ENDO/HEME ONC PACKET 1 Flashcards
HASHIMOTOS
TREATMENT
• Hypothyroidism: ______ should be given in usual replacement doses
• Goiter
• may shrink with doses of levothyroxine that drives the serum TSH below the reference range while maintaining clinical euthyroidism (normal thyroid gland function)
• Suppressive doses of __ tends to shrink the goiter.
• Dietary supplementation with ______ reduces the levels of TPO ab
levothyroxine
T4
selenium
SUBACUTE THYROIDITIS
TREATMENT
• Disease is ______
• Does not require long-term therapy
• During acute painful phase, use _______ agents (ASA, NSAIDS, steroids); ___ is the drug of choice
• Hyperthyroidism treated with ______ (Bilivist) or iopanoic acid (Telepaque)
• Brief periods of____ for symptoms of hyperthyroidism à HR fast, BP goes up (s/s of hyperthyroidism à so BB calms it all down)
• Transient hypothyroidism if symptomatic is treated with T4 orally
self limiting anti inflammatory ASA ipodate sodium b-blockers
INFECTIVE SUPPORITIVE THYROIDITIS
TREATMENT
• Treatment is with _____ and possible _____ drainage
• Surgical ______ may be required
antibiotics
surgical
thyroidectomy
RIEDAL THYROIDITIS
TREATMENT
• ______ 20 mg BID often indefinitely. Steroids can be used short-term to control symptoms
TAMOXIFEN
hypothyroidism
• Most hypothyroid pts: oral ______(75-150 ug/d) is sufficient replacement therapy
o Use same prep at same time of day à very important
• Verify if dose is enough: need normal ___ and a normal free __ level
o TSH, T4 and T3 monitored monthly and dose is adjusted to normalize the TSH within 2 months of initiating therapy
• Don’t give too much!! Can cause ______ & cardiac arrhythmias
• T4 has long half-life (7 days)
• A change in levothyroxine dosage does NOT produce a new steady state for 4-5 weeks
• After tmt stopped, return of hypothyroidism: slow, insidious; pt may have no discomfort
• THINGS TO NOTE:
o Increased levothyroxine dosage requirements can occur with drugs that increase the hepatic metabolism of levothyroxine
o May treat T4, T3 or symptomatically in patients that have a normalized TSH
o Can use desiccated natural porcine thyroid preps with T4 and T3 (Armour thyroid, Nature-Throid, NP Thyroid)
o IF the TSH is suppressed or low, can mean _______ and patient can have symptoms of hyperthyroidism, atrial fibrillation, osteoporosis
levothyroxine
TSH, T4
osteoporosis
overtreatment
MYXEDEMA COMA MANAGEMENT - ICU monitoring _- respiratory SUPPORT - general supportive care - IV \_\_\_\_\_\_ -\_\_\_\_\_\_\_ therapy as prophylaxis against adrenal crisis TREATMENT • Passive \_\_\_\_\_ (blankets) • Preferred over heated blankets (avoid vascular collapse) • All meds \_\_\_ Treat underlying illness
levothyroxine
glucocorticoid
warming
IV
hyperthyroidism and thyrotoxicosis
THERAPY FOR HYPERTHYROIDISM
• ________: DESTROYS THYROID TISSUE
• Drugs that inhibit thyroid hormone synthesis
• Surgery
• Thyrotoxic symptoms from any cause of hyperthyroidism: helped w/______
radioactive iodine
b blockers
GRAVES DISEASE
• A _____ (Propranolol) is started to control symptoms (tachycardia, tremor, diaphoresis, anxiety) until the hyperthyroidism is treated.
