ENDOCRINE Flashcards
How to treat hyperthyroidism in first trimester preg
PTU
How to treat hyperthyroid in 2nd and 3rd trimester pregnancy
Methimazole
Teratogenic effects of methimazole when used during first trimester of pregnancy
Aplasia cutis
Scalp defects
Omphalocele
TE fistula
Cause of 60-90% of congenital heart block
Neonatal lupus
Girl missed her period for 2 months and prig test is negative. Next step?
TSH or prolactin.
Treatment for heart failure and/or a fib in thyroid storm
Digoxin
If pt is hyperthyroid based on TSH and thyroid sono, next step?
radionucleotide uptake scan
If radio nucleotide uptake scan shows a hot nodule?
Treat as hyperthyroid
If radio nucleotide uptake scan shows a cold nodule?
FNA
If hypothyroid based on thyroid sono and TSH, next step?
Replace thyroid hormone and monitor for decrease in nodule size. If nodule persists AFTER thyroid replacement, do an FNA.
What to do if FNA of thyroid is non diagnostic
Repeat FNA.
If FNA of thyroid is benign …
Repeat sono q 6m-1 yr to make sure no increase in size. If size does end up increasing, repeat FNA.
Somogyi effect
Evening NPH is too high so pt ends up bottoming out overnight and the release of stress hormone GREATLY increases morning glucose.
Treatment of somogyi effect
Decrease nighttime dose of NPH or give it later.
What is the dawn phenomenon?
Too low dose of evening NPH so glucose creeps up throughout the night, causing very high morning glucose.
Treatment of dawn phenomenon
Increase nighttime dose of NPH.
How to distinguish between dawn and smoggy effect
Check a 3am glucose.
Which 2 oral DM agents have the most common SE of hypoglycemia
Sulfonylurea, meglutinides
Which is the oldest and cheapest of DM oral agents?
Sulfonylureas
Which oral DM agent also helps lower TG and LDL
Metformin
Which oral DM agent is not safe in settings of CHF
TZD
Which 2 oral DM agents should not be used in pts with elevated serum creatinine
Metformin, sulfonylureas
Which oral DM agent should not be used in pts with IBD
Alpha glucosidase inhibitors (acarbose)
Hepatic serum transaminase levels should b carefully monitored when using these oral DM agents.
Metformin or TZDs
Which oral DM agent is metabolized by the liver and is thus an excellent choice in pts with renal disease
TZD
MOA of exenatide
Glucagon like peptide-1 derived from Gila monster saliva. It prolongs incretin secretion, which decreases glucagon secretion and increases insulin secretion. It also delays gastric emptying.
SE of exenatide
Acute pancreatitis.
MOA of Sitagliptin
Inhibitor of dipeptidyl peptidase IV which affects GLP-1 among other hormones. Therefore it prolongs uncertain secretion which decreases glucagon secretion and increases insulin secretion. It also delays gastric emptying.
How is eventide administered
SQ twice daily at morning and evening meals
MOA of Pramlintide
Amylin analog, normally secreted with insulin, decreases glucagon secretion and gastric emptying. USED ONLY IN PTS TAKING INSULIN.
How is pramlintide administered
IM prior to meals.
Anti-islet Abs seen in pts with Type 1 DM
Anti insulin
Anti islet cell cytoplasm
Anti glutamic acid decarboxylase
Anti tyrosine phosphatase
Criteria for diagnosis of metabolic syndrome
Any 3 of following: Abdominal obesity with waist circum >40 in in men or >35 in in women TG >150 HDL 130/85 Glc > 100 or 2 hr post oral glucose >140
Tx options for diabetic gastroparesis
Metoclopramide
Cisapride
Erythromycin
What medications should never be taken with cisapride due to risk of cardiac arrhythmias?
Drugs metabolized by CYP 450 - 3A4 system. MACROCODES, antifungals, phenothiazines like prochlorperazine and chlorpromazine.
How often should HbA1c be checked if >7? >6?
If >7, q3 months.
If >6, q6 months.
Goal LDL in diabetics
Which anti - HLD agent can worsen insulin resistance
Niacin
How often is a dilated eye exam performed in a diabetic?
annually
How often are chem 8 and UA performed in diabeticcs
annually
If pt has a pituitary adenoma and surgery is indicated, which glands removed?
Removal of only the gland containing the adenoma and biopsy of 1-3 others.
If pt has pituitary hyperplasia and surgery is indicated, which glands are removed?
Remove 3.5 glands and mark the remaining half with a surgical clip (or forearm autotransplantation of the gland to remain in cases where recurrence is likely, such as MEN type 1)
Meds to avoid in hyperparathyroidism
Thiazides
Lithium
Calcium ingestion >1000 mg/day
How often is serum calcium monitored in pts with hyperparathyroidism? serum creatinine? bone density?
Calcium q6 mos
Creatinine q12 mos
Bone density q12 mos
3 oral phosphate binders
Calcium carb or acetate (most commonly used)
Sevelamer (can be taken with calcium)
Lanthanum
Tx of hyperparathyroidism due to renal osteodystrophy
Calcitriol, other vitamin D analog, or cinacalcet (calcimimetic) to suppress PTH secretion
Tx for prolactinoma
DA agonsit. CABERGOLINE > bromocriptine or pergolide.
