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Metabolic Flashcards

1
Q

Name the 4 indications for insulin treatment

A
  1. insulin replacement in T1DM
  2. control of blood glucose in T2DM, where oral hypoglycameics fail to control adequately
  3. given IV in diabetic emergencies
  4. alongside glucose to treat hyperkalaemia
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2
Q
  1. What is the onset, peak and duration of action of rapid acting insulin?
  2. Name 2 examples
A
  1. onset within 5-15 mins; peaks after 30mins; cleared after 5 hours
  2. Novorapid; Humalog (lispro)
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3
Q
  1. What is the onset, peak and duration of action of short acting insulin?
  2. how is absorption into plasma delayed?
  3. Name 3 examples
A
  1. onset within 30 mins; peaks at 2-4 hours; duration 6-8 hours
  2. soluble; when injected, aggregates into hexamers
  3. actrapid; Humulin S; Insuman rapid
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4
Q

Name an example of intermediate acting insulin

A

Isophane/NPH insulin

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5
Q
  1. What is the onset of action of long acting insulin?
  2. What is long acting insulin used as?
  3. Name 3 examples of long acting insulin
A
  1. 4 hours
  2. background insulin
  3. lantus; levemir; insulin degludec
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6
Q

What insulins are used in combination in Biphasic insulin?

A

short and intermediate acting insulins

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7
Q
  1. Describe the multiple daily injection insulin regimen

2. What is it used for?

A
  1. long acting insulin + short acting bolus at meal time

2. most T1DM

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8
Q
  1. Describe the biphasic insulin regimen

2. What is it used for?

A
  1. biphasic insulin administered BD

2. T2DM or T1DM incapable of using multiple daily injection regimen

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9
Q
  1. Describe the long acting once daily insulin regimen

2. What is it used for?

A
  1. Long acting insulin administered OD

2. T2DM with concurrent oral hypoglycaemics

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10
Q
  1. Describe the continuous subcutaneous insulin infusion regimen
  2. What is it used for?
A
  1. continuous insulin infusion plus boluses at mealtimes. Closest to physiological insulin
  2. patients with T1DM who are unable to use multiple or biphasic regimens, or those with hypo-awareness
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11
Q

Name 4 adverse effects of insulin therapy

A
  1. risk of hypoglycaemia
  2. rebound hypoglycaemia following hypos (results from compensatory release of adrenaline)
  3. hypokalaemia (IV insulin)
  4. Weight gain and lipid hypertrophy around injection site
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12
Q

What are the 5 steps of T2DM management outlined by NICE?

A
  1. LIFESTYLE MODIFICATION
    • diet
    • weight control
    • exercise
  2. MONOTHERAPY
    • metformin
  3. DUAL THERAPY
    • metformin + sufonyluria/sitagliptin/piaglitazone/gliflozin
  4. TRIPLE THERAPY
    • metformin + sulfonylurea + another
  5. Insulin therapy
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13
Q
  1. What is the MOA of metformin?
  2. Name 2 advantages of metformin therapy
  3. What is the affect of metformin on weight?
  4. Name a contraindication of metformin therapy
  5. Name 2 adverse effects of metformin therapy
A
  1. acts on liver to reduce gluconeogenesis therefore reduces hepatic insulin resistance
  2. rarely causes hypos; reduces micro and macrovascular risk
  3. weight neutral
  4. renal impairment (avoid if eGFR <30)
  5. GI side effects (often poorly tolerated)
    lactic acidosis
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14
Q
  1. What is the MOA of sulfonylureas?
  2. Name 2 examples of sulfonylureas?
  3. What is the affect of sulfonylureas on weight?
  4. Name an adverse effect of sulfonylureas?
  5. Why should alternatives to sulfonylureas be considered in patients with poor treatment compliance?
A
  1. act on beta cells to produce insulin (secretologues) - requires functional beta cell mass; eventually effect decreases
  2. gliclazide; glipizide
  3. weight gain
  4. hypoglycaemia
  5. requires multiple daily dosing
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15
Q
  1. What is the MOA of Pioglitazone?
  2. what is the effect of pioglitazone on weight?
  3. Name 3 adverse effects of pioglitazone
A
  1. PPARgamma agonist - promotes expression of GLUT4 and insulin receptors
  2. weight gain
  3. fluid retention (contraindicated in HF)
    small bone fractures
    increased risk of bladder cancer
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16
Q

Describe the incretin effect

A

Incretins - GLP-1 and GIP are produced in response to oral glucose
they have a potentiating effect on pancreatic insulin secretion
they are degraded by DPP-4
the incretin effect is diminished in T2DM

