Endocrine Flashcards
Hypoglycemia
Level 1 hypoglycemia (glucose alert): FBS ≤70 mg/dL
Level 2 hypoglycemia: Blood glucose ≤54 mg/dL
More common with DMT1
If non-diabetic usually from fasting or diet related
S&S: weak, hand tremors, anxiety, feeling like passing out, sweaty hands, rapid pulse, confusion
Sx can be blocked by beta-blocker
Can progress to coma
Tx: 15-15 Rule
15g carbs
Check BS in 15 min
Edu: keep taking meds when sick
May need to reduce medication when exercising if they do not compensate with diet (simple carbs before, complex carbs after)
Thyroid cancer
S&S: engirded cervical LN, swelling, pain. Hoarseness, trouble swallowing
Risk factors: Asian, family history, Radiation as a child, low-iodine diet
Pheochromocytoma
Hormone-releasing adrenal tumor
Rare
S&S: Random episodes of headache, diaphoresis, tachycardia, HTN
Triggers; exercise, anxiety, surgery, change in body position
Hyperprolactinemia
Can be sign of pituitary adenoma
S&S: amenrhea, galactorrhea
What does the hypothalamus secrete?
follicle-stimulating hormone [FSH], luteinizing hormone [LH], thyroid-stimulating hormone [or thyrotropin; TSH]
What does the Anterior pituitary secrete?
FSH:
Stimulates the ovaries to enable growth of follicles (or eggs)
Production of estrogen
LH:
Stimulates the ovaries to ovulate
Production of progesterone (by corpus luteum)
In males, LH stimulates the testicles (Leydig cells) to produce testosterone
TSH:
Stimulates thyroid gland
Production of triiodothyronine (T3) and thyroxine (T4)
GH:
Stimulates somatic growth of the body
ACTH:
Stimulates the adrenal glands (two portions of gland: medulla and cortex)
Production of glucocorticoids (cortisol) and mineralocorticoids (aldosterone)
Prolactin:
Affects lactation and milk production
Melanocyte-stimulating hormone:
Production of melatonin in response to UV light; highest levels at night between 11 p.m. and 3 a.m.
What does the posterior pituitary secrete?
antidiuretic hormone (vasopressin) and oxytocin, which are made by the hypothalamus but stored and secreted by the posterior pituitary.
Lab results in Thyroid disease
Normal range: TSH of 0.5 to 5.0 mU/L
Hypothyroidism TSH >5.0 mU/L, Free T4 Low, T3 Low
Subclinical hypothyroidism TSH >5.0 mU/L, Free T4 Normal, T3 Normal
Hyperthyroidism TSH <0.05 mU/L, Free T4 High, T3 High
Subclinical hyperthyroidism TSH <0.05 mU/L Free T4 Normal, T3 Normal
Primary Hyperthyroidism
Cause: 60-8-% caused by Grave’s disease
S&S: Weight loss, anxiety, insomnia, tachycardia, HTN, afib, inc perspiration, eye lid lag, frequent BMs, amenorrhea, heat intolerance, enlarged thyroid (goiter), pretibial myxedema. Tremors, exophthalmos
Dx: Low THS, High T3& free T4
If Frave’s - positive thyrotropin receptor antibodies (TRAb) aka thyroid-stimulating immunoglobulins
TPO + for Graves and Hashimoto
Thyroid ultrasound
RAIU
Tx:
Thionamides:
Methimazole (Tapazole): Shrinks thyroid gland/decreases hormone production.
Propylthiouracil (PTU): Shrinks thyroid gland/decreases hormone production. Use w/ moderate to severe hyperthyroidism (can cause liver failure).
