Baseline

• U&E 1–2 weeks after starting treatment and 1–2 weeks after each dose increase
• For people who are at higher risk of hyperkalaemia or deteriorating renal function (eg peripheral vascular disease, heart failure diabetes mellitus, or pre-existing renal impairment or older people) within 1 week of each dose titration

Ongoing

• Annual U&E

If ACE affects kidneys there is an increase in K+ and decrease in Na+

Potassium 

• >6.0mmol/L (Hyperkalaemia)
  • Stop ACEI/ARB therapy
  • check that other drugs known to promote hyperkalaemia have been discontinued
  • try another antihypertensive if need be
  • repeat bloods
• Small rise in isolated potassium < 5.8,
  • likely spurious: repeat bloods in a week
  • If second reading is under 5.8 we an ignore unless they have HF
  • In patients with heart failure >5.5 mmol/l stop ACE inhibitor and refer to specialist advice
• Low potassium (Hypokalaemia) 2.5 mmol/L- 3.5mmol/L 
  • stop diuretic - treat with sando K 
  • can be due to due to severe diarrhoea and vomiting
  • can also be lost through your kidneys in urine
  • inadequate diet
  • conditions:
    • diabetics - potassium concentration may fall after insulin
    • low levels of magnesium - treat
    • overactive thyroid - treat
• Very low potassium level < 2.5 mmol/L
  • can be life-threatening and requires urgent medical attention

eGFR & creatinine

• eGFR falls by 25% or plasma creatinine increases by 30% from baseline : Stop the ACEI/ARB or reduce to a previously tolerated dose once potential alternative causes of renal impairment have been ruled out.
• If the changes indicating a decrease in renal function are less than described do not modify the dose but repeat the test in 1-2 weeks.
• In patients with heart failure creatinine increases by >100% or to above 310 micromol/l the ACE inhibitor should be stopped and specialist advice sought
• Any deterioration of renal function you need to consider things ike glomerulonephritis and also assess proteinuria - dipstick to assess this as well as pick up new diagnoses of diabetes potentially too. HCAs can dip sample if you ask them to drop in one.

Sodium 

• If decreased, stop or reduce ACEi/diuretics
• or try another antihypertensive 
• repeat bloods
• <132 mmol/L : specialist advice should be obtained

Annual

• Calcium
• Vitamin D

6 monthly

• TFT
• LFT 

TFT

• borderline
  • repeat test in 6 weeks
• increased T4 or slight decrease/normal free-T3
  • Amiodarone may cause isolated biochemical changes in clinically euthyroid patients, no reason in such cases to discontinue amiodarone if there is no clinical or further biological (TSH) evidence of thyroid disease
• inreased T4 with high or high/normal T3 and undetectable TSH
  • Amiodarone-associated hyperthyroidism
  • withdrawal of amiodarone
  • refer to specialist
  • euthyroidism is usually obtained within 3 months following discontinuation

LFT

• discontinued if severe LFT abnormalities or clinical signs of liver disease develop

Antipsychotics

• Amisulpiride
• Aripiprazole
• Clozapine
• Olanzapine
• Quetiapine
• Risperidone

Annual

• Prolactin
• lipids
• HbA1c
• U&E
• BP
• BMI

High Lipids 

• offer lifestyle advice
• consider changing antipsychotic and/or initiating statin therapy
• ALT > 45 refer to specialist

High BMI

• offer lifestyle advice
• consider changing antipsychotic and/or dietary/pharmacological intervention.

Prolactin >800

• review patient for prolactin symptoms of prolactinoma
  • irregular menstrual periods or no menstrual periods
  • Milky discharge from the breasts when not pregnant or breast-feeding
  • Painful intercourse due to vaginal dryness
  • Acne and excessive body and facial hair growth
• AND refer to specialist
• consider swtching drugs

LFT

• if hepatitis indicated (transaminases x3 normal) or functional damage (PT or albumin change), stop therapy

Apixaban

Annual 

• U&E
• Weight
• LFT
• FBC

6 Monthly

• if CrCl 30-60mL/min or 
• where intercurrent illness, or concomitant medicinal products may impact on hepatic function

