Endocrine disorders Flashcards
Diabetes screening recommendations
Testing should be considered in adults who are overweight (BMI >25) and have risk factors
- In the absence of risk factors, testing should begin at age 45 and then every 3 years thereafter
Lab indicators of DM
- Fasting plasma glucose (8 hour fast) = >126
- Random plasma glucose = >200
- OGTT at 2 hours = >200
- Hgb A1c = >6.5%
When is repeat A1c indicated for patients with DM?
If asymptomatic, A1c repeated with glucose <200
Repeat not needed in presence of DM symptoms and/or glucose levels >200
DM laboratory tests
- A1c every 3-6 months
- Fasting blood glucose (as indicated)
- Lipid profile (annual)
- Urine microalbumin/creatinine (annual)
- Serum creatinine with GFR (annual)
DM treatment (lifestyle modifications)
- Prediabetes
- Target weight loss of 7% body weight
- Increase physical activity to 150 minutes/week
- Consider adding metformin
- Smoking cessation
- Mediterranean diet
- Eat frequent, small, high fiber meals and foods with low glycemic index
- Calorie deficit
Metformin therapy contraindications
Can lead to lactic acidosis
- Renal impairment (GFR <45)
- Concurrent IV contrast dye use
- HF
- Age 80+ years
Sulfonylurea → glipizide, glyburide, glimepiride
- MOA
- Comments
MOA: insulin secretagogue
Comments:
- Hypoglycemia risk
- Caution in ASCVD
- Require functioning pancreatic beta cells
Metformin MOA
- Reduces hepatic glucose production and intestinal glucose absorption
- Insulin sensitizer via increased peripheral glucose uptake and utilization
Example of TZDs
- Pioglitazone
- Rosiglitazone
GLP-1 agonist → eventide, liraglutide, dulaglutide (incretin mimetic)
- MOA
- Comments
MOA: stimulates insulin production in response to increase in plasma glucose, inhibits postprandial glucagon release, slows gastric emptying
Comments:
- N/V
- Contraindicated with gastroparesis
- Use with caution in patients with mild-moderate renal impairment
DPP-4 inhibitor → -gliptin
- MOA
- Comments
MOA: increases levels of incretin, increasing synthesis and release of insulin from pancreatic beta cells, decrease release of glucagon from pancreatic alpha cells
Comments:
- Monitor for development of pancreatitis
SGLT-2 inhibitor → -gliflozin
- MOA
- Comments
MOA: lowers renal glucose threshold, increased urinary glucose excretion
Comments:
- Increased risk of ketoacidosis, hyperkalemia
- Weight neutral
When is insulin therapy indicated for T2DM management?
- At time of diagnosis to help achieve initial control (especially if glucose greater than 250-300)
- Acutely ill (should be kept at 140-180)
- When >2 insulin secretagogues (sulfonylureas, GLP-1 agonist, DPP-4 inhibitor) at optimized use are inadequate
What is the somogyi effect in DM management?
An insulin-induced hypoglycemia triggers excess secretion of glucagon and cortisol → hyperglycemia
- Lower dinnertime dose of intermediate acting insulin (NPH, novolin or humuling)
What is the dawn phenomenon in DM management?
Result of reduced insulin sensitivity developing between 5-8am
- Caused by earlier spikes in GH → cortisol release → hepatic glucose secretion → early morning hyperglycemia
- Split evening intermediate insulin dose between dinner and bedtime OR switch to bedtime dose of basal insulin (glargine)
Clinical presentation of T1DM and associated ketoacidosis
- Severe dehydration
- Abdominal pain
- Vomiting
- Altered LOC
Diagnostic criteria for metabolic syndrome
Insulin resistance (T2DM or impaired fasting glucose) plus 2+ of the following:
- Abdominal/central obesity
- Hypertriglyceridemia (150 or greater)
- Low HDL
- <35 for men
- <40 for women
- High BP (>140/90) or documented use of antihypertensives
- Microalbuminuria (glucose intolerance)
True/false: A 10% body weight loss yields nearly immediate improvements of death rates from heart disease and stroke
True
Obesity labs
- Fasting lipid panel
- LFTs
- Thyroid function tests
- Fasting plasma glucose
- A1c
Obesity pharmacotherapy
D/c if patient has not achieved 5% weight loss by week 12 of treatment
- Orlistat → reduces dietary fat absorption
- Taken with or within 1 hour of a meal that contains fat
- Phentermine and topiramate (Qsymia)
- Need negative pregnancy test before starting b/c of topiramate
- Naltrexone and bupropion (Contrave)
- Black box warning for neuropsychological symptoms
- Liraglutide → GLP-1 agonist
How soon after levothyroxine therapy is initiated for hypothyroidism treatment, should TSH levels be checked again?
6-8 weeks after initiation
- Once levels are stable, check again after 6 months then at 12 month intervals
What foods and/or medications should be avoided, or separated by at least several hours, when on levothyroxine therapy?