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17
Q
  1. What is the MOA of DPP-4 inhibitors?
  2. Name an example of a DPP-4 inhibitor?
  3. what is the effect of DPP-4 inhibitors on weight?
  4. Name 3 cautions to the use of DPP-4 inhibitors?
A
  1. enhance the incretin effect by preventing the degradation of incretins
  2. sitagliptin
  3. weight neutral
  4. acute pancreatitis
    renal dysfunction
    gastroparesis
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18
Q
  1. What is the MOA of SGLT2 inhibitors?
  2. Name an example of an SGLT2 inhibitor
  3. Name advantages of SGLT2 inhibitors (3)
  4. When are these drugs contraindicated?
A
  1. inhibits renal SGLT2 therefore prevents the reabsorption of glucose from the renal filtrate
  2. gliflozin
  3. weight loss
    diuretic effect - improved BP and CV risk
    reduced HbA1c
  4. renal impairment (GFR <40)
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19
Q
  1. Why can it be difficult to control blood glucose in diabetic patients perioperatively?
  2. How is this achieved?
A
  1. patients are nil by mouth
  2. give variable rate insulin + glucose
    maintain long acting insulin treatment
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20
Q

What are the sick day rules for insulin therapy? (3)

A
  1. continue long acting insulin; may need to adjust dose of short acting insulin
  2. drink/sip clear sugar free fluids to prevent dehydration
  3. check urine for ketones
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21
Q
  1. Which drug should be prescribed as soon as a diagnosis of hyperthyroidism is made?
  2. What does this drug do in hyperthyroidism?
A
  1. Beta blockers
  2. ameliorate symptoms caused by increased beta adrenergic tone
    inhibit peripheral conversion of T4 to T3 (high doses)
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22
Q

Which drug is indicated for treatment of hyperthyroidism?

A

Carbimazole

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23
Q
  1. What is the MOA of carbimazole?
  2. What are the 2 treatment regimens of carbimazole?
  3. Name a contraindication for carbimazole therapy?
A
  1. thyroid peroxidase inhibitor - reduces synthesis of T3/T4
  2. titration therapy
    block and replace therapy
  3. Pregnancy - teratogenic
    (contraception should be used in women undergoing carbimazole therapy)
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24
Q
  1. Which drug is used as an alternative to carbimazole in pregnancy?
  2. When in pregnancy should a switch from this drug to carbimazole be considered and why?
A
  1. Propylthiouracil

2. second and third trimesters due to risk of hepatotoxicity with propylthiouracil

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25
Q

What is the MOA of propylthiouracil?

A

prevents peripheral conversion of T4 to T3

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26
Q

Name a potentially serious side effect of carbimaxole and propylthiouracil therapy

A

Neutropenia and agranulocytosis

  • patients should report symptoms suggestive of infection
  • WCC should be performed if there is any clinical evidence of infection
  • carbimaxole should be stopped promptly if there is clinical or laboratory evidence of neutropenia
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27
Q
  1. What drug is used in the treatment of Hypothyroidism?
  2. Name 5 drugs which can interfere with its absorption?
  3. What types of drugs affect its metabolism?
A
  1. Levothyroxine
  2. iron; calcium carbonate; mineral suppliments; colestyramine; sucralfate
  3. hepatic enzyme INDUCERS (phenobarbitol, phenytoin, carbamazepine; rifampicin)
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28
Q
  1. In which condition is radioiodine indicated first line?
  2. Name a side effect of radioiodine therapy?
  3. When is radioiodine contraindicated?
A
  1. Graves disease
  2. can worsen thyroid ophthalmopathy
  3. pregnancy
29
Q

Why do patients with secondary adrenal insufficiency not require mineralocorticoid replacement?

A

RAAS is intact

30
Q

How is an Addisonian crisis managed?

A
  1. IV fluid resuscitation
  2. IV hydrocorisone
  3. prevention of hypoglycaemia
  4. treatment of precipitating cause
31
Q

What is the advice given to patients taking adrenal replacement therapy/long term corticosteroids?

A
  1. carry steroid card
  2. do not stop steroid treatment abruptly
  3. seek urgent medical assistance if unable to take hydrocortisone due to vomiting
  4. use IM hydrocortisone as rescue therapy if unable to take orally
32
Q

why must plasma sodium levels not be corrected too quickly?

A

risk of osmotic demyelination syndrome

33
Q

How is chronic hyponatraemia managed in primary care?

A
  1. regular sodium measurements
  2. fluid restriction
  3. treat underlying cause
34
Q
  1. What is the MOA of bisphosphonates?
  2. How often are they administered?
  3. What is a potentially serious side effect of bisophoshonates?
A
  1. inhibit osteoclasts; specificity comes from affinity for Ca
  2. weekly
  3. osteonecrosis of the jaw
35
Q
  1. What is the MOA of raloxifine?