3 Monthly 

• if CrCl 15- 30mL/min

Ideally 3 Monthly

• Patient compliance assessment
  • enquire about presence of any adverse effects, in particular signs and symptoms of bleeding and anaemia

Calculate CrCl then review dose

LFT review as per protocol

A low haemoglobin and/or haematocrit may suggest that occult bleeding is occurring and may require further investigations. Stop if severe bleeding occurs

ARBs:

• Candesartan
• Losartan
• Olmesartan
• Telmisartan
• Valsartan 

Baseline

• U&E 1–2 weeks after starting treatment and 1–2 weeks after each dose increase
• For people who are at higher risk of hyperkalaemia or deteriorating renal function (eg peripheral vascular disease, heart failure diabetes mellitus, or pre-existing renal impairment or older people) within 1 week of each dose titration

Ongoing

• Annual U&E

If kidneys are affected there is an increase in K+ and decrease in Na+

Potassium 

• >6.0mmol/L Stop ACEI/ARB therapy
• check that other drugs known to promote hyperkalaemia have been discontinued
• try another antihypertensive if need be
• repeat bloods
• Small rise in isolated potassium < 5.8, likely spurious: repeat bloods in a week
• In patients with heart failure >5.5 mmol/l stop ACE inhibitor and refer to specialist advice

eGFR & creatinine

• eGFR falls by 25% or plasma creatinine increases by 30% from baseline : Stop the ACEI/ARB or reduce to a previously tolerated dose once potential alternative causes of renal impairment have been ruled out.
• If the changes indicating a decrease in renal function are less than described do not modify the dose but repeat the test in 1-2 weeks.
• In patients with heart failure creatinine increases by >100% or to above 310 micromol/l the ACE inhibitor should be stopped and specialist advice sought

Sodium 

• If decreased, stop or reduce ACEi/diuretics
• or try another antihypertensive 
• repeat bloods
• <132 mmol/L : specialist advice should be obtained

 3 monthly 

• FBC
• LFT
• U&E

Withhold treatment until discussion with consultant specialist if:

• WCC < 3.5 x 109/L,

• Neutrophils< 1.6 x 109/L

• Unexplained eosinophilia > 0.5x 10 9/L

• Platelets < 140x 109/l,

• AST and/or ALT increase to >100units/L

• Unexplained fall in serum albumin 105f/L

• Creatinine increase > 30% above baseline over 12 months and/or calculated GFR < 60ml/min/1.73m2 If patient develops renal impairment (eGFR < 50ml/min) check dosing with specialist

 Annual 

• TFT
• LFT

every 6 months if carbimazole is being used as part of a block and replace regimen

Following the onset of any signs and symptoms of hepatic disorder, stop carbimazole and perform liver function tests immediately

 3 Monthly 

• FBC
• LFT
• U&E
• Glucose
• ESR
• fasting lipids
• BP

Withhold treatment until discussion with consultant specialist if:

• WCC < 3.5 x 109/L,

• Neutrophils< 1.6 x 109/L

• Unexplained eosinophilia > 0.5x 10 9/L

• Platelets < 140 x 109/l,

• AST and/or ALT increase to >100units/ml

• Unexplained fall in serum albumin 105f/L

• Creatinine increase > 30% above baseline over 12 months and/or calculated GFR < 140/90 on two consecutive occasions two weeks apart

CKS note that ciclosporin can cause a significant increase in fasting lipids

BSG state that the risk of seizures with ciclosporin is increased in patients with a low cholesterol or magnesium (see guidelines)

Baseline

• weight
• BP
• triglycerides glucose
• U&E

Offer weight management advice if necessary.

Treat elevated BP if necessary

In patients with existing diabetes, oral antidiabetic drugs may need to be increased, or insulin therapy started

Refer children and adolescents to a paediatrician if growth suppression is suspected.1 If adrenal suppression is suspected, biochemical testing of the HPA axis should be considered after steroid treatment has been reduced to a physiological dose.

Consider referral if fracture risk is high and/or BMD is decreasing

If patient is considered to be at increased risk of a fragility fracture initiate treatment with an oral bisphosphonate.