Can use beta-blocker for HR
Radioactive iodine - will destroy thyroid gland, will need supplementation for life
Thyroid storm (thyrotoxicosis): Dangerously high HR, PB, temp. D/t stress/infection. Lifethreatening
Primary hypothyroidism
Cause: Hashimoto’s thyroiditis, postpartum, thyroid ablation
Hashimoto: chronic autoimmune disorder, Cx destructive antibodies (TPOs) against the thyroid gland. More common in women
S&S: Weight gain, goiter, fatigue, cold intolerance, constipation, alopecia, elevated cholesterol. At risk w/ other autoimmune disorder
Dx: Order TSH first, if elevated order freeT4. If T4 low, dx is hypothyroidism, order TPO to confirm Hashimotos
Tx: Start Levo (25-50 mcg/day starting), caution with heart disease
Increase every few weeks until TSH is normalized
Complications: Myxedema - emergency, s&s slowed thinking, short-term memory loss, depression, hypotension, hypothermia
Diabetes Mellitus Long term damaged
Microvascular damage: Retinopathy, nephropathy, and neuropathy
Macrovascular damage: Atherosclerosis, heart disease (coronary artery disease, MI)
DMT1
Destruction of B-cells in the islets of Langerhans
Untreated, body fats will be used for energy, ketones build up causing diabetic ketonic acidosis
DMT2
Progressive decreased secretion of insulin with insulin resistance
Risk factors: Obesity, metabolic syndrome, gestational diabetes
S&S: hyperglycemia = polyuria, polydipsia, polyphagia
Dx: when first diagnoses, checked A1C every 3 months until controlled, then every 6 months
Lipid panel yearly
Urine microalbuminuria yearly
Normal glucose levels - non-diabetic
FPG: 70 to 100 mg/dL
Peak postprandial plasma glucose: <180 mg/dL
Glycosylated hemoglobin (A1C <6.0%)
Metabolic syndrome qualifications
Presence of any three of the following four traits:
Obesity, abdominal obesity. Waist size:
Male: >40 inches (102 cm)
Female: >35 inches (88 cm)
Hypertension: BP >130/85 mmHg
Dyslipidemia: Triglycerides >150 mg/dL, high-density lipoprotein (HDL) <40 in males or <50 in females
Hyperglycemia: Fasting plasma glucose (FPG) >100 mg/dL or type 2 DM
Lab criteria for diabetes
Prediabetes
A1C - 5.7% and 6.4%
Fasting glucose of 100 to 125 mg/dL (impaired FPG)
Two-hour oral glucose tolerance test (OGTT; 75 g load) of 140 to 199 mg/dL
Diabetes Mellitus
A1C ≥6.5%
FPG ≥126 mg/dL (fasting 8 hours)
Symptoms of hyperglycemia (polyuria, polydipsia, polyphagia) plus random blood glucose ≥200 mg/dL
Two-hour plasma glucose ≥200 mg/dL during an OGTT with a 75-g glucose load
Diabetes preventative care recommendations
The CDC recommends adults >50 years be given Shingrix in two doses, 2 to 6 months apart.
Influenza immunization every year.
Pneumococcal polysaccharide vaccine: If vaccinated before 65 years of age, give one-time revaccination in 5 years; if age 65 years, give one dose of the vaccine only.
Prescribe aspirin 81 mg if high risk for MI, stroke (if <30 years, not recommended).
Ophthalmologist: Yearly dilated eye exam needed. If type 2, eye exam at diagnosis; if type 1 DM, first eye exam needed 5 years after diagnosis.
Podiatrist: Refer to once or twice a year, especially with older diabetics.
BP: Goal is 130/80 mmHg.
Dental/tooth care: Important (poor oral health associated with heart disease).
Dawn Phenomenon
Surge in blood sugar between 4-8am
Somogyi Effect
Severe noctural hypoglycemia, then high levels of glucagon resulting in high FBG by 7am
D/t over-treatment in the evening/bedtime
Tx: eat a snack before bed or lower nightime dosing
Biguanides
Metformin
First-line DMT2
Decreases gluconeogenesis and decreases peripheral insulin resistance
Rarely causes hypoglycemia
Neutral weight change
GI side effects: diarrhea and nausea
Contraindications: Do not use if renal disease, hepatic disease acidosis, alcoholics, hypoxia.
