Endo Block 2 Flashcards
What is the most convenient population level measure of overweight and obesity currently available?
BMIs of what percentage are categorized as overweight, Class 1-3?
BMI- kg/m^2
Normal: 18.5-24.9 Over: 25-29.9 Class 1: 30-34.9 Class 2: 35-39.9 Class 3: Greater than 40
What are four cons of using BMI as a measurement tool?
Upper body obesity that is located ? and ? is more significant than lower body obesity of fat located ? or ?
Mis-classifies 25% of PTs
No account for fat location
Not accurate for sedentary/body builders
Not distinguished between fat/lean mass
Abdomen/flank
Thigh/buttocks
Fat that is located ? is more hazardous to health and is composed of ? fat
Females must have a minimum body fat of -% to have a regular menstruation?
Abdominal fat
Visceral
13-17%
Upper body obesity and abdominal fat is associated w/ abnormal adipose lipolysis leading to ? and higher incidences of ? complications
What is the number one cause of high output heart failure?
What is the number one public health concern linked to increasing levels of obesity?
Insulin resistance
Metabolic
Obesity
DM
Men must have _% body fat
What is the name of an environment that can increase the chance of a PT becoming obese?
3%
Obesigenic
What are the 5 parts of the motivational interview?
What is the most common genetic cause of obesity?
What is an independent predictor of metabolic abnormalities associated w/ obesity over and above the effects of exercise?
Nutrition intervention Physical activity Behavior therapy Pharmacotherapy Bariatric surgery
Prader-Willi Syndrome- demonstrates hyperphagia (compulsive overeating over long periods of time)
Sedentary activities
If an adopted PT is concerned about weight gain, how can this be predicted?
What are the typical features of Prader-Willi Syndrome?
Biological parents weight
Hypotonia
Almond shaped eyes
Narrow bifrontal diameter
Thin upper lip
What is done during PE for an obesity work up?
What diabetic drugs can cause weight gain?
BMI, degree/distribution of body fat, nutritional status, signs of secondary cause
Insulin
Sulfonyureas
Thizolidinediones
How much weight loss can be expected with conventional diet techniques?
What is the more important part of obesity management?
20% lose 20lbs and maintain for 2yrs
5% maintain a 40lbs loss
Avg= 7% loss from baseline
PT-Provider contact
Trimble’s obesity management plan and associated goals?
Define Very Low Calorie Diet
Diet/Exercise= greatest loss
Only diet= moderate loss
Only exercise= small loss
No Tx= no loss
800-1000cal/day x 4-6mon w/ average loss of 15%
Significant weight gain after 18mon
What are six classes of drugs that are known to cause weight gain?
What class of medication can be considered for these PTs that have underlying psych issues?
Psych/Neurological Steroid hormones Anti-diabetes (Insulin, Sulfonylureas, Thiazolidinediones) Anti-histamines Anti-HTN Anti-retroviral therapy
SSRIs
How much exercise is recommended per week by the College of Sports Med?
How much moderate exercise is recommended per day?
150min moderate
75min vigorous
Equivalent mod/vigorous combo
Weights 2x/wk
1hr
When are meds added to obesity management?
What GI agent is used for management and how does it exert it’s effect in PTs?
BMI >30
BMI >27 w/ obesity related RFs: HTN, DM2, CVD
Orlistat- Inhibits intestinal lipase/fat absorption
S/e- oily stool/diarrhea, incontinence
What CNS stimulant/anorexants are used for obesity management and how does it do it?
Lorcaserin- SSRA, promotes satiety for moderate weight loss >5%
S/e= HA, breast tumors
Phentermine- inc NorEpi/dopamine uptake suppressing appetite x 3mon
Phen/Topiramte- migraine prophylaxis, weight loss effect. C/i- hypothyroid, glaucoma
D/c if no loss in 4wks
What antidepressant/opioid agonist is used for obesity management?
Bupropion/Naltrexone- regulates dopamine reward system, cravings and overeating behaviors
S/e- GI upset
Caution in Psych Hx
C/i- HTN, opioid use, seizure, eating d/o
What GLP-1 agonist can be used for obesity management
Liraglutide- DM management med, increases insulin secretion, decreases inappropriate glucagon and slows gastric emptying
S/e- tachy, HA, hypoglycemia, nausea
C/i- medullary thyroid CA, MEN2a
What are the general contraindications for using weight loss meds?
Uncontrolled CAD Pregnancy/feeding Hx of psych dz <18y/o Certain med use- MAOIs
When is bariatric surgery a consideration for obesity management?
What is the name of the gastric bypass procedure?
> 40% BMI or >35 w/ co-morbidities
Roux-en-Y gastric bypass
Restrictive/malabsorptive surgery, distal stomach resected. Remaining pouch is anastomosed to retro-colic segment of jejunum leaving gastric capacity at 30-50mL
Dec food intake/absorption of ingested food
What is the name of the Lap Band procedure?
Define Sleeve Gastronomy
Vertical banded gastroplasty
Prosthetic band dec size of gastric outlet
Multiple f/u visits for adjustment
Creation of sleeve over bougie, removing portion of greater curvature
Dec ghrelin levels x 1yr
Restricts food intake
Define Dumping Syndrome
What does Hirsutism mean?
Bariatric surgery complication when PT has to defecate nearly immediately after eating
Latin- shaggy, hairy
Excessive terminal hair growth that appears in women in a male pattern
Androgens act on sex-hormone responsive hair follicles causing a transition from ? to ?
Half of women with Hirsutism will have ?
Vellus into terminal
Hyperandrogenism
What will be seen in women with hirsutism that have increased follicle sensitivity to normal levels of androgens?
What is the Hirsutism is pathological?
How is Hirsutism scored?
Normal labs- genetics
Elevated circulating androgens, will have elevated labs
Ferriman-Gallwey score
Norm: <8
Max: 36
Where does DHEA S come from?