 Annual 

• U&E
• Weight 
• LFT

6 Monthly if

• CrCl 30–60 mL/min
• patient > 75 years
• fragile
• where intercurrent illness, or concomitant medicinal products may impact on hepatic function

Calculate CrCl then review dose

LFT review as per protocol

A low haemoglobin and/or haematocrit may suggest that occult bleeding is occurring and may require further investigations. Stop if severe bleeding occurs

• 2 Monthly
• FBC
• Vitamin D
• Calcium 2

The presence of toxic symptoms such as nausea, vomiting, visual disturbance (yellow-green discoloration), or severe dysrhythmias may prompt an urgent measurement of digoxin level

Samples for digoxin measurement should be taken at least 6 hours after the last dose

Annual

• U&E

6 Monthly 

• U&E
  • elderly
  • patients at risk of hypokalaemia (e.g. on loop diuretics)
  • patients with renal dysfunction and in elderly people morefrequently in elderly patients or patients with renal impairment

If toxicity occurs, digoxin should be withdrawn; serious manifestations require urgent specialist management. Digoxin-specific antibody fragments are available for reversal of life-threatening overdosage.

Hypokalaemia, hypomagnesaemia and hypocalcaemia predispose the patient to digoxin related problems.

If toxicity is suspected potassium level should also always be measured – if it is low, digoxin toxicity should be assumed without waiting for digoxin level. Low potassium levels require correction

Diuretics 

Acetazolamide

Amiloride

Bendroflumethiazide

Bumetanide

Brinzolamide

Chlortalidone

Cyclopenthiazide

Furosemide

Hydrochlorthiazide

Indapamide

Spironolactone

Triamterene 

Initiation 

• U&E 1–2 weeks after starting treatment and 1–2 weeks after each dose increase
• For people who are at higher risk of hyperkalaemia or deteriorating renal function (eg peripheral vascular disease, heart failure diabetes mellitus, or pre-existing renal impairment or older people) within 1 week of each dose titration

Ongoing

• Annual U&E

If Diuretics affect kidneys there is an increase in K+ and decrease in Na+

Potassium 

• >6.0mmol/L Stop diuretic
• check that other drugs known to promote hyperkalaemia have been discontinued
• repeat bloods
• Small rise in isolated potassium < 5.8, likely spurious: repeat bloods in a week
• In patients with heart failure >5.5 mmol/l stop diuretic 

eGFR & creatinine

• eGFR falls by 25% or plasma creatinine increases by 30% from baseline : Stop the diuretic or reduce to a previously tolerated dose once potential alternative causes of renal impairment have been ruled out.
• If the changes indicating a decrease in renal function are less than described do not modify the dose but repeat the test in 1-2 weeks.
• In patients with heart failure creatinine increases by >100% or to above 310 micromol/l the diuretic should be stopped and specialist advice sought

Sodium 

• If decreased, stop or reduce diuretic 
• repeat bloods
• <132 mmol/L : specialist advice should be obtained

Annual

• U&E
• Weight
• Cr 
• LFTs
• FBC

6 Monthly

• patient > 75years
• fragile
• if CrCl 30-60mL/min
• where intercurrent illness, or concomitant medicinal products may impact on hepatic function

3 Monthly

• if CrCl 15-30mL/min

Calculate CrCl then review dose

LFT review as per protocol

A low haemoglobin and/or haematocrit may suggest that occult bleeding is occurring and may require further investigations. Stop if severe bleeding occurs

• Halve the dose of eplerenone if the potassium rises to >5.5-5.9 mmol/L
• Stop if potassium rises to >6.0mmol/L or serum creatinine rises to >220micromol/L and seek specialist advice

Sickle cell 

Monthly

• FBC

3 monthly

• U+E
• LFTs
• Urate
• LDH
• HBF

Psoriasis

1-3 monthly

• FBC
• U&E 
• uric acid

LFTs

Stop hydroxycarbamide until blood counts have recovered if:

• neutrophils < 1.5 x109/L
• platelets < 80 x109/L
• reticulocytes< 10 x109/L
• Hb drops by >3g/dL from baseline

Review & initiate treatment at half dose if:

• If creatinine clearance < 60ml/min

Initiation

Within 7–10 days of starting treatment

• FBC
• reticulocyte count
• potassium 
• B12
  • If there is no improvement, check serum folate level (if this has not been done already)

