Endocrine Disorders part 2 Flashcards
Peak plasma levels in the…
morning or wake time
What zones of the adrenal cortex are aldosterone, cortisol, and androgens produced in?
aldosterone - glomerulosa
cortisol - fasciculata
androgens - reticularis
What is the action of aldosterone?
- Kidneys–distal tubules
- Intravascular volume and RAA system
- Regulates Na and H20 balance –affects BP
What is the action of cortisol?
- Increases contractility and vascular reactivity to vascoconstriction (results in increased BP)
- Antagonizes insulin
- Activates lipolysis – increased FFA
- Stimulates gluconeogenesis (results in increased sugar, insulin intolerance, and cholesterol)
- Muscle catabolism – increases glucose
- Decreases calcium absorption and activates osteoclasts
— (results in osteoporosis) - Inhibits PLA2 and mobilization, migration, function of leukocytes
— (results in decreased immune response) - Increases appetite, suppresses sleep, regulates emotion and memory
What does cortisol do to…
BP
sugar
insulin resistance
immune response
osteoporosis
BP - increase
sugar - increase
insulin resistance - increase
immune response - decrease
osteoporosis - increase
What is the action of androgens?
- Gonads
- Sexual maturation, growth and developmeny
Where is norepinephrine and epinephrine produced?
adrenal medulla
What is the action of norepinephrine and epinephrine?
- Fight or flight - stress response
- Increases BP, peripheral resistance, cardiac output
What is hyperadrenalism?
↑ Aldosterone, cortisol, androgen, estrogen isolated or in combination
What is hyperaldosteronism?
Hypertension
hypokalemia
edema
What is the most common form of hyperadrenalism?
Glucocorticoid excess
- high levels of cortisol
What diseases are associated with glucocorticoid excess?
- Cushing disease (pituitary or adrenal tumor)
- Cushing syndrome (exogenous corticosteroids)
Wht are the complications associated with glucocorticoid excess?
o Diabetes
o Hypertension
o Weight gain
o Moon facies
o Buffalo hump
o Hirsutism
o Acne
o Heart failure
o Osteoporosis
o Delayed wound healing
o Susceptibility to infection
o irregular menses Insomnia
o Psychiatric disorders
o Peptic ulcers
o Glaucoma and cataracts
What does the pneumonic “cushingoid” stand for?
C - cataracts
U - ulcers
S - striae and skin thinning
H - hypertension and hirsutism (women)
I - immunosuppressiona nd infections
N - necrosis of femoral heads
G - glucose elevation
O - osteoporosis and obesity
I - impaired wound healing
D - depression and mood changes
What are the cutaneous findings in cushing syndrome?
- increased central adiposity with thin extremities
- skin thinning and easy brusing
- violaceous striae
- acanthosis nigricans
- increased dermatophyte, candidal skin, and nail infections
What are the related features for cushings syndrome?
- diabetes
- hypertension
- osteoporosis
- irregular menses
How is cushings diagnosed?
don’t really need to know
- measurement of 24-hr urinary free cortisol and late-night salivary control
- failure to suppress cortisol production with a low-dose dexamethasone suppression test
How do you manage cushings?
don’t really need to know
- endorcine and surgical consult
- surgical removal of pituitary or adrenal tumor
- adrenal enzyme inhibitors
- radiation therapy
How are immediate-acting glucocorticoids (prednisolone, triamcinolone, methylprednisolone) and long-acting glucocorticoids (dexamethasone, betamethasone) different from naturally occuring versions?
they are way more potent and require a prescription (not over the counter)
What is primary adrenal insufficiency?
addison disease
➢ Destruction of adrenal cortex
o ↓ Cortisol and ↑ ACTH (adrenocorticotropic
hormone)
What is the etiology of addisons disease?
o Most commonly autoimmune
o Chronic infectious disease and sepsis
❑ HIV, CMV, fungal infection
o Drugs
What is the problem with people with addison disease getting stressed?
