Endocrine Flashcards
Thyroid cancer risk is increased by
- history of radiation therapy during childhood for Wilm’s tumor, lymphoma, neuroblastoma
- low-iodine diet
Hyperprolactinemia can be a sign of
-pituitary adenoma
Hyperprolactinemia presentation
- slow onset
- amenorrhea
- galactorrhea in both males and females
- serum prolactin elevated
- if large tumor, c/o HA and vision changes
Prolactin purpose
-stimulate breast milk production after childbirth
Hormones from anterior pituitary
FSH LH TSH GH ACTH MSH Prolactin
Hypothalamus stimulates what
anterior pituitary
Posterior pituitary secretes
antidiuretic hormone (vasopressin) oxytocin
Thyroid gland uses what to produce T3 and T4
iodine
Parathyroid gland is responsible for
- PTH
- for calcium balance from bones, kidneys, and GI
Pineal gland produces
melatonin
Primary hyperthyroidism (Thyrotoxicosis) findings
-very low TSH with elevated free T4 and T3
Most common cause of primary hyperthyroidism in US
Grave’s disease
Grave’s disease presentation
- middle aged women
- rapid weight loss
- anxiety
- insomnia
- Cardiac: palpitations, HTN, afib, PAC
- warm and moist skin, diaphoretic
- opthalmopathy and lid lag
- diarrhea
- amenorrhea
- heat intolerance
- goiter
- pretibial myxedema: thickened skin over ankles, orange-peel look
- brisk DTR
Grave’s disease labs
- Low TSH
- elevated free T3, T4
- Positive thyrotropin receptor antibodies (TSI)
- Thyroid peroxidase antibody (TPO): positive with graves and hashimoto’s
- palpable thyroid
Grave’s disease treatment
- Thyroid ultrasound
- refer to endocrinologist
Grave’s disease medications
PTU: shrink thyroid, decrease hormone production
Methimazole: same
Grave’s disease medication side effects
- skin rash
- aplastic anemia
- thrombocytopenia
- hepatic necrosis
Medication to manage symptoms of hyperstimulation in Grave’s
beta blockers
Thyroid storm
need hospitalization
-look for decreased LOC, fever, abdominal pain
Diagnostic test for thyroid cancer
fine-needle biopsy
Monitoring response to treatment of thyroid disease
- recheck TSH every 6-8 weeks
- TSH goal is less than 5
- when stable, recheck every 6-12 months
Primary hypothyroidism findings
- high TSH with low free T4
- common causes: Hashimoto’s thyroiditis, postpartum thyroiditis, thyroid ablation with radioactive iodine
Most common cause of hypothyroidism in US
Hashimoto’s
Hashimoto’s patho
- chronic autoimmune disorder of thyroid gland
- body produces destructive antibodies (TPO) against thyroid gland
Hashimoto’s presentation
- overweight
- fatigue
- weight gain
- cold intolerance
- constipation
- menstrual abnormalities
- alopecia
- serum cholesterol elevated
- history of autoimmune disorders
Myxedema
- severe hypothyroidism
- endocrine emergency
- cognitive symptoms
Hashimoto’s labs
- TSH, if elevated, order again with free T4
- Order TPO to confirm Hashimoto’s thyroiditis
Gold standard for diagnosing Hashimoto
TPO
Subclinical hypothyroidism
- TSH >5 but serum free T4 WNL
- asymptomatic to mild symptoms
- recheck again in 6 months
Hypothyroidism treatment
- Levothyroxine start 25-50 mcg/day
- start with lowest dose for elderly with CVD history (12.5)
- Increase every few weeks until TSH normal
- recheck every 6-8 weeks until normal, then check every 12 months when stable
Radioactive treatment for hyperthyroidism results in
hypothyroidism for life
Levothyroxine is synthetic ___
T4
Which thyroid hormone is more active
T3
Subclinical hypothyroidism with TSH >10
treat to prevent conversion to primary hypothyroidism
Subclinical hypothyroidism with TSH 4.5-10
- treatment not recommended
- recheck in 6-12 months unless they are symptomatic
Major risks of prescribing levothyroxine
- accelerated bone loss
- afib
Suggested Synthroid starting dose for young (<50) patients
1.6 mcg/kg/day