After 8 weeks of treatment

• FBC
• reticulocyte count
• potassium 
• iron 
• folate
• B12
  • cobalamin can be measured if there is no response

Ongoing monitoring is unnecessary unless a lack of compliance with treatment is suspected, anaemia recurs, or neurological symptoms do not improve or progress

• A rise in the haemoglobin level and an increase in the reticulocyte count to above the normal range indicates that treatment is having a positive effect
• The mean cell volume (MCV) should have normalised
• Neurological recovery may take some time — improvement begins within one week and complete resolution usually occurs between six weeks and three months

Initiation 

After one month 

• LFT

Ongoing 

Annual 

• LFT

• Discontinue if abnormalities in liver function tests
• Recovery upon stopping therapy can be delayed for several weeks and generally takes 4 to 10 weeks, although in some cases recovery may be prolonged
• Symptoms may present as fatigue and jaundice

3 Monthly (More frequent monitoring is appropriate in patients at higher risk of toxicity)

• FBC
• LFT
• U&E
• ESR 

6 Monthly 

• BP
• Weight

Withhold treatment until discussion with consultant specialist if

• WCC < 3.5 x 109/L
• Neutrophils< 1.6 x 109/L
• Unexplained eosinophilia > 0.5x 109/L
• Platelets < 140 x 109/l
• AST and/or ALT increase to >100units/ml
• Unexplained fall in serum albumin <30g/L
• MCV > 105f/L
• Creatinine increase > 30% above baseline over 12 months and/or calculated GFR < 60ml/min/1.73m2 CKS advise that the following symptoms may be a sign of leflunomide toxicity.

Withhold until discussion with rheumatologist if

• Rash or itch
• Hair loss
• Severe sore throat or abnormal bruising (check FBC immediately)
• Hypertension (BP>140/90) despite standard anti-hypertensives
• Breathlessness
• Unexplained weight loss >10%Severe or persistent headache or GI upset (nausea, diarrhoea)

Thyroid hormones:

Levothyroxine

Armour thyroid

Nature thyroid

Erfa thyroid 

Annual 

• TFT

• adjust dose by 25-50µg until euthyroid
• Repeat TSH every 3 months after dosage adjustment
• Aim for T4 in the upper half of the reference range and TSH normal (within range)
• Be aware that the TSH level can take up to 6 months to normalise and aim for around 2mU/L

3 Monthly

• Lithium levels

6 Monthly

• TFT 
• U&E (more often if on ACE/diuretics/NSAIDS)
• BMI (more often if rapid weight gain)

Annual

• Calcium
• BP 
• LFT
• FBC
• HbA1c
• Lipids 

Lithium

should be 0.6-0.8

• >1.5mmol
  • if signs of toxicity present
  • refer to specialist 
  • stop treatment
  • check plasma levels
  • dose should be reduced gradually over at least 4 weeks, and preferably up to 3 months, even if the person has started taking another antimanic drug. During dose reduction and for 3 months after lithium treatment is stopped, monitor the person closely for early signs of mania and depression
• >2mmol/L
  • requires urgent treatment

TFT

• TSH 5 - 10 mU/L
  • more frequent monitoring
  • if patient symptomatic trial of levothyroxine
• TSH >10
  • high risk of progression to overt hypothyroidism
  • prescribe levothyroxine

Calcium

• Patients with raised calcium and parathyroid hormone levels should be referred for specialist treatment.
• Patients with raised calcium levels only, should be monitored more closely unless the level exceeds 2.75mmol/L in which case lithium treatment should be stopped.
• Monitor TFT more often if there is raised calcium (might be related to impaired thyroid function )

BMI, BP, lipids - for CVD risks - needs lifestyle changes or stop medication

 Annual 

• U&E
• B12

• Reduce dose in moderate impairment
• Avoid if eGFR <30 mL/minute/1.73 m²

3 Monthly 

• LFT
• FBC

Withold treatment until discussion with consultant specialist if

• WBC < 3.5 x 109/l
• Neutrophils< 2 x 109/l
• Platelets < 150 x 109/l
• AST, ALT increase to > twice the upper limit of normal
• eGFR < 50ml/min - check dosing with specialist
• MCV > 105fl: check B12 , serum folate and TSH – withhold until results are available and discuss with specialist