Adrenal crisis
How is addison disease managed?
o Surgery and stress may require supplemental corticosteroids
o Pain control is important
What are the cutaneous findings in addison disease?
- hyperpigmentation of skin and mucosal membranes
- longitudinal pigmented bands in nails
- vitiligo
- decreased axillary and pubic hair in women
- calcification of auricular cartilage in men
What are the related features of addison disease?
- abdominal pain
- electrolyte abnormalities
- postural hypotension
- anorexia and weight loss
- fatigue
- shock, coma, and death if untreated
How do you diagnose addison disease?
don’t really have to know
failure to respond adequately to coricotropin stimulation test
How do you manage addison disease?
lifelong replacment therapy of glucocorticoids and mineralocorticoids
Undiagnosed patient with signs and symptoms of adrenal disease should be…
promptly be referred to their primary physician for comprehensive work-up
What do you need to do to determine the type and severity of adrenal disease?
- BP and glucose levels
- Avoid NSAIDs and aspirin → peptic ulcers, GI bleed
- If osteoporosis and osteopenia
o More prone to periodontal bone loss - monitor
o May have history of bisphosphonate use
Impaired wound healing may be a consequence of…
both hyperadrenalism and adrenal insufficiency
Is it necessary to supplement corticosteroids for people with adrenal insufficiency?
o Depends on
✓ Type
✓ Severity/ stability/ medical status
✓ Dental procedure being performed (long: >1hr or invasive) /type of stress/dental infection
What are the signs of adrenal crisis?
o Hypotension - Monitor BP – vasopressors, patient position, fluid replacement
o Abdominal pain
o Myalgia
o Fever
o Supplement with 100 mg of hydrocortisone and send to ED
What do you do for pain control in those with adrenal insufficiency?
o Adequate anesthesia, long-acting agent at end of procedure
o Good post-up pain control
What is the function of the thyroid?
- Involved in developmental and
metabolic processes - Depends on iodide
- Thyroid produces 3 hormones
➢T3 and T4
➢Calcitonin
What controls T3 and T4 secretion?
TSH (pituitary)
What is the role of calcitonin from the thyroid?
o Regulates circulating calcium and phosphorus levels
o Also influenced by actions of PTH and Vit D
What are the target tissues from the thyroid?
- heart
- adipose tissue (lipolysis)
- muscle (portein breakdown)
- bone
- nervous system
- gut (increased carb absorption)
- lipoprotein (formation of LDL receptors)
- other
What are the thyroid disorders?
- Thyroid enlargement = Goiter
- Thyroid nodules
- Thyroiditis (hashimoto)
- Hyperthyroidism (thyrotoxicosis)
- Hypothyroidism (congenital or acquired)
- Neoplasia
What are the characteristics of thyroid enlargment (goiter)?
- May be functional or non-functional
- Most are non-functional (euthyroid)
- Hyperthryoidism goiter – Graves disease
- Hypothyroidism goiter – Hashimoto thyroiditis
What are the causes of throid nodules?
- Hyperplasia
- Adenoma
- Carcinoma
What is another name for thyroiditis?
hasimoto (autoimmune)
What are the types of hyperthyroidisim (thyrotoxicosis)?
- Primary – Graves disease (auto-immune disease)
- Secondary – Pituitary adenoma
What are the types of hypothyroidisim (congenital or acquired)?
- Primary – Graves disease (end-stage)
- Secondary
- Transient
What are the causes of neoplasia of the throid?
- Adenoma
- Carcinoma (papillary, follicular)
What are the symptoms of hyperthyroidism?
- unintentional weight loss
- heat intolerance/sweating
- palpitations
- agitation/emotional lability
- multiple daily loose stools
- pruritus
- weakness
- oligomenorrhea in women
What are the clinical findings of hyperthyroidism?
kinda not important (he didn’t really talk about this)
- goiter
- tachycardia
- atrial fibrillation
- high output cardiac failure
- fine tremor
- hot sweaty extremities
- ophthalmopathy
- agitation/confusion
- muscle weakness/wasting
- exopthalmia (bulging eyes)
- “thyroid storm” with fever, confusion, dehydration, and eventually death if untreated
How do you diagnose hyperthyroidism?