• Propranolol ER 60 mg (titrate up to max 320 mg to control sxs)
• Beta-blocker does nothing to control hormone secretion
• Thiourea Drugs
o ________ (mostly use this one) or ______ (PTU)
Methimazole is used primarily, except in the ____ trimester of pregnancy
o Patients with _____ thyroid disease, or who cannot tolerate radioactive iodine
o Can be used in patients who are planning surgery until their surgery is scheduled
o Side effects: pruritus, allergic dermatitis, nausea and dyspepsia
o Thioureas can cause agranulocytosis/pancytopenia
½ the cases are discovered because of fever, pharyngitis, bleeding
½ from routine CBC
• Iodinated Contrast Agents
o _______ relief of thyrotoxicosis symptoms, if not controlled by Propranolol alone
o In Graves Disease, Dose first with Methimazole, then give Iopanoic acid (Telpaque) or ipdodate sodium (Bilivist)
o These drugs are for symptoms relief, do not cure underlying process
• Lithium Carbonate à not used much bc low therapeutic window
o May be used in cases of Methimazole or PTU induced hepatic toxicity or leukopenia
o Not used during pregnancy
• Radioactive iodine (RAI, 131I)
o Destroys overactive thyroid tissue
o Cannot give before or during pregnancy
o Can worsen Grave’s ophthalmopathy
• Thyroid surgery
o Removal of one total lobe, and most of other lobe
o Pre-operatively dosed with thiourea until they are euthyroid
o Propranolol dosed to control cardiac sxs
beta blocker methimazole, propylthiouracil first milder temporary
THYROID STORM
- Treat with ______ drug to block iodine uptake and hormone synthesis
- ________ if begun 1 hour after the first dose of thiourea
- _____ is given 1 hour later as potassium iodide
- ______ IV or orally
- Prescribe ____ (inhibit T4 to T3) – steroids inhibit t4 conversion to t3 **ON EXAM
- Plasmapheresis can be effective in refractory cases
- Acute MI may be precipitated
thiourea ipodate sodium iodide propranolol steroids
SOLITARY NODULE
- Can treat as you do for Graves Disease: Propranolol and ______
- 131 I (radioactive iodine) and surgery
- Almost always benign; rarely malignant; can do ___
thiourea
FNA
MULTINODULAR GOITER
- TREATMENT: Can treat with ______ and thioureas
- ______ is the definitive treatment; can do RAI (radioactive iodine)
- If RAI, avoid Iodine in diet to increase uptake of RAI
propranolol
surgery
HYPOPARATHYROIDISM
TREATMENT
EMERGENCY TREATMENT FOR ACUTE HYPOCALCEMIA (HYPOPARATHYOID TETANY)
1. ___ maintenance
2. IV calcium ____ given slowly until the tetany ceases
3. ____ calcium (liquid calcium carbonate)
4. ______ preparations à started with oral calcium
______ = the active metabolite of vitamin D, 1,25-dihydroxycholecalciferol
Can use Calcitriol (form of vitamin D) – helps to reabsorb dietary calcium
5. Magnesium deficiencies must be corrected
MAINTENANCE TREATMENT OF HYPOTHYROIDISM
- Required for patients with symptomatic hypocalcemia or serum calcium levels below 8.0 mg/dL
- _____ , calcium and ____ therapy:
o Pts have a reduced renal tubular reabsorption of calcium and are thus prone to hypercalciuria (excess calcium in urine) and kidney stones if serum calcium is normalized with calcium and vitamin D therapy
o Maintain serum calcium in a slightly low but asymptomatic range of 8-8.6 mg/dL
- ____ supplementation 800-1000 mg orally daily: calcium carbonate or citrate
o Calcium carbonate is best absorbed at the low gastric pH that occurs with meals
o Calcium citrate with or without meals and better choice for pts on PPIs or H2 blockers
- Vitamin D daily: _____ (active metabolite of vitamin D) or ergocalciferol (vitamin D2 derived from plants) for recurrent hypocalcemia
o Ergocalciferol gives stable serum calcium level
- Monitor serum calcium every 3 months or more
àOTHER
- PTH – restricted to patients whose hypocalcemia cannot be adequately treated with calcium and vitamin D analogs
- Hypoparathyroidism in pregnancy is a challenge à can adversely affect the developing skeleton of the fetus causing compensatory hyperparathyroidism
- CAUTION:
o Phenothiazine drugs should be administered with caution because they may precipitate EPS
o Furosemide should be avoided since it may worsen hypocalcemia
airway gluconate oral vitamin d calcitriol
vitamin d, magnesum
calcium
calcitriol
HYPERPARATHYROIDISM
- Medical treatment:
o Large ___ intake
o _______ calm bone pain
o CaSr activators
_______ (Sensipar) is a calcimimetic agent that binds to receptor sites in parathyroid, blocking PTH production
o Vitamin D replacement in deficient pts