Mesalazine

asacol

octasa

3 Monthly (for 12 months)

• U&E
• eGFR
• LFT

Annual (6 monthly if high risk patient)

• U&E
• eGFR
• LFT

Mesalazine should be discontinued if

• renal function deteriorates
• AST, ALT > twice upper limit of reference range
• withhold treatment until discussed with the specialist team

Haematological investigations should be performed if the patient develops

• unexplained bleeding
• bruising
• purpura
• anaemia
• fever or sore throat
• Treatment should be stopped if there is suspicion or evidence of blood dyscrasia

3 Monthly 

• FBC
• LFT
• U&E

Treatment should be withheld until discussion with specialist if:

• WCC < 3.5 x 109/L
• Neutrophils< 1.6 x 109/L
• Unexplained eosinophilia > 0.5x 10 9/L
• Platelets < 140 x 109/l
• AST and/or ALT increase to >100units/ml
• Unexplained fall in serum albumin <30g/L
• MCV > 105f/L
• Creatinine increase > 30% above baseline over 12 months and/or calculated GFR<60ml/min/1.73m2

Mycophenolate

Monthly 

• FBC
• U&E
• LFT

• WCC < 3.5 x 109/L
• Neutrophils< 1.6 x 109/L
• Unexplained eosinophilia > 0.5x 10 9/L
• Platelets < 140 x 109/l
• AST and/or ALT increase to >100units/ml
• Unexplained fall in serum albumin <30g/L
• MCV > 105f/L
• Creatinine increase > 30% above baseline over 12 months and/or calculated GFR<60ml/min/1.73m2

Monthly

• FBC
• U&E
• LFT
• Urinalysis monthly

Withhold treatment until discussion with rheumatologist if

• WBC<3.5
• neutrophils<2.0
• platelets​<1501

Consideration of withdrawal if

• WCC < 2.5
• platelets < 120 or there are 3 successive falls in count

Restart at reduced dose when counts return to within reference range

• permanent withdrawal necessary if recurrence of leucopenia or thrombocytopenia
• if proteinuria is 2+ or more, check MSSU
  • If evidence of infection treat appropriately
• If sterile and 2+ proteinuria or more persists (on two consecutive measurements), withhold until discussed with specialist team
• If abnormal bruising or sore throat- withhold until FBC available

Proton Pump Inhibitors:

esomeprazole

lansoprazole

omeprazole

pantoprazole

rabeprazole

Annual 

• Magnesium
• B12
• Calcium

Rivaroxaban 

Annual

• FBC
• U&E

6 Monthly if

• CrCl 30–60 mL/min

3 Monhtly if

• CrCl 15–30 mL/min.

Calculate CrCl then review dose

A low haemoglobin and/or haematocrit may suggest that occult bleeding is occurring and may require further investigations. Stop if severe bleeding occurs

Statin:

Simvastatin 

Atorvasatin

Rosuvastatin 

Pravastatin 

Fluvastatin 

Initiation

3 Months

• LFT
• Lipids 

12 months

• LFT

Statin therapy should not be started/should be discontinued if

• ALT or AST >3x upper limit of normal
• creatine kinase levels are more than 5 times the upper limit of normal
  • discontinued and re-measured after 7 days
  • If levels are still 5 times the upper limit of normal do not start/re-start.
  • If levels are raised but less than 5 times the upper limit of normal, start statin treatment at a lower dose
• eGFR is less than 30ml/min/1.73m2
  • check appropriateness of dosing of statin with a renal specialist
  • Rosuvastatin contra-indicated CrCl <30ml/min and maximum 40mg dose if CrCl > 60ml/min
• Patients with hypothyroidism should receive adequate replacement therapy before assessing their requirement for lipid-regulating treatment because correction may resolve the lipid abnormality and untreated hypothyroidism increases the risk of myositis
• Lipids high - check compliance and offer lifestyle advice; refer to duty
  • Triglycerides >10 refer to lipid clinic as may be pancreatic 