2. What is it used to treat?

A
  1. selective oestrogen receptor modulator

2. post-menopausal and glucocorticoid associated osteoporosis

36
Q
  1. What is teriparatide?
A
  1. recombinant PTH - stimulates osteoblasts
37
Q
  1. What is the MOA of strontium ranelate?

2. What does it increase the risk of?

A
  1. increases deposition of new bone by osteoblasts and reduces the resorption of bone by osteoclasts
  2. VTE
38
Q
  1. What is the MOA of denosumab?

2. In what condition is it contraindicated?

A
  1. RANK-L inhibitor - prevents the development of osteoclasts
  2. hypocalcaemia
39
Q
  1. Name 3 drugs used to correct hypocalcaemia
  2. Which 2 can be used in renal failure?
  3. Which is contraindicated in renal failure?
A
  1. alfacalcidol, calcitrol and colecalciferol
  2. alfacalcidol and calcitrol
  3. colecalciferol
40
Q
  1. How is hypocalcaemia secondary to parathyroidectomy corrected?
  2. What additional supplimentation is given if PTH is deficient?
  3. Why is it important to check Mg levels?
A
  1. IV Calcium gluconate initially; oral Ca suppliments
  2. Vitamin D
  3. PTH activity is affected by hypomagnesaemia
41
Q

What is the immediate therapy for AKI?

A
  1. IV fluid
  2. optimise BP
    • withhold drugs that interfere with renal autoregulation (ACEi/ARB)
    • temporary cessation of antihypertensives
  3. correct hypovolaemia
  4. prescribe appropriately
42
Q

Name 3 classes of drugs that interfere with renal perfusion and therefore should be avoided in AKI

A
  1. ACEi
  2. ARB
  3. NSAIDs
43
Q

Name 3 drugs which can aggravate hyperkalaemia

A
  1. trimethoprim
  2. spironolactone
  3. amiloride
44
Q

Name 3 drugs which require close monitoring in AKI

A
  1. warfarin
  2. aminoglycosides
  3. lithium
45
Q

Name 6 drugs which require dose reduction or cessation in AKI

A
  1. fractionated heparins
  2. opiates
  3. penicillin based antibiotics
  4. sulfonylureas
  5. metformin
  6. acyclovir
46
Q
  1. What does the cockroft gault equation calculate?

2. What parameters are taken into account in the cockroft gault equation?

A
  1. creatine clearance

2. serum creatinine concentration, age, sex and weight

47
Q
  1. How does the cockroft gault equation differ from eGFR calculations?
  2. Name 2 instances where the cockroft gault equation should be used to calculate creatinine clearance, rather than using eGFR
A
  1. Cockroft gault takes into account patient weight whereas eGFR doesnt
  2. potentially toxic drugs with a small safety margin (to adjust drug dosages)
    patients at the extremes of weight, to calculate drug doses
48
Q
  1. What is the first line treatment for UTI?
  2. What is the MOA of this drug?
  3. Name 2 important adverse effects of this drug?
  4. Name 3 contraindications of using this drug
A
  1. Trimethoprim
  2. inhibits bacterial folate synthesis
  3. haematological disorders such as megaloblastic anaemia, leukopenia and thrombocytopenia
    hyperkalaemia
  4. first trimester of pregnancy
    folate deficiency
    renal impairment
49
Q
  1. What is the MOA of nitrofurantoin?
  2. Name 4 uncommon but serious side effects of nitrofurantoin
  3. Name 3 contraindications of nitrofurantoin
A
  1. damages bacterial DNA
  2. chronic pulmonary reactions
    hepatitis
    peripheral neuropathy
    haemolytic anaemia in neonates
  3. pregnant women towards term
    babies <3 months
    renal impairment
50
Q

Which antibiotics are indicated for the treatment of pyelonephritis? (3)

A
  1. co-amoxiclav
  2. ciprofloxacin
  3. gentamycin
51
Q

Name 2 adverse effects of co-amoxiclav

A
  1. GI upset and penicillin related colitis

2. self limiting acute liver injury

52
Q
  1. What is the MOA of ciprofloxacin?
  2. Name a potentially serious side effect of ciprofloxacin
  3. Name 2 interractions of ciprofloxacin
A
  1. inhibits bacterial DNA synthesis (quinolone)
  2. QT prelongation
    neurological effects
  3. drugs which prolong QT interval
    CYP350 inhibitors
53
Q
  1. What is the MOA of gentamycin?
  2. against what bacteria does it work?
  3. What are the main adverse effects of gentamycin?
  4. Describe the pharmacokinetics of gentamycin
A
  1. 30s ribosome inhibitor (aminoglycoside)
  2. gram positive
  3. ototoxicity and nephrotoxicitiy
  4. highly hydrophillic - not distributed into the body fat and minimally distributed into tissue fluids
    excreted unchanged by the kidney
54
Q

