Endocrine Flashcards
DKA Criteria
Anion Gap (arterial pH < 7.3, serum bicarb < 15)
Ketonuria
Hyperglycemia (> 250)
Hyperprolactinemia
Can be a sign of a pituitary adenoma
Hypoglycemia
Level 1: FBS < 70 - > 54
Level 2: FBS < 54
Level 3: severe characterized by AMS or physical status requiring assistance for hypoglycemia
Myxedema Coma
Severe hypothyroidism w/ progression to decreased mental status, hypothermia and decrease in organ function.
check T4 (usually low, TSH (may be high), cortisol
Pheochromocytoma
Rare hormone-releasing adrenal tumor. Typically occurs in persons 20-50. sx HA, diaphoresis and tachy w/ HTN
Triggers: physical exertion, anziety, stress, surgery, anesthesia, changes in body position, L&D. Foods high in Tyramine as well as MAOIz and stimulants.
Hormes stimulated by Pituitary Gland
FSH
LH
TSH
Adrenocorticotropic hormone (ACTH)
growth hormone (GH)
Addison’s Disease Symptoms
Lethargy, nausea, anorexia w/ diarrhea, and pain.
Tanned skin and hyperpigmentation
Hyperkalemia and hypothermia
FSH
stimulates ovaries to enable growth of follicles (or eggs); production of estrogran
LH
Stimulates steroid release from ovaries, ovulation, and the release of progesterone after ovulation; stimulates testicles (Leydig cells) to produce testosterone
ACTH
Stimulates adrenal glands; production of glucocorticoids(cortisol) and mineralocorticoids (aldosterone)
Melanocyte-stimulating hormone
Production of melatonin in response to UV light; highest levels at night btwn 11 pm and 3 am
Posterior Pituitary Gland hormones
antidiuretic hormone (vasopressin) and oxytocin
Melatonin is produced by..
Pineal Gland
Addison’s disease
adrenal glands do not produce enough essential hormones, resulting in mineralocorticoid and glucocorticoid deficiency
Symptoms of Addison’s Disease
hyperpigmentation in buccal mucosa and skin creases, diffuse tanning and freckles, orthostasis and hypotension, scant axillary and pubic hair
Addison Disease electrolyte findings
hyponatremia, hyperkalemia
Primary Adrenal Insufficiency
Low serum cortisol and high ACTH concentration
Secondary (pituitary) and Tertiary (hypothalamic) adrenal insufficiency
Serum cortisol and ACTH are low
How to differentiate between secondary and tertiary adrenal insufficiency
Corticotropin-releasing hormone (CRH)
Chronic primary adrenal insufficiency treatment
Replacement of glucocorticoids (hydrocortisone, dexamethasone, or prednisone) and mineralocorticoids (often fludrocortisone)
Dehydroepiandrosterone (DHEA) therapy may be considered for some women w/ impaired mood or sense of well-being
Cushing’s Disease
Hypersecretion of ACTH by pituitary or exogenous admin of glucocorticoids
Symptoms: moon face w/ buffalo hump, acne, poor wound healing, purple striae, hirsutism, HTN, weakness, amenorrhea, impotence, HA, polyuria and thirst, labile mood, freq infections
Metabolic Syndrome
Presence of 3 of the 5 traits:
- waist circumference: male > 40 inch, female > 35 inch
- HTN: BP >/= 130/85 or on drug treatment for HTN
Triglycerides: >/= 150 or on drug treatment
HDL: < 40 in males and < 50 in females or on drug tx
Hyperglycemia: FPG >/= 100 or drug tx for glucose
Prediabetes
A1C btwn 5.7%-6.4%
OR
FBG 100-125
OR
2-hr oral glucose tolerance test 140-199
DM
AI1 >/= 6.5%
OR
FBG >/= 126
OR
Classis symptoms of hyperglycemia (polyuria, polydipsia, polyphagia) plus random BG >/= 200
OR
two-hr plasma glucose >/= 200