If ineffective, switch to a 2nd DA agonist.
If a female with prolactinoma >3 cm and a desire to become pregnant …
Transphenoidal surgery, even if DA agonist is effective.
How to screen for acromegaly
Measure serum IGF-1
How to confirm dx of acromegaly
oral glucsoe suppression test. If GH concentration is >1ng/mL = acromegaly.
What do you do if your pt has acromegaly and your somatostatin analog ineffective
Cabergoline, a DA agonist that inhibits GH secretion.
What is pegvisomant
GH receptor antagonist
A pt with elevated BP, palpitations, headache, excessive perspiration is found to have elevated urine VMA. What effect would giving a beta blocker have on this pt?
Would increase BP.
Of DHEA, DHEA-S and testosterone, which is made by the ADRENALS ONLY is a more specific marker for an androgen producing adrenal tumor in a woman
DHEA-S
Most specific lab finding in making dx of primary hyperaldosteronism
Aldosterone renin ratio
Most likely cause of increased PTH and decreased serum calcium and increased serum phosphate
Renal failure with vitamin D deficiency
Next step in mgmt of pt found to have an absent pituitary on MRI (empty sella)
Reassurance. If symptomatic, treat the hormone deficiency.
Pituitary adenoma’s response to high dose dexamethasone
Suppressed.
Drugs known for causing elevated prolactin
Phenothiazines
Anti psychotics
Methyldopa
Pages disease lab levels
Increased alk phos.
Labs in osteomalacia/rickets
Decreased serum calcium and phosphate. Normal/increased alk phos.
Increased PTH.
Labs in osteoporosis
Normal.
Labs in osteopetrosis
Normal
Labs in pseudohypoparathyroidism
This is a receptor problem (not responding to PTH).
Thus calcium is low, phosphate is high, and PTH is high.
Indications for surgical parathyroidectomy
Ca > 1 mg/dL above ULN CrCl decreased by 30% 24 hr urine calcium >400 mg Symptomatic Bone min density ..
How do you calculate a corrected HCO3 ?
(Measured anion gap - normal anion gap of 12 ) + HCO3.
If corrected is greater than a normal HCO3 of about 24, you probably have a concomitant metabolic alkalosis.
MOA of Glyburide and glipizide
Second gen sulfonylureas which reduce serum glucose levels by increasing insulin secretion from beta cells.
Thyroid peroxidase is also known as?
Microsomal antigen
Which thyroid autoimmune disease has higher levels of thyroid peroxidase antibody?
Hasimotos. Note, they BOTH HAVE THEM!!
What is thyroglobulin
Protein produced by the follicular cells of the thyroid gland and stored as colloid. When stimulated by TSH, it produces the thyroid hormones. Its also responsible for storing iodine.
High levels of anti thyroglobulin antibody are more diagnostic of which autoimmune disease?
Hashimotos. It can be elevated in many other autoimmune disorders though including graves.
Thyroid stimulating hormone receptor antibody is the direct cause of ?
Graves disease. There are 3 types of TSH receptor antibodies and these Abs stimulate the production of thyroid hormones in addition to the thyroid gland. As a result, 15% of pts with a positive TSH-R Ab assay develop a diffuse multi nodular goiter.
Regular insulin onset and duration
Onset 30-60 min
Diration 5-8 hours
Insulin detemir onset and duration
Onset 1-2 hours
Duration 24 hours
NPH insulin onset and duration
Onset 1-2 hours
Duration 18-24 hrs
Glargine insulin onset and duration
Onset 1-4 hours
Duration 24-28 hours
Fastest onset of action for insulin
Insulin lispro, 5-10 minutes.
How do bile acid resins work
Prevent intestinal reabsorption of bile acids. Therefore, the liver must use cholesterol to make more. Increases the LDL receptor expression.
How does niacin work
Inhibits lipolysis in adipose tissue and reduces hepatic VLDL secretion into circulation.
How do fibrates work
Upregulate LPL, leading to increased TG clearance.
Nitrates cause what effect on contractility and heart rate
Increase. Its a reflex.
Beta blockers do what to EDV
Increase! They affect after load.
Beta blockers do what to ejection time
Increase
Tx of malignant hypertension
NITROPRUSSIDE. It increases cGMP via direct release of NO. However it can cause CYANIDE TOXICITY!!
Can also use fenoldapam.
What hormone is increased in 17 a hydroxyls deficiency?
Mineralocorticoids. Therefore you have HTN but hypokalemia. decreased sex hormones.
What hormone is increased in 21 hydroxyls deficiency
SEX. HYPOtension, HYPERkalemia and increased renin activity due to the lack of aldosterone. Leads to masculinization.
Which hormones are increased in 11 B hydroxylase deficiency
11 deoxycorticosterone and sex hormones. Though you’re low in aldosterone, the corticosterone is a mineralocorticoid and secreted in excess.
Why does CAH cause enlargement of both adrenal glands?
