endocrine

Question 1

HPA axis diagrammed

Answer 1

Question 2

Adrenal Gland

Answer 2

Comprised of adrenal cortex and adrenal medulla
◦ Inner – medulla
– secretes catecholamines
◦ Outer – cortex
– secretes adrenal steroids
— Adrenal cortex produces about 50 different chemicals

Question 3

adrenal products with pharmacologic properties:

Answer 3

– Mineralocorticoids
– Glucocorticoids, cortisol
– Androgens

Question 4

Adrenal Cortex layers

Answer 4

— 3 layers within cortex
◦ zona glomerulosa: produces mineralocorticoids
◦ zona fasciculata produces glucocorticoids
◦ zona reticularis: produces sex hormones, mostly androgens and small amount of glucocorticoid

Question 5

Mineralocorticoids function

Answer 5

(produced in zona glomerulosa)
— Regulate water and electrolyte balance
◦ Sodium (Na +), Potassium (K+) and fluid balance
◦ Provide important homeostatic functions

Question 6

main mineralcorticoid and its function

Answer 6

Aldosterone – main endogenous hormone
◦ essential for blood pressure regulation and electrolyte and fluid homeostasis - helps to maintain normal blood pressure and electrolyte balance
◦ acts on the Mineralocorticoid Receptor (MR

Question 7

Mineralocorticoid Receptor roles:
– MR renal
– Extra-renal MR plays a relevant role in?
– Overactivation of the MR is implicated in?

Answer 7

– MR present in kidneys impacts fluid and electrolyte balance
– Extra-renal MR plays a relevant role in the control of cardiovascular and metabolic functions
– Overactivation of the MR is implicated in the pathophysiology of aging related to cardiovascular, metabolic and kidney dysfunction and progress of diseas

Question 8

Aldosterone Basics
—

Answer 8

Aldosterone Basics
— Increases Na+ reabsorption by distal tubules in kidney
with concomitant increased excretion of K + and H +
— Increases BP and blood volume – balance/control the
amount of sodium and fluids in the body
— Work on specific intercellular receptors in kidney

Question 9

Pharmacotherapeutic use of medications involving
mineralocorticoid effects

Answer 9

— Replacement therapy Addison’s Disease/Adrenal Insufficiency
◦ Addison’s Disease (autoimmune disease)/Adrenal Insufficiency –
adrenal do not produce enough of the steroid hormones, cortisol
and aldosterone

Question 10

Fludrocortisone (Florinef)
class?
– Functionally similar to?
– Most effect of all available roids?
– Other steroids have much smaller amounts of? or no?
– Other indications:

Answer 10

mineralocorticoid
– Functionally similar to aldosterone
– Most mineralocorticoid effect of available steroids
– Other steroids have much smaller amounts of mineralocorticoid effects
(example: hydrocortisone, prednisone) or no mineralocorticoid effects
(example: dexamethasone, methylprednisolone)
– Other indications: orthostatic hypotension, septic shock

Question 11

Drugs that Inhibit Aldosterone:
imbalances of aldo and its results?
—

Answer 11

Imbalances in aldosterone and overactivity of the mineralocorticoid receptor contribute to hypertension, kidney insufficiency, heart failure and potentially other cardiovascular disease
◦ Due to idiopathic adrenal hyperactivity (most common) or benign tumor (Conn’s
syndrome)

Question 12

Spironolactone (Aldactone) and Eplerenone (Inspra)

with steroidal structure

Answer 12

– competitive aldosterone antagonist at receptor sites in distal renal tubules (block higher
concentration of kidney-specific MR), increasing sodium chloride and water excretion while conserving potassium and hydrogen ions – prevents mineralocorticoid effects of adrenal steroids on the renal tubule
– Steroidal structure
– Also known as a potassium sparing diuretics

Question 13

Spironolactone (Aldactone) and Eplerenone (Inspra) indications

Answer 13

– Hyperaldosteronism (secondary cause of hypertension and causes low potassium)
– Heart failure
– Hypertension

Question 14

Drugs that Inhibit Aldosterone (Non-steroidal)

Answer 14

Finerenone (Kerendia)

Question 15

Finerenone moa

Answer 15

◦ Blocks Mineralocorticoid receptor (MR) in kidney and heart
◦ Selectively blocks (antagonist) mineralocorticoid receptor-mediated sodium reabsorption and overactivation of kidney, blood vessel, and heart tissues, reducing fibrosis and inflammation
◦ MR overactivation is an important factor associated with CV events and Chronic Kidney Disease (CKD) progression (similar to SGLT2 inhib)

Question 16

Glucocorticoids:
(endogenously produced in?
Mechanism of action –
* Widespread actions on?
* Potent regulatory effects on?
◦ Glucocorticoid receptors up regulate expression of? and down regulate expression of?