Where does Androstenedione released from?
Where is testosterone ( the most potent) secreted from?
Adrenal gland
Ovary and adrenal gland
Ovary/adrenal gland
What is the most potent androgen in females?
65% is bound to ? protein
33% is bound to ? protein
Testosterone
Sex hormone binding globulin
Albumin
How and where is free testosterone converted into dihydrotestosterone?
Why is this conversion important?
In the skin by 5a-reductase
5-DHT stimulates androgen dependent hair follicles
What are the 5 etiologies of hirsutism?
Which etiology is most common in middle eastern and Mediterranean groups?
Idiopathic/familial PCOS Steroidogenic enzyme defect Neoplastic d/o Rare/pharmacologic
Idiopathic/Familial
What lab results would be seen in Med/Middle eastern females w/ Hirsutism?
What is believed to be that cause of this?
Normal androgen levels
Onset at puberty
Regular menses, PE
Higher 5a-reductase activity
What is beleived to be the most common cause of Hirsutism in females?
How is this acquired?
PCOS- function d/o of ovaries
Functional d/o of ovaries
Familial passsage of autosomal dominant trait
50% of Hirsutism PTs have elevated levels of ?
What criteria is used to Dx Hirsutism?
Testosterone
Rotterdam Criteria
1- extra androgen (hirsutism, acne, androgenic alopecia)
2- ovarian dysfunction/polycystic morphology (oligo/amenorrhea, infertility)
3- Absence of other causes of excess testosterone (pregnancy, thyroid, neoplasm)
What are the S/Sxs associated with the 3 parts of Rotterdam criteria?
Androgen excess/Elevated testosterone- Hirsutism, Acne, Androgenic alopecia
Ovarian dysfunction- Oligo/Amenorrhea w/ anovulation, infertility
Absence of other causes of testosterone- pregnancy, thyroid dysfunction, neoplasm, Cushings, Hyperprolactinemia
What are two unique facts about a PCOS Dx?
How is PCOS Tx?
30% of PCOS women doen’t have cystic ovaries
30% of normal menstruating women do have cystic ovaries
Restore cycles/fertility
Reduce Sxs- hair, oil, weight
Congenital adrenal hyperplasia is a defected level of ? enzyme?
What are the two types?
21-hydroxylase
Classic- complete deficiency; ambiguous genitals, virilized when treated w/ CCS
Non-classic: partial deficiency; PCOS and adrenal adenomas are more likely to develop
Irregular menses, gradual onset of hirsutism
What neoplastic d/os can cause Hirsutism?
Ovarian tumors
Adrenal carcinoma
Pure androgen secreting adrenal tumor
What are the 4 features of neoplastic d/o hirsutism?
What is the next step for this PT?
Onset out of peri-menarchal period
Rapid/severe hair progression
Recent menstrual irregularity
Signs of virilization (deep voice, inc muscles)
Measure androgen levels
What are the rare causes of hirsutism?
What medications can cause hirsutism?
Acromegaly
Cushings
Minoxidil- Tx of androgenic alopecia (frontal balding) Cyclosporine- imm suppressant Phenytoin- anti-seizure Anabolic steroids Progestins in OCPs (Norethindrone)
Key S/Sxs of Hirsutism
Inc hair Inc sebaceious activity Menstrual irregularities Anovulation Amenorrhea Defeminization Virilization
What lab is the most useful test for evaluating Hirsutism?
Serum androgen to find adreanl/ovarian neoplasm
Free testosterone- most important
Androstenedione
DHEA-S
If female PT has testosterone levels >200ng/dl what is the next step?
What if these tests are negative?
Pelvic exam and US
Bilateral CT of adrenal glands
What are the second and third labs evaluated during hirsutism?
Serum androstenedione- >1000 suggests ovarian/adrenal neoplasm. Do pelvic US and bilateral CT adrenal scan
Serum DHEA-S- >700mcg= adrenal source
Order bilateral adrenal CT scan
What labs are ordered for a hirsutism work up?
What images are ordered for hirsutism after PE and labs?
LH/FSH 17-hydroxyprogesterone Fasting insulin/glucose TSH/FT4/PRL UA- cortisol Lipids
Adrenal CT- elevated DHEAS, elevated testosterone after negative pelvic and US
Pelvic US- elevated testosterone/androstenedione
Pelvic MRI- visualized tumors of ovary
When are neoplastic origins of hirsutism treated?
Surgery
What are the non-surgical Tx options of hirsutism and are c/i in pregnancy?
Spirinolactone- K sparing w/ anti-androgenic action
Flutamide- non-steroid, non-selective anti-androgen
Finasteride- 5a-reductase inhibitor, only used in post-menopause females
What med can be added to spirinolactone to increase it’s efficacy?
What drug combo is more effective than spirinolactone?
OCPs
Metformin
OCPs and Flutamide
What are the new combined OCPs used to reduce hirsutism and acne?
What are the s/e of using these combos
Desogestrel
Drospirenone
Norgestimate
Inc DVT risk, use lower estrogen formulas
When/why is metformin used for hirsutism?
What is it’s use combined with?
PCOS to improve menses and promote weight loss
W/ Sironolactone
When/why is Simvastatin used for hirsutism?
When is Clomiphene used?
Reduces hirsutism and testosterone levels in PCOS, improved when sued w/ OCPs
Fertility aid in PCOS and infertility
What cosmetic therapies can be used for hirsutism?
What are the etiologies of gynecomastia?
Vaniqa cream- dec hair growth in 4-8wks
Physiologic Endocrine Dz Systemic Dz Neoplasms Meds- 59 total
What are the 4 physiological causes of gynecomastia?
Neonatal- transient and self resolving, due to high estrogen from pregnancy
Puberty- very tall/overweight boys, 60% of normal boys affected and self resolves in 1yr
Aging- seen w/ dec testosterone and weight gain, increased SHBG reduces free testosterone
Obesity- inc fat increases aromatse activity converting testosterone into estradiol (usually pseudo-gynecomastia)
What’s the difference between glandular and fatty gynecomastia?
