Endocrine & Metabolic Disorders

Question 1

What is methimazole, what is it used for, who is it best for, and what is the dose

Answer 1

Methimazole is for graves disease. It is a thiourea. It is for patients not in the first trimester of pregnancy. It inhibits iodination and synthesis of thyroid hormone. Initial dosing is 10 to 20 mg once a day the maximum is 40 mg three times a day.

Question 2

What is a black box warning for PTU and what other adverse effects do the thioureas have?

Answer 2

PTU blackbox warning is hepatotoxicity. Other adverse effects include rash, arthralgias, fevers, agranulocytosis(Early in therapy).

Question 3

Which beta blockers are used in hyperthyroidism and what are they used for/how do they work? Dosing?

Answer 3

Propranolol and sometimes nadolol. Dosing is 20 to 40 mg 3 to 4 times a day. Max of 240-480 a day. mostly for symptomatic relief in the elderly and patients with heart rate greater than 90 bpm. Also use for thyroiditis and during thyroid storm. Other alternatives are clonidine non-dihydropyridine calcium channel blocker.

Question 4

What is Lugol’s solution or saturated solution of potassium iodide

Answer 4

The solution is for graves disease.Limited efficacy after 7 to 14 days of therapy. Use before surgery to shrink the size of the gland. Also used post ablative therapy 3 to 7 days to inhibit thyroiditis really mediated release of stored hormone. Also used in thyroid storm.

Question 5

What is the definition of subclinical hyperthyroidism

Answer 5

Low TSH, normal T4. Can cause a fib in patient older than 60. Can also cause bone fractures.

Question 6

What is the treatment for thyroid storm?

Answer 6

PTU at 500 to 1000 mg loading dose, then 250 mg every four hours. Plus iodide therapy one hour after PT you. As mobile or preprint along to control symptoms and block conversion to T3. APAP for fever if needed, and corticosteroids such as prednisones 25 to 100 mg a day in divided doses against adrenal insufficiency

Question 7

Why not use NSAIDs during thyroid storm?

Answer 7

And said to me cause displacement of protein-bound hormones.

Question 8

What things can cause Hashimoto’s disease and what is Hashimoto’s disease?

Answer 8

Lithium, amiodarone, and pituitary insufficiency. Hashimoto’s is a hypothyroid disorder. It is diagnosed with low T4 and high TSH (10 mIU/L)

Question 9

What does initial dosing for levothyroxine for healthy adults and adults 50 to 60 years of age and for patients with existing cardiovascular disease? In pregnant patients?

Answer 9

1.6 µg per kilograms of ideal body weight per day. And patients 50 to 60 years old consider 50 µg per day. And patients with cardiovascular disease consider 12.5 to 25 µg per day. Does higher in pregnancy.

Question 10

What is subclinical hypothyroidism? And why is that bad?

Answer 10

Subclinical hypothyroidism is high TSH and normal T4. Usually beginnings of Hashimoto’s.

Question 11

Why should we treat subclinical hypothyroidism? When do we treat and with what to do we treat it with?

Answer 11

High risk of heart failure and coronary heart disease between seven and 10. Retreat between 4.5 and 10 with symptoms and anti-thyroid antibodies and patients with cardiovascular disease heart failure or risk factors. We treat with 25 to 75 µg.

Question 12

What types of medications or conditions or disease states can precipitate myxedema coma?

Answer 12

Trauma, infections, heart failure. medication such as sedatives, narcotics, anesthesia, lithium, amiodarone

Question 13

What is treatment for hypothyroid coma?

Answer 13

IV T4 thyroid hormone replacement 100 to 500 µg loading dose, followed by 75 to 100 µg per day until patient can tolerate oral therapy. Frail patients or patients with cardiovascular disease may need lower doses.

It’s also treated with broad-spectrum antibiotics empirically. Hydrocortisone 100 mg every eight hours. Can be dc’d if random cortisol concentration is not depressed.

Question 14

What is treatment of choice and second line treatment for acromegaly?

