Endocrine - DM, thyroid, etc

Question 1

For patients with low vitamin D, what is the recommended treatment?

Answer 1

For patients with serum 25(OH)D <12 ng/mL (30 nmol/L), we typically treat with 50,000 international units (1250 micrograms) of vitamin D2 or D3 orally once per week for six to eight weeks, and then 800 international units (20 micrograms) of vitamin D2 or D3 daily thereafter.

We suggest cholecalciferol (vitamin D3), when available, rather than ergocalciferol (vitamin D2) for vitamin D supplementation

Question 2

What are the levels of vitamin D considered to be low?

Answer 2

For healthy, < 12; for high-risk individuals < 20

The majority of healthy adults with serum 25(OH)D in the range of 12 to 20 ng/mL (30 to 50 nmol/L) do not require any additional evaluation. Patients with serum 25(OH)D levels <12 ng/mL are at risk for developing osteomalacia. In such patients, we measure serum calcium, phosphorus, alkaline phosphatase, parathyroid hormone (PTH), electrolytes, blood urea nitrogen (BUN), creatinine, and tissue transglutaminase antibodies (to assess for celiac disease). Some UpToDate editors also measure similar tests in patients with serum 25(OH)D between 12 and 20 ng/mL, particularly if the level is 12 to 15 ng/mL (30 to 37.5 nmol/L) and there is clinical concern for a secondary cause of vitamin D deficiency (eg, malabsorption, celiac disease). Radiographs are necessary only in certain settings, such as the presence of bone pain. (See ‘Evaluation’ above.)

Question 3

When should you re-check vit D levels after starting supplementation?

Answer 3

Patients being treated specifically for serum 25(OH)D <20 ng/mL (50 nmol/L) should have a repeat 25(OH)D measurement approximately three to four months after initiating therapy to confirm that the target level has been achieved.

Question 4

criteria for HHS?

Answer 4

Effective serum OSM > 320 = 2(Na) + BG/18
Measured Na

blood glucose ? 600
ph> 7.3
bicarb > 18

Question 5

treatment for DKA

Answer 5

IVF - NS bolus with mIVF
maintenance - replacement WITH K+
Add a bit of dextrose when sugar starts falling

Insulin

Electrolytes - monitor K, replete K if low < 3.3 or go K if 3.3-5.3

Question 6

for subclinical hypothyroidism, do you treat over 65?

Answer 6

No.

Subclinical hypothyroidism (SCH) is defined as an elevation in TSH level with a normal free T4 level. It is relatively common in adults over the age of 65, with a prevalence of 20%. The TRUST (Thyroid Hormone Therapy for Older Adults with Subclinical Hypothyroidism) trial and subsequent meta-analyses of randomized, controlled trials demonstrate that there is no benefit in treating SCH. Symptoms such as change in muscle strength, fatigue or tiredness, depression, and change in BMI do not improve with L-thyroxine treatment (SOR A), and up to 60% of cases resolve within 5 years without intervention in older adults.

Appropriate management of an elevated TSH level includes repeat testing in 1–3 months along with a free T4 level. If SCH is diagnosed, levels should be monitored yearly. Only 2%–4% of patients with SCH develop overt hypothyroidism.