o Denosumab for pts with severe hypercalcemia due to parathyroid carcinoma
o Avoid thiazide diuretics and dietary phosphate - Surgical _________:
o Recommended for symptomatic patients, kidney stones, bone disease, and pregnancy
o Young pts (under 50-60)
o Complications to surgery:
Serum PTH levels fall below normal in 70% of pts post-surgery (hours)
Can cause hypocalcemic paresthesias or ___
Hyperthyroidism occurs immediately post-surgery, but calms down over several days (may need a beta blocker during that time) - Parathyroid hyperplasia is common in chronic renal failure – because hypocalcemia from CKD which can stimulate and cause parathyroid hyperplasia
o 3 1/2 glands removed
o Metal clip left to mark residual parathyroid tissue
fluid bisphosphonates cinacalcet parathyroidectomy tetany
HYPERALDOSTERONISM
TREATMENT
• ______ (Spironolactone) or Eplerenone (no antiandrogen activity)
o But why? Increases __
o What is a physical side effect to look out for?
o Is this a primary or secondary cause of hypertension?
o This is not going to cure hyperaldosteronism, but is strictly used to control the symptoms
o If there is an adrenal mass contributing to the symptoms, then _______ may be necessary.
• Glucocorticoids (cortisol)
o Stress hormone
o Reduces bone formation, thus increasing your risk for osteoporosis
What test should patients on chronic steroids get to help monitor this?
o Immune system
B-cell-mediated antibody response
Used for allergies, RA, inflammation
o Glucose regulation through gluconeogenesis
Where does this happen?
aldactone
K+
surgical intervention
ACUTE ADRENAL INSUFFICIENCY
• Treat patient with IV ______ (IV hydrocortisone) and symptoms should improve
solu-cortef
CHRONIC ADRENAL INSUFFICIENCT (ADDISONS) (COMBINED FROM 2 PLACES ON FR)
TREATMENT
• _______ is the drug of choice.
o Glucocorticoid: secreted from the zona fasciculate
• ______ (Florinef) has a potent sodium retaining effect, thus is given to patients that have significant postural hypotension, hyponatremia, or hyperkalemia
o Mineralcorticoid: secreted from the zona glomerulosa
• Patients who have AI (or are on chronic steroids) and will be having surgery will need stress dose steroids (IV solucortef 100 mg 1 hour before surgery, then 100 mg q8 hour x 2 doses after)
TREATMENT
• General Measures
o Wear a medical alert _____ or medal saying “takes hydrocortisone”
o Provide dose escalation schedule for increased corticosteroids for illness, accidents or prior to minor surgical procedures
o Increased fludrocortisone for hot weather or prolonged strenuous exercise
o Prescribe with refills so patient does not run out; _______ for nausea; parenteral hydrocortisone for self injection if vomiting.
• Specific therapy
o Hydrocortisone orally daily in 2 or 3 divided doses; 15-30 mg daily
o Some may respond better to prednisone or methylprednisolone 3-6 mg in divided doses daily
o Additional corticosteroid must be given during stress (infection, trauma, surgical procedures); IV for severe illness, trauma or major surgical stress
o Monitor patients closely; clinical improvement; WBC: relative neutrophilia and lymphopenia can indicate corticosteroid over replacement and vice versa
• Mineralocorticoid replacement therapy
o Fludrocortisone acetate: potent sodium-retaining effect
o 0.05-0.3 mg orally daily or every other day
o Increased in the presence of postural hypotension, hyponatremia or hyperkalemia
o With edema, hypokalemia or hypertension, dose is decreased
o _____is given to some women with adrenal insufficiency
o 50mg orally improved well0being, increased muscle mass and a reversal in bone loss
• TREATMENT OF ADRENAL CRISIS
o Without established adrenal insufficiency diagnosis: emergency lab tests, blood cultures and serum cortisol and ACTH levels
o Without waiting for results; immediate treatment:
_________ or hydrocortisone sodium succinate 100-300 mg IV along with saline solution
Thereafter, hydrocortisone is continued as IV infusions of 50-100 mg every 6 hours for the first day
Broad spectrum ___ empirically
Treat ______ abnormalities
When able to switch to oral hydrocortisone, 10-20 mg q 6 hours; then reduced to maintenance dosing
Mineralocorticoid replacement is not needed when large amounts of hydrocortisone are being given but when the dose is reduced it is usually necessary to add fludrocortisone acetate 0.05-0.2 mg orally daily.
