Endocrine, Diabetes, and Metabolism Flashcards
labs/raiu exogenous thyroid
high T3 (dietary supps higher amounts), low thyroglobulin, suppressed TSH, <1% uptake
use of thyroglobulin
helpful differentiate exogenous vs other for thyrotoxicosis (low in exogenous)
increase risk of ? with acromegaly
cancer - esophageal, gastric, colon, melanoma
also - elevated CV risk
best lag dx acromegaly
IGF-1
phos in acromegaly
70% are hyperP (IGF-1 increases tubular P reabsorption)
monitoring and size for pituitary incidentaloma
greater 10mm - check hyper/hypofxn and visual field
5-9mm - follow up MRI 12 months
2-4mm - no further testing
T score cut offs
osteopenia -1.1 to -2.5
osteoporosis less than -2.5
tool to determine osteoporosis screening
FRAX
how to eval risk for adrenal incidentaloma
based on morphologic characteristics
- irregular, contrast enhancing, high attenuation
if B/L or larger 4cm - suggests malignancy
screening labs for adrenal incidentaloma
dex supp test - cushings
plasma/urine metanephrines - pheo
plasma aldo:renin ratio - hyperaldo
meds to give prior to pheo resection
alpha-blockade
typical Ca for malignancy
Ca more than 13
- most often PTH-rp secreting tumor
typical Ca for primary hyperPTH
mild (less than 11)
produced by lymphoma, leads to hyperCa
a1-hydroxylase
- leads to 1,25 vit D formation and GI absorption
tx diabetic peripheral neuropathy
antidepressant - amitriptyline/duloxetine
anticonvulsant - pregabalin/valproic acid
topical capsaicin
alpha-lipoic acid
TENS
lido patch
abx makes sulfonylurea hypoglycemia worse
bactrim
tx of dequervain thyroiditis
NSAIDs and supportive severe pain - glucocorticoids thyroid is ALWAYS tender thyrotoxicosis = consider BB monitor TSH every 2-8 weeks 95% recover
clinical course dequervain thyroiditis
hyperT - euthyroid - hypoT
each phase up to 8 weeks
rule out test for acromegaly
IGF-1
test if IGF-1 is positive
oral glucose suppression test
- if suppressed - no acromegaly
- if does NOT suppress - MRI brain
- MRI brain normal - check ectopic source GH
oral glucose suppression test
75g oral glucose load
- normal - GH decreases to less than 1ng/mL in 2hrs
- acromegaly - will have GH >2 - get brain MRI
labs for central hypoT
low TSH and low T4
work up central hypoT
neuroimaging
and other pituitary hormone testing
before start central hypoT on treatment
check for adrenal insufficiency
- can precipitate crisis!
meds increase thyroid binding globulin
OCPs
adrenal infarct in complicated pregnancy
sheehan syndrome
indications to treat subclinical hypoT
TSH over 10
TSH 7 - 9.9 - if less than 70yo
TSH ULN - 6.9 - convincing symptoms and less 70yo
if age over 70yo - do NOT treat (more harm than good)
anti-TPO Abs
big three for primary hyperaldo
HTN
metabolic alkalosis
hypokalemia
- potassium - may be normal (hint is muscle cramps)
- may then become hypoK with loops/thiazides
plasma:renin suggesting primary hyperaldo
greater than 20
confirm diagnosis primary hyperaldo
oral saline load for adrenal suppression
- also consider CT or adrenal venous sampling
management primary hyperaldo
unilateral - surgery
bilateral - aldosterone antagonist
initial test androgen deficiency
AM testosterone level if low - then REPEAT then - LH and FSH - elevated - primary hypogonad - low or normal - secondary hypogonad
cutoff for adrenal incidentaloma CT findings high risk
greater 10 hounsfield units
greater 4cm
greater 50% contrast retention after 10 minutes
indications for statin
LDL greater 190
established ASCVD - MI, CVA, etc
40yo and DM
40yo and ASCVD 7.5% - mod-high intensity
high intensity statins
atorva 40-80
rosuva 20-40
dexamethasone and thyroid biochem?