Describe the Hartford/Extended interval dosing regimen for Gentamycin

A

Blood sample taken between 6 and 14 hours after start of first infusion
Gentamicin concentration of this blood sample is used to determine hours between dosing (using nomogram)

55
Q
  1. What is the role of sympathetic stimulation in micturition?
  2. What receptors are involved?
  3. What is the role of parasympathetic stimulation in micturition?
A
  1. relaxation of the bladder to accomodate filling; sphincter closure
  2. beta adrenoreceptors (relaxation of detrusor)
    alpha receptors (sphincter contraction)
  3. Stimulation of detrusor (M3 receptors)
    inhibition of sympathetic outflow
56
Q
  1. What class of drugs are used to treat urge incontinence?
  2. Name 2 examples of these drugs
  3. Name side effects of these drugs?
  4. Name another drug and its MOA used to treat urge incontinence?
A
  1. muscarinic antagonists
  2. oxybutinin and tolterodine
  3. dry mouth, tachycardia, constipation, blurred vision, urinary retention
  4. beta agonists - mirabegron
57
Q
  1. what is the first line treatment for stress incontinence?
  2. When is drug therapy recommended?
  3. What drugs (2) are indicated for stress incontience?
A
  1. pelvic floor muscle training for at least 8-12 weeks
  2. when surgical management is not suitable
  3. vaginal oestrogens
    duloxetine
58
Q
  1. What is the first line treatment for BPH?
  2. What is its MOA?
  3. Name some adverse drug effects
  4. Name interractions
A
  1. tamsulosin
  2. alpha receptor blocker - induces relaxation of sphincter
  3. orthostatic hypotension
    headache and dizziness
    erectile disorders
    oedema
  4. sildenafil and hypotensive agents
59
Q
  1. What is the second line treatment of BPH?
  2. What is its MOA?
  3. Name some adverse drug effects
  4. name 2 interractions
A
  1. finasteride
  2. 5-alpha reductase inhibitor - prevents conversion of testosterone to DHT
  3. breast enlargement and tenderness
    decreased libido
    ejaculation disorders
    impotence
    abnormal development of external genitalia if pregnant women are exposed
  4. verapamil and diltiazem
60
Q

Name 2 approaches to the treatment of prostate cancer

A
  1. Anti-androgens - flutamide

2. GNRH analogues - leuprolide, goserelin and buserelin

61
Q
  1. What type of chemotherapy is bladder cancer most sensitive to?
  2. what type of chemotherapy is preferred initial approach for patients with metastatic bladder cancer?
A
  1. cisplatin

2. platinum based

62
Q
  1. What is parenteral iron reserved for?
  2. Name some adverse drug effects of iron treatment
  3. How do most drug interractions with iron come about?
A
  1. when oral therapy is unsuccessful/untolerated; patient does not take oral iron reliably; continuing blood loss or malabsorption
  2. constipation; faecal impaction; GI irritation; nausea
  3. iron reduces absorption of other drugs
63
Q
  1. What is the typical oral dose of iron for iron deficiency anaemia?
  2. How long should this be continued?
A
  1. 100-200mg TDS

2. 3 months after the Hb concentration has been restored

64
Q
  1. What is the difference between folate and folic acid?
  2. What is folate required for? (2)
  3. What can folate deficiency lead to? (4)
A
  1. folate = water soluble vitamin B9
    folic acid = synthetic form of folate found in fortified foods and suppliments
  2. amino acid proteins and biosynthesis of purines and pyramidines
  3. neural tube defects
    megaloblastic anaemia
    accelerated arterioscerlosis
    neurological deterioration
65
Q

Name 7 factors associated with increased risk of neural tube defects

A
  1. previous Hx of NTD
  2. maternal folate deficiency
  3. maternal B12 deficiency
  4. smoking
  5. diabetes
  6. obesity
  7. use of antiepileptic drugs (valproate, carbamazepine)
66
Q

What dose of periconceptual folic acid supplimentation is recommended for:

  1. women at high risk of NTD?
  2. All other women attempting to concieve?
A
  1. 5mg

2. 400microg

67
Q
  1. What deficiency is subacute combined degeneration of the spinal cord associated with?
  2. What are the effects of this degeneration?
A
  1. B12

2. loss of vibration sense and proprioception in the hands of feet. Progression to sensory loss of all modalities

68
Q
  1. Why when treating macrocytic anaemia of unknown cause is it important to start B12 supplementation before folate?
  2. Why is B12 deficiency treated with IM supplementation rather than oral?
A
  1. due to risk of subacute combined degeneration of the spinal cord associated with B12 deficiency
  2. because B12 deficiency is mostly caused by malabsorption

Phase 2 Y3 PPT (8 decks)

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