Endocrine Flashcards
Test for type 2 diabetes
- fasting plasma glucose level (>126 mg/dL)
- random plasma glucose level (>200 mg/dL)
- oral glucose tolerance testing (2-hour blood glucose level >200 mg/dL) with a 75-g glucose load.
- A1c 6.5% or over
Primary adrenal insufficiency is characterized by…..
Low serum cortisol and a very high ACTH concentration.
A patient has secondary (pituitary disease) or tertiary (hypothalamic disease) adrenal insufficiency when …
both the serum cortisol and the plasma ACTH concentrations are inappropriately low
Risk factors for developing diabetes
- High BMI
- Giving birth to large gestational age baby
Your 63-year-old female patient newly started on paroxetine after the death of her spouse presents to the urgent care with a lethargic state and a sodium of 125. Which of the following do you suspect?
Syndrome of inappropriate ADH (SIADH)
SIADH can be caused by initiation of SSRIs.
DI would likely have an elevated sodium and polyuria, polyphagia, and polydipsia as key symptoms. Serotonin syndrome would be more likely to have symptoms of muscle spasm, hypertension, diaphoresis, tachycardia. Takotsubo cardiomyopathy is broken-heart syndrome and may precipitate heart failure due to the loss of a spouse but does not explain a sodium of 125.
Myxedema coma
Severe hypothyroidism with progression to decreased mental status, hypothermia, and other symptoms secondary to slowing of function in multiple organs
Pheochromocytoma
Rare hormone-releasing adrenal tumor.
Random episodes of headache (can be mild to severe), diaphoresis, and tachycardia accompanied by hypertension (HTN). Episodes resolve spontaneously. In between attacks, patient’s vital signs are normal. Triggers include physical exertion, anxiety, stress, surgery, anesthesia, changes in body position, or labor and delivery.
Addison’s Disease
Primary adrenal insufficiency. Failure of the body to release enough essential hormones, resulting in mineralocorticoid and glucocorticoid deficiency. Often the cause of autoimmune destruction of the adrenal gland
S/S Addisons disease
Fatigue, weight loss (usually secondary to anorexia), GI side effects (nausea, vomiting, abdominal pain, diarrhea and/or constipation), amenorrhea, myalgia, and psychiatric changes (e.g., depression, psychosis). Other common findings include postural hypotension, salt craving, and hyperpigmentation (characteristic finding). Patients presenting in adrenal crisis will present in vasodilatory shock (dehydration, hypotension, acute abdomen, unexplained fever, tachycardia)
Hyponatremia, hyperkalemia, hypercalcemiaLa
Labs for addison’s diease
ACTH
aldosterone
cortisol
CRH (differentiate between primary and secondary)
Treatment plan for Addison’s disease
Replacement of glucocorticoids (e.g., hydrocortisone, dexamethasone, or prednisone) and mineralocorticoids (often fludrocortisone). Dehydroepiandrosterone (DHEA) therapy may be considered for some women with impaired mood or sense of well-being.
Causes of Cushing’s Disease
Exogenous administration of glucocorticoids (treating for Addison’s).
Second most common form is Cushing’s disease, a subset of Cushing’s syndrome, which is pituitary hypersecretion of ACTH.
Cushing’s disease
Condition that occurs when the body produces too much cortisol.
Lab findings for Cushing’s disease
Hypernatremia
Hypokalemia
Hyperglycemia
Diagnostics for Cushing’s
Labs:
ACTH
Cortisol
Aldosterone
- Late-night salivary cortisol (two measurements)
- 24-hour urinary free cortisol excretion (two measurements),
- overnight 1 mg dexamethasone suppression test
S/S Cushing’s Disease
moon face with buffalo hump, acne, poor wound healing, purple striae, hirsutism, HTN, weakness, amenorrhea, impotence, headache, polyuria and thirst, labile mood, frequent infections
S/S Addison’s Disease
hyperpigmentation in buccal mucosa and skin creases, diffuse tanning and freckles, orthostasis and hypotension, scant axillary and pubic hair
Treatment for Cushing’s
Goal of therapy: Reverse signs, symptoms, and comorbidities of Cushing’s syndrome by reducing cortisol secretion to normal; eradicate any tumor; avoid permanent dependence on medication or hormone deficiency.
Acute management: Manage electrolyte balance and supportive care of symptoms.
Cushing’s disease: May require surgical intervention to excise pituitary tumor or pituitary irradiation. Medical management often is the primary treatment option if patient is not a surgical candidate or if symptoms do not resolve after excision.
