids have with prolonged/ repeated use in pregnancy?
Risk of intra-uterine growth restriction
137
***Corticosteroid Responsive Conditions***
What should be monitored in corticosteroid treatment of pregnant women?
Monitor fluid retention
138
***Corticosteroid Responsive Conditions***
Describe the potency of topical hydrocortisone.
Mild
139
***Corticosteroid Responsive Conditions***
Describe the potency of topical clobetasone.
Moderate
140
***Corticosteroid Responsive Conditions***
Describe the potency of topical betamethasone 0.025%.
Moderate
141
***Corticosteroid Responsive Conditions***
Describe the potency of topical betamethasone 0.1%.
Potent
142
***Corticosteroid Responsive Conditions***
Describe the potency of topical mometasone.
Potent
143
***Corticosteroid Responsive Conditions***
Describe the potency of topical clobetasol.
Very potent
144
***Corticosteroid Responsive Conditions***
Why should topical corticosteroids be applied thinly?
To prevent skin thinning
145
***Corticosteroid Responsive Conditions***
Why should topical corticosteroids not be applied to broken skin?
Increased risk of infection
146
***Corticosteroid Responsive Conditions***
What are the potential causes of adrenal insufficiency?
- Addison’s disease
- congenital adrenal hyperplasia
147
***Corticosteroid Responsive Conditions***
What is the treatment for adrenal insufficiency?
Hydrocortisone
Can be treated with fludrocortisone as well
148
***Corticosteroid Responsive Conditions***
What can adrenal insufficiency lead to?
Adrenal crisis
149
***Corticosteroid Responsive Conditions***
What are some symptoms of adrenal crisis?
- severe dehydration
- hypovolaemic shock
- altered consciousness
- seizures
- stroke
- cardiac arrest
- death (if left untreated)
150
***Corticosteroid Responsive Conditions***
What is the treatment of adrenal crisis?
Medical EMERGENCY- treat rapidly with hydrocortisone
151
***Corticosteroid Responsive Conditions***
What is the treatment for low cortisol and low aldosterone?
Hydrocortisone and fludrocortisone
152
***Corticosteroid Responsive Conditions***
What is the treatment for hypopituitarism?
Replacement hydrocortisone
153
***Corticosteroid Responsive Conditions***
What is Cushing’s syndrome characterised by?
Hypercortisolism
154
***Corticosteroid Responsive Conditions***
What are some symptoms of Cushing’s syndrome?
- 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
***Corticosteroid Responsive Conditions***
(1) What are some causes of Cushing’s syndrome? (2) How can they be resolved?
- corticosteroids: reduce dose/ withdraw
- tumour: surgery/ cortisol-inhibiting drugs
156
***Corticosteroid Responsive Conditions***
What is the treatment for Cushing’s syndrome?
Ketoconazole
157
***Corticosteroid Responsive Conditions***
What is the required patient counselling for treatment of Cushing’s syndrome with ketoconazole?
- report signs of liver toxicity
- anorexia
- abdo pain
- dark urine
- jaundice
- itching
- pale stools
- N+V
158
***Corticosteroid Responsive Conditions***
What effects can adrenal suppression have on electrolytes?
- hypOnatraemia
- hypOglycaemia
- hypERkalaemia
159
***Corticosteroid Responsive Conditions***
What is the dosing of prednisolone for an asthma exacerbation?
40mg for at least 5 days
160
***Corticosteroid Responsive Conditions***
What is the dosing of prednisolone for treatment of COPD exacerbation?
30mg for 7-14 days
161
***Diabetes in Pregnancy and Breastfeeding***
Describe the insulin requirements for diabetes in pregnancy?
Insulin requirements increase in 2nd and 3rd trimester
162
***Diabetes in Pregnancy and Breastfeeding***
(1) Why should folic acid be taken during pregnancy? (2) At what dose?
(1) Reduce risk of neural tube defects
(2) 5mg OD
163
***Diabetes in Pregnancy and Breastfeeding***
Which oral antidiabetics should be stopped for treatment of diabetes during pregnancy?
All except metformin should be stopped and changed to insulin
164
***Diabetes in Pregnancy and Breastfeeding***
Which oral antidiabetics should be avoided during breastfeeding?
All except metformin
165
***Diabetes in Pregnancy and Breastfeeding***
Which type of insulin is first choice for a long-acting insulin during pregnancy?
