Endocrine / Diabetes Flashcards
Lupus erythematosus
“great mimicker”
population
- women in childbearing years
- 15-45 y.o.
- Black, Asian, Latino
- maybe genetics
Lupus erythematosus
(“great mimicker” =
signs/symptoms are vague)
- Fatigue
- Joint pains comes and goes
- Mental fog
Lupus erythematosus
Diagnostic Criteria
Must have 4 out of 11
1. positive ANA (antinuclear antibody) test, but cannot be diagnose with ANA test alone
2. malar rash
3. discoid rash
4. photosensitivity
5. oral / nasal ulcers
6. non-erosive arthritis
7. cardio-pulmonary complaints
8. renal complaints
9. neurological concerns
10. immunological disorders
11. hematologic disorder
If we suspect Lupus, who do we refer them to?
Rheumatology
Malar rash looks like…
- butterfly rash
- spares nasolabial folds (80% lupus patients) which distinguishes it from roseacea
Sjogren’s Syndrome (secondary to Lupus)
What is it?
s/s
chronic autoimmune disorder when the immune system attacks the glands that make moisture in the eyes, mouth, and other parts of the body
Think desert
- dry itchy eyes (artificial tears)
- dry mouth (hard candies)
because the tear and salivary gland no longer produce lubrication appropriately
Lupus nephritis (secondary to Lupus) labs
- glomerulonephritis
- protein urea
- urinalysis
- do not need follow-up ANA
Who else do we refer out Lupus patients to and why?
Nephrology because over 50% of patients have kidney issues
Thyroid functions
- hormone gland
- metabolism regulation of every cell
- growth & development
What is TSH? Normal Values?
Pituitary gland produces thyroid stimulating hormone and signals the thyroid gland when to release T3 and T4 (order this first)
- normal TSH: 0.5 to 5 milli-units per liter (mU/L)
Hypothyroidism Labs
TSH: high
T3/T4: low
If TSH is high, order free T4, if T4 is low = diagnosis
Hyperthyroidism Labs
TSH: low
T3/T4: high
If TSH is low, order free T3 and free T4. If TSH low, T3 or T4 is high = diagnosis
Hypothyroidism
Tx
levothyroxine (Synthroid)
*strong association with cardiac issues
check 4-8 weeks regarding the dose
Hyperthyroidism
Tx
Propanolol
Propylthiouracil / PTU
Radioactive Iodine
What if pregnant? Tx for hyperthyroidism?
PTU first trimester. Safe to take synthroid during pregnancy, but may need more Synthroid (increase of ~ 25-50%)
Hypothyroidism s/s
- weight gain
- constipation
- dry skin
- cold intolerance
- fatigue
- big tongue
- coarse hair
When to initiate levothyroxine (Synthroid)?
TSH > 10 initiate levothyroxine (Synthroid)
TSH 5-10 may initiate levothyroxine, if T4 is normal, this is subclinical hypothyroidism, recheck in 6 months
When to take levothyroxine (Synthroid) - remember synthetic T4?
- first thing in the morning
- empty stomach
- before other meds
When to recheck TSH level after starting levothyroxine (Synthroid)
~ recheck every 6-8 weeks after starting Synthroid until goal of TSH < 5 is reached
~ once stable recheck every 6 to 12 months
Levothyroxine initial dosing for adults v. elderly?
Adults: 25 mcg-50 mcg PO Qday
Elderly: 12.5 mcg-25 mcg PO Qday
Myxedema Coma (hypothyroidism)
- life threatening = send ED
- precipitated by meds lithium, amiodarone
Myxedema Coma (hypothyroidism)
- endocrine emergency with 30%-40% mortality rate
- low body temp
- swelling
- confusion / hallucinations
- lethargy
- difficulty breathing
Hashimoto’s Thyroiditis (hypothyroidism)
Autoimmune disorder of thyroid gland that produces destructive thyroid peroxidase antibodies (TPOs)
Hashimoto’s s/s and gold standard diagnosis (hypothyroidism)
- overweight
- fatigue
- cold intolerance
- constipation
- menstrual abnormalities
- alopecia on 1/3 of one or both eyebrows
- Gold Standard: TPO test
Presentation if too much Synthroid?
Patient takes too much or dose is too high:
- heart palpitations
- nervousness
- tremors
Hyperthyroidism s/s
- rapid weight loss
- anxiety
- insomnia
- Cardiac overstimulation s/s
- enlarged goiter
- lid lag
- exophthalmos (eyes are bulging out of head) in one or both eyes
- frequent loose stools
- heat intolerance
- increased appetite
Hyperthyroidism Tx
Depends on underlying cause
- methimazole (Tapazole)
- Proplythiouracil (PTU) - lots of monitoring and several doses per day
- radioactive iodine therapy
- thyroidectomy = hormone replacement
What if the patient has hyperthyroidism and is pregnant?
- Proplythiouracil (PTU)
- 1st trimester then transition to methimazole
Grave’s Disease patient population
(hyperthyroid)
~ 60% to 80% of hyperthyroid patients
- women 7:1 ratio
Grave’s Disease Tx
(hyperthyroid)
- Radioactive iodine therapy
- if this does not work then thyroidectomy, but will need lifelong Synthroid replacement
Grave’s Disease increases risk of…
(hyperthyroid)
- rheumatoid arthritis
- pernicious anemia
- osteopenia / osteoporosis
Grave’s Disease Diagnosis
(hyperthyroid)
TRaB: thyroid stimulating hormone receptor antibodies
TPO: Thyroid peroxidase antibodies
TSI: Thyroid Stimulating Immunoglobulin
Levothyroxine initial dosing for adults v. elderly?