decreases T4 to T3 peripheral conversion
tx thyroid storm
BB and thionamide
consider dexamethasone
risk with thionamide
agranulocytosis
euthyroid sick lab to check
low T3 can differentiate from hyperT (has high T3)
there is decreased T4 to T3 conversion
enzyme = 5 monodeiodinase
also - decreased T4 production / clearance
TSH is suppressed due to illness
labs = low T3, low TSH, low T4
hyperCa due to antacids - lab findings?
metabolic alkalosis
renal insufficiency
low-normal PTH
test to distinguish primary hyperPTH vs FHH
test urinary Ca
- low in FHH
- high in primary hyperPTH
parathyroidectomy indications in primary hyperPTH (6)
age less 50yo osteoporosis serum Ca greater than 1 above ULN renal insufficiency stones urine Ca greater 400mg/d
whipples triad
for hypoglycemia
- blood glucose less 55, symptoms, better with sugar
test to tell factitious insulin use
c peptide - low
- proinsulin is low as well
insulinoma - has high c peptide and high proinsulin
indication for imaging in hypogonadism
serum T less 200 if age less 65 serum T less 150 if age greater 65 mass effect sx multiple pituitary hormone deficiencies hyperPRL
central hypogonad
frequently seen in men with DMII
- low serum T and inappropriately low/normal FSH/LH
when to start insulin?
A1c >10%, fasting glucose greater 300, symptoms of hyperglycemia
etiology of acquired hypogonad
mumps, cirrhosis, chronic renal failure, HIV
patient gets radioactive iodine ablation - how do you adjust levoT dose?
TSH - remains suppressed for months
- instead base tx on T3 and T4 levels and symptoms
indications bariatric surgery
BIM greater 40
BMI greater 35 with at least 1 comorbid
blood pressure and thyroid
hyperT = increase SBP hypoT = increased DBP
initial eval for thyroid nodule
TSH and ultrasound
labs monitor medullary thyroid cancer
calcitonin
urine Cl in hypoK with met alkalosis?
low - vomiting/GI loss
high - renal handling issues, diuretics
stridor after thyroidectomy
medical emergency
- DDX - hematoma, hypoCa, nerve injury
DDx hypogonadism
primary - testicular
- klinefelter, drugs, orchitis, trauma, CKD
secondary - pituitary and hypothalamic
- tumor, cranial trauma, hemochroma, apoplexy
combined - hypercortisol and cirrhosis
HA and visual loss - check a PRL
urine Ca in hyperPTH work up
helpful for prognosis as well as diagnosis
- more complications if greater 400 mg/d
acute onset HA, bitemporal visual field deficits, paresis of CN III
pituitary apoplexy - most often hemorrhage
red irritated eye
may represent grave ophthalmopathy
thyrotoxicosis and Ca
increased osteoclast activity - lead to hyperCa
vit D deficiency with primary hyperPTH
can mask hyperCa (increases once repleted)
work up severe or early onset osteoporosis
hyperT, hyperPTH, vit D/Ca deficient, malabsorption, cushings, RA, meds (steroids), CKD, liver disease, alcohol
PRL in CKD?
can see hypePRL - very common
- modest elevation and still less 100
urine Ca in FHH
less than 100
hyperCa and elevated 1,25 vit D
get a CXR - sarcoid/lymphoma?
vit D testing in PTH independent hyperCa?
elevated 1,25 - sarcoid/lymphoma
elevated 25 - vit D toxicity
normal vit D - hyperT, MM, adrenal tumor, acromegaly, vit A toxic, immobile, milk alkali
cushings diagnosis
abnormal results on TWO separate tests
- low dose dex supp, 24hr urine cortisol, late night salivary cortisol
then - check ACTH
ACTH independent hypercortisolism
ACTH low
- adrenal mass or hyperplasia - get CT scan
ACTH dependent hypercortisolism
ACTH high
- pituitary adenoma
- may need pituitary MRI or petrosal sampling
use of high dose dex supp test
ectopic ACTH tumor - will have NO suppression
- they are resistant to feedback with high dose dex
hyperTG cutoffs for tx
150-500 - lifestyle, statins if ASCVD risk
greater 1000 - fibrate, fish oil, NO alcohol
- this is to prevent pancreatitis
risks with sulfonylureas
hypoglycemia and weight gain
DPP-4 and weight?