Answer 14

Treatment of choice is surgical resection. Second line is dopamine agonist (bromocriptine, cabergoline). Bromocriptine dosing is 1.25 mg per day with a max of 20 to 30 per day.
Next is somatostatin analog(Octreotide). 40 times more potent than endogenous some medicine. 50 to 100 µg every eight hours subQ. Causes arrhythmias and hypothyroidism and decreases glucose.
Next is pegvisomant. 40 mg once a day subcutaneous injection loading dose, then 10 mg once a day. Max 30 mg a day. Increases liver enzymes

Question 15

What is diagnoses for growth hormone acromegaly?

Answer 15

Failure of an oral glucose tolerance test to suppress growth hormone concentration but elevates IGF-1.

Question 16

What is treatment for hyperprolactinemia?

Answer 16

Treatment of choice is surgical resection of tumor. Second line is dopamine agonist specifically Cabegoline. 0.5 mg once a week.

Question 17

When is treatment of choice and second line treatment for Cushing’s disease?

Answer 17

Surgical resection of the tumor
Second line is pasireotide. The blocks ACTH secretion from pituitary leading to lower cortisol. Dosing is 0.62 0.9 mg twice daily subcutaneously. it can cause bradycardia, and gallbladder issues so ECG liver function tests gallbladder ultrasound before starting therapy.

Third line is ketoconazole 200 mg twice a day. Next line is mitotane at 500 to 1000 mg a day. Next line is etomidate. Dosing a 0.03 mg per kilogram IV followed by 0.1 mg per kilogram per hour infusion. Next line is metyrapone.

Question 18

What is the treatment for hyperaldosteronism?

Answer 18

Sparano lactone 25 to 50 mg a day by mouth Max 400 mg a day.

Question 19

What is treatment for Addison’s disease?

Answer 19

Hydrocortisone 15 mg a day plus fludrocortisone 0.05 to 0.2 mg per day. Other options are cortisone acetate 20 mg a day or prednisone 2.5 mg a day. And then with decreased libido or low-energy DH EA 25 to 50 mg a day.

Question 20

What is dosing for orlistat and what is its mechanism of action? Side effects?

Answer 20

Dosing is 120 mg three times daily during or one hour after meals. It is a inhibitor of gastric and pancreatic lipases.
Side effects are flatulence, low fatty vitamins, and rarely hepatotoxicity and kidney stones

Question 21

What are medications used to treat obesity and anything special about them?

Answer 21

Phentermine, topiramate, Diethylpropion, Byetta, SSRI, bupropion with or without naltrexone, zonisamide, metformin, Pramlintide

Question 22

What is treatment for fertility problems on PC OS?

Answer 22

Clomiphene 50 mg a day for five days starting on the third or fifth day of the menstrual cycle. Increased to 100 mg if ovulation does not occur after first cycle of treatment. Max daily dose is 150 to 200 mg a day.
Next is good not a true been with or without clomiphene- it normalizes LH/FSH ratios

Question 23

What’s the diagnosis of diabetes versus gestational diabetes?

Answer 23

Diabetes is fasting fglucose over 126 or random number over 200 or random number over 202 hours after the glucose tolerance test it has to be another positive test before diagnosis. Or just using A-1 C or 6.5.
Gestational diabetes is fasting over 92 one-hour post glucose test 180 or more, two hours plus glucose test 153 or more.

Question 24

What are some contraindications or precautions to use of metformin?

Answer 24

Renal impairment, age 80 years or older, high risk of cardiovascular event or hypoxic state, CHF, liver impairment,procedures using iodinated contrast dye start after 48 hours and after normal SCr concentrations.

Question 25

What are contraindications or precautions to use of sulfonylureas?

Answer 25

Sulfa allergies, patients on beta blockers, poor renal function (use glipizide).

Question 26

What do meglitinides do, what is dosing, and what are the names?