Goals for DM
BP < 130/80
LDL < 70
AIC < 7%
FBG 80-130
Postprandial glucose < 180
First-line medication for DM
Metformin (Biguanides)
Decreases gluconeogenesis and intestinal absorption of glucose and improves insulin sensitivity
May have GI side effects
Monitor kidney and liver function
Metformin Dosing
If patient is on metformin 500 mg daily and A1C is high (>7%), increase dose to metformin 500 mg BID. If A1C is still high (>7%) after dose adjustment, increase dose to metformin 1,000 mg BID
If taking maximum dose of metformin (1 g BID) and glycemic control is inadequate, can use combination therapy with additional oral agents such as a sulfonylurea, glipizide (Glucotrol XL) 5 mg PO daily (do not exceed maximum dose of glipizide 20 mg/day
Sulfonylureas
Stimulate beta cells of the pancreas to secrete more insulin, reduce glucose output from liver, increase insulin sensitivity
Ex: Glipizide, Glimepiride
SE: hypoglycemia, avoid if impaired hepatic or renal function, concurrent use w/ Warfarin
Causes wt gain
How often should A1C be checked in DM
Twice a year
Unless some frail older adults, hx of severe hypoglycemia, extensive comorbidity, limited life expectancy
Glucose Goals
Fasting blood glucose (FBG) 80-130
Postprandial: < 180
Metformin and IV contrast
Hold Metformin on day of precedure and 48 hrs after
Check baseline Cr and recheck after procedure - Cr must normalize prior to restarting Metformin
Thiazolidinediones
Enhances insulin sensitivity and decreases gluconeogenesis
Ex: Pioglitazone and rosiglitazone
Take w/ meals
Do not use w/ HF
GLP-1
Increase in insulin production and inhibits postprandial glucose release, slows gastric emptying
Ex: Exenatide or Liraglutide
Avoid if personal or family hx of medullary thyroid carcinoma
SGLT2
Promotes renal excretion of glucose
Ex: Canagliflozin, Dapagliflozin, Empagliflozin
Reduce CVD events/death and helps slow progression of CKD
Dipeptidyl Peptidase-4 (DPP-4 Inhibitors)
Enhancement of glucose-dependent insulin secretion, slowed gastric emptying, and reduction of postprandial glucagon
Ex: Sitagliptin, saxagliptin, linagliptin, alogliptin
Okay for CKD, though s/e include joint pain, angioedema, urticaria, acute pancreatitis, IBD
Which diabetic products should not be used in combination?
GLP-1 and DPP-4
No additive glucose lowering effects
DM Meds for pt’s w/ CVD and/or CKD or HFrEF
SGLT2 or GLP-1
Recommended vaccines for pt’s w/ DM
Influenza, pneumococcal, Tdap, hepatitis B, zoster, and COVID-19 vaccinations
Diabetic Retinopathy PE
- Neovascularization (new growth of arterioles in retina)
- Microaneurysms (dot and blot hemorhages due to neovascularization)
- Cotton-wool spots or soft exudates (nerve fiber layer infarcts)
- hard exudates
Charcot’s foot
Often seen in ppl w/ DM
Grave’s Disease
Hyperthyroidism
s/sx: lid lag, exophthalmos
Hyperthyroidism tx
Thionamides: Methimazole, Propylithiouracil
Hashimotos
Hypothyroidism
Confirm w/ TPO blood test
Subclinical hypothyroidism
TSH > 5, but serum free T4 is w/in normal limits
Often do not require tx - recheck in 6 mo
Myxedema coma
Severe hypothyroidism
Sx: cognitive symptoms - slow thinking, poor short-term memory, depression (or dementia), hypotension, hypothermia
Levothyroxine for older patients
20-50 mcg and gradually increas to avoid cardiac effects from overstimulation (palpitations, angina, MI)
Eval every 6-8 weeks until TSH has normalized