neutral
adrenal incidentaloma work up?
functional testing - urine metanephrines, aldosterone:renin, overnight dex suppression
if negative - FNA if cancer concern - greater 4cm or concerning imaging characteristics
normocytic anemia, leukopenia, myeloneuropathy in gastric bypass patient
copper deficient
ataxia, spasticity, weakness, positive romberg, dorsal column nutrient
B12
metabolics with adrenal insuffiency
non-gap acidosis, hypoNa, hypoglycemia, hyperK
can worsen copper deficient
zinc deficient
low risk of per-op HPA suppression
daily morning prednisone less 5mg for less 3 weeks or 10mg QOD
- no need for per-op steroids
intermediate risk peri-op HPA suppression
daily pred 5-20mg for greater 3 weeks
- pre-op- HPA axis testing recommended
high risk peri-op HPA suppression
daily pred greater 20mg for greater 3 weeks or if cushingoid appearance present
- need stress dose peri-op
- 100mg IV hydrocort during surgery
- then 50mg Q8h for 1-2 day with taper
testing to monitor central hypoT
T4 levels
antidiabetic oral that is weight neutral and lower risk of hypoglycemia in CKD
DPP-IV
tx of osteoporosis in CKD patients
denosumab
FRAX score indicating treatment
10 year hip greater 3% risk
major osteoporotic fracture risk 20%
ED in ESRD
most men will experience
- tx - sildenafil
develop anti-androgen adverse effect on spironolactone - alternative option
eplerenone
PTH with even mild elevation of Ca?
PTH should be less than 20
hypoCa after parathyroidectomy
hungry bone syndrome
- monitor Ca 2-4 times per day
- IV Ca if less 7.5 or severe symptoms
- replete Mg, P replete only if severe (less than 1)
- labs - hyperCa, hypoP, hypoMg
pred mechanism in thyroid storm
inhibit T4 to T3 conversion
central hypoT work up
DDx - mass lesion, radiation, infiltrative (hemochrom, sarcoid)
should get MRI - look for mass lesion
also - determine if AI present - cosyn stim test
MEN 2A
parathyroid hyperplasia
medullary thyroid cancer
pheo
MEN 2B
medullary thyroid cancer, pheo, marfan, mucosal neuroma
diagnosis cushing syndrome
requires 2 different screening tests
1 - low dose overnight dex supp test
2 - late night salivary cortisol
3 - 24 hour urine free cortisol
can lead to false positive dex supp test
estrogen - increases cortisol binding globulin
can worsen statin myopathy
hypoT
oral estrogen and thyroid binding globulin
increase it
cancer risk in klinefelters
breast
work up thyroid nodule
thyroid U/S and TSH
- risk fx or concerning U/S finding = FNA
- no risk fx but normal thyroid and normal/high TSH = FNA
low TSH - iodine scintigraphy
- hot nodule - treat hyperT
- cold nodule - FNA
concerning findings for thyroid nodule
larger, microCa, hypoechoic, indistinct margins
contraindications for GLP-1
medullary thyroid cancer
MEN 2
pancreatitis history
weight loss and low risk of hypoglycemia oral diabetic med
GLP-1
size of micro vs macro prolactinoma
10mm
work up if elevated aldosterone:renin
adrenal suppression test = salt load
- positive - image adrenals
treatment for adrenal hyperplasia
unilateral - surgery
bilateral - medical
MEN 1
primary hyperPTH, enteropancreatic tumor, pituitary
what to do if diagnose medullary thyroid cancer? (3 things)
1 - eval for mets
2 - ID co-existing tumors
3 - identify possible germline RET mutations
fibrate in hyperTG indication?
if greater 1000 TG level
management TG pancreatitis
insulin gtt if glucose greater 500