- serum thryoid-stimulating hormone (BEST TEST)
- serum free thyroxine (T4), total T3, and thyrotropin receptor antibodies
- radioactive iodine uptake and imaging
How do you manage hyperthyroidism?
- endocrine and surgical consult
- propranolol for symptomatic treatment of tremor, tachycardia, and sweating
- propythiouracil to inhibit throid homrone metabolism
- methimazole to inhibit thyroid hormone synthesis
- radioiodine ablation of the thyroid gland
Thyroid storm may be precipitated by…
oral infection or surgical procedure in a patient who is poorly controlled
What are the symptoms of hypothyroidism?
- unexplained weight gain
- fatigue
- constipation
- cold intolerance
- dry skin
- muscle weakness
- carpal tunnel syndrome
- hoarseness
- decrease body temp
- facial swelling
- menorrhagia in women
What are the clinical findings of hypothyroidism?
he didn’t really talk about this
- goiter
- cold, doughy skin
- bradycardia
- facial and finger swelling
- slowed relaxation of deep tendon reflexes
- hair loss/lateral eyebrow loss
- pericardial effusion
- myocardial infarction or congestive heart failure with aggressive thyroid hormone replacement
- coma and death without treatment
What are the related features of hypothyroidism?
- macroglossia
- broadened nose, thickened lips, puffy eyes
- imparied wound healing
- cretinism in patients with congential hypothyroisim
- “myxedema coma”
How do you diagnosis hypothyroidism?
- serum thyroid-stimulating hormone (BEST TEST) - should be high
- other useful tests are T4, T3, and anti-TPO antibodies, and lipid panel
What is the management for hypothyroidism?
- endocrine consult
- oral thyroxine replacement (usually 75-150 ug/day)
- careful followup for the heart, lungs, adrenal glands
How does hyperthyroidism affect dentistry?
- Increased periodontal bone loss
- Increased susceptibility to caries
How does hypothyroidism affect dentistry?
- Delayed tooth eruption and altered bone formation
- Macroglossia
- Dysgeusia and burning mouth
- Salivary gland enlargement
- Oral lichen planus
Patients with both hyper and hypothyroidism may be more susceptible to…
infections- treat aggressively
Patients with uncontrolled, poorly controlled, suspected hyperthyroidism or hypothyroism should or should not receive dental care until disease is under control?
SHOULD NOT
Risk of __________ from medications used to treat hyperthyroidism
Agranulocytosis
➢ Fever, sore throat, oral ulcers are warning signs
What do you do if a patient has a thyrotoxic crisis/storm?
➢ CPR and vital signs
➢ Ice packs or wet packs
➢ Administer hydrocortisone 100-300 mg
➢ IV glucose
➢ Administer propylthiouracil
➢ Send to ED
What do you do if a patient has myxedema coma?
➢ CPR and vital signs
➢ Conserve body heat – blanket
➢ Administer hydrocortisone 100-300 mg
➢ IV saline and glucose
➢ Administer thyroxine
➢ Send to ED
What are the drug interactions to be aware of in hyperthyroidism?
- Caution with aspirin and NSAIDS- can increase T4
- Ciprofloxacin contraindicated – decreases absorption of thyroid hormone
- Avoid local anesthestics containing epinephrine and ginigval retraction cord with epinephrine in poorly controlled patients
What are the drug interactions to be aware of in hypothyroidism?
- Avoid CNS depressants (narcotics, barbituates, sedatives) if patient is poorly controlled
- Cytochrome p450 inducers (phenytoin, carbamazepine, and rifampin) should be avoided – increases metabolism of levothyroxine