Adrenalectomy: Definitive treatment for ACTH-secreting pituitary or ectopic tumors
HHS
hyperglycemia, severe dehydration, and obtundation, but without ketoacidosis
Metabolic syndrome
Male waist circumference: >40 inches (102 cm); female waist circumference: >35 inches (88 cm)
HTN: Blood pressure [BP] ≥130/85 mmHg or drug treatment for elevated BP
Triglycerides: Level ≥150 mg/dL or drug treatment for elevated triglycerides
Serum high-density lipoprotein (HDL) cholesterol: <40 mg/dL in males and <50 mg/dL in females or drug treatment for low HDL cholesterol
Hyperglycemia: Fasting plasma glucose (FPG) ≥100 mg/dL or drug treatment for elevated blood glucose
Diagnostic criteria for pre-DM
A1C) between 5.7% and 6.4%
OR
Fasting glucose of 100 to 125 mg/dL (impaired FPG)
OR
Two-hour oral glucose tolerance test (OGTT; 75 g load) of 140 to 199 mg/dL
Diagnostic criteria for DM
A1C ≥6.5%
OR
FPG ≥126 mg/dL (fasting is no caloric intake for at least 8 hours)
OR
Classic symptoms of hyperglycemia (polyuria, polydipsia, polyphagia) plus random blood glucose ≥200 mg/dL
OR
Two-hour plasma glucose ≥200 mg/dL during an OGTT with a 75-g glucose load
Recommendations for patients with DM
Blood pressure < 130/80 mmHg
LDL cholesterol < 70 mg/dL
A1C < 7% (although exceptions exist for certain populations)
Fasting blood glucose 80–130 mg/dL
Postprandial glucose (~2 hours after meal) < 180 mg/dL
In diabetic patients with CVD and/or CKD, or heart failure with reduced ejection fraction (HFrEF) what medications should be considered?
An SGLT2 inhibitor and/or GLP-1 receptor agonist.
Dawn Phenomenon
Proposed to result from diurnal secretion patterns of hormones, particularly increased GH at midnight to 2 a.m. This tends to antagonize the actions of insulin in the early morning hours. The result is high FBG concentrations. To determine if insulin dosing needs to be adjusted, examine glucose patterns at least 3 to 4 hours after the last meal or snack and insulin bolus, as well as at 3 a.m. Ask the patient about evening snacking and bedtime insulin bolusing for food. Inadequate correction can cause hyperglycemia
Types of insulin and duration of effectiveness
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”
Levels of hypoglycemia
Level 1 hypoglycemia (glucose alert): Blood glucose ≤70 and >54 mg/dL
Level 2 hypoglycemia: Blood glucose ≤54 mg/dL (severe hypoglycemia)
Level 3: Severe event characterized by altered mental and/or physical status requiring assistance for treatment of hypoglycemia
Treatment for hyperthyroidism
Methimazole (Tapazole): Shrinks thyroid gland/decreases hormone production.
Propylthiouracil (PTU): Shrinks thyroid gland/decreases hormone production. PTU is preferred treatment for moderate to severe hyperthyroidism (can cause liver failure).
Side effects: Skin rash, granulocytopenia/aplastic anemia, thrombocytopenia (check CBC with platelets), hepatic necrosis (monitor CBC, LFTs).
Thyroid storm
heart rate, BP, and body temperature can elevate rapidly to dangerously high levels. Acute worsening of symptoms due to stress or infection. Look for decreased LOC, fever, abdominal pain. Life-threatening. Immediate hospitalization is necessary.
TSH goal for thyroid supplementation
Keep TSH between .4 and 4.0 mU/L.
subclinical hypothyroidism
normal free T4 but with elevated TSH
Doesn’t necessarily need treatment
myxedema coma
Medical emergency
Slowed thinking, poor short-term memory, depression (or dementia), hypotension, and hypothermia.
Treatment for hypothyroidism
Start older patients at low dose of levothyroxine (Synthroid) (25–50 mcg/day) and gradually increase to avoid adverse cardiac effects from overstimulation (palpitations, angina, MI).
Average full replacement dose of synthetic thyroxine (T4, levothyroxine [Synthroid]) in adults is 1.6 mcg/kg body weight per day; dose ranges from 50 to >200 mcg/day.
Check TSH every 6 to 8 weeks to monitor treatment response to thyroid hormone replacement therapy. Aim to keep serum TSH within the normal reference range (about .4 to 4.0 mU/L).
Hyperthyroidism managment
All hyperthyroid patients should be referred to an endocrinologist as soon as possible.