Adults: 25 mcg-50 mcg PO Qday
Elderly: 12.5 mcg-25 mcg PO Qday
- also low for Heart Hx: angina, acute MI, afib patients
Complications of Hyperthyroid
- heart disease (constant high output state)
- atrial fibrillation
- osteoporosis d/t decreasing bone mineral density
- infertility
Drug induced hyperthyroid
- lithium
- amiodarone
- high doses of iodine
- interferone alpha
- dopamine
Alternative Therapy for hyperthyroid
Armour thyroid produced from desiccated dried pig thyroid glands (contains T3 and T4)
What labs to check for parathyroid?
Calcium
Phosphorus
Hyperparathyroidism: calcium is high, phosphorus will be low (inverse relationship)
- elevated calcium levels has strong association with underlying malignancy
Diabetes Screening
- start at age 45, screen every 3 years
- high risk screened early: overweight, hypertension
- PCOS
Diabetes Type 1
insulin dependent
Autoimmune destruction of pancreatic beta cells, insulin production will cease all together, never get them back
- diagnosed no later than 30 y.o.
- diabetic ketoacidosis (DKA)
- do not decrease insulin when sick
Diabetes Type 2
Most patients lost 40-60% of beta cells, insulin production slows down
DM-2
Risk Factors
- most of these are modifiable
obesity
sedentary lifestyle
unhealthy eating
family history
age
hypertension
smoking
hyperlipidemia
Diabetes
s/s
Polyuria (increased urination)
Polydipsia (increased thirst)
Polyphagia (increased hunger)
Diabetes
Diagnostics
HgbA1C
Fasting blood glucose
Randome plasma glucose
Two-hour oral glucose tolerance test
Pre/Diabetes
HgbA1c
Pre: 5.7%-6.5%
Diabetes: > 6.5%
Pre/Diabetes
Fasting blood glucose
Pre: 100-125
Diabetes: >125
Pre/Diabetes
*Random plasma glucose
Pre: 140-199
Diabetes: > 200 with symptoms
Pre/Diabetes
Two-hour oral glucose tolerance
Pre: 140-199
Diabetes: >200
DM-2 initiate insulin
HgbA1c > 9% (or > 10%)
metformin (Glucophage)
- for DM-2 pts
- does not cause hypoglycemia (inhibits glucose production in liver)
- weight neutral
- max dose: 2000 mg to 2550 mg
- starting dose
–500 mg BID, increase every week as tolerated or
–850 mg qday, increase every 2 weeks as tolerated - GI side effect of diarrhea prohibits dose increase
- eGFR < 30; 30-45 dose is 1/2
- stop leading up to procedures to protect kidneys and prevent lactic acidosis or CT contrast (48 hours before)
- B12 deficiency anemia
- may cause Polycystic Ovary Syndrome (enlarged ovaries/cysts) d/t association with insulin resistance
- no alcoholics
SGLT2 Inhibitors
-flozin
- empagliflozin / jardiance
- dapagliflozin / arxiga
- cardioprotective
do not prescribe for:
- frequent UTIs
- incontinence
- BPH
GLP-1 agonists
glucagon-like peptide-1 receptor agonist
-tide
- semaglutide / Ozempic
- dulaglutide / Trulicity
- cardioprotective
do not prescribe for:
- pancreatitis
- thyroid cancer
TZDs
thiazolidinediones
-zone
- rosiglitazone
- pioglitazone
do not prescribe for:
- heart failure and liver issues
- fluid retention
- weight gain
Sulfonylureas
-ide
- Diabinese / chlorpropamide
- Glucotrol / glipizide
- hypoglycemia
- cheap/affordable
- weight gain
Pregnant Patients with diabetes
metformin for gestational diabetes
insulin
Glucagon-like peptide-1 (GLP-1) and
glucose-dependent insulinotropic polypeptide (GIP)
- tirzepatide / Mounjaro
- enhances insulin secretion
- improves insulin sensitivity
- reduce appetite
Postprandial insulin higher increase…
short acting insulin titrate up 1 to 2 units every 2-3 days
Fasting blood glucose is higher increase…
basal insulin (long or intermediate insulin) titrate up by 2 units per day
*novolin NPH or novolin regular is the cheapest options
Regular Screenings for DM patients and preventative care
Ophthalmology annually
- eyes: cotton wool spots, neovascularization, microaneurysms, cataracts, glaucoma
Podiatry annually
- restrictive blood flow to feet, neuropathy, injury
Blood Pressure
- < 130/80 AHA/ACC guidelines
Immunizations
- influenza, pneumococcal, Tdap, Hep B, zoster
Renal Function annually
- BUN, creatinine, eGFR, microalbumin in urine (chronic kidney disease)
Aspirin
- low dose aspirin therapy with higher cardiovascular risk
Microvascular
- neuropathy
- retinopathy
- nephropathy
Macrovascular
- coronary artery disease
- peripheral artery disease
- stroke
Somgyi Effect
a dip in blood sugar in middle of the night in their blood glucose before it rises in the morning
- cutting back on night time insulin
- do not skip nighttime snack
Dawn Phenomenon
Blood glucose steadily rises all night resulting in elevated blood glucose upon awakening
- increase hormone release in body (commonly seen in adolescence)
Addison’s
- too little cortisol
- skin will show hyperpigmentation
- labs: high potassium
- Addisonian Crisis: emergency kit of steroids
Cushings
- too much cortisol
- moon face, muscle wasting in extremities
- labs: low potassium