Insulin isophane
166
***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?
(1) Women with pre-existing diabetes
(2) Reduce their insulin immediately after birth
167
***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?
(1) Dextrose tablets/ glucose-containing drink
(2) HypOglycaemia risk
(3) Carry a glucagon injection
168
***Diabetes in Pregnancy and Breastfeeding***
What should be done if a pregnant diabetic patient is taking statins?
Discontinue during pregnancy
169
***Diabetes in Pregnancy and Breastfeeding***
What should be done if a pregnant diabetic patient is taking ACEis/ ARBs?
Discontinue
Replace with alternative antihypertensives suitable for use in pregnancy
170
***Diabetes in Pregnancy and Breastfeeding***
When should treatment for gestational diabetes be stopped?
Immediately after birth
171
***Diabetes in Pregnancy and Breastfeeding***
What is the management for a patient with gestational diabetes with blood glucose of <7mmol/L?
Diet and exercise
- metformin if requirement not met within 2 weeks
- insulin if metformin contraindicated or not effective
172
***Diabetes in Pregnancy and Breastfeeding***
What is the management for a patient with gestational diabetes with blood glucose of >7mmol/L?
Diet and exercise
AND
insulin immediately +/- metformin
173
***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?
Insulin immediately +/- metformin
174
***Diabetes & Driving***
Which diabetic patients should notify the DVLA?
Those on insulin
175
***Diabetes & Driving***
What are the hypo requirements to be a Group 1 driver?
No more than 1 episode of severe hypoglycaemia while awake in the previous 12 months
176
***Diabetes & Driving***
What are the hypo requirements to be a Group 2 driver?
Must report ALL episodes of severe hypoglycaemia (including sleep)
No episodes of severe hypoglycaemia in the preceding 12 months
177
***Diabetes & Driving***
What is the advice from the DVLA for diabetic drivers?
- 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
***Diabetes & Driving***
What CBG range is considered as hypoglycaemic when driving?
<4mmol/L
179
***Diabetes***
How frequently should HbA1c be monitored in diabetes?
Every 3-6 months
180
***Diabetes***
What are some of the typical features of type 1 diabetes?
- hyperglycaemia
- ketosis
- rapid weight loss
- BMI <25
- age <50
- FHx of autoimmune disease
181
***Diabetes & Driving***
How often should CBGs be monitored in type 1 diabetic patients?
Four times a day
(Before each meal and before bed)
182
***Diabetes & Driving***
For type 1 diabetes, what is the blood glucose target on waking?
5-7mmol/L
183
***Diabetes & Driving***
For type 1 diabetes, what is the blood glucose target when fasted during the day?
4-7mmol/L
184
***Diabetes & Driving***
For type 1 diabetes, what is the blood glucose target 90mins after eating?
5-9mmol/L
185
***Diabetes & Driving***
For type 1 diabetes, what is the blood glucose target while driving?
>5mmol/L
186
***Diabetes***
What regimen should all insulin patients be on?
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
***Diabetes***
What is the first line generic basal insulin?
Insulin detemir BD
188
***Diabetes***
What is the second line generic basal insulin?
Insulin glargine OD
189
***Diabetes***
What is an alternative generic basal insulin if first and second line are not suitable?
Insulin degludec OD
190
***Diabetes***
What are some factors that increase insulin requirements?
- infection
- stress
- trauma
191
***Diabetes***
What are some factors that decrease insulin requirements?
- physical activity
- reduced food intake
- impaired renal/ hepatic function
- certain endocrine disorders (thyroid, coeliac, Addison’s)
192
***Diabetes***
Which injection site for insulin has the fastest absorption rate?
Abdomen
193
***Diabetes***
Why must injection site of insulins be rotated?
Lipohypertrophy can occur
Leads to erratic absorption of insulin
194
***Diabetes***
What is some important safety information for insulins?
- 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
***Diabetes***
Name the rapid-acting insulins (generic).
- lispro
- aspartame
- glulisine
196
***Diabetes***
Name the intermediate-acting insulins (generic).
- bisphasic isophane
- biphasic aspart/ lispro
197
***Diabetes***
Name the long-acting insulins (generic).
- detemir
- degludec
- glargine
198
***Diabetes***
Which long-acting insulin requires a BD regime?
Detemir
199
***Diabetes***
Which antidiabetics cause weight LOSS?
- GLP-1 analogues
- SGLT2i
200
***Diabetes***
Which antidiabetics cause weight gain?
- sulfonylureas
- pioglitazone
- insulin
201
***Diabetes***
Which antidiabetics have no effect on weight?
- DPP4i
- metformin
202
***Diabetes***
What is the first line diabetes treatment in patients with low CVD risk?
