Endocrine Disorders Flashcards
Pathophysiology of Diabetes in the Elderly
- 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
Risk Factors for Diabetes in the Elderly
- Obesity
- Family history
- Increased age
- Co-morbid conditions - hypertension, hyperlipidemia (metabolic syndrome)
- Medications: Corticosteroids
Describe the signs and symptoms of diabetes in the elderly
- 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
What are the goals of therapy of treating diabetes ? in the elderly?
Prevention of microvascular complications
• Prevention of macrovascular complication
• Prevention of short term complications
• Prevention of hypoglycemia
What are microvascular complications that can happen?
- retinopathy
- nephropathy
- neuropathy
What are macrovascular complication that can happen?
- CHD
- CVD
- PVD
What are short term complications that can happen?
- Blurred vision
- weakness
- HHNC (hyperosmolar hyperglycemic nonketotic syndrome; will not see this unless blood sugar is 700-900)
Summarize the concerns about hypoglycemia in the elderly diabetic
- 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
Which medication has the greatest reduction in A1C?
metformin
Prioritize the use of oral agents in the treatment of diabetes in the elderly
- 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
Which SGLT-2 inhibitors has CV benefits?
- canaglifozin
- empaglifozin
Which TZD’s has CV benefits?
pioglitazone
Consideration for the use of Metformin?
- Do not use if CrCl < 30 ml/min
- Monitor B12
- GI side effects common
Consideration for the use of Pioglitazone?
- Edema, do not use in CHF patients
* Increased fracture risk
Consideration for the use of SGLT-2 Inhibitors?
- UTI risk
- Fracture risk
- Black Box warning about increased risk of amputation
Consideration for the use of DPP – 4 Inhibitors?
Risk of acute pancreatitis
Consideration for the use of GLP-1?
GI (N,V)
Discriminate signs and symptoms of hypothyroidism in the young versus older patient
• Signs and symptoms develop insidiously and typical signs of hypothyroidism (cold intolerance, lethargy, fatigue, constipation, etc) are often attributed to “normal aging”
Thyroid tests in the elderly
- 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
prevalence of hypothyroidism
Prevalence of chemically overt hypothyroidism in the elderly is 2.5 to 3%
Describe laboratory parameters that are used to diagnose hypothyroidism in the elderly
Characterized by normal T4 but elevated TSH
What is the most common cause of hypothyroidism?
Hashimoto’s thyroiditis
Treatment of Hypothyroidism in the Elderly
- 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
Subclinical Hypothyroidism
- 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?
prevalence of hyperthyroidism
Prevalence of hyperthyroidism in the elderly varies from 0.5 to 2.3%
What is the most common cause of hyperthyroidism?
Grave’s disease
Treatment of Hyperthyroidism in the Elderly
- Radioactive iodine ablation
- Precede radioactive iodine by symptomatic treatment with betablockers (cautiously) or antithyroid medication for more rapid control of symptoms
List the risk factors for osteoporosis
- Postmenopausal
- Early menopause
- Caucasian or Asian ancestry
- Thin, small build
- Family history
- Excessive Alcohol
- Cigarette Smoking
- Drugs - corticosteroids
Risk Factors for Falls
- Poor vision
- Co-morbid diseases
- Environmental elements: Throw rugs, Bath tub, Lighting
- Drugs: CNS and antihypertensives
Describe the etiology of osteoporosis
- Calcium deficiency and secondary hyperparathyroidism
- Estrogen deficiency in women
- Androgen deficiency in older men
- Decreased osteoblast activity in aging
Diagnosis of Osteopenia / Osteoporosis
- 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
Construct a treatment strategy for osteoporosis
- Calcium, Vitamin D
- Raloxifene
- Bisphosphonates
- Teriperitide
- Denosumab (Prolia*)
Calcium in treating osteoporosis
- 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
Calcium dosing
- 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
Calcium adverse effects
- constipation
- possible increased risk of cardiac events
Calcium drug interactions
decreases absorption • Tetracylines and quinolones • Alendronate and etidronate • Phenytoin • Fluoride
Vitamin D in treating osteoporosis
- 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
Vitamin D dosing
- 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)
Estrogen in treating osteoporosis
- Given current evidence that long term risk exceeds benefit.
- Estrogens should never be used for prevention unless there is no other alternative
Bisphosphonates in treating osteoporosis
- 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
Bisphosphonates dosing
- 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
Bisphosphonates adverse effects
- abdominal pain
- dyspepsia
- constipation
- diarrhea
- flatulence
- esophageal ulcer
- abdominal distention
- dysphagia
Bisphosphonates contraindications
- Patient unable to stand or sit-up
* Patient with esophageal emptying problems
Bisphosphonates: extent of therapy
- 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
Raloxifene (Evista*) in treating osteoporosis
- Selective estrogen receptor modulator (SERM)
- Is indicated for both prevention and treatment
- Effective in preventing fractures
- Has beneficial effects on lipids
Raloxifene (Evista*) dosing
Dose: 60 mg daily
Raloxifene (Evista*) contraindications
patients with history of thromboembolic disorders
Raloxifene (Evista*) adverse effects
- Hot flashes
* Leg cramps
Teriperitide (Forteo*) in treating osteoporosis
- Pen injection device
- Costly, refrigerated
- Caution with digoxin
- Treatment only
Teriperitide (Forteo*) dosing
20 mcg SQ every day
Denosumab (Prolia*) in treating osteoporosis
- Monoclonal antibody
* High co-pay
Denosumab (Prolia*) dosing
60 mg SubQ as a single dose every six months
Calcitonin in treating osteoporosis
- 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
Calcitonin dosing
- Intranasal - 200 IU/d
* Subcutaneous or IM - 50 to 100 IU 3 to 5 X/wk
