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OU Geriatrics Spring 2018 > Endocrine Disorders > Flashcards

Endocrine Disorders Flashcards

1
Q

Pathophysiology of Diabetes in the Elderly

A
  • Age associated decline in beta cell function
  • Age associated insulin resistance
  • Increased body fat, decreased muscle mass
  • Decreased physical activity
  • Increased hepatic glucose production
  • Progression from impaired glucose tolerance to diabetes mellitus
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2
Q

Risk Factors for Diabetes in the Elderly

A
  • Obesity
  • Family history
  • Increased age
  • Co-morbid conditions - hypertension, hyperlipidemia (metabolic syndrome)
  • Medications: Corticosteroids
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3
Q

Describe the signs and symptoms of diabetes in the elderly

A
  • Traditional signs of polydipsia, polyuria and polyphagia occur less frequently in the elderly
  • Dehydration with confusion and delirium as presenting symptoms are more common in the elderly
  • Incontinence due to glycosuria
  • Weight loss and anorexia more common in the elderly
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4
Q

What are the goals of therapy of treating diabetes ? in the elderly?

A

Prevention of microvascular complications
• Prevention of macrovascular complication
• Prevention of short term complications
• Prevention of hypoglycemia

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5
Q

What are microvascular complications that can happen?

A
  • retinopathy
  • nephropathy
  • neuropathy
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6
Q

What are macrovascular complication that can happen?

A
  • CHD
  • CVD
  • PVD
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7
Q

What are short term complications that can happen?

A
  • Blurred vision
  • weakness
  • HHNC (hyperosmolar hyperglycemic nonketotic syndrome; will not see this unless blood sugar is 700-900)
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8
Q

Summarize the concerns about hypoglycemia in the elderly diabetic

A
  • Elderly are at greater risk of hypoglycemia during treatment
  • Greater morbidity from hypoglycemia in the elderly
  • Hypoglycemia presents atypically in the elderly
  • Symptoms can include: confusion, delirium, dizziness, weakness, falls
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9
Q

Which medication has the greatest reduction in A1C?

A

metformin

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10
Q

Prioritize the use of oral agents in the treatment of diabetes in the elderly

A
  • metformin first
  • secondary: SGLT-2 inhibitors or TZD’s because they have CV benefits
  • try to avoid sulfonylureas b/c of risk of hypoglyemia; avoid glyburide at all cost
  • try to avoid insulin b/c of administration and compliance
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11
Q

Which SGLT-2 inhibitors has CV benefits?

A
  • canaglifozin

- empaglifozin

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12
Q

Which TZD’s has CV benefits?

A

pioglitazone

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13
Q

Consideration for the use of Metformin?

A
  • Do not use if CrCl < 30 ml/min
  • Monitor B12
  • GI side effects common
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14
Q

Consideration for the use of Pioglitazone?

A
  • Edema, do not use in CHF patients

* Increased fracture risk

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15
Q

Consideration for the use of SGLT-2 Inhibitors?

A
  • UTI risk
  • Fracture risk
  • Black Box warning about increased risk of amputation
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16
Q

Consideration for the use of DPP – 4 Inhibitors?

A

Risk of acute pancreatitis

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17
Q

Consideration for the use of GLP-1?

A

GI (N,V)

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18
Q

Discriminate signs and symptoms of hypothyroidism in the young versus older patient

A

• Signs and symptoms develop insidiously and typical signs of hypothyroidism (cold intolerance, lethargy, fatigue, constipation, etc) are often attributed to “normal aging”

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19
Q

Thyroid tests in the elderly

A
  • Abnormal thyroid function tests are common in the elderly but the clinical significance varies
  • Abnormal thyroid function tests may be diagnostic of overt disease or represent subclinical dysfunction
  • Patients with markedly abnormal TFTs are often asymptomatic or have atypical symptoms
  • TFTs can be influenced by non-thyroidal illness or medications
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20
Q

prevalence of hypothyroidism

A

Prevalence of chemically overt hypothyroidism in the elderly is 2.5 to 3%

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21
Q

Describe laboratory parameters that are used to diagnose hypothyroidism in the elderly

A

Characterized by normal T4 but elevated TSH

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22
Q

What is the most common cause of hypothyroidism?

A

Hashimoto’s thyroiditis

23
Q

Treatment of Hypothyroidism in the Elderly

A
  • Levothyroxine starting at 0.025mg/d in the elderly and increase by 0.025 mg/d every four to six weeks until euthyroid
  • Take on an empty stomach
  • Too aggressive dosing may precipitate angina
24
Q

Subclinical Hypothyroidism

A
  • 6% in patients 70 to 79 and 10% in patients over the age of 80 have elevated TSH and normal T4
  • 17% of these patients progress to overt hypothyroidism
  • To treat or not to treat?
25
Q

prevalence of hyperthyroidism

A

Prevalence of hyperthyroidism in the elderly varies from 0.5 to 2.3%

26
Q

What is the most common cause of hyperthyroidism?