Answer 26

McClinton either similar to sulfonoureas, but have a shorter duration of activity. There activity is dependent on glucose. The names are repaglinide and Nateglinide, dosed 15 minutes before meals. Repaglinide is 0.5 to 1 mg 15 minutes before meals and Nateglinide is 120 mg before meals. Repaglinide is more potent.

Question 27

What is the mechanism of action of thiazolidinadones?? What are names and dosing? What are contraindications/precautions?

Answer 27

Mechanism of action is peroxisomal proliferator activated receptor gamma agonist. Increase his expressions of jeans responsible for glucose metabolism resulting in improved insulin sensitivity. Pioglitazone and rosiglitazone. Dosing pioglitazone 15 to 45 mg a day. Titrate every 8 to 12 weeks. Contraindications precautions liver impairment heart failure and fluid retention. Pioglitazone increase HDL and decrease LDL and triglycerides.

Question 28

What are a-glucosidase inhibitors and what do they do?

Answer 28

Acarbose and miglitol
They slow absorption of glucose from the intestine into the bloodstream by slowing breakdown of large carbs into smaller absorbable sugars.
Both 25 mg three times a day each meal Max 300 mg. Titrate every 4 to 8 weeks. diarrhea abdominal pain and increased liver enzymes from acarbose. G.I. conditions are contraindications.

Question 29

DPP 4 inhibitors? What did they do? what are the names what are the doses?

Answer 29

They inhibit the breakdown of GLP– 1 secreted during meals, increases insulin, limit to glucagon, slows gastric emptying, promotes satiety.
Sitagliptin 10 100 mg a day renally dosed by half with clearance between 30 and 50 really does 225 mg with clearance less than 30.
Saxagliptin 5 mg daily reduced by half with Clarence less than 50.
Linagliptin 5 mg a day with no renal dosing.
Alogliptoin 25 mg once a day with renal dosing of clearance less than 60 half 12 mg a day, Clarence less than 36.25 mg a day.
Upper respiratory and UTIs and headaches are AEs.

Question 30

What bile acid sequestrant is used in diabetes, dosing, adverse effects, Contra indications?

Answer 30

Colesevelam 6 – 625 mg tablets once daily or three 625 mg tablets twice daily. Constipation heartburn nausea myalgia. Contra indicated in bowel obstruction and triglycerides greater than 500. Caution with triglycerides greater than 300.

Question 31

Bromocriptine is used in what conditions? Tell me dosing, Adverse events, and contraindications

Answer 31

Bromocriptine is also used in acromegaly and hyper prolactinemia. Dosing is 0.8 mg daily in the morning with food. Titrate weekly. Address if it orthostatic hypotension, syncope, nausea, fatigue, dizziness. Contraindications patients on medication for psychosis, And patients with syncopal migraines.

Question 32

What is a SGLT 2 inhibitor?sodium glucose cotransporter

Answer 32

Increases urinary glucose excretion by blocking normal reabsorption in the proximal convoluted tubule. Canagliflozin/dapagliflozin.
Cana: 100 mg once a day before the first meal of the day. Max 300 mg. Renal dosing with clearance between 45 and 59 equals Max 100 mg daily.
Adverse affects increased urination, UTIs, genital mycotic infections. Contraindications clearance less than 45. Do not give to dehydrated patients

Question 33

What are increasing analogues more specifically GLP 1 analog?

Answer 33

They are in analog of the human GLP one that binds to GLP one receptors, results in glucose dependent insulin secretion, glucagon secretion God, gastric emptying slow reduction, Promote satiety.
Exenatide: 5 mg twice a day, 60 minutes before morning and evening meals. Max 10 mg twice a day. Titration after one month. Once weekly formulation is 2 mg once weekly.

Liraglutide: 0.6 mg subcutaneously once a day for one week anytime. Maximum 1.8 mg a day.
Adverse affects nausea vomiting diarrhea hypoglycemia. Contraindicated in clearance less than 30 exanitide, Gastroparesis, pancreatitis.
Liraglutide: Patient with history of thyroid carcinoma.

Question 34

Tell me about amylin analogues.