Metformin
203
***Diabetes***
What is the second line diabetes treatment in patients with low CVD risk?
DPP4i, pioglitazone, sulfonylurea or SGLT2i
204
***Diabetes***
What is the third line diabetes treatment in patients with low CVD risk?
Triple therapy
205
***Diabetes***
What is the first line diabetes treatment in patients with high CVD risk?
Metformin
Consider addition of SGLTi as soon as diabetes is controlled
206
***Diabetes***
What is the second line diabetes treatment in patients with high CVD risk?
DPP4i, pioglitazone, sulfonylurea or SGLT2i
207
***Antidiabetics***
Name a biguanide.
Metformin
208
***Antidiabetics***
Describe the MoA of biguanides.
Decrease gluconeogenesis
Increase peripheral utilisation of glucose
209
***Antidiabetics***
What are some side effects of metformin?
- lactic acidosis
- GI side effects
- can reduce vitamin b12
210
***Antidiabetics***
What are some side effects of sulfonylureas?
- high risk of hypoglycaemia
- weight gain
211
***Antidiabetics***
Can sulfonylureas be used in hepatic or renal failure?
No. Avoid.
212
***Antidiabetics***
Describe the MoA of pioglitazone.
Reduces peripheral resistance to insulin
213
***Antidiabetics***
What are some cautions for pioglitazone?
- increased risk of bladder cancer
- avoid in Hx of HF
- increased risk of bone fractures
- increased risk of liver toxicity
214
***Antidiabetics***
Name a side effect of DPP4i.
Pancreatitis
215
***Antidiabetics***
What are the MHRA warnings for SGLT2is?
- life-threatening and fatal cases of DKA
- Fournier’s gangrene
- lower limb amputation - canagliflozin ONLY
- increased risk of UTIs
216
***Antidiabetics***
What are some MHRA warnings for GLP1 analogues?
- risk of DKA when given with insulin
- acute pancreatitis
- dehydration due to GI side effects
217
***Antidiabetics***
How often are eye tests required for diabetic patients, to monitor for retinopathy?
Yearly
218
***Antidiabetics***
(1) What antihypertensive can have an effect on glycaemic control from antidiabetic drugs/ insulin? (2) What is this effect?
(1) ACEi
(2) Potentiates hypoglycaemic effects
219
***Diabetes***
In which type of diabetes is DKA more common?
Type 1
220
***Diabetes***
Name some risk factors for DKA.
- discontinuation/ inadequate insulin therapy
- acute illness, e.g. MI/ pancreatitis
- new onset diabetes
- stress (trauma/ diabetes)
221
***Diabetes***
How is DKA diagnosed?
1) hyperglycaemia: >11mmol/L
2) plasma ketones >3mmol/L
3) acidosis
222
***Diabetes***
What are some symptoms of DKA?
- polyurea
- polydipsia
- weight loss
- nausea/ vomiting
- pear drop breath
- kussmaul respiration (deep/ fast breathing)
- excessive tiredness
- confusion
223
***Diabetes***
What is HHS?
Hyperosmolar hyperglycaemic state
224
***Diabetes***
How is HHS diagnosed?
Marked hyperglycaemia (>30mmol/L)
Hypovolaemia
225
***Diabetes***
What are symptoms of HHS?
- dehydration
- weakness
- weight loss
- tachycardia
- dry mucous membranes
- poor skin turgor
- hypotension
- acute cognitive impairment
- shock (in severe cases only)
226
***Diabetes***
What dose adjustments are required for insulin for elective surgery for minor procedures?
Day before: Reduce OD long-acting dose by 20%
227
***Diabetes***
What dose adjustments are required for insulin for elective surgery for major procedures?
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
***Diabetes***
What are the insulin changes following surgery?
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
***Diabetes***
How should patients’ understanding of hypoglycaemia be tested?
Gold score or Clarke score
230
***Diabetes***
What blood glucose range is considered to be hypoglycaemic?
<4mmol/L
231
***Diabetes***
What are some symptoms of hypoglycaemia?
- sweating
- dizziness
- lethargy
- hunger
- tremor
- tingling lips
- palpitations
- extreme moods
- pale
232
***Diabetes***
(1) What effect can beta blockers have on glycaemic control observation? (2) How?
(1) Can mask signs of hypoglycaemia
(2) Preventing warning signs such as tremors
233
***Diabetes***
(1) Which snacks should be avoided for correction of hypoglycaemia? (2) Why?
(1) Chocolate and biscuits
(2) Likely to have low sugar content and high fat content - can delay gastric emptying
