Chempath - pituitary + adrenals + lipid management

Question 1

High TSH and high prolactin

Answer 1

Primary hypothyroidism

Question 2

TRH stimulates…?

Answer 2

TSH + prolactin

Question 3

Prolactin levels in a non-functioning pituitary adenoma?

Answer 3

Super high prolactin

normally, dopamine inhibits prolactin release. In non-functioning pituitary adenoma, dopamine release is affected

Question 4

Sheehan’s syndrome - TSH levels?

Answer 4

normal

Question 5

How to assess visual field in macro adenoma?

Answer 5

Humphreys 30-2 test

Question 6

How does lactational amenorrhoea work (i.e. breastfeeding prevents pregnancy how??)

Answer 6

Prolactin –> inhibits GnRH release

Question 7

Prolactinoma is when prolactin is…

Answer 7

> 6000

Question 8

Pituitary microadenoma - how should you approach these patients?

Answer 8

Most of them are asymptomatic + don’t grow - removing the pit gland would require medications for life

. Scan 1 year later

Question 9

Pituitary function testing - what 3 things do you give?

Answer 9

1. Induce hypoglycaemia w insulin 0.15U/kg
2. give GnRH (to see if LH/FSH is released) 100mcg
3. give TRH (to see if TSH if released) 200mcg

Question 10

What must be checked in a patient before testing for pituitary function?

Answer 10

No Hx of epilepsy
Normal ECG
No cardiac RFs

–> hypoglycaemia is dangerous ok1!!

Question 11

How to prevent dangerous hypoglycaemia when testing pituitary function

Answer 11

Ensure iv access with large bore canulae (so dextrose can be given if induced hypoglycaemia is too extreme)

Question 12

What is the first symptom of hypoglycaemia?

Answer 12

Sympathetic activation: palpitations + sweating

Question 13

Hypoglycaemia at around 2mM - how does the patient respond?

Answer 13

AGGRESSION

Question 14

In a patient undergoing combined pituitary function testing: if severe hypoglycemia/unconsciousness occurs, how do you rescue the patient?

Answer 14

50mL of 20% dextrose

Question 15

what dose of insulin is given in combined pituitary function test?

Answer 15

0.15units/kg

Question 16

what plasma level of glucose should be achieved for combined pituitary function testing

Answer 16

<2.2mM

Only at this low level of glucose will the patient elicit a stress response

Question 17

GnRH, TRH, insulin is given to ?pituitary failure patient. What is monitored once these are given? 7 things

Answer 17

1. Glucose - to ensure hypoglycaemia isn’t too extreme
2. GH
3. Cortisol
4. LH
5. FSH
6. TSH
7. Prolactin

Question 18

30 mins into the combined pituitary function test, the glucose level is 4mM. what should you do?

Answer 18

give more insulin

Question 19

In a pt with prolactinoma, which treatment is urgent

Answer 19

Hydrocortisone replacement

Question 20

In a pt with prolactinoma, if LH FSH is low, what do you need to give?

Answer 20

Oestrogen replacement

Question 21

which hormone does not need to be replaced in prolactinoma?

Answer 21

Fludrocortisone

Question 22

2 tests to confirm acromegaly dx

Answer 22

OGTT

IGF1

Question 23

Treatments for acromegaly

Answer 23

Pituitary surgery = number 1!!!

2nd line = radiotherapy

Drugs: cabergoline, Ocreotide

Question 24

Ocreotide

Answer 24

GH inhibitor

Question 25

Management of addison's disease

Answer 25

1) if severely hypotensive --> IV 0.9% saline | 2) Hormone replacement - fludrocortisone and hydrocoritson

Question 26

Ddx for adrenal mass and hypertension? | give 3

Answer 26

Phaeo Conn's Cushing's

Question 27

Management of Phaeochromocytoma

Answer 27

1) IV fluids 2) urgent alpha blockade w phenoxybenzamine 3) beta blockade 4) surgical resection

Question 28

static test for suspected cushing's

Answer 28

morning and evening cortisol

Question 29

top 3 investigations for suspected cushing's

Answer 29

1) morning + evening cortisol 2) dexamethasone suppression test 3) pituitary MRI

Question 30

2nd line drugs for lipid lowering

Answer 30

Ezetimibe + evolocumab

Question 31

PCSK9 inhibitor - eg? how does it work?

Answer 31

Evolocumab | reduces LDLR recycling, so more LDLR is mopped up from plasma

Question 32

Ezetimibe - MOA?

Answer 32

NPC1L1 inhibitor | Prevents cholesterol absoprtion

Question 33

Empagliflozin - MOA?

Answer 33

SGLT2 inhibitor --> reduces glucose reabsorption --> glycosuria + lower plasma glucose level

Question 34

SGLT2 inhibitor - eg? how does it work?

Answer 34

Empagliflozin | - inhibits glucose reabsorption in kidney, so plasma glucose is lowered

Question 35

GLP1 agonists - give egs?

Answer 35

Seraglutide, liraglutide

Question 36

GLP1 agonists - MOA?

Answer 36

induces insulin release

Question 37

Seraglutide - MOA?

Answer 37

GLP1 agonist --> induces insulin release

Question 38

Which drug causes glycosuria in a good way?

Answer 38

Empaglifozin = SGLT2 inhibitor (inhibits renal glucose reabsorption)