Hold if getting IV contrast, day of and 48 hr later
Monitor renal function
Sulfonylureas
1st gen: Chlorpropamide
2nd gen: Glipizide (Glucotrol), glyburide (DiaBeta)
MOA: stimulate beta cells of pancreas to secrete insulin
AEs: hypoglycemia, photosensitivity, weight gain
Avoid w/ hepatic or renal impairment
Thiazolidinediones
-zone
Pioglitazone (Actos)
MOA: Enhances insulin sensitivity in muscle tissue, reduces hepatic glucagon production
Monitor LFTs, causes weight gain
Contraindicated: DO NOT USE WITH HF, causes water retention, bladder cancer, liver disease, pregnancy
Bile-acid sequestrants
Cholestyramine (Questran), colesevelam (Welchol), colestipol (Colestid)
Reduce hepatic glucose production and may reduce intestinal absorption of glucose, lowers LDLs
AEs: GI related
Meglitinides (Glinides)
Repaglinide (Prandin), nateglinide (Starlix)
Stimulates pancreatic secretion of insulin
Indicated: DMT2 w/ postprandial hyperglycemia
Rapid acting, short half-life
Hold if fasting
Can cause hypoglycemia, weight neutral
AEs: GI (bloating, abd cramps, diarrhea)
Insulins
Rapid acting: Lispro/aspart.glulisine (Onset 15 min/Peak 30m-2.5h/Duration 4.5h)
Short acting: Regular (Onset 30m/Peak 1-5h/Duration6-8h)
Intermediate acting: NPH (Onset 1h/Peak 6-14h/Duration 18/24h)
Basil insulin analog: glargine(Lantus)/detemir(Levemir) (Onset1h/Peak none/Duration 24h)
Rapid-acting insulin covers “one meal at a time”
Regular insulin lasts “from meal to meal”
NPH insulin lasts “from breakfast to dinner”
Lantus is “once a day”
Alpha-Glucosidase Inhibitor
Slows intestinal carbohydrate digestion and absorption; a nonsystemic oral drug
Does not cause hypoglycemia; modest effect on A1C level
GI side effects are flatulence, diarrhea
Glucagon-Like Peptide-1 Receptor Agonists (GLP-1 RAs)
Exenatide (Byetta), liraglutide (Victoza), -tide
MOA: Stimulate GLP-1, inc insulin, dec postprandial glucagon, inc satiety
Reduces CVD, kidney dz, weight loss, no hypoglycemia
AEs: pancreatitis
Contraindication: medullary thyroid cancer, MEN-2
Sodium-Glucose Cotransporter-2 Inhibitors (SGLT-2 inhibitors)
Canagliflozin (Invokana), dapagliflozin (Farxiga), empagliflozin (Jardiance) -flozin
MOA: block reabsorption by kidney and inc glucosuria
No hypoglycemia
Reduce CVD, kidney dz
Weight loss, hypotension
AEs: polyuria, UTIs (pee sugar), pyelonephritis
Can lead to DKA
Dipeptidyl Peptidase-4 Inhibitors (DPP-4 inhibitors)
-lip
Sitagliptin (Januvia), saxagliptin (Onglyza), linagliptin (Tradjenta)
MOA: Increase insulin secretion and decrease glucagon
No hypoglycemia, renoprotective
AEs: joint pain, angioedema/urticaria, acute pancreatitis
Amylin Mimetic/Analog (Symlin)
Decreases glucagon secretion; slows gastric emptying; leads to feeling satiety early; causes weight loss
Route: Injectable; frequent dosing; requires patient training
Causes hypoglycemia if used with insulin (decrease insulin dose)
Do not combine incretin mimetics (_______) with any incretin enhancers (________). Both act on incretin.
GLP-1 Byetta, Victoza
DPP-4 Januvia, Onglyza
T2DM medication steps
- Lifestyle changes
- Metformin (starting dose 500mg , max dose 2000mg daily)
- If Metformin maxed out, add sulfonylurea (can use other drugs also)
- Still high sugar, might need insulin
Presence of CVD and/or chronic kidney disease, or heart failure with reduced ejection fraction (HFrEF), start on an SGLT-2 inhibitor and/or GLP-1 RA.
DM meds, effect on weight
Causes weight loss: Metformin, incretin mimetic, GLT-2 inhibitors
Causes weight gain: Insulins, sulfonylureas, TZDs (Actos)
Weight neutral: Meglitinides (Starlix, Prandin), bile-acid sequestrants (Welchol), alpha-glucosidase inhibitors
