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Endocrine > Anterior Pit (5/6) > Flashcards

Anterior Pit (5/6) Flashcards

1
Q

what important shit sits around the anterior pituitary

A

common carotid

sphenoid sinus with CN III, IV, VI

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2
Q

What does the anterior pit secreate?

A

Prolactin

Growth hormone (GH)

Adrenocorticotropic hormone (ACTH)

Follicle stimulating hormone (FSH)

Luteinizing hormone (LH)

Thyroid‐stimulating hormone (TSH)

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3
Q

Prolactin synthesis and secretion is mainly under tonic inhibitory control by_____ which is made in the hypothalamus and it keeps prolactin at its basal level.

A

dopamine

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4
Q

Stimulators of _______ include reduced dopamine availability to the lactotroph, thyrotropin‐releasing hormone (TRH), estrogen, vasopressin, vasoactive intestinal polypeptide (VIP), oxytocin and epidermal growth factor.

A

prolactin synthesis and secretion

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5
Q

How is hyperprolactinemia diagnosed?

A

single measurement of serum prolactin and a level above the appropriate population reference range confirms the diagnosis.

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6
Q

A serum prolactin concentration of >250 ng/ml usually indicates the presence of a

A

prolactinoma (prolactin‐secreting pituitary tumor)

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7
Q

However, some drugs, including _____and _____ may increase prolactin to >200 ng/ml

A

metoclopramide and risperidone (dopamine antagonists),

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8
Q

What is the likely cause of mild/mod hyperprolactinemia in the 25-100ng/ml range?

A

in the presence of a larger pituitary mass, is more likely to be due to a nonprolactin‐secreting tumor with infundibular stalk compression and inhibition of dopamine transport to the lactotroph.

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9
Q

PHysiological causes of HYPERprolactinemia

A

Pregnancy, lactation, exercise, sleep and stree

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10
Q

Medications that cause hyperprolactinemia

A

Antihypertensives such as methyldopa

Estrogens

D2 dopamine receptor antagonists such as metoclopramide, domperidone Neuroleptics/antipsychotics such as phenothiazines, butyrophenones,risperidone also block dopamine receptors

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11
Q

Hyperprolactinemia can be a result of hypothalamic-pituitary stalk damage as a result of:

A

Infiltrative disorders (Sarcoidosis)

Irradiation to brain

Trauma with pituitary stalk section or pituitary surgery Tumors

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12
Q

Hyperprolactinemia due to pitutiary origin may result from

A

Prolactinomas

Macroadenoma (compression of infundibular stalk)

Lymphocytic hypophysitis (autoimmune)

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13
Q

Prolactinomas and hyperprolactinemia are more common in women with peak prevalence being between ___ years

A

25‐35

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14
Q

How do young menstrating women present with a prolactinoma?

A

young menstruating women present with menstrual irregularities, galactorrhea (occurs in 50‐80% of affected women) and infertility.

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15
Q

How do men present with hyperprolactinemia

A

Men may report a decrease in libido and erectile dysfunction as a result of hypogonadism, but galactorrhea is less common, occurring in approximately 20‐30% of affected men.

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16
Q

In hyperprolactinemia, The hypogonadism in men and decrease in menses in women are both caused by the hyperprolactinemia inhibiting the

A

pituitary gonadotropins, FSH and LH.

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17
Q

When prolactinoma is the cause of the hyperprolactinemia, women tend to present with microadenomas due to

A

the early presentation and work up of the menstrual irregularities

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18
Q

macroprolactinomas are more frequent in

A

men and postmenopausal women at presentation.

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19
Q

signs and symptoms of macroprolactinomas include

A

headaches, neurologic deficits due to cavernous sinus involvement and visions changes due to optic chiasm compression and cavernous sinus involvement

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20
Q

Main treatement for Hyperprolactinemia

A

Dopamine agonist to supress produciton of prolactin via D2 receptor

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21
Q

MOA of Cabergoline in tx of hyperprolactinemia

efficacy:

A

dompaine agonist

– higher efficacy in normalizing prolactin levels and in shrinking tumor size and fewer side effects.