Increased ACTH stimulation due to decreased cortisol.
How does GH affect insulin?
Increases insulin resistance.
Secretion of GH is inhibited by what 2 things
Glucose
Somatostatin.
What does TRH do to prolactin
Increases secretion.
How does prolactin affect GnRH
INHIBITS
How does cortisol affect BP?
Maintains by up regulating alpha 1 receptors on arterioles, increasing the sensitivity to NE and epinephrine.
What does cortisol do to bone formation
Decreases via inhibition of osteoBLasts and DECREASING intestinal calcium absorption.
What causes the abdominal striae in cushion syndrome
Cortisol inhibits fibroblasts.
Regulation of cholecalciferol
This is vitamin D.
Increased PTH, decreased calcium and phosphate cause increased 1,25 OH2 production.
What happens if a man has increased sex hormone binding globulin
Lowered free testosterone – > gynecomastia
What happens if a woman has decreased sex hormone binding globulin
Raises our free testosterone.
In conns syndrome, what happens to renin?
Low (increased aldosterone will obviously negatively FB)
In renal artery stenosis, what happens to renin?
HIGH plasma renin. The renal perception of a low intravascular volume results in an overactive renin-angiotensin system
Pheochromocytoma is associated with which 3 problems
NF 1
Men 2A
Men 2B
Elevated homovanillic acid in the urine indicates ?
Neuroblastoma.
Bombesin is the tumor marker for ?
Neuroblastoma!
RAdial arrangement of cells around fibrils on histology
Neuroblastoma
3 causes of addison disease
autoimmune
TB
mets
How does metyrapone work
Decreases cortisol synthesis thus stimulating ACTH secretion and increasing plasma deoxycortisol.
Thyroid replaced by fibrous tissue, causing hypothyroidism.
Riedels thyroiditis
Pot bellied, pale, puffy faced child with protruding umbilicus and protuberant tongue
CRETINISM!
Subacute thyroidits causes hypo or hyper ?
Hyperthyroid early in course (basically thyroid fractures and releases a bunch of T4. But then it might exhaust itself and necrose causing later hypothyroidism.)
Orphan annie nuclei
Papillary carcinoma. Also a/w psammoma bodies, increased risk with childhood irradiation.
Medullary CA a/w what 2 dz?
MEN 2A, 2B
What CA a/w hashimotos?
Lymphoma.
Osteitis fibrosa cystica
Cystic bone spaces filled with brown fibrous tissue, causing bone pain.
Renal osteodystrophy
Bone lesions due to secondary or tertiary hyper PTH due in turn to renal disease.
Wich type of DM a/w islet amyloid deposit ?
Type II
Which DM is a/w HLA system?
Type 1. DR3 and DR4.
Kidney stones and stomach ulcers
MEN 1 – WERMERSE syndrome
What kind of heart dz a/w carcinoid syndrome
Tricuspid stenosed by serotonin action.
What vitamin might be deficient in carcinoid syndrome
Niacin. Tryptophan is the precursor for serotonin and niacin and if most is being used to make serotonin a niacin deficiency may result.
Which diabetes drug decreases gluconeogenesis
Biguanides (METFORMIN). Also increases glycolysis and peripheral glucose uptake.
What class of drugs are tolbutamide and chlorpropamide
FIRST gen sulfonylureas which cause DISULFIRAM LIKE EFFECTS !!!!
Which class of DM drugs trigger insulin release via increased calcium influx?
Sulfonylureas. They close the potassium channel in Beta cell membrane so the cell depolarizes.
What class of drugs are glyburide, glimepiride, and glipizide
Second gen sulfonylureas, a/w HYPOglycemia
Why are sulfonylureas useless in type 1 DM
Require some islet function as they stimulate the release of endogenous insulin
MOA of TZD
Increases insulin sensitivity in peripheral tissue by binding to PPAR-gamma nuclear transcription regulator.
4 toxicities of the glitazones
These are TZDs and they cause weight gain! edema. Hepatotoxicity and HEART FAILURE.
Which class of DM drugs decrease postprandial hyperglycemia
Alpha glucosidase inhibitors.
What class of med is Miglitol
Alpha glucosidase inhibitor
What class of med is pramlintide
Amylin analog
What is the MOA of pramlintide
Decreaes glucagon and gastric emptying
Exenatide and liraglutide are what class of drugs
GLP-1 analogs
How do GLP-1 analogs and DPP-4 inhibitors work
Increase insulin and decrease glucagon release.
What class of drugs are the gliptins
DPP-4 inhibitors.
Which DM drugs may cause pancreatitis as a SE?
Exenatide
Liraglutide (GLP-1 analogs)
Turner syndrome can use what kind of pituitary drug
GH!
SE of octreotide
Inhibit GH release from AP which is similar to ADH ..as in it can cause hyponatremia and seizures!
MOA of glucocorticoids
Decreases production of leukotrienes and prostaglandins by inhibiting phospholipase A2 and expression of COX-2
Which thyroid med also decreases peripheral conversion of T4 to T3
PTU
Which endocrine drug can cause agranulocytosis
PTU