A

Grave’s disease

27
Q

Treatment of Hyperthyroidism in the Elderly

A
  • Radioactive iodine ablation
  • Precede radioactive iodine by symptomatic treatment with betablockers (cautiously) or antithyroid medication for more rapid control of symptoms
28
Q

List the risk factors for osteoporosis

A
  • Postmenopausal
  • Early menopause
  • Caucasian or Asian ancestry
  • Thin, small build
  • Family history
  • Excessive Alcohol
  • Cigarette Smoking
  • Drugs - corticosteroids
29
Q

Risk Factors for Falls

A
  • Poor vision
  • Co-morbid diseases
  • Environmental elements: Throw rugs, Bath tub, Lighting
  • Drugs: CNS and antihypertensives
30
Q

Describe the etiology of osteoporosis

A
  • Calcium deficiency and secondary hyperparathyroidism
  • Estrogen deficiency in women
  • Androgen deficiency in older men
  • Decreased osteoblast activity in aging
31
Q

Diagnosis of Osteopenia / Osteoporosis

A
  • Osteopenia is defined as a T score of –1.0 to –2.5

* Osteoporosis is defined as a T score of less than –2.5

32
Q

Construct a treatment strategy for osteoporosis

A
  • Calcium, Vitamin D
  • Raloxifene
  • Bisphosphonates
  • Teriperitide
  • Denosumab (Prolia*)
33
Q

Calcium in treating osteoporosis

A
  • Insufficient evidence that proves prevention of fracture but insufficient evidence to recommend against it
  • Inconclusive results in maintenance of BMD
  • Safe and well tolerated
  • New USPSTF recommendation
  • Use with caution in patients with history of kidney stones
34
Q

Calcium dosing

A
  • Dose: supplement dietary intake to achieve 1500 mg elemental calcium in post-menopausal women or patients over 65
  • Calcium carbonate is cheapest but requires administration with meals
  • Calcium citrate does not require administration with meals
35
Q

Calcium adverse effects

A
  • constipation

- possible increased risk of cardiac events

36
Q

Calcium drug interactions

A 
decreases absorption 
• Tetracylines and quinolones 
• Alendronate and etidronate 
• Phenytoin 
• Fluoride
37
Q

Vitamin D in treating osteoporosis

A
  • Inconclusive results regarding fracture risk
  • Limited studies demonstrate inconsistent effects on BMD in patients without vitamin D deficiency
  • Use with caution with patients with a history of renal stones
  • Safe and well tolerated
  • Consideration to hepatic and renal function should be given
38
Q

Vitamin D dosing

A
  • 800 IU Vitamin D3 (cholecalciferol) -> May be increased to 1200 IU/d
  • 20-50 ug 25-OHD3 (calcifediol)
  • 25-50 ug 1,25-(OH)2D3 (calcitriol)
39
Q

Estrogen in treating osteoporosis

A
  • Given current evidence that long term risk exceeds benefit.
  • Estrogens should never be used for prevention unless there is no other alternative
40
Q

Bisphosphonates in treating osteoporosis

A
  • Bisphosphonates are incorporated into bone, and exhibit an inhibitory effect on osteoclasts
  • For prevention and treatment
  • Maintain supplemental calcium and vitamin D
  • Have demonstrated a reduction in fracture
  • Parenteral agents – zoledronic acid
41
Q

Bisphosphonates dosing

A
  • Alendronate (Fosamax*) -> 10 mg daily or 70 mg once weekly
  • Risedronate (Actonel*) -> 5 mg daily or 35 mg once weekly or 150 mg monthly
  • Ibandronate (Boniva*) -> 150 mg once per month
  • Patient should take it first thing in the a.m. with a full glass of water
  • No food, beverages, or medication should be taken within 30 minutes of the dose
  • Patient must remain upright for 30 minutes
42
Q

Bisphosphonates adverse effects

A
  • abdominal pain
  • dyspepsia
  • constipation
  • diarrhea
  • flatulence
  • esophageal ulcer
  • abdominal distention
  • dysphagia
43
Q

Bisphosphonates contraindications

A
  • Patient unable to stand or sit-up

* Patient with esophageal emptying problems

44
Q

Bisphosphonates: extent of therapy

A
  • Consider drug holiday after three to five years of therapy in appropriate patients
  • Consideration should be given to life expectancy
  • Increased risk of these with long term use: Spontaneous femur fractures, Bone pain, jaw osteonecrosis, (?)afib
45
Q

Raloxifene (Evista*) in treating osteoporosis

A
  • Selective estrogen receptor modulator (SERM)
  • Is indicated for both prevention and treatment
  • Effective in preventing fractures
  • Has beneficial effects on lipids
46
Q

Raloxifene (Evista*) dosing

A

Dose: 60 mg daily

47
Q

Raloxifene (Evista*) contraindications

A

patients with history of thromboembolic disorders

48
Q

Raloxifene (Evista*) adverse effects

A
  • Hot flashes

* Leg cramps

49
Q

Teriperitide (Forteo*) in treating osteoporosis

A
  • Pen injection device
  • Costly, refrigerated
  • Caution with digoxin
  • Treatment only
50
Q

Teriperitide (Forteo*) dosing

A

20 mcg SQ every day

51
Q

Denosumab (Prolia*) in treating osteoporosis

A
  • Monoclonal antibody

* High co-pay

52
Q

Denosumab (Prolia*) dosing

A

60 mg SubQ as a single dose every six months

53
Q

Calcitonin in treating osteoporosis

A
  • Costly and difficult to administer
  • Lack of efficacy data
  • Possible risk of cancer
  • Not recommended for osteoporosis
  • May have utility for managing pain from an acute fracture short term
54
Q

Calcitonin dosing

A
  • Intranasal - 200 IU/d

* Subcutaneous or IM - 50 to 100 IU 3 to 5 X/wk

OU Geriatrics Spring 2018 (9 decks)

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