– longer half-life (65 hours), higher affinity, and greater selectivity for the D2 receptor (approximately four times more potent) than bromocriptine

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22
Q

Side effects of Cabergoline

A

nausea, vomiting, orthostatic lightheadedness, dizziness and nasal congestion, but cabergoline has also been reported to cause a cardiac valvulopathy in Parkinson’s patients treated with much higher doses of.

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23
Q

Dopamine agonist recommended in patients undergoing fertility induction that also have hyperprolactinemia, because of its greater track record.

A

Bromocriptine:

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24
Q

Whats the half life of bromocriptine

A

Bromocriptine has a relatively short elimination half-life (between 2 and 8 hours) and requires frequent dosing.

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25
What are the results of using bromocriptine in pt with prolactinoma?
Normalize prolactin, decrease tumor size and restore gonadal function in greater than 80% of patients with prolactinomas
26
Initial treatment for macroprolactinomas that have caused compromise of vision, neurologic deficits and pituitary function.
Bromocriptine
27
What two factors inhibit GH release? What increaes it?
inhibited by IGF-1 and somatostatin increased by GHRH
28
. GH stimulates _____ secretion by the liver which circulates in the blood attached to binding proteins
insulin‐like growth factor 1 (IGF‐1)
29
\_\_\_\_and _____ are critical in determining longitudinal skeletal growth, as well as skeletal maturation and acquisition of bone mass and in adulthood, they are instrumental in the maintenance of skeletal architecture and bone mass
GH and IGF‐1
30
GH also has effects on carbohydrate, lipid and protein metabolism by :
antagonizing insulin action, increasing lipolysis and free fatty acid production and increasing protein synthesis.
31
e abnormal enlargement of the extremities of the skeleton and is caused by unrestrained hypersecretion of GH in adulthood
acromegaly
32
. In children, excessive GH secretion prior to closure of the epiphyseal growth plate leads to
gigantism or very tall stature
33
Acromegaly is always due to
due to a GH‐secreting pituitary tumor
34
Approximately, 30% of GH‐secreting pituitary adenomas are\_\_\_\_\_ and also secrete prolactin. The incidence of acromegaly is about 2‐4 per million with a mean age at diagnosis of 40‐50 years.
plurihormonal
35
period from the earliest onset of symptoms and signs to diagnosis is 8‐10 years during which time many patients have been treated both medically and surgically for many of the metabolic abnormalities and morbidities caused by GH excess.
timeline for acromegaly
36
common features of somatic changes we see with acromegaly
big hands/feet, prognathism or enlarged mandible, frontal bossing, malocculsion w/ spaced teeth, sleep apnea, skin tags and nevi, excess sweating, cardiomegaly, HTN
37
Endocrin changes seen inpts with acromegaly
Menstrual abnormalities and male hypogonadism due to concomitant PRL production by tumor or tumor compression of gonadotrophs Galactorrhea due to (a) concomitant PRL production by tumor or (b) direct GH stimulation of PRL‐ binding sites in the breast Diabetes mellitus type 2/impaired glucose tolerance caused by direct anti‐insulin effects of GH.
38
Measurement of\_\_\_\_\_\_ can diagnose excess GH in 99% of patients with acromegaly.
serum IGF‐1
39
IGF‐1 has a half life of 16 hours so a single measurement is more constant and accurate than a single measurement of GH due to
its very short half life and very pulsatile secretion.
40
Conditions that can cause inaccurate low IGF‐1 levels include
malnutrition, acute illness, celiac disease, poorly controlled diabetes mellitus, liver disease, and estrogen ingestion.
41
What is another test besides IGF-1 to diagnose GH excess
Oral glucose tolerance test, using a 100 gram glucose load, is another test used to diagnose GH excess
42
whats the #1 tx for acromegaly?