Answer 16

(endogenously produced in zona fasciculata)
Mechanism of action – complex: work through specific glucocorticoid intracellular receptors to regulate several vital cell activities
◦ Metabolic
◦ Immune function
* Widespread actions on intermediate metabolism, affecting carbohydrate (glucose), protein and fat metabolism
* Potent regulatory effects on host defense mechanisms including inflammation and immune function
◦ Glucocorticoid receptors up regulate expression of anti- inflammatory proteins and down regulate expression of pro- inflammatory proteins

Question 17

main endogenous hormone of humans

Answer 17

Main endogenous hormone in humans – hydrocortisone
(also called cortisol)
◦ Produce 24-30 mg endogenous hydrocortisone/cortisol
◦ Use up to 300 mg/day in times of significant stress

Question 18

how is cortisol secreted/when is it highest?

Answer 18

circadian rhythm, highest early in morning

Question 19

HPA axis pathway

Answer 19

◦ Hypothalamus releases Corticotrophin-Releasing Hormone [CRH]
◦ Adrenocorticotropic hormone [ACTH] released from the anterior Pituitary
◦ Adrenals release glucocorticoids
◦ Negative feedback mechanism to inhibit CRH and ACTH when glucocorticoid concentrations increase in the blood

Question 20

Therapeutic Use of Corticosteroids
—

Answer 20

• — Many have partial mineralocorticoid and glucocorticoid properties
• — Most are used for anti-inflammatory and immunosuppressive properties

Question 21

common indications of corticosteroids

Answer 21

◦ Addison’s disease/Adrenal Insufficiency
◦ Cancer therapy (reduce ADE)
◦ Anaphylaxis
◦ Hypersensitivity states
◦ Shock
◦ Autoimmune disease
◦ Asthma (inhaled)
◦ Chronic obstructive pulmonary disease
◦ Respiratory distress syndrome in infants
◦ Suppressing rejection
◦ Acute renal insufficiency
◦ Inflammatory conditions of eyes, ears, nose or skin /rashes of the skin

Question 22

Use of Steroids in Dentistry

Answer 22

Use for anti-inflammatory, pain management and auto-immune properties
— Oral lesions
◦ Aphthous ulcers/stomatitis
◦ Oral lichen planus
◦ Erythema multiforme
◦ Behcet’s disease
◦ Pemphigus
◦ Bullous pemphigoid
◦ Systemic lupus erythematosus
— Restorative dentistry/pain management
— Bell’s palsy
— Post herpetic neuralgia
— Temporomandibular joint disorder
— Temporal arteritis

Question 23

Formulations of Corticosteroids for dentistry (topical)
◦ Importance of ?
◦ Example of commercially available product:

Answer 23

— Dental (topical oral) applications
◦ Pastes, ointments/orabase, gels, lozenges, intralesional therapy, rinses – commercially
available or compounded
◦ Importance of contact time with lesion
◦ Example of commercially available product:
– Kenalog® in Orabase® / Triamcinolone Dental Paste

Question 24

pt education for corticosteroids used in dentistry

Answer 24

• Using a cotton swab, press (do not rub) a small amount of paste onto the area to be treated until the paste sticks and a smooth, slippery film forms. Do not try to spread the medicine because it will become crumbly and gritty.
• (Usually applied 2-3 times per day – see dosing information of the product). Apply the paste at bedtime so the medicine can work overnight. The other applications of the paste should be made following meals.

Question 25

Other Formulations of Corticosteroids

Answer 25

Systemic
◦ Oral/IM/IV
◦ Pulse dosing/bursts
◦ Life-long replacement for adrenal suppression
—
Others
◦ Topical/external (creams/ointments) – skin/joints
◦ Intra-articular – joints
◦ Inhalation – asthma/COPD

Question 26

Steroid Dosing Consideration
Consider the?
Weigh?
Topical/other types of administration may cause?
◦ Depends on?
— Use lwhat doses/durations?
— Monitor for ?
— If patient on systemic therapy longer than? how do they stop?
— Consult with?
with Addison’s Disease?