What are the 5 etiologies of gynecomastia?
Glandular- tender
Fatty- non-tender
Physiologic Endocrine dz Neoplasm Systemic Dz Meds- 59 of them
What are the endocrine abnormalities that can cause gynecomastia?
What are the 3 systemic diseases that can cause gynecomastia?
Androgen insensitivity
Hypogonadism- Klinefelters
Hyperprolactinemia
Hyperthyroidism
Liver, renal dz
Spinal cord injury
What types of neoplasms can cause gynecomastia?
Steroid producing (estrogen)
hCG producing in lung, teste, hepatocellular, gastric carcinoma
Breast Ca- unilateral, irregular, painless, firm/fixed to underlying tissue
At a BioChem level, what causes gynecomastia?
Male breast cancer has a higher incidence rate in ? PT population?
Testosterone converted by aromatase into estradiol in adipose/extra-gonadal tissues
Klinefelters
What are 5 meds that can cause gynecomastia?
Spironolactone*- only common
Cimetidine
Ketoconazole
5a-reducatse inhibitors for BPH (Proscar, Avodart)
Exogenous steroid/androgen
HIV Tx w/ highly active antiretroviral therapy- especially Efacirenz or Didanosine
FSH stimulates ? process
LH stimulates ? process?
Gynecomastia presents as ? development while CA presents as ?
F- binds to Sertoli cells in seminiferous tubules to stimulate spermatogenesis
L- Leydig cells in testes to produce testosterone
G: concentric
C: ecentric, off to side
Gynecomastia is usually located ? when compared to where female breast cancer usually shows
How is gynecomastia Dx?
CA- supper lateral quad, gynecomastia- under nipple
Clinically
DDx of gynecomastia
Unilateral, Painless, Eccentric= Breast Ca, Lipoma, Neurofibroma
Bilateral, Painless= obesity, pseudogynecomasti
What labs are ordered for gynecomastia?
How is Klinefeltors Dx’d?
PRL, hCG, LH, testosterone, estradiol, TSH
Persistent gynecomastia w/out identifiable etiology
If a male has one of what 5 conditions, no work up is needed for gyneocmastia
Hypogonadism Liver Dz Testicular tumor Hyperthyroid Medication Hx
Lab results for gynecomastia
PRL and b-hCG
High PRL= hyperprolactinemia, pituitary lesion
High b-hCG= malignancy in liver, lung, testis
Testosterone/LH
Low T, High LH= primary hypogonadism
Low T, low LH= secondary hypogonadism
Estradiol
Inc in testicular tumors, liver dz, obesity, inc levels of b=hCG
TSH/FT4
Hyperthyroid inc SHBG, dec free testosterone
What imaging is needed for gynecomastia PTs?
Mammography, CXR
US for suspicious mammogram findings
Needle biopsy w/ cytology for suspicious unilateral/asymmetric enlargement to distinguish tumor from mastitis
How is pubertal gynecomastia Tx?
Observe, f/u Q6mon
Self resolving in 1-2yrs
Painful/Persistant: SERM (Ramoxifen, Faloxifene) better for glandular type Aromatase inhib (Anast/Letrozole)
How is hypogonadism related gynecomastia Tx?
This Tx can only occur after ?
Testosterone replacement, can worsen condition
Lab confirmed Dx
When is radiation therapy used for gynecomastia?
When is surgery used as a last resort?
Prostate CA + gynecomastia
Persistent and severe cases
Testosterone + aromatase= ?
Testosterone + 5a-reductase= ?
Estradiol- wolffian duct, brain, muscles, body hair, spermatogenesis, libido
5a-DHT- (masculine effects) External genitals,
Male body hair pattern
Temporal baldness
What are the three effects testosterone exerts?
Most important androgen in men is testosterone due to its impact on what non-endocrine organs?
1: Direct impact on androgen receptors
2: converted to estradiol/5a-DHT
3: non-endocrine organ impact
Muscle, adipose, bone, metabolism, brain function
Define Hypogonadism
What are the two types?
Deficient testosterone secretion from testes (low testosterone)
P: failure of testes to produce (hypergonadotropic hypo- high LH/FSH)
S: hypothalamus/pituitary failure to secrete gonadotropins
(hypogonad- low LH/FSH)
S/Sxs of hypogonadism
Hypogonadism can occur in what four time frames?
Low libido
ED, Fatigue, depression
Reduced endurance
Early prenatal
Late prenatal
Pre-puberty/puberty deficient
Post-puberty deficient
Define Early Prenatal Hypogonadism
Define Later Prenatal Hypogonadism
1st trimester T deficiency
Ambiguous genitalia
Pseudohermaphroditism- ovary or testi
True hermaphrodite: both
Deficiency of testosterone during 3rd trimester= micropenis, cryptochordism
Define Puberty Hypogonadism
Define Post-puberty hypogonadism
T deficiency at puberty
Dec strength/endurance
High voice/Dec hair
No sexual maturity or differentiation
Mid life lack of testosterone
Dec libido/energy/hair
Impotence/Wrinkles
Define Eunochoidal Proportions
What d/o is this normally seen in?
GH stims bones to grow out of proportion
Testosterone=closed plates
Arm span>height by +5cm
Crown-pubis
What 4 labs need to be drawn in the morning due to diurnal release?
What class drug is given to PTs w/ BPH?
GnRH, LH, FSH, Testosterone
5a-reductase inhibitor
How much of testosterone is bound and where is it bound to?
What part of life has a lower portion of free testosterone?
54-75% to SHBG
44% to albumin
Elderly, higher SHBG levels
What are the three main types of hypogonadism?