hydrocortisone
fludrocortisone
bracelet
ondansetron
DHEA
hydrocortisone phosphate
ABX
electrolyte
CUSHINGS
TREATMENT
• Treatment for cortisol-dependent comorbidities including osteoporosis, psychiatric disorders, DM, HTN, hypokalemia, muscle weakness and infections
• _____
o Pituitary Cushing Disease: transsphenoidal selective resection of the pituitary adenoma
o Ectopic ACTH secreting tumors should be surgically resected; if it can’t be localized or is metastatic, laparoscopic bilateral dis usually recommended
o Benign Adrenal Adenomas: resected laparoscopically if they are smaller than 6 cm
o Adrenocortical carcinomas are resected surgically
• MEDICAL THERAPY
o ______ 2-5 years postoperatively; can cause hypogonadism, suppress TSH and cause hypothyroidism; can also cause primary adrenal insufficiency.
o Replacement hydrocortisone or prednisone started when mitotane doses reach 2 g daily
o ______ is an oral drug that reduces cortisol synthesis by blocking the adrenal enzyme 11B-hydroxylase.
o Medical therapy for people that refuse surgery is aimed at treated the symptoms of hypercortisolism.
surgical therapy
Mitolane
osilodrostat
PRIMARY ALDOSTERONISM
TREATMENT • Unilateral Adrenal Adenoma o Conn syndrome: laparoscopic \_\_\_\_\_\_ o Second trimester in pregnancy o Long term medical therapy is an option • Bilateral adrenal hyperplasia o Best treated with medical therapy o \_\_\_\_\_\_\_ diuretic (spironolactone, eplerenone or amiloride) o \_\_\_\_\_\_\_ is the most effective; antiandrogen activity; men get breast tenderness, gynecomastia, reduced libido
adrenolactomy
potassium sparing
spironolactone
anterior hypopituitarism
LIFELONG HORMONE REPLACEMENT THERAPY
- _______ replacement (for ACTH deficiency)
- _____ replacement (for TSH deficiency)
- ______ replacement (for LH/FSH deficiency)
o hCG equivalent to LH for men (for men with oligospermia, or low sperm count)
o With continued low sperm count à follitropin beta (synthetic recombinant FSH) or urofollitropins (urine derived FSH)
o An alternative is ____ (GnRH analog)
o Clomiphene can stimulate men’s own gonadotropins, increasing testosterone and sperm production
Induction of ovulation in women
- hGH (human growth hormone) replacement with rhGH, somatropin (recombinant human growth hormone
glucocorticoid
thyroid
gonadotropin
leuprolide
SIADH
TREATMENT
- Identify and treat underlying cause
- Fluid ______ don’t give a lot of free water
- Correct underlying _______ –> BUT if I give you too much salt too quickly, water follows salt (draws water from cells) à causes osmotic demyelination (pulls myelin off those nerve fibers)
o Do not correct severe hyponatremia too ____ à causes central pontine myelinolysis (rapid correction of sodium pulls water from the cells, causing osmotic demyelination within the central basis pontis)
- _______ – a tetracycline abx that causes renal tubules to develop resistance to ADH
- vaptans – ADH receptor antagonists (not widely used for clinical practice)
restriction
hyponatremia
rapidly
demeclocycline
DIABETES INSIPIDUS
TREATMENT
- Mild cases? Require no treatment – just ensure adequate fluid intake (GIVE THEM _____, MAKE SURE THEY HAVE ACCESS TO WATER) and avoid steroids
- Central DI? _______ acetate nasal spray every 12-24 hours
o Desmopressin is also available orally and by IV.