Answer 26

— Consider the potency of steroids and formulations
— Weigh pros/cons of oral topical vs. systemic therapy
— Topical/other types of administration may cause systemic effects
◦ Depends on potency, amount, surface area covered, absorption,
permeability of tissue, dosing frequency, site treated, etc.
— Use lowest effective dose for shortest duration
— Monitor for adverse events
— If patient on systemic therapy longer than 14 days, taper dose off.
DO NOT STOP ABRUPTLY – use taper
— Consult with the patient’s provider for management of patients
with Addison’s Disease, chronic steroid use or steroid tapering
plans, when needed.

Question 27

Relative Potencies and Equivalent Doses of
Common Corticosteroids

Answer 27

Question 28

```

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taking systemic steroids
* Take when?
* Take with?
* If given for chronic adrenal insufficiency, may need to?

Answer 28

• Take in the morning if taking orally once a day
• Take with food if taking orally
• If given for chronic adrenal insufficiency, may need to give 2/3 dose in AM and 1/3 dose in PM

Question 29

potnetcy with topical steroids

Answer 29

many products available can start high and go low or go from low and titrate up

Question 30

Steroid Dosing
— Systemic considerations
◦ Low dose
◦ Moderate dose
◦ High dose

Answer 30

◦ Low dose < 10 mg prednisone/day
◦ Moderate dose 10-20 mg prednisone/day
◦ High dose > 20 mg prednisone/day

Question 31

Prednisone
◦ cost?
◦ Available in ?
◦ dosing?

Answer 31

◦ Usually, lowest cost oral steroid
◦ Available in wide range of strength for titration
◦ Morning dosing/can split larger doses to BID, but give earlier in the day to minimize insomnia and mimic higher endogenous steroid production in the AM

Question 32

Methylprednisolone (Medrol) Dose Pack dosing

Answer 32

could see insomnia with bedtime doses

Question 33

Examples of Steroids/Dosing Used in Dental
Practice

how to write these Rx’s

Answer 33

Question 34

Use of IV Steroids
— Intra-operative administration

Answer 34

◦ Example: 3rd molar extractions with IV sedated patient
– IV dexamethasone or IV methylprednisolone
◦ Provides anti-inflammatory effect (reduces pain and swelling)
◦ Helps reduce post-op nausea from the sedation

Question 35

HPA Axis Suppression/Adrenal Suppression with use of corticosteroids

Answer 35

• When providing supraphysiologic doses of corticosteroids (> 25-30 mg of hydrocortisone/cortisol equivalents) X 14 days or more = HPA Axis SUPPRESSION
• May take weeks to months to fully recover function
• Use of chronic exogenous corticosteroids = suppression of adrenal gland = atrophy
• — Inability of the adrenals to respond to stress can result in adrenal crisis
• — Patient may develop chronic adrenal insufficiency (AI) from various causes

Question 36

Chronic Adrenal Insufficiency (AI) causes

Answer 36

— Primary Chronic AI – Addison’s Disease (autoimmune)
— Secondary AI – damage/disease of the pituitary or hypothalamus
◦ Also caused from long-term use of glucocorticoids

Question 37

chromnic primary AI tx regimens

Answer 37

• Treatment for chronic primary AI often includes oral hydrocortisone +/- fludrocortisone
• Other options for treatment of AI – prednisone, dexamethasone

Question 38

Adrenal crisis prophylaxis
— Acute adrenal crisis =
◦ Life-threatening?
◦ Predicated in?
◦ Symptoms
◦ Laboratory findings

Answer 38

— Acute adrenal crisis = medical emergency (rare)
◦ Life-threatening condition
◦ Predicated in patients with chronic adrenal insufficiency (AI) with increased significant stress such as from infection, trauma or surgery
◦ Symptoms –fever, abdominal pain, weakness, hypotension, dehydration, nausea, vomiting, slow, sluggish movement, fatigue, profound weakness, rapid heart rate, rapid respiratory rate, confusion, loss of consciousness/coma
◦ Laboratory findings – low K + , low Na + , acidosis, uremia

Question 39

Management of Acute Adrenal Insufficiency (AI) in Surgery – Steroid Cover
—

Answer 39

• IV fluids (5% dextrose in Normal Saline)
• Hydrocortisone
