Chempath - pituitary + adrenals + lipid management Flashcards
High TSH and high prolactin
Primary hypothyroidism
TRH stimulates…?
TSH and prolactin
Prolactin levels in a non-functioning pituitary adenoma?
Super high prolactin
normally, dopamine inhibits prolactin release. In non-functioning pituitary adenoma, dopamine release is affected
Sheehan’s syndrome - TSH levels?
normal
How to assess visual field in macro adenoma?
Humphreys 30-2 test
How does lactational amenorrhoea work (i.e. breastfeeding prevents pregnancy how??)
Prolactin –> inhibits GnRH release
Prolactinoma is when prolactin is…
> 6000
Pituitary microadenoma - how should you approach these patients?
Most of them are asymptomatic + don’t grow - removing the pit gland would require medications for life
. Scan 1 year later
Pituitary function testing - what 3 things do you give?
- Induce hypoglycaemia w insulin 0.15U/kg
- give GnRH (to see if LH/FSH is released) 100mcg
- give TRH (to see if TSH if released) 200mcg
What must be checked in a patient before testing for pituitary function?
No Hx of epilepsy
Normal ECG
No cardiac RFs
–> hypoglycaemia is dangerous ok1!!
How to prevent dangerous hypoglycaemia when testing pituitary function
Ensure iv access with large bore canulae (so dextrose can be given if induced hypoglycaemia is too extreme)
What is the first symptom of hypoglycaemia?
Sympathetic activation: palpitations + sweating
Hypoglycaemia at around 2mM - how does the patient respond?
AGGRESSION
In a patient undergoing combined pituitary function testing: if severe hypoglycemia/unconsciousness occurs, how do you rescue the patient?
50mL of 20% dextrose
what dose of insulin is given in combined pituitary function test?
0.15units/kg
what plasma level of glucose should be achieved for combined pituitary function testing
<2.2mM
Only at this low level of glucose will the patient elicit a stress response
GnRH, TRH, insulin is given to ?pituitary failure patient. What is monitored once these are given? 7 things
- Glucose - to ensure hypoglycaemia isn’t too extreme
- GH
- Cortisol
- LH
- FSH
- TSH
- Prolactin
30 mins into the combined pituitary function test, the glucose level is 4mM. what should you do?
give more insulin
In a pt with prolactinoma, which treatment is urgent
Hydrocortisone replacement
In a pt with prolactinoma, if LH FSH is low, what do you need to give?
Oestrogen replacement
which hormone does not need to be replaced in prolactinoma?
Fludrocortisone
2 tests to confirm acromegaly dx
OGTT
IGF1
Treatments for acromegaly
Pituitary surgery = number 1!!!
2nd line = radiotherapy
Drugs: cabergoline, Ocreotide
Ocreotide
GH inhibitor
Management of addison’s disease
1) if severely hypotensive –> IV 0.9% saline
2) Hormone replacement - fludrocortisone and hydrocoritson
Ddx for adrenal mass and hypertension?
give 3
Phaeo
Conn’s
Cushing’s
Management of Phaeochromocytoma
1) IV fluids
2) urgent alpha blockade w phenoxybenzamine
3) beta blockade
4) surgical resection
static test for suspected cushing’s
morning and evening cortisol
top 3 investigations for suspected cushing’s
1) morning + evening cortisol
2) dexamethasone suppression test
3) pituitary MRI
2nd line drugs for lipid lowering
Ezetimibe + evolocumab
PCSK9 inhibitor - eg? how does it work?
Evolocumab
reduces LDLR recycling, so more LDLR is mopped up from plasma
Ezetimibe - MOA?
NPC1L1 inhibitor
Prevents cholesterol absoprtion
Empagliflozin - MOA?
SGLT2 inhibitor –> reduces glucose reabsorption –> glycosuria + lower plasma glucose level
SGLT2 inhibitor - eg? how does it work?
Empagliflozin
- inhibits glucose reabsorption in kidney, so plasma glucose is lowered
GLP1 agonists - give egs?
Seraglutide, liraglutide
GLP1 agonists - MOA?
induces insulin release
Seraglutide - MOA?
GLP1 agonist –> induces insulin release
Which drug causes glycosuria in a good way?
Empaglifozin = SGLT2 inhibitor (inhibits renal glucose reabsorption)
