A 56-year-old man is reviewed in the Cardiology outpatient clinic following a myocardial infarction one year previously. During his admission he was found to be hypertensive and diabetic. He complains that he has put on 5kg in weight in the past 6 months.
Which of his medications may be contributing to his weight gain?
Correct Answer D: Sulfonylureas are oral hypoglycaemic drugs used in the management of type 2 diabetes mellitus. They work by increasing pancreatic insulin secretion and hence are only effective if functional B-cells are present.
Sulfonylureas common adverse effects:
Sulfonylureas rarer adverse effects:
Sulfonylureas should be avoided in breast feeding and pregnancy.
A 48-year-old man who was diagnosed with type 2 diabetes mellitus presents for review. During his annual review he was noted to have the following results:
His current medication is metformin 500mg tds. According to recent NICE guidelines, what is the most appropriate action?
Correct Answer A: Patients over the age of 40 years with type 2 diabetes mellitus should be started on a statin if they have any other risk factors for cardiovascular disease, such as smoking, hypertension or a 'high-risk' lipid profile. This patient has a high-risk lipid profile and should therefore be offered statin therapy.
A high-risk lipid profile may be defined as:
Hyperlipidaemia: management:
In 2008 NICE issued guidelines on lipid modification.
Primary prevention: A systematic strategy should be used to identify people aged 40-74 who are likely to be at high risk of cardiovascular disease (CVD), defined as a 10-year risk of 20% or greater.
NICE updated their lipid guidelines so that the following risk models are valid:
The 1991 Framingham equations may still be used. It is however recommended that adjustments are made in the following situations:
Secondary prevention: All patients with CVD should be taking a statin in the absence of any contraindication NICE recommend increasing simvastatin to 80mg if a total cholesterol of less than 4 mmol/litre or an LDL cholesterol of less than 2 mmol/litre is not attained.
A 35-year-old man is investigated for lethargy, arthralgia and deranged liver function tests. He is eventually diagnosed as having hereditary hemochromatosis. His wife has a genetic test which shows she is not a carrier of the disease.
What is the chance his child will develop hemochromatosis?
Correct Answer A: Hemochromatosis is an autosomal recessive condition. If one of the parents has hemochromatosis (i.e. is homozygous) and the other is not a carrier/affected then all the children will inherit one copy of the gene from the affected parent and hence will be carriers.
Hemochromatosis: features:
Hemochromatosis is an autosomal recessive disorder of iron absorption and metabolism resulting in iron accumulation. It is caused by inheritance of mutations in the HFE gene on both copies of chromosome 6*. It is often asymptomatic in early disease and initial symptoms often non-specific e.g. lethargy and arthralgia.
Epidemiology:
Presenting features:
Which features are reversible with treatment:
*There are rare cases of families with classic features of genetic hemochromatosis but no mutation in the HFE gene
**Whilst elevated liver function tests and hepatomegaly may be reversible, cirrhosis is not
A 61-year-old man presents as he developed enlargement of his breast tissue. He has become very self conscious and is worried about going on holiday in the summer.
Which one of the following drugs is most likely to be responsible?
Correct Answer E: All the above drugs may cause gynaecomastia but spironolactone is the most common cause.
Gynaecomastia: Gynaecomastia describes an abnormal amount of breast tissue in males and is usually caused by an increased oestrogen:androgen ratio. It is important to differentiate the causes of galactorrhoea (due to the actions of prolactin on breast tissue) from those of gynaecomastia.
Causes of Gynaecomastia:
Drug causes of Gynaecomastia:
Very rare drug causes of Gynaecomastia:
A 53 year man presents as his wife has noticed a change in his appearance. He has also noticed his hands seem larger. On examination blood pressure is 170/94 and he is noted to have bitemporal hemianopia.
What is the most appropriate first-line treatment?
Correct Answer D: Trans-sphenoidal surgery is the treatment of choice in acromegaly. There is no significant evidence base supporting the use of pre-operative octreotide.
Acromegaly: management :
Trans-sphenoidal surgery is first-line treatment for acromegaly in the majority of patients.
Dopamine agonists:
Somatostatin analogue:
Pegvisomant:
External irradiation is sometimes used for older patients or following failed surgical/medical treatment.
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