  ◦ 20-25 mg/day- Primary AI (Addison’s Disease – idiopathic, most commonly auto-immune)
  ◦ 15-20 mg/day – Secondary AI (exogenous corticosteroids or disease/disorders of hypothalamus or pituitary)
  – Secondary AI selectively causes glucocorticoid deficiency; therefore, mineralocorticoid function is better maintained
  – Adrenal crisis less likely than in primary AI
• Hydrocortisone – IV initially then change to oral when patient is stable

Question 40

Current evidence shows that routine dental care and minor oral surgical
procedures under local anesthesia, including uncomplicated dental extractions,
do not?

Answer 40

Current evidence shows that routine dental care and minor oral surgical
procedures under local anesthesia, including uncomplicated dental extractions,
do not increase stress levels enough to precipitate an adrenal crisis

Question 41

Addisons dx undergoing major sx with general anesthesia prophy?

Answer 41

Consider 10 mg-25 mg hydrocortisone equivalents orally(po) stress dose cover for
those at highest risk (Addison’s Disease) undergoing major dental surgery with general
anesthesia (steroid cover)

Question 42

Acute Adverse Effects to Long-term Effects of steroid use at diff systems

Answer 42

Question 43

corticosteroids Interactions:
* warfarin?
* diuretics
* cardiac effects?
* Interferes withwhat absorption in food?
* Absorption of glucocorticoids is decreased in presence of?

Answer 43

• Increased prothrombin time/INR with warfarin
• Risk of hypokalemia with potassium-depleting diuretics (hydrochlorothiazide, others)
• Increased risk of cardiac toxicity and arrhythmias with cardiac glycosides (digoxin)
• Interferes with calcium absorption in food
• Absorption of glucocorticoids is decreased in presence of St. John’s wort

Question 44

Contraindications to corticosteroids

Answer 44

• Severe infections,
• severe hypertension,
• severe heart failure,
• severe renal impairment

Question 45

Corticosteroids: dental implications summary
— Effective in?
◦ Alternative to?
—Altered responses to ?
— Oral thrush?
— Contribute to ?
— Patients with chronic adrenal insufficiency (AI): risk of developing?

Answer 45

• Effective in decreasing swelling/inflammation and pain
  ◦ Alternative to NSAIDS or opioids for pain in some cases or may decrease need for opioids
• Altered responses to infection and wound healing
• Oral thrush from inhaled steroids (advise patients to rinse mouth after each inhaler use)
• Contribute to tooth decay, periodontal disease, decreased bone density (long-
  term)
• Patients with chronic adrenal insufficiency (AI): risk of developing acute adrenal
  crisis when placed in a stressful situation such as major dental procedures

Question 46

General Considerations for dental corticosteroid use
◦ dose/duratrion?
◦ abx?
◦ For inhaled steroids?
◦ Anxiety control?
◦ Increased administration of glucocorticoids (steroid cover)?

Answer 46

◦ Pulse steroid/lowest effective dose/shortest duration
◦ Systemic antibiotic therapy – if indicated
◦ For inhaled steroids - rinse/spit and spacers
◦ Anxiety control – for all patients, especially those with AI
◦ Increased administration of glucocorticoids (steroid cover)? - only in patients with AI at high risk/major dental procedures/surgery

Question 47

Patient Education for Steroid Use
— Purpose of steroids:

Answer 47

— Purpose:
◦ Relieve the discomfort and redness, swelling/inflammation of some mouth and gum
problems or during/after dental procedures
◦ Useful for pain
◦ Timeframe for expected improvement

Question 48

Dose/frequency/dosing instructions for steroids
◦ for systemic?
– Adjustment if patient to receive?
– If taper is involved?
◦ Length of ?
◦ Specific instructions for ?
◦ Do not use more often or for a longer time than?

Answer 48

◦ Take in AM for systemic administration
– Adjustment if patient to receive steroid prescription (Medrol) in the afternoon to get all tablets in the first day
– If taper is involved, specifics of taper, what dose to take each day
◦ Length of therapy
◦ Specific instructions for dental paste/topical application