transphenoid surgery to remove the tumor Patients with intrasellar microadenomas have a 75‐95% cure rate with surgery. Even in patients with noninvasive macroadenomas surgical removal results in normalization of IGF‐1 in 40‐68% of patients
43
How does radiation therapy work for pts with GH excess?
can decrease and normalize GH secreation; may take 10-20 yrs to achieve has 60% in normalizing ; single dose gamma knife radiotherapy with 5 year remission rate
44
What drug therapy is recommended for acromegaly?
somatostatin receptor ligands (SRLs); ocreotide and lanreotide Cabergoline Pegvisomat
45
GH receptor antagonist used to tx acromegaly. Works by blocking peripheral action of GH (liver GH receptor)
Pegvisomant
46
is indicated in patients who have persistent elevation in IGF‐1 with maximum doses of SRLs.
Pegvisomant
47
. This drug is highly effective in the treatment of acromegaly and normalizes IGF‐1 levels in 97% of patients; however, transient elevation in liver function tests is seen in 25% and tumor growth is seen in \<2% of patients treated with this drug.
Pegvisomant
48
is the most efficacious of the dopamine agonist in acromegaly but it is very limited and is effective in less than 10% of patients.
Cabergoline
49
In acromegaly these are indicated for first line treatment when there is low probability of surgical cure, after failed surgical cure of GH hypersecretion, before surgery to improve severe comorbidities that prevent or could complicate immediate surgery, and to provide GH and IGF‐1 control or partial control while waiting for radiotherapy to its maximum effect
Octreotide and lanreotide
50
Receptor targets for treatment of acromegaly. Pituitary somatostatin receptor subtypes and D2 receptors and peripheral growth hormone (GH) receptors are targets for therapeutic ligands
targets for pituitary receptors
51
results from the failure of one or more pituitary hormones to be produced or secreted from the anterior pituitary gland while panhypopituitarism is the deficiency of all anterior pituitary hormones
Hypopituitarism
52
Mass lesions that can cause Panhyopituitarism/Hypopituitarism
such as pituitary tumors, craniopharyngiomas, cysts (Rathke’s cleft cyst), other brain tumors (meningiomas), pituitary carcinomas, metastatic tumors (breast, lung, colon)
53
Treatment of sellar, parasellar and hypothalamic disease, such as pituitary/hypothalamic surgery, radiotherapy, radiosurgery (gamma knife) can lead to:
Panyhypopituitarism/Hypopituitarism
54
other causes of Panhypopituitarism
Infiltrative disease, such as autoimmune (lymphocytic hypophysitis), hemochromatosis, sarcoidosis Traumatic, such as head injury, perinatal trauma Vascular, such as Sheehan’s syndrome, pituitary tumor apoplexy Medications, such as opiates, pharmacologic glucocorticoid therapy, suppressive thyroxine therapy,sex steroid treatment
55
Key clinical findings of Panhypopituitarism
ACTH deficiency or secondary adrenal insufficiency TSH deficiency or secondary hypothyroidism GH deficiency in adult Prolactin deficiency Gonadotropin deficiency of hypogonadotropic hypogonadism
56
ACTH deficiency or secondary adrenal insufficiency
Unintentional weight loss, Generalized weakness, Lethargy and fatigue, Nausea/vomiting/anorexia, Abdominal pain, Diffuse arthralgias and myalgias, Orthostatic hypotension, Hyponatremia, Hypoglycemia
57
TSH deficiency or secondary hypothyroidism causes:
Weight gain, Generalized weakness, Fatigue and lethargy, Diffuse arthralgias and myalgias, Cold intolerance, Constipation, Dry skin and hair, Diffuse edema with periorbital edema Bradycardia
58
GH deficiency in adult
Abnormal body composition with increased visceral fat and decreased lean muscle mass, Psychological impairment with reduced energy, social isolation, emotional lability, depressed mood, Reduced muscle strength and exercise performance, Reduced bone mineralization, Abnormal lipid profile with elevated LDL and TG and decreased HDL
59
When diagnosing panHYPOpituitarism, what do we order for Prolactin, TSH?
Prolactin: see basal prolactin level TSH: see basal TSH and free T4: low T4 with low or inappropriately normal TSH
60
ACTH in Panhypopituitarism:
cortisol 8AM fasting: insufficient if cortisol\<3 mcg/dl - ACTH stimulation test: serum cortisol insufficiency if response \<18 mcg/dl - Insulin tolerance test with serum measurement of cortisol at 0, 30, and 60 mins: insufficiency if serum cortisol resonpse is \<18mcg/dl
61
Testing for Panhypopituitarism: FSH/LH Males: 8AM fasting serum total testosterone, FSH, LH:
insufficiency if testosterone is below the normal range with low or inappropriately normal LH and FSH.
62
Testing for Panhypopituitarism In Females: Basal serum estradiol, FSH, LH: insufficiency if
estradiol is low with low or inappropriately normal FSH and LH.
63
Hormone replacement recomended for low thyroid
TSH or thyroid is replaced with levothyroxine or T4, adjust dose according to free T4 and not TSH
64
What do we do to tx panhypopituitarism from adrenal gland standpoint?
ACTH or cortisol is replaced with hydrocortisone 10 mg QAM and 5 mg QPM or prednisone 5‐7.5 mg QD, no mineralocorticoid is needed with secondary adrenal insufficiency
65
What do you to do tx females with panhypopituitarism suffering from lack of Gonadotropins
Gonadotropins female is replaced with estrogen and progesterone (if uterus present), such as OCP, patch. Fertility will require fertility drugs, gonadotropins, for ovulation.
66
What do you to do tx males with panhypopituitarism suffering from lack of Gonadotropins
Gonadotropins male is replaced with testosterone, such as injections, gel, patch forms. Fertility will require HCG injections IM 3 times per week.
67
Newborn baby has jaundice, hypoglycemia, microphallus these are all symptoms of:
GH deficiency in nenoate
68
Propensity for hypoglycemia Increased fat High‐pitched voice Microphallus Absent or delayed puberty in the adolescent Weight less affected than height all signs of
GH deficiency in children
69
GH deficiency in children can be seen doing which type of test
often order combo of tests: see stuff like arginine,Levodopa, or insulin or clonidine signlas for GH peak at sleep, exercise
70
Recommended therapy for child with GH deficiency
e recombinant human growth hormone (rGH), which is given as a subcutaneous injection. It is typically given each evening to mimic the normal diurnal pattern of growth hormone release.
71
How do you dose rGH for child with true GH deficiency
need much smaller doses of GH than a child with idiopathic short stature (ISS), and the dose is around 0.2‐0.3 mg/kg/week.
72
How do we determine dose changes for rGH in GH deficienct children?
check IGF‐I (insulin‐like growth factor 1) levels to determine dose changes.
73
is used therapeutically in children with short stature with growth hormone deficiency and short stature despite adequate GH production with other conditions including Turner's syndrome, N
Growth hormone (hGH)
74
a dopamine agonist, is used for the treatment of hyperprolactinemia, prolactin‐secreting adenomas, acromegaly and Parkinson's disease.
Bromocriptine,
75
is also a dopamine agonist used to treat hyperprolactinemic disorders.
Cabergoline
76
somatostatin analogs used to treat acromegaly
Octreotide and lanreotideare
77
is a GH receptor antagonist used for the treatment of acromegaly
Pegvisomant
78
Pt has milky discharge from fluid, not pregnant, no recent deliveries. get prolactin level: its at 1250 (normal is \<23.3) what is the next step?
MRI of pituitary
79
What is the recommended treatement for prolactin secreating pituitary tumor?
For macro: start a dopamine agonist such as carbergoline
80
What is the preferred D2 receptor agonist to use over bromocriptine bc has less side effects and better efficacy to normalize prolactin levels
cabergoline
81
why do we see hypogonadism with hyperprolactinemia
dt its inhibitory effect on gonadotorpins
82
What is a side effect with hGH injections that you need to be careful of?
headaches with nausea or vomitting
83
in children tx for growth hormone deficiency, rhGH is given each night by subQ injeciton and you need to check\_\_\_\_\_\_ to insure proper dosing
IGF-1
84
Side effects of GH are rare and include:
slipped capital femoral epiphysis, scoliosis, psuedotumor cerebri, obstructive sleep apnea

Endocrine (20 decks)

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