3 monthly for 12 months thereafter 6 monthly

• FBC
• U&E
• LFT

Withhold treatment until discussion with consultant specialist if

• WCC < 3.5 x 109/L
• Neutrophils< 1.6 x 109/L
• Unexplained eosinophilia > 0.5x 109/L
• Platelets < 140 150 x 109/l
• AST and/or ALT increase to > twice the upper limit of normal increase to >100units/ml
• Unexplained fall in serum albumin <30g/L
• MCV > 105f/L
• CrCl > 30% above baseline over 12 months and/or calculated GFR < 60ml/min/1.73m2

 2 Monthly 

• LFT

https://app.askshilpa.com/medical-conditions/gender-dysphoria/testosterone-for-gender-dysphoria

Trostan 

Adjust pumps to achieve serum testosterone level around 18

ALP

ALT

B12

CRP 

eGFR >60

• repeat if new result
• stable - continue
• reduced – show GP
• = kidney disease
  • usually associated with increased urea 
  • ususally associated with increased creatinine 
• may be due to other causes
  • urine infection
  • medication
  • dehydration 
  • diarrhoea / vomiting
  • if sudden drop, then likely dehydration; increase fluid intake and repeat bloods in a week 

eGFR falls by 25% / plasma creatinine increases by 30% from baseline

• stop the ACEI/ARB or reduce to a previously tolerated dose once potential alternative causes of renal impairment have been ruled out

eGFR falls by LESS than 25% / plasma creatinine increases by LESS than 30% from baseline 

• do not modify the dose but repeat the test in 1-2 weeks

Creatinine increase by >100% or to above 310 micromol/l

• ACE inhibitor should be stopped and specialist advice sought 

• WBC
• Platelets
• Hb conc

Lymphocytes - raised

• < 10 can probably infection
  • check with patient
  • If no infection recently redo after 2-3 weeks
• >10 possible leukaemia - refer

Low Ferritin

• long-term iron deficiency
• when body's protein levels are very low as in some cases of malnutrition

Raised Ferritin

• in states of long-term iron overload, especially in haemochromatosis
• a number of other reasons including inflammatory conditions and liver disease
• Further investigation is therefore required before a diagnosis of iron overload can be made

• Further testing may be necessary to determine the exact cause of the anaemia
• Conditions that can result in a low PCV include
  • Bleeding
  • Nutritional - iron, vitamin (e.g. B12 or folate) or other mineral deficiencies
  • Inflammatory conditions such as rheumatoid arthritis
  • polycythaemia where there are too many red cells
  • Kidney disease 
  • Cirrhosis of the liver
  • Haemolysis
  • Bone marrow disorders such as aplastic anaemia, myelodysplastic syndrome, leukaemia, lymphoma or myeloma
  • Some medicines– including chemotherapy

Haemoglobin

Low haemoglobin levels may be the result of:

• iron deficiency
• vitamin deficiencies e.g. vitamin B12
• bleeding
• kidney disease
• inflammatory disorders such as rheumatoid arthritis or infections
• haemolysis (accelerated loss of red blood cells through destruction)
• inherited haemoglobin defects such as thalassaemia or sickle cell anaemia
• cirrhosis of the liver (during which the liver becomes scarred),
• bone marrow failure
• cancers that affect the bone marrow
• infection

Raised haemoglobin levels may be the result of:

• dehydration 
• excess production of red blood cells in the bone marrow 
• severe lung disease  
• several other conditions

• < 42 mmol/mol (6.0%): Not diabetes
• 42 - 47 mmol/mol (6.0–6.4%): Impaired glucose regulation or prediabetes
• > 47 mmol/mol (6.5%): type 2 diabetes

see article on iron

LFT

Think: Is patient alcoholic?

Lipids

Note:::: In hypothyroidism, cholesterol goes up - Blood test for hypothyroidism to rule out 

MCH

Mean Cell Hb 

Not important 

Potassium

>6.0mmol/L

• stop ACEI/ARB therapy or anymedication causing hyperkalaemia
• repeat bloods
• small rise in isolated potassium < 5.8 -  likely spurious: repeat bloods in a week
• B-agonists – affect K+ levels, especially salbutamol

Prolactin

Refer to specialist if over 800

Protein

Low total protein levels can suggest

• a liver or kidney disorder
• a disorder in which protein is not digested or absorbed properly
• immunoglobulin not being made (for example in bone marrow failure)
• More specific tests, LFT, must be performed to make an accurate diagnosis
• for the purpose of medication monitoring this is not an important indicator