◦ Do not use more often or for a longer time than your medical doctor or dentist
ordered

Question 49

Common (short-term) side effects of steroids
◦ sleep?
– how to reduce?
◦ mood
◦ Legs
◦ Weight
◦ blood sugar?
◦ bp?

Answer 49

◦ Insomnia/difficulty sleeping (one of the most common complaints)
– Taking all in AM may help
– Use of sleep agent for 1-2 nights? (risk vs. benefit)
◦ Agitation/changes in mood/irritability
◦ Leg swelling
◦ Weight gain (more with long-term use)
◦ Risk of increased blood glucose (especially in diabetics)
◦ Risk of increased blood pressure (especially if already elevated)

Question 50

hypothal-pit-thyroid axis diagrammed

Answer 50

Question 51

thyroid hormones
forms?
coversion?

Answer 51

◦ thyroxine (T4) – large storage – high serum concentrations in body
◦ tri-iodothyronine (T3) – small storage – low serum concentrations in body (fast
turnover rate)
– 80% of T3 daily production is a result of peripheral conversion of T4 →T3
– T4 is converted to T3 primarily in the liver and kidney but also in many other tissues
◦ calcitonin

Question 52

thyroid hormone functions

Answer 52

T3 and T4 (combined are referred to as thyroid hormone)
◦ normal growth and development in children (brain and body)
◦ control energy/metabolism
◦ involved in normal functioning of almost every organ system including the brain, heart, liver, and muscles

Calcitonin
◦ control of plasma calcium (Ca2+

Question 53

Basics of Regulation of Thyroid Function

Answer 53

• Thyrotrophin releasing hormone (TRH) stimulated from hypothalamus
• Thyroid stimulating hormone (TSH) from anterior pituitary
• Thyroid hormone synthesi resulting in release of T3 and T4
• Negative feedback on anterior pituitary with T3 more active than T4 ( increased thyroid hormone = decreased TSH)
• Plasma iodine also impacts thyroid hormone production (decrease of iodine = decreased hormone production and decreased TSH)

Question 54

Actions of Thyroid Hormones: metabolism and growth/development

Answer 54

Effects on metabolism
◦ increased metabolism on carbohydrates, fats and protein (most effects in conjunction with other hormones)
◦ T3 3-5X more active than T4

Effects on growth and development
◦ direct action and indirectly influences growth hormone
– skeletal development
– growth and maturation of CNS

Question 55

HYPERthyroidism (Thyrotoxicosis)

Answer 55

Diffuse toxic goiter (Graves Disease/exopthalmic goiter)
◦ autoimmune disease (autoantibodies to TSH receptor)
◦ protruding eyeballs (exophthalmos)
—
Toxic nodular goiter
◦ benign neoplasm or adenoma

Question 56

HYPERthyroidism Symptom

Answer 56

Question 57

HYPERthyroidism treatments

Answer 57

— Surgery
— Radioactive Iodine (RAI)- 131 I (destroys thyroid follicles)
◦ hypothyroidism usually results from surgery or RAI
— Drug Therapy (oral)
◦ Propylthiouracil (PTU)
◦ Methimazole (MMI)s
◦ Beta Blockers (propranolol): symptomatic relief only!
◦ Glucocorticoids for exophthalmos in Graves Disease

Question 58

◦ Propylthiouracil (PTU) and Methimazole (MMU) moa

Answer 58

– MOA → inhibit biosynthesis of thyroid hormones by blocking the oxidation of iodine in the thyroid gland; blocks synthesis of thyroxine (T 4) and triiodothyronine (T 3); does not inactivate circulating T 4 and T 3

Question 59

PTU and MMU ADRs

Answer 59

neutropenia, agranulocytosis, aplastic anemia, liver toxicity

Question 60

HYPOthyroidism General Definition:
◦ Myxedema?

Answer 60

◦ Free thyroxine (fT4) is: sub-normal/low (normal range 0.8 – 2.8 mg/dl) and Thyroid-
Stimulating Hormone (TSH) is usually elevated/high (normal range 0.45 mIU/L - 4.12
mIU/L-varies depending on lab)
◦ Myxedema – term used for severe hypothyroidism
– dermatologic changes that can occur (swelling in legs/eyes)
– coma that can occur as an extreme complication

Question 61

Subclinical Hypothyroidism (early hypothyroidism)
◦ Free thyroxine (fT4) ?
◦ Thyroid-Stimulating Hormone (TSH) ?
◦ s/s?

Answer 61

◦ Free thyroxine (fT4) is: normal
◦ Thyroid-Stimulating Hormone (TSH) is: elevated/high