- Nephrogenic? Manage underlying disease (ex. end stage renal disease), remove _____ agent if there is one (ex. lithium), make sure they have access to water to ensure they do not become hypernatremic
WATER
desmopressin
offending
HYPERPITUITARISM
TREATMENT
PITUITARY MICROSURGERY
- Transphenoidal pituitary ______ removes the adenoma while preserving anterior pituitary function
- Complications in 12% = infection, CSF leak, hypopituitarism
- POST-OPERATIVELY:
o GH levels fall immediately with diaphoresis and CTS improves 1 day post-op
o Fluid and electrolyte disturbances post-op – DI 2 days post-op, but usually mild and self-limiting
o hyponatrema 4 days post-op – nausea, vomiting, headache, malaise, seizure à treated with free water and hypotonic fluid restriction
- Corticosteroid perioperatively à tapered to replacement doses over 1 week
o 6 weeks post-op à hydrocortisone is discontinued; cosyntropin test done
o Screen for hypothyroidism and hypogonadism (6 weeks post-op)
MEDICATIONS – incomplete biochemical remission after pituitary surgery (did surgery and pituitary not in complete remission OR cannot do surgery à BUT, surgery > meds)
Include dopamine agonists, somatostatin analogs, tamoxifen, or pegvisomant
- _______: dopamine agonists of choice (oral)
o Best for GH/PRL tumors; shrinks tumors and safe in pregnancy
o Side effects: nausea, fatigue, constipation, abdominal pain, dizziness
- ______ LAR and LANREOTIDE: long-acting somatostatin analogs (monthly subq injection)
- RALOXIFENE: selective estrogen receptor modulator (SERM) (oral)
o May be useful for persistent acromegaly in men or women with hx of breast cancer
o Does not reduce GH levels but reduces IGF-1 and may normalize it
o Testosterone levels increase in men à used for osteoporosis (selective for bones, not going to affect other organs)
- PEGVISOMANT: GH receptor antagonist (daily subq )
o Blocks hepatic IGF-1 production, but does not shrink tumors
o Monitor patients for tumor growth
àSTEREOTACTIC ______
- For pts that do not go into remission with transsphenoidal surgery or meds
- May be treated with one or a combination of three types of stereotactic radiosurgery:
o Linear accelerator: x-rays to the tumor
o Gamma knife radiosurgery: gamma rays to the tumor
o Proton beam: charged particles to the tumor
- Normalizes serum IGF-1 in up to 80% of treated patients
- Take lifelong ASA because of increased risk of small vessel stroke
- Monitor for anterior pituitarism for 5 years
microsurgery
CABERGOLINE
OCTREOTIDE
radiosurgery
HYPERPROLACTINEMIA
TREATMENT
- Stop meds known to induce prolactinemia
- Hypothyroidism should be corrected
- Amenorrhea à OCPs with microprolactinemias (give ____s to maintain cycle)
- Infertility = ______ agonist
- Pregnancy = dopamine agonists throughout pregnancy
- No treatment –> at risk for ______– because suppressing estrogen or testosterone, at risk for imbalance and thus osteoporosis
- Macroprolactinomas –> higher risk of progressive especially during estrogen, testosterone HRT or during pregnancy – if you get testosterone or estrogen HRT, tumor can get bigger because stimulating pituitary
àDOPAMINE AGONISTS = _____ and _______
- ______: most tolerated and most effective; for those desiring normal sexual function and fertility
- Taken at bedtime to minimize side effects of nausea, dizziness, orthostatic hypotension
- Psychiatric side effects
- Restores fertility à pregnancy possible and no increased risk of teratogenicity
SURGERY – if candidate for surgery DO _____! Instant results, less side effects, life-long results
- Transphenoidal surgery
o Complications: CSF leakage, meningitis, stroke, visual loss (3%), sinusitis, nasal septal perforation, or infection; DI, hyponatremia
- Stereotactic radiosurgery
*Chemotherapy for small percentage of pts
OCPS DOPAMINE osteoporosis cabergoline, bromocriptine cabergoline surgery