High total protein levels can indicate 

• dehydration 
• some types of cancer that lead to an accumulation of an abnormal protein
• for the purpose of medication monitoring this is not an important indicator

• if PSA > 40, there is a high chance that there is nodal or metastatic spread
• if PSA > 100, there is almost certainly metastatic spread

High >5.5 RBC may indicate

• congenital heart disease
• dehydration
• obstructive lung disease
• bone marrow over-production

Low <4.5 RBC may indicate

• anaemia 
• bleeding
• kidney disease 
• bone marrow failure
• nutritional deficiencies of iron, folate and vitamin B12  

Different types of anaemia:

• Microcytic; small, pale cells
  • Fe def anaemia
  • give Fe supplement
  • common in GI bleed
• Macrocytic; big and pale or big and dark
  • common in B12 def, pregnancy, alcoholism, thyroid problems
• Normocytic; normal size and normal colour
  • anaemia of chronic disease
  • common in HIV

Sex Hormone Binding Globulin

• Changes in SHBG can affect the amount of testosterone that is available to be used by the body
• Normally, about 45% of testosterone in men and about 70% in women, is tightly bound to SHBG, and most of the rest is weakly and reversibly bound to another protein, albumin
• Only about 1-3% is not bound and immediately available to the tissues as free testosterone
• A total testosterone test does not distinguish between bound and free testosterone; it measures the overall quantity of testosterone
• In many cases, this measurement is sufficient to discover excessive or deficient testosterone production; but, if a patient’s SHBG level is not normal, then the total testosterone may be misleading.

<135 mmol/L (hyponatraemia)

• too much water intake or retention
• fluid accumulation in the body (oedema)
• stop or reduce ACEi/diuretics or any medication casuing hypernaetraemia
• repeat bloods

<132 mmol/L

• specialist advice should be obtained
• Slow Sodium 600mg tablets may be recommended:
  • For treatment dosage to be adjusted to individual needs up to a maximum of 20 tablets per day in cases of severe salt depletion
  • For prophylaxis 4-8 tablets per day
  • For control of muscle cramps during routine maintenance haemodialysis usually 10-16 tablets per dialysis
  • In some cases of chronic renal salt-wasting up to 20 tablets per day may be required with appropriate fluid intake

>145 (hypernatraemia)

• almost always due to excessive loss of water (dehydration)
• symptoms include dry mucous membranes (mouth, eyes etc.), thirst, agitation, restlessness, acting irrationally, and coma or convulsions if concentrations rise extremely high
• In rare cases, hypernatraemia may be due to increased salt intake without enough water, Cushing's syndrome or too little anti-diuretic hormone (diabetes insipidus)

Excreted by kidney

High urea levels suggest poor kidney function. This may be due to acute or chronic kidney disease. However, there are many things besides kidney disease that can affect urea levels such as decreased blood flow to the kidneys as in congestive heart failure, shock, stress, recent heart attack or severe burns; bleeding from the gastrointestinal tract; conditions that cause obstruction of urine flow; or dehydration.

Low urea levels are not common and are not usually a cause for concern. They can be seen in severe liver disease or malnutrition but are not used to diagnose or monitor these conditions. Low urea levels are also seen in normal pregnancy.

If its sooo high, the Cr and/or eGFR would be increased too – if not, leave it

Elevated: 11.0–17.0x109/L cells = mild to moderate leucocytosis - Can be due to:

• bacterial infections
• inflammation
• leukaemia and other blood disorders
• trauma
• medication; epinephrine, allopurinol, aspirin, chloroform, heparin, quinine, corticosteroids, and triamterene
• post-operative

Decreased: 3.0–4.0x109/L cells = mild leucopenia - Can be due to:

• medication; antibiotics, anticonvulsants, antihistamine, antithyroid drugs, arsenicals, barbiturates, chemotherapeutic agents, diuretics and sulfonamides, chemotherapy, or radiotherapy
• bone marrow disorder
• vitamin deficiency, such as B12 or folic acid
• liver disease
• an enlarged spleen
• occasionally in inflammatory conditions such as rheumatoid arthritis or SLE
• some infections (particularly viral infections)
• diseases of the immune system

Look at the individual markers - if they are all normal then this is satisfactory