◦ Mild to no symptoms of hypothyroidism

Question 62

Overt Hypothyroidism
◦ Free thyroxine (fT4)?
◦ Thyroid-Stimulating Hormone (TSH) ? /

Answer 62

◦ Free thyroxine (fT4) is: sub-normal/low
◦ Thyroid-Stimulating Hormone (TSH) is usually: elevated (normally > 10 U/ml)

Question 63

HYPOthyroidism Causes
— worldwide vs US

Answer 63

— Worldwide:
◦ Iodine deficiency
— Iodine sufficient countries:
◦ Chronic Autoimmune Thyroiditis (AITD/Hashimoto’s)

Question 64

hashimotos
risk factors

Answer 64

– reaction against thyroglobulin or other thyroid tissue
– Women > Men
– Age
– Other autoimmune disorders
– Goiter may or may not be presen

Question 65

hypothyroid s/s

Answer 65

Question 66

Goal of therapy for hypothy
— Restore ?
— TSH?
— Reduction in?
— Avoidance of ?

Answer 66

— Restore euthyroid state
— TSH – usually 0.45 mIU/L - 4.12 mIU/L for reference population
— Alleviate symptoms
— Reduction in size of goiter (if present)
— Avoidance of overtreatment (iatrogenic thyrotoxicosis)

Question 67

Drug Therapy for hypothy

Answer 67

— Levothyroxine/Synthroid (synthetic T4 ) – most common therapy
◦ usual dose 50-100 mcg
* ◦ lower doses in patients with coronary artery disease
* other options:
— Liothyronine/Cytomel, Triostat (synthetic T3 )
— Liotrix / Thyrolar (4:1 ratio of synthtic T4 :T3 )
— Thyroid desiccated /Armour Thyroid (“natural” – pig - T4 +T3

Question 68

Clinical Pearls for hypothyroid rx’s
◦ Dosing dependent on?
◦ Onset of action/ full affects?
◦ Take on an?
◦ Recommended to?
◦ Dangers of using thyroid supplementation for?

Answer 68

◦ Dosing dependent on age, sex and body size
◦ Onset of action 1-2 weeks, full effects 4-6 week
◦ Take on an empty stomach 30-60 minutes before meals (in morning) and before other medications!
◦ Recommended to a consistent product to minimize variability! (narrow therapeutic index)
◦ Dangers of using thyroid supplementation for weight loss in euthyroid patients

Question 69

Adverse Effects of thyroid treatments

Answer 69

• Too much or too little supplementation/thyroid hormone, could essnetially overcorrect to opposite dx

Question 70

Drug Interactions with Thyroid Supplementation

Answer 70

• — Interference with absorption
• Decreased hormone production/secretion
• Peripheral metabolism of T4
• Altered secretion of TSH
• Increased clearance of T4

Question 71

Interference with absorption with thyroid supplementing rx

Answer 71

◦ Bile acid sequestrants
◦ PPIs
◦ Oral bisphosphonates
◦ Iron and calcium supplements
◦ Orlistat

Question 72

Decreased hormone production/secretion with thyroid supplementing rx

Answer 72

◦ Amiodarone (can also cause hyperthyroidism - iodine rich)
◦ Lithium

Question 73

Peripheral metabolism of T4 ddi with thyroid supplementation

Answer 73

◦ Glucocorticoids, amiodarone

Question 74

altered secretion of TSH with thryoid supps

Answer 74

◦ Dopamine (and dopaminergic agonists)
◦ Glucocorticoids
◦ Octreotide
◦ St John’s Wort
◦ Amphetamine

Question 75

Increased clearance of T4 ddi for thyroid supps

Answer 75

◦ Many antiepileptics
◦ Quetiapine

Question 76

levothyroxine therapeutic index

Answer 76

Narrow therapeutic index (NTI) drugs
◦ Small differences in dose or blood concentration may lead to serious therapeutic failures and/or adverse drug reactions that are life-threatening or result in persistent or significant disability or incapacity
Evidence from studies hasn’t showing any clinical difference in brand, generic or switching generic manufacturers

Question 77

when should levothyroxine be taken?

Answer 77

Because absorption can be decreased by other vitamins, minerals and/or medications, it’s recommended to be taken on an empty stomach (usually in the morning), 30-60 minutes before food or other medication intake to avoid erratic absorption

Question 78

Undiagnosed thyroid dx in pt

Answer 78

Undiagnosed – be aware of hyper/hypo-thyroid symptoms and refer to provider
◦ identification of enlarged thyroid/goiter

Question 79

Hyperthyroidism implications in dentistry
◦ increased sensitivity to ?
◦ decrease effectiveness of ?
