Pharmacotherapy of Endocrine, Metabolic, and Nutritional Disorders
What the exam tests
Endocrine and metabolic questions cover diabetes, thyroid disease, adrenal disorders, obesity, electrolytes and nutrition support. The exam favors practical decision-making: which agent, which insulin regimen, and how to avoid iatrogenic harm.
Core rules
- Type 2 diabetes: metformin remains first-line unless contraindicated. Add an SGLT2 inhibitor or GLP-1 receptor agonist early when there is ASCVD, heart failure, CKD or obesity.
- Do not start metformin if eGFR <30; reduce the dose at eGFR 30–45; hold during acute illness, hypoxia or contrast procedures.
- DKA: isotonic saline first, then IV insulin infusion at 0.1 units/kg/h; add dextrose when glucose <11 mmol/L; replace potassium when K+ <5.2 and urine output is adequate.
- Levothyroxine is taken on an empty stomach, 30–60 minutes before food, separated from calcium and iron by four hours.
- Steroid therapy: taper only after long courses; monitor glucose, bone and infection risk.
Worked example
A 22-year-old with type 1 diabetes presents with glucose 28 mmol/L, pH 7.15, bicarbonate 10 mmol/L and K+ 4.0 mmol/L. Start 0.9% saline, then insulin infusion; because potassium is normal and renal function is adequate, add 20–30 mmol KCl per litre once potassium falls below 5.2. Do not give bicarbonate routinely. Continue long-acting insulin.
Traps
Using sliding-scale insulin alone in type 1 diabetes; giving potassium before confirming urine output; stopping basal insulin in DKA; starting an SGLT2 inhibitor in a patient with recurrent genital infections without counseling; forgetting that levothyroxine absorption changes with food and PPIs.