Primary- defect of testes (hypergonad hypogonad)
Low T, Inc LH/FSH
Secondary- defect of hypothalamus/pituitary
(hypo, hypo)
Low T, L or N LH/FSH (inappropriately normal)
Androgen defect/resistance
Inc T, Inc LH/FSH but effects of low T
What can cause Primary Hypogonadism?
Congenital: Klinefelter, Cryptochordism, Bilatearal anorchia
Acquired: age trauma infection(mumps/gonorrhea, leprosy) chemo/radiation
What is the most common congenital/chromosomal abnormality among males causing primary hypogonadism?
What are the comorbidities that come w/ this Dx?
Klinefelter 47XXY
Breast Ca DM CPDz Osteoporosis Varicose veins
What type of testicular development does Klinefelters cause and how is it Dx?
Firm, Fibrotic, Nontender, Small <2cm (N=>3.5)
High LH/FSH, low T
Keryotyping
How is Cryptorchidism Tx non-surgically?
If surgical Tx must be done for cryptorchidism, what age is it done at?
What are the associated risks w/ infertility?
hCG 1500mg x 3 days
Orchipexy @12-24mon
75% if bilateral
50% if unilateral
Define Vanishing Testicle Syndrome
Primary Hypogonadism. Bilateral Anorchia
Testes @ 14-16wks of gestation, empty scrotum
Normal growth/development until secondary sexual development fails to show at puberty
How is Bilateral Anorchia Dx?
How are all forms of Primary Hypognoadism Tx?
hCG stimulation test
+ test= no inc of testosterone
Crypto= inc of testosterone
Testosterone IM Q2-3wks Testosterone patches Topical application= most stable levels, transfer risk Buccal- Q12hrs PO from not avail in US Pellets- SQ administration
When does monitoring needs to be done for PTs taking testosterone?
What also needs to be checked every 6-12mon in these PTs?
Starting 14 days after initiation
Lipids, LFTs, CBC, PSA, DRE
Repeat Q6mon
What are the 5 s/e of testosterone replacement?
What are the c/i of using this therapy?
Dec HDL Acne Gynecomastia Liver abnormalities Polycythemia
Prostate hyperplasia/CA
Boys <13y/o
What are the four causes of Secondary Hypogonadism?
Congenital: Kallmann (most common cause of 2* Hypo)
Acquired: Panhypopituitary, Hyperprolactinemia
Other-meds age obesity illness ETOH drugs
Define Kallmann Syndrome
What odd Sx do they present with?
X-linked inheritance causing isolated gonadotropin deficiency
GnRH cells near olfactory bulbs= anosmia
How do PTs w/ Kallmann Syndrome present?
How are they Dx?
Prepubertal testes (small/rubber)
Eunuchoidal build
+/- gynecomastia
50% unilateral renal agenesis
Low T, Low/N LH/FSH
What is the most common cause of hyperprolactinemia
What are the two major causes of “other” etiologies of Secondary Hypogonadism
Pituitary adenoma
Inhibits GnRh and T
Dec LH efficacy
Obesity
Poor health
How is Secondary Hypogonadism Tx?
Defective androgen action/resistance only happens in ? PTs?
Weight loss
Underlying issue
Testosterone + other hormone for fertility
High T, FSH, LH in 46XY
Phenotype female
Genotype male
How/why are PTs w/ 46XY Dx?
What PE finding is indicative of this Dx?
Amenorrhea
No uterus is palpable
blind pouch w/out uterus, cervix, Fallopian tubes
How are PTs w/ CAIS Tx?
Where is 5-AR Deficiency frequency increased?
Remove testes
Estrogen Tx
Dominican republic
New Guinea
Turkey
DHT is needed for neonatal target organ development during what point of development?
How doe these PTs present to clinic and on lab results?
8-12wks
Poorly developed prostate/external genitals
Appears female
Crytorchid tested
Normal T/FSH/LH
Define Guevedoce
What other findings are seen with 5a-reductase deficiency?
Penis development at 12 from inc T due to alternate DHT production pathways
Masculinity
Adams apple
Deep voice
A cells make ?
B cells make ?
D cells make ?
F cells make ?
Glucagon
Insulin
Somatostatin
Ghrelin
Glucagon acts on ? to convert ?
Glucagon promotes ?
Hepatocytes- glycogen to glucose
Gluconeogenesis- formation of glucose from lactic acid and amino acids
What is the most important regulator of glucagon and insulin levels?
DM is a syndrome of disordered ? and inappropriate ?
Blood glucose
Metabolism, Hyperglycemia
Define DM Type 1
What is the greatest risk factor for DMT2 insulin resistance?
Usual PT= kids Autoimmune destruction of B-cells/Catabolic d/o REQUIRES insulin UnTx= Ketosis Not linked w/ FamHx
Visceral Obesity- adipocytes secrete adipokines, impair insulin signaling
Define MODY
How does this get passed through generations?
Maturity Onset Diabetes of Young
Non insulin dependent DM
<25, non-obese PTs due to impaired glucose-induced secretion of insulin
Autosomal dominant
What are secondary causes of hyperglycemia?
What does Diabetes, Insipidus, and Mellitus mean?
Insulin insensitivity: Tumors, Steroids, Liver dz
Red insulin secretion
Pheo, Pancreatitis, Drugs
D: excessive urine/siphon
I: tasteless
M: honeyed, sweet
Metabolic Syndrome puts PTs at risk to develop ?
What waist size is dangerous for this development?
What organ system is first to start the decline towards metabolic syndrome?
DM2, CVD
> 40 / >35
Renal function: hyperuricemia
3 of what 5 criteria are needed to Dx metabolic syndrome?
What Dx is given to these PTs?
Ab obesity: >102/88cm TG: >150 HDL: < 40/50 BP: +130/85 Fasting glucose: +110
Pre-Diabetic
What are the characteristic S/Sxs of DM1
Polyuria- osmotic diuresis Polydipsia Polyphagia Blurry vision- hyperosmolar fluids Weight loss PHOTN Pareasthesia DKA
Since DM2 is ASx, what is a common initial complaint in women?
What derm issue is seen in DM2 PTs?
Vaginitis
Acanthosis Nigricans- hyperpigmented thickened skin on neck/groin/axilla
What is the equivalent to DKA of DM2?
What is not a screening test for DM?
Hyperglycemic Hyperosmolar Coma
UA
What are the two tests primarily used for DM?
What diabetic like issue is seen on UA of pregnant PTs?
Plasma glucose
HbA1c
Nondiabetic glycosuria
What ketonuria levels require hospitalization?
How long does glycated HgB circulate in blood?
> 3.0mmol
120d
Reflects glycemia for up to 12wks previously
How often is A1C measured in diabetics?
What can this measurement be used for?
Q3-4mon
Screening/Dx
What are the normal plasma glucose levels?
What are normal, impaired and diabetic OGTT results?
What are normal, impaired and diabetic A1C levels?
Fasting: +126= DM
Fasting: 100-125= impaired
Random: +200 w/ Sxs= DM
N: <140
I: 140-199
D: >200
N: <5.7
I: 5.7-6.4
D: 6.5 or higher
What steps can be done to prevent/delay development of DM2?
What is the next step for suspected DM but normal plasma glucose?
Dec weight 5-10%
Diet, Exercise, Drugs
OGTT
What can cause a false high OGTT result?
Low RBC turnover:
Fe, B12, Folate deficient
Kidney/liver failure
Rapid RBC turn over: Bleeding Anemia Transfusion Hemolysis Kidney/Liver Failure
What is the first and descending complications to occur with an average A1C of 6.5% or higher?
What blood measurement is used for A1C scores if PT hs abnormal HgB or hemolytic states?
Retinopathy
Nephropathy
Neuroapthy/Microalbuminuria
Skin/membrane
Serum Fructosamine- nonenzymatic glycosylation of serum protein (albumin) from past 1-2wks
What two measurements can be taken to differentiate between Dm1 and DM2
An abnormal lab should be confirmed on a different day using ? test?
Insulin
C-peptide: fragment of proinsulin, mirrors levels
Fasting glucose
What are the levels of FPG, HbA1C, random and 2hr OGTT needed for Dx and won’t be on test
FPG: +126mg
HbA1c: +6.5%
Random: >200mg w/ Sxs
OGTT: >200mg
What is the first step in diabetic management?
What Sxs are seen in DM w/ glucose levels >200 or <60
Self management, education and support
+200: Thirst, dry, tired
-60: Shaky, sweaty, weak
Don’t use UA for monitoring
Medical Nutritional Therapy can decrease HgA1C by how much?
What is the most important part of DM Diet?
- 0-1.9% for DMT1
- 3-2% for DMT2
Healthy eating patterns, especially Mediterranean style pattern (high in/soluble fiber)
Low glycemic index foods are _ or less
High glycemic index foods are _ or more
55 or less
70 or more
What is the “magical pill” for health and diet?
This “magic pill” mimics what class of drug?
These two things can reduce the effects of ? DM Sx?
Protection from polyphenols- inhibits glucose absorption, oxidative stress and inflammation
A-glucosidase inhibitors
Neuropathy
What is the first, last and anytime line of Tx of diabetes?
What are the next two steps?
Therapeutic lifestyle change
Weight loss
Exercise
Since all DM PTs are ImmComp, what vaccines do they need?
What meds are considered in all PTs w/ DM?
Influenza
Penumococcal- at Dx and repeat at 65 if first dose was prior to 65y/o
Glycemic agents
ASA
Lipid lowering
ACE/ARB
What is the JNC 8 B goal for PTs w/ DM?
GLP-1 RA meds are only used for ? type of DM?
This is the 1st line medication for all new cases of DM2
<140/90
Only DMT2
Metformin
Glycemic control agents are used for DM, what are the classes and meds of each class?
Biguinide: metformin DPP4i: -gliptin GLP-1RA: tide SGLT2i: -gliflozing TZD: glitazone AGI: -acarbose
SU/GLN: -glipizide/-glyburide
What is the MOA of Metformin?
What are the advantages, disadvantages and c/i of using metformin?
Dec gluconeogenesis, inc hepatic insulin sensitivity
A: Lipids, no hypoglycemia, weight loss
D: lactic acidosis
C: CKD, alcoholics, CHF
What two classes are included under “Incretin Therapy”?
Meds in this class end w/ ?
What is the DPP4/Metformin combo pill?
DPP4 inhibitors
GLP-1 agonists
-gliptin
Janumet
What is the MOA of DPP4s?
What are the advantages, disadvantages and c/i of using DPP4 inhibitors?
Prevent degradation of incretins which stimulate insulin release, dec glucagon
Low hypoglycemia risk
Reactions, pancreatitis, URI
Renal impairment,
What are GLP-1 agonists effect on hypoglycemia and weight?
When are GLP-1 agonists used in DM therapy?
Hypo: neutral
Weight: decrease
No solo use, added to Metformin or Sulfonylureas
What is the MOA of GLP-1 agonists?
What are the advantages, disadvantages and c/i of using this drug?
Stimulate insulin release, reduce glucagon and slow GI emptying
Weight loss, addresses post-prandial glucose, weekly administration
GI, pancreatitis, medullary thyroid CA, injection
MEN2, medullary CA, gastroparesis
What DM Tx med is also a formulation for obesity Tx?
What are SGLT-2 inhibitors effect on hypoglycemia and weight?
GLP1 agonist: Liraglutide
Hypo: neutral
W: loss
What is the MOA of SGLT-2 inhibitors?
What is an FDA benefit of this med?
What are the advantages disadvantages and c/i of using SGLT-2 inhibitors?
ONLY med to work at level of kidney
Dec re-absorption, inc urinary excretion
Approved for reducing CV risk
Weight loss
Inc urination, reduced BP, UTIs
What are TZDs effect on hypoglycemia and weight gain?
What are their MOA?
Hypo: neutral
Weight: GAIN
Sensitizes peripheral tissue to insulin
What are the advantages, disadvantages and c/i of TZDs?
Improved lipids, slows DM progression
Inc risk of MI, edema, Osteoporoses, weight inc
NYHA 3,4
Liver Dz
What is the effect of sulfonylurea on hypoglycemia and weight?
What is their MOA?
Severe hypo
Weight gain
Stims insulin release
What are the 1st and 2nd generation sulfonyureas?
What are the advantages, disadvantages and c/i of using them?
1st: Tolbutamide
2nd: Glipizide- long acting
Longevity, cheap
Only PO med to cause Hypoglycemia (SFN>GLN)
Liver/renal dz
What is the MOA of AGIs?
What are the advantages, disadvantages, c/i of using these?
Delay carb absorption
Weight neutral, address post-prandial glucose
GI
Intestine d/o, Cirrhosis
What PT populations have an A1C goal of <6.5, <7, <7.5, <8 ad <8.5
- 5: pregnant adults if able w/out hypoglycemia/polypharm
7: non-pregnant healthy adult - 5: Older/healthy adult, children, adolescents
8: Hx of severe hypoglycemia - 5: Older adult, frail, limited life span
What is the DM2 oral agent algorithm?
What DM med is started/used first for PTs w/ A1C >9 w/ Sxs?
If HbA1C <9 Nutrition/exercise Metformin x 3mon (D-Day) 3mon: D+3, Dual therapy 3mon D+6, Triple therapy 3mon: D+9, Insulin w/ PO agents (never more than 3 PO agents), except
Insulin + metformin
Major s/e of Metformin, Pioglitazone, GLP-1, DPP4, SGLT2 classes?
Met: lactic acidosis
Pio: fluid retention, Fxs, bladder CA
GLP: N/V/pancreatitis
DPP4: pancreatitis (only moderate efficacy class)
SGLT2: UTI, GU fungal infxn, dehydration
What are the two groups of insulin and what belongs in each?
Bolus-
Rapid: Lispro, Aspart, Glulisine
Short: Regular
Basal-
Intermediate: NPH
Long: Glargline, Detemir
What type of insulin is used in the ER to Tx DKA?
DMT2 Pts need to stop taking ? med if insulin is added to their Tx routine?
Short acting- Regular, can be given IV
Sulfonylureas- only PO agent that causes hypoglycemia
When adding insulin to DMT2 PTs, what type is usually added first?
Define Dawn Phenomenon and Somogyi Effect and how each one is Tx?
NPH/Long acting (Glargine, Detemir) at bed time
Dawn: inc 02-0300 glucose levels, inc bed time dose
Somogyi: low 02-0300 glucose levels, reduce bedtime insulin dose
Both result in morning hyperglycemia, 02-0300 check to differentiate
Why do Dawn and Somogyi Phenomenons happen?
D: reduced tissue sensitivity to insulin that develops between 05-0600 due to GH
S: surge of Epi produces high glucose by 0700
What DMT2 medication is used for DM and weight loss?
Hypoglycemia is the most common complication inf DM PTs being Tx w/ and feel Sxs when levels are below ?
GLP1 receptor agonists - add on therapy on to Metformin or Sulfonylurea
Insulin
<54mg
What are the first 3 Sxs of hypoglycemia?
What class med can blunt these Sxs?
Neurological Sxs don’t show until blood glucose is below ?
Tachy, Palpitation, Termulousness
BBs
<50mg
How can mild/mod hypoglycemia be Tx?
How is severe cases Tx?
15g of carbs
Glucagon kit- 1mg
Given to every PTs receiving insulin
What is given in the ER for hypoglycemia?
Who is most likely to have DKA?
IV glucose 50ml
IM glucagon 1mg if glucose is unavailable
DMT1 w/ pump
DMT2 during trauma/sepsis
How can early DKA be detected quickly in PTs w/ pumps?
What is the cut off indicator that PTs need to seek medical help while self-monitoring w/ DKA during sick day?
UA ketones
Test urine ketone Q2-4hrs
>250mg x >6hrs
4-6ox fluid Q30m
How does DKA present?
Polyuria/dipsia x 1-2 days N/V/Fatigue Hypothermia Tachy w/ HOTN pH <7.4 (6.9-7.2) Hyper-K on lab, actually depleted in body
How is DKA Tx?
What is one of the most serious shortcoming of DKA Tx?
What is the fluid of choice for Tx DKA?
What fluid is used if PT presents w/ hypernatremia (Na>150)
IV fluid, Insulin, K, BiCarb
Fluid deficit: 4-5L
- 9% NS: 1L over 1-2hrs
- 45% NS
What can be induced if Tx w/ DKA fluid resuscitation is too aggressive?
During DKA Tx, when is fluid Tx switched?
> 5L in 8hrs= ARDS, Cerebral edema
<250mg= switch to 5% glucose solution
Insulin replacement falls where in the DKA Tx algorith?
What is the f/u step to this sequence
After fluids IF K is >3/5meq
If K is <3.5, delay insulin until K is normal
How much K is given to PTs during DKA Tx?
How does hyper/hypo-K show on EKG?
KCl 10-30meq during 2 or 3rd hr of Tx
Hyper= peaked T
Hypo: flat T, U wave
When is NaBicarb used for DKA Tx?
What is the last step of consideration when Tx DKA?
pH <7.0
1-2 ampules added to 1L of 0.45% of saline
ABX- cholecystitis, polynephritis may be severe in these PTs
What is the second most common form of hyperglycemic coma?
What PT population is it normally seen in?
HHS- hyperglycemia w/ no ketosis
Middle age/elder w/ DM2
PTs suffering from HHS usually have what underlying systemic Dz or are taking ? meds?
Why is HHS more deadly than DKA?
CHF, CKD
Thiazides, Glucocorticoids
Slow onset w/ 10x higher glucose levels
What will be seen on PE of PT w/ HHS?
What will be seen on labs?
Profound dehydration w/ no Kussmaul respirations
Hyperglycemia
Hyponatremia
Prerenal azotemia
NO ketosis or acidosis
How is HHS Tx?
IV fluid, insulin, K
4-6L over 8-10hrs
Hypovolemia+oliguria= NS 0.9%
No hypovolemia= 0.45% NS
Once glucose is <250, start 5% dextrose, 0.45% or 0.9% NS
Insulin- only if glucose >250
KCl- added earlier than DKA Tx, not if CKD/oliguria is present
What are the DMT1 complications?
What are the DMT2 complications
Renal Dz
Blindness
Neuropathy
Death from end stage renal dz
Renal dz
Blindness
Neuropathy
Macrovascular Dz= MI*/stroke
What is the difference of the anion gap between HHS and DKA?
Chronic DM complications include what 5 systems?
HHS: Norm
DKA: High (>10)
Ocular Nephropathy Neuropathy CV Skin/membrane
What are the two categories of diabetic retinopathy?
Nonrpoliferative “background”:
Microaneurysms
Exudates
Dot hemorrhage
Proliferative “malignant”
Cotton wool spots
Leading cause of blindness in US
How is proliferative retinopathy Tx?
Photocoagulation
Bevacizumab- injection to stop growth of new vessels
HTN management
Tobacco cessation
When do DMT1 or DMT2 get eye exams ? that coincide for testing for?
What are seen as kidney function begins to decline?
1: 5yrs after Dx then annually
2: at Dx, then annually
Microalbuminuria
Albuminuria to urea/creatinine accumulation in blood
What is the TOC for diabetic nephropathy
What levels/how many positive tests are needed for Dx?
Morning spot urine for albumin/creatinine ratio, can’t be detected by urine dipstick
30-300mcg
2-3pos tests within 3-6mon before Dx
How id DM microalbuminuria Tx?
How is progressive diabetic nephropathy Tx?
ACEI (even in T1 PT w/ normal BP)
ARBs
Low protein diet
Dialysis due to macro proteins in urine
What is the most common form of diabetic peripheral neuropathy
What is “rocker bottom” foot deformity
Distal symmetric polyneuropathy (glove/stocking or Charcot) starting w/ the longest axons
Charcot arthropathy- joint subluxation, periarticular Fxs
What type of diabetic neuropathy is reversible?
What nerves are most likely to be involved by this?
Isolated peripheral
Femoral and CNs (CN3 palsy)
How is painful diabetic neuropathy Tx?
Autonomic neuroapthy in DM can effect what 4 things?
Amitriptyline- TCA
Duloxetine- SNRI
Gabapentin
Capsaicin cream
BP/P, GI tract, Bladder, ED
What med can be used for DM w/ GI tract autonomic neuropathy induced gastroparesis
What can be used for diarrhea
Metoclopromide 30min before meals/bed, only for 3mon
Broad spectrum ABX Loperimide
What can be used for ED from DM?
Half of PTs w/ DM will develop ? after 20yrs of the Dz
Sildenafil
Papaverine- intracavernous injection
Peripheral vascular dz: Ischemia of LE ED Intestinal angina Gangrene of feet
What meds are given to DM w/ PVDz?
What are the lipid goals for these PTs?
ACE/ARB
ASA
Statin
LDL <100/<70 w/ CAD
HDL >40
TG <150
DM get annual foot exams to check for ulcers IAW ? program
What three factors lead to diabetic foot problems?
LEAP: lower extremity amputation prevention w/ monofilament test, 10g pressure, 10 spots
Ischemia
Peripheral neuropathy
Secondary infection
DMT2 can have increased risk of developing ? fungal infection?
What skin finding can be seen on shins/dorsal surface of foot?
When are DM PTs referred to Endocrinology?
Thrush
Necrobiosis Lipoidica Diabetricorum
Type 1: at Dx
Type 2: if difficulty w/ reaching goals
What hand issue can be seen in DM w/ long standing diabetes?
What labs are drawn at each DM visit?
Dupuytrens contracture
Fasting CMP: 110-120 HbA1C: <7% Microalbumin for DMT2 (at Dx and annually) Lipid- annual Ophthalmology- dx and annual
What vaccines do DM PTs need?
Leading cause of death for type 1/2 DM?
Pneumovax
Influenza
1: Renal Dz
2: MI
What is normal Ca level?
What organs are directly and indirectly responsible for Ca regulation?
Serum: 8.5-10.5mg
Ionized/Free: 4.6-5.3mg
Direct: parathyroid, kidney w/ Ca sensing receptors
Indirect: intestine
What hormones regulate serum Ca?
What stimulates for the major one to inc/dec?
PTH, Vit D, Calcitonin
Stim: falling Ca/Mg level
Inhib: rising free Ca/Mg level
What does PTH stimulate/inhibit
Where is calcitonin made and what does it do?
Resorption of bone to inc systemic Ca/Phosph
Opposite of PTH
Parafollicular cells in thyroid gland in response to elevated serum Ca level to Inhibits osteoclasts
Produced in
When are calcitonin levels monitored?
What are the first and second most common causes of Hypercalcemia?
Thyroid Ca
High Ca, High PTH Primary hyperparathyroidism (adenoma, hyperplasia, CA)
Norm Ca, High PTH: (familial hypocalciuric hypercalcemia)
High Ca, Low PTH:
Secondary malignancy, non parathyroid CA (milk alkali syndrome)
Can be from any type of CA
What is the first step in investigating hypercalcemia?
What are the S/Sxs of hypercalcemia
What is the PTH doing?
Mild: ASx
Severe: >14mg, CA concern
Groans Moans Overtones Bones Stones
What is the first part of Tx for parathyroid adenomas?
What monitoring steps are done for ASx PTs?
Hydration
F/u Q6mon: BP, SrCr
Yearly: Urine Ca, Kidney function
Bone density Q2yrs
What Ortho Dx is indicative of Hypercalcemia?
What is a rare but serious cause of High Ca/High PTh?
How is MEN induced parathyroid hyperplasia Tx?
Osteitis Fibrosa Cystica
MEN 1, 2, 4
Subtotal parathyroidectomy, 3.5 glands removed
What are the three types of hyperparathyroidism?
What lab results are seen in Parathyroid CA?
Benign parathyroid adenoma
Parathyroid hyperplasia
Parathyroid CA
Sever hyperCa, Very high PTH corrected w/ surgery
What lab results are seen in Familial Hypocalciuric Hypercalcemia?
How is it Tx?
Defective Ca receptors in parathyroid leading to:
Normal PTH
Permanent HyperCa, HypoCalciruia
None avail, autosomal dominant d/o
How do you tell between parathyroid cancer and small lung cell cancer?
What protein will increase in PTs w/ parathyroid malignancy?
What will be seen on labs?
High PTH= parathyroid
Low PTH= SCLCa
PTHrP
Severe HyperCa
Low PTH
High PTHrP
What types of CA can cause PTHrP increases?
Define Milk Alkali Syndrome
Squamous CA of lung, esophagus, head/neck
Renal, Bladder, Ovarian, Breast CA
Triad of HyperCa, Metabolic alkalosis, Acute kidney injury
What vitamin increase can suppress PTH?
Where can this increase be causes by if it wasn’t ingested?
Vit D
Lymphoma
Granulomatous Dz: Sarcoidosis, TB, Histoplasmosis, Coccidiomycosis
Thyrotoxicosis
Immobilization- ICU PT, Dx of exclusion
How is hypercalcemia managed?
Hydration/Activity Furosemide- + calciuresis No thiazides, Vit A/D, Antacids Avoid Vit A/D Dialysis if renal failure
When are Bisphosphonates used for hypercalcemia?
What is the MOA in Tx?
Hyperparathyroidism, Malignancy,
Immobilization
Surgery Pre-Op-
Inhibits osteoclast reabsoprtion of Ca
What is the TOC in malignancy associated hypercalcemia
What Tx is added for post-menopause PTs?
IV Bisphosphonates
Estrogen
What is the most common cause of hypocalcemia?
Elderly hospitalized PTs w/ hypocalcemia, variant PTH levels are likely to be deficient in ?
CKD
Vit D
Hypoalbuminemia is a common cause of low ?
If this is due to hypoalbuminemia, it’s not clinically significant if ?
Total serum Ca
Ionized Ca is normal
If albumin is low, check ? or calculate the correct one
What can cause HypoCa w/ High PTH
What causes HypoCa w/ low PTH
Ca
Pseudohypoparathyroid (PTH resistance)
Vit D deficient/resistance
Hypoparathyroidism (PTH deficiency)
What are the S/Sxs of HypoCa
CATS go numb Convulsion Arrhythmia Tetany Seizure Numb/parasthesia in hands, feet, mouth
Chvetskys
Trousseaus
What are the lab results in true HypoCa
What all is checked?
Serum Ca <8.5
Ionized serum Ca <4.6
Mg, PTH, Vit D
What is happening in the body during HypoCa w/ inc PTH?
What bone changes are seen due to inc PTH?
Defected renal PTH receptors
Inc Ca excreted in urine
Cystic lesions
Pathologic Fxs
Demineralization
Define Albrights Hereditary Osteodystrophy
What can cause Vit D induced HypoCa, Inc PTH
HypoCa, Inc PTH PTH resistance (pseudohypoparathyroid) Short, round face, short 4th/5th metacarpals
Defective supply
Malabsorption: Sprue, Crohns
Meds: Rifampin INH Phenytoin
Rickets
Define Osteomalacia
How do PTs present and what X-ray finding is seen?
Adult Vit D deficiency
Bone pain
Radiolucent lines perpendicular to cortex- Loosers Lines
Pseudo Fxs- pathognomonic for Rickets/Osteomalacia
How is ASx Hypocalcemia from any origin Tx?
Define Hypoparathyroid Tetany
PO supplements, Vit D, Sunlight
Acute Hypocalcemia
Medical emergency- dec PTH circulating causes dec Ca level
How is Hypoparathyroid Tetany Tx on inpatient status?
What maintenance Tx are they placed on after emergent Tx?
Airway
Tx HypoMg first w/ Mg Sulfate
Tx low Ca w/ Ca Gluconate
1-3g PO Ca/Vit D w/ meals per day
How often are post-Acute Hypocalcemia Tetany PTs monitored?
What is given it PT presents w/ hypercalciuria
Q3mon for Ca levels w/ Spot urine Ca
HCTZ- keeps Ca in blood
Define Osteitis Deformans
What happens in this Dz?
Paget’s Dz
Autosomal dominant Dz
Bone lysis replaced by vascular fibrous CT tissue leading to bone formation that’s more likely to Fx
What is the first Sx of Paget’s Dz?
Why do these PTs go deaf?
Pain, constant and worse at night, not relieved w/ rest
Inc warmth over bones
Leads to HOutput HF
Middle/inner ear cavities lay w/in petrous portion of temporal bone
What is the name of Fx that occurs in Paget’s PTs?
What will be seen on labs?
Chalk stick
Inc alkaline phosphatase (ALP)
Normal Ca, Phosph, PTH
Inc Ca if PT is immobile
What would a bone scan of Paget’s show?
What x-ray finding can be seen?
Inc uptake in skull, spine and long bones
Pic frame vertebrae
How is ASx Paget’s Tx?
What is the DOC for Sx Tx?
Annual ALP checks/x-rays
Bisphosphantes- IV Zoledronate
Vit D is controlled by ?
Intestines