◦ symptoms mistaken for?

Answer 79

◦ increased sensitivity to sympathomimetic drugs/vasopressors such as epinephrine - hypertensive crisis, tachycardia, and/or dysrhythmia
◦ decrease effectiveness of CNS depressants
◦ symptoms mistaken for anxiety

Question 80

Hypothyroidism implications in dentistry
◦ increased respiratory and cardiac depression with?
◦ Over supplementation could result in?

Answer 80

◦ increased respiratory and cardiac depression with benzodiazepines (diazepam,
alprazolam), barbiturates (sodium thiopental), and opioid analgesics (hydrocodone)
◦ Over supplementation could result in cardiovascular symptoms seen in hyperthyroidism

Question 81

Dental Implications
* If euthyroid (treated thyroid disorders)?
* Hyper/hypo-thyroid symptoms - consider decreasing or avoiding:
* Severe/uncontrolled hyper/hypo-thyroid condition:

Answer 81

— If euthyroid (treated thyroid disorders) – manage normally during dental interventions /treatment /procedures
Hyper/hypo-thyroid symptoms - consider decreasing or avoiding:
◦ sympathomimetics/ vasopressors in symptomatic hyperthyroidism
◦ CNS depressants in symptomatic hypothyroidism
Severe/uncontrolled hyper/hypo-thyroid condition – consider postponing dental treatment until consultation from provider or condition better managed (may take weeks to months)

Question 82

Dental Implications
* On Propylthiouracil (PTU) or Methimazole (MMI) for hyperthyroidism- caution with? r patients on thyroid supplementation?

Answer 82

On Propylthiouracil (PTU) or Methimazole (MMI) for hyperthyroidism- caution with bleeding from agranulocytosis or risk of infection from neutropenia
Absorption issues or other drug interactions for patients on thyroid supplementation

Question 83

Steroids for adrenal crisis in patients with Adrenal Insufficiency
only needed for?

Answer 83

Steroids for adrenal crisis in patients with Adrenal Insufficiency
only needed for patients undergoing major dental surgery

Question 84

which aldo antagonist works at both the kidneys and heart

Answer 84

Finerenone

Question 85

mineralocorticoid
– Functionally similar to aldosterone
– Most mineralocorticoid effect of available steroids
– Other steroids have much smaller amounts of mineralocorticoid effects
(example: hydrocortisone, prednisone) or no mineralocorticoid effects
(example: dexamethasone, methylprednisolone)
– Other indications: orthostatic hypotension, septic shock

Answer 85

Fludrocortisone (Florinef)
class?
– Functionally similar to?
– Most effect of all available roids?
– Other steroids have much smaller amounts of? or no?
– Other indications:

Question 86

– competitive aldosterone antagonist at receptor sites in distal renal tubules (block higher
concentration of kidney-specific MR), increasing sodium chloride and water excretion while conserving potassium and hydrogen ions – prevents mineralocorticoid effects of adrenal steroids on the renal tubule
– Steroidal structure
– Also known as a potassium sparing diuretics

Answer 86

Spironolactone (Aldactone) and Eplerenone (Inspra)

with steroidal structure

Question 87

◦ Blocks Mineralocorticoid receptor (MR) in kidney and heart
◦ Selectively blocks (antagonist) mineralocorticoid receptor-mediated sodium reabsorption and overactivation of kidney, blood vessel, and heart tissues, reducing fibrosis and inflammation
◦ MR overactivation is an important factor associated with CV events and Chronic Kidney Disease (CKD) progression (similar to SGLT2 inhib)

Answer 87

Finerenone moa

Question 88

• Severe infections,
• severe hypertension,
• severe heart failure,
• severe renal impairment

Answer 88

Contraindications to corticosteroids

Question 89

– MOA → inhibit biosynthesis of thyroid hormones by blocking the oxidation of
iodine in the thyroid gland; blocks synthesis of thyroxine (T 4) and triiodothyronine
(T 3); does not inactivate circulating T 4 and T 3

Answer 89

◦ Propylthiouracil (PTU) and Methimazole (MMU) moa

Question 90

neutropenia, agranulocytosis, aplastic anemia, liver toxicity

Answer 90

PTU and MMU ADRs