Suggested Synthroid starting dose for middle (50-60) patients
50 mcg
Suggested Synthroid starting dose for older or with CVD, or multiple comorbidities
25 mcg
T1DM patho
- destruction of B-cell sin islets of Langerhans
- abrupt cessation of insulin production
- ketone buildup–> DKA and coma
Ketone
-byproduct of fat breakdown
T2DM patho
- progressive decreased secretion of insulin resulting in chronic state of hyperglycemia and hyperinsulinemia
- genetic component
Other names for metabolic syndrome
- insulin-resistance syndrome
- syndrome X
Metabolic syndrome increases risk for
CVD
T2DM
Prediabetes labs
- A1C: 5.7-6.4
- Fasting glucose: 100-125
- 2 OGTT: 140-199
Diagnostic criteria for DM
- A1C: >6.5
- FPG: >126
- hyperglycemia symptoms: polyuria, polydipsia, polyphagia + random glucose >200
- 2 hour OGTT >200
Normal serum blood glucose
- FPG: 70-100
- Peak postprandial glucose: <180
- A1C: <6
- Elderly may have A1C <8 if tolerable
Newly diagnosed diabetic labs
- A1C every 3 months until normal
- A1C every 6 months once stabilized
- lipid panel once a year
- random urine for microalbuminuria once a year
- CMP, TSH, LFT’s
LDL goal for DM
<100
A1C goal for DM
<7
BP goal for DM
<140/80
Preprandial plasma glucose goal
70-130
DM what to check every visit
- BP, feet, weight, BMI, blood sugar
- vibratory sense
- light and deep touch
- pedal pulses, reflexes
DM preventative care
- > 50: Shingrix, 0, 2-6 months
- flu shot annually
- pneumococcal vaccine
- ASA 81 mg if risk for MI, stroke (not rec in <30)
- Yearly dilated exam
- T2DM: eye exam at diagnosis
- T1DM: first exam 5 years after diagnosis
- podiatry: once to twice a year
- BP goal: 130/80
- Dental health
Level 1 hypoglycemia
FBS < 70
Level 2 hypoglycemia
FBS < 54
What medication can blunt hypoglycemic response
beta blockers
A1C goal for T1Dm and most pregnant patients
<6
A1C goal for older adults with T2DM comorbids
<8-8.5
A1C goal for T2DM and healthy older adult
<7.5
A1C goal for T2DM for most adults
<7
Screening for T2DM
- annual for BMI> 25 and one or more risk factors for DM
- entire population >45 every 3 years if screening is normal
Hypoglycemia treatment
- glucose 15-20 g for conscious patients
- orange juice, soft drink, candy
- recheck in 15 minutes
- glucagon for severe hypoglycemia (<54)
Exercising and DM
- may need to decrease medication before
- increased risk of hypoglycemia if they do not compensate
Dawn phenomenon
- normal physiological event
- FBG elevation between 4-8 am
- normal people have insulin to combat this
Somogyi effect
- aka rebound hyperglycemia
- severe nocturnal hypoglycemia stimulates counterregulatory hormones (glucagon) from liver
- results in high fasting blood glucose by 7am
- due to overtreatment with evening and or bedtime insulin
- more common with T1DM
How to diagnose Somogyi effect
-check blood glucose early in morning (3am) for 1-2 weeks
Somogyi effect treatment
- eat snack before HS
- or remove dinnertime NPH or lower dose
Diabetic retinopathy findings
- neovascularization (new growth of fragile arterioles)
- microaneurysms (dot and blot hemorrhages d/t neovascularization)
- cotton-wool spots or soft exudates (nerve fiber layer infarcts)
- hard exudates
T/F Patients with diabetic neuropathy should avoid excessive running or walking
True: avoid risk of foot injury
Charcot’s foot and ankle
- aka neuropathic arthropathy
- deformity of foot caused by joint and bone dislocation and fractures due to neuropathy
- midfoot arch collapse (rocker bottom foot)
First line medication for T2DM
Metformin (glucophage)
Metformin (glucophage) mechanism
- biguanide
- decrease gluconeogenesis
- decrease peripheral insulin resistance
- rare hypoglycemia
Metformin side effects
-diarrhea
nausea
Metformin contraindications
- renal disease
- hepatic disease acidosis
- alcoholics
- hypoxia
Metformin labs
- renal function
- LFTs
Metformin has increased risk for
- lactic acidosis
- occurs with hypoxia, hypoperfusion, renal insufficiency
Metformin and IV contrast dye
-hold on day of procedure and 48 hours after
Sulfonylurea mechanism
-stimulate beta cells of pancreas to secrete more insulin
Sulfonylurea examples
glipizide
Glyburide
Glimepiride
Sulfonylurea adverse effects
- increased risk of CV mortality
- hypoglycemia
- increased risk of photosensitivity
- blood dyscrasias
- avoid if impaired hepatic or renal function (monitor LFTs, creatinine, UA)
- Causes weight gain
Thiazolidinediones examples
-Pioglitazone (Actos)
TZD mechanism
-enhance insulin sensitivity in muscles and reduce hepatic glucagon production
TZD can be combined with
-metformin
-sulfonylurea
-GLP-1
-SGLT2
-DPP-4
-insulins
…so any diabetic med
TZD contraindications
- BBW: NYHA class 3 and 4, symptomatic heart failure
- water retention and edema ‘
- avoid with bladder cancer or history
- active liver disease
- Type 1 DM
- pregnancy
Bile-acid sequestrant example
-Cholestyramine
Bile-acid sequestrant mechanism
reduce hepatic glucose production and reduce intestinal absorption of glucose
-take with meals, lower LDL
Meglitinide (Glinides) examples
- Repaglinide (Prandin)
- Nateglinide (Starlix)
Meglitinide mechanism
- stimulate pancreatic secretion of insulin
- For T2DM with postprandial hyperglycemia
Meglitinide side effects
- weight neutral
- may cause hypoglycemia
- take before meals or 30 minutes after
- Hold if skipping a meal
- bloating, abdominal cramps, diarrhea, farting
Rapid acting insulins
- Lispro
- Aspart
- Glulisine
Basal insulins
- Glargine (lantus)
- Detemir (Levemir)
alpha glucosidase inhibitors mechanism
Acarbose (Precose)
- slow intestinal carb digestion and absorption
- no hypoglycemia
- modest effect on A1C
- GI s/e: farting, diarrhea
Incretin mimetics or glucagonlike peptide mimetics examples
- Exenatide (Byetta)
- Liraglutide (Victoza) injections
GLP-1 mechanism
-stimulate GLP-1
-increase in insulin production and inhibit postprandial glucagon release
increase satiety
GLP-1 may cause
- weight loss
- appetite suppression
- NO hypoglycemia
- Pancreatitis
- medullary thyroid tumors
GLP-1 contraindication
-personal or fam hx of medullary thyroid carcinoma, multiple endocrine neoplasia syndrome type 2
SGLT2 inhibitor examples
- Canagliflozin (Invokana)
- Dapagliflozin (Farxiga)
- Empagliflozin (Jardiance)
SGLT2 inhibitor mechanism
-blocks glucose reabsorption by kidney and increases glucosuria
SGLT2 is effective for
T2DM in any stage
-no hypoglycemia
SGLT2 FDA warning
- may lead to DKA
- weight loss, hypotension
SGLT2 renal s/sx
- polyuria
- increased creatinine
- increase in UTIs
- PN
SGLT2 increased risk for
leg and foot amputations
DPP-4 inhibitor examples
- Sitagliptin (Januvia)
- Saxagliptin (Onglyza)
- Linagliptin (Tradjenta)
DPP-4 inhibitor mechanism
- inhibit DPP-4 activity
- increase active incretin concentrations
- increase insulin secretion
- decrease glucagon
- no hypoglycemia
DPP-4 inhibitor FDA warning
may cause joint pain that can be severe and disability
- occur on day 1 or years later
- angioedema
- urticaria
- acute pancreatitis
T/F Incretin mimetics and Incretin enhancers can be combined
False
Treatment for mild A1C elevation
-try lifestyle modifications for 3-6 months
Metformin starting dose
500 mg daily
max 2000 mg
If patient on max metformin and A1C not within range, then what
add sulfonylurea
Other choices for adding onto metformin
- any other medication
- DPP-4 inhibitor
- incretin mimetics
- TZD
Insulin should not be combined with what
meglitinides
-severe hypoglycemia
Which diabetic meds can cause hypoglycemia
- sulfonylureas
- meglitinides
- rarely metformin
If A1C still elevated with metformin and sulfonylurea..
consider adding basal insulin
Causes weight loss
- metformin
- incretin mimetic
- GLT-2 inhibitors
Causes weight gain
- insulins
- sulfonylureas
- TZDs
Weight neutral
- meglitinides
- bile-acid sequestrants
- alpha-glucosidase inhibitors
Primary prevention for patients at high risk for T2DM
- encourage weight loss
- regular physical activity
- increase fiber
Metformin dosage increments
- 500mg once daily
- 500 mg BID
- 1000 mg BID
Initial A1C 9, plan
-start basal insulin
Diabetics are at risk for which eye problems
- cataracts
- glaucoma
With new onset-afib, what endocrine complication should be checked
TSH
Insulin sensitivity and labs
-Elevated TG with low HDL
What other medications should be started with diabetics
- Statin
- ACEI
What second agent should be considered in a patient with DM and ASCVD
- SGLT2-I
- empagliflozin (Jardiance)
- or Liraglutide (Victoza)
Dose to start basal insulin
0.1-0.2 units/kg
or 10 units daily
adjust 2-4 units once-twice weekly to reach FBG goal
if hypoglycemia, reduce by 4 units
Postprandial glucose goal
<180
Addison’s disease
- adrenal insufficiency
- deficiency of cortisol and aldosterone
- aldosterone: sodium and K balance
- cortisol: maintain BP, cardiac function, blood sugars
Addison’s disease presentation
- dysphagia
- fatigue
- weight loss
- hypotension
- abdominal pain
- amenorrhea
- NV
- thin, brittle nail
- hyperpigmentation
Addison’s disease diagnosis
- measure AM serum cortisol level
- low cortisol level with normal to high K and low to normal Na
- ACTH stimulation test: measure cortisol level before and after injection
- CT
Addison’s disease treatment
- Hydrocortisone (Cortef), prednisone, or methylprednisolone
- Fludrocortisone to replace aldosterone
- increase salt intake
Addisonian crisis treatment
- ED
- IV corticosteroids, saline, dextrose
Cushing syndrome
-excess cortisol from adrenal glands
Cushing syndrome presentation
- red cheeks
- Buffalo hump
- abdominal stretch marks
- easy brusing
- pendulous abdomen
- thin arms and legs
- thin skin
Cushing syndrome diagnosis
- cortisol levels
- CT MRI
Cushing syndrome treatment
- reduce corticosteroid use
- surgery if due to tumor
- Ketoconazole, Mifepristone (if with T2DM)
- i guess refer to endocrinology
Which diabetic med should be used with caution in patient with severe sulfa allergy
-Glyburide
T/F hyperglycemia can occur as a result of aerobic exercise
False
Which diabetic medication is helpful for minimizing postprandial hyperglycemia
meglitinide
T/F Insulin resistance can contribute to prothrombotic and proatherogenic state
true
Prolonged metformin usage increases risk for
Vitamin B12 deficiency
GLP-1 agonists increases risk for
pancreatitis
At minimum, what interval should TSH be reassessed after Synthroid dosage adjustment?
6-8 weeks
Hypercalcemia with suppressed PTH should raise concern for what
malignancy
How to distinguish between T1DM and T2DM
T1DM has HLA-DR3 or HLA-DR4
Normal free T4
4.6-11.2 mcg/dL
Which diabetic medication is contraindicated with history of medullary thyroid carcinoma?
GLP-1 agonists