- Medications
- Iron
- Calcium
- Aluminum containing antacids
- Rifampin
- Phenytoin
- Carbamazepine
- Phenobarbital
- Sucralfate
- Cow or soy milk
How should levothyroxine be taken?
Same time every day on empty stomach with water only
- If taken in morning, no food should be eaten for 1 hour
- If taken after eating, wait 4 hours after eating with 1 hour wait postdose
Subclinical hypothyroidism diagnostic testing
Add test for TPO antibodies - clinical marker of autoimmune thyroid disease
Is treatment necessary for subclinical hypothyroidism?
Yes if…
- TSH levels increase to more than 10
- Increase in LDL
- Increased CVD risk
- Infertility
- Pregnancy
- Plans to become pregnant in the near future
Hyperthyroidism treatment
- Methimazole and PTU (if pregnant, PTU in first trimester)
- Hepatotoxicity warning
- Once euthyroid state achieved, radioactive iodine for thyroid ablation next step
Dyslipidemia diagnostic testing recommendations
Begin lipid screening (TC, HDL, LDL, TG) for adults ages 20-78 years without ASCVD every 4-6 years
- If non fasting and TGs are >400, repeat profile in fasting state
When is repeat testing of lipid profiles indicated for patients on drug therapy and those focusing on lifestyle modifications?
If on drug therapy, check after 6 weeks of therapy
If not on drug therapy, monitor every 3-6 months
Four groups for the prevention of ASCVD risk reduction (indication for statin therapy)
- LDL 190 or higher (high intensity)
- DM who are aged 40-75 years (moderate intensity)
- Older than 75 years
- Aged 40-75 years who have LDL between 70-189
Statin therapy considerations before initiation
- Check baseline hepatic enzyme levels
- Causes LDL reduction
- High intensity statin → atorvastatin 40-80, rosuvastatin 20-40
- Moderate intensity statin → simvastatin, atorvastatin 10-20, pravastatin, rosuvastatin)
When is a repeat lipid profile indicated after statin therapy?
After 4-12 weeks then repeated every 12 months
Primary vs secondary adrenal insufficiency
Primary - adrenal gland is damaged and hinders production of hormones (autoimmune, infection, hemorrhage, tumor, anticoagulant)
Secondary - pituitary gland is diseased, those who have taken systemic corticosteroids for a chronic condition and then abruptly stop taking them
Addison’s disease clinical presentation
- GI upset (chronic diarrhea, N/V, loss of appetite)
- Weight loss
- Paleness
- Darkening of skin, patchy appearance
- Muscle wasting, fatigue
- Slow or sluggish movement
- Hypoglycemia
- Low BP
Addison’s disease diagnostic testin
- Serum potassium, sodium, cortisol, ACTH
- ACTH stimulation test
- Inject synthetic ACTH and compare level of cortisol before and after
- Damage to adrenal gland will show no response to synthetic ACTH
- Abdominal CT scan
Addison’s disease treatment and management
- Corticosteroid replacement therapy
- Increase salt intake before heavy exercise, hot climates, during GI upset (diarrhea)
Cushing’s syndrome clinical presentation
- Progressive weight gain
- Altered fatty tissue deposits (mid section and upper back)
- Moon face
- Buffalo hump
- Pink or purple stretch marks
- Fragile skin that bruises easily
- Slow healing cuts
- Fatigue
- High BP
- Glucose intolerance
- Hirsutism
- Menorrhagia
Cushing’s syndrome diagnostic testing
- Without history of long term corticosteroid use
- Urine, blood, saliva tests to evaluate cortisol levels
- MRI or CT scan to determine any abnormality of pituitary
Cushing’s syndrome treatment and management
- For endogenous Cushing’s syndrome or Cushing’s disease → surgery
- Mifepristone for patients with endogenous Cushing’s syndrome and T2DM or glucose intolerance
PALM-COEIN classification system for abnormal uterine bleeding (heavy menstrual bleeding or intermenstrual bleeding)
PALM (structural)
- Polyp
- Adenomyosis
- Leiomyoma
- Malignancy and hyperplasia
COEIN (non structural)
- Coagulopathy
- Ovulatory dysfunction
- Endometrial
- Iatrogenic
- Not yet classified
Abnormal uterine bleeding diagnostic testing
- CBC
- Pap smear (if due)
- Pregnancy test
- Endometrial sampling via biopsy (for hyperplasia or cancer)
- Thyroid function (hypothyroid)
- Prolactin (pituitary function)
- LFT
- Coagulation studies
- Pelvic US
Abnormal uterine bleeding treatment and management
- Up to age 39 years → COCs, LNG IUD
- Pre or perimenopause (40+ years) → cyclic progestin therapy, low dose COC, LNG IUD, cyclic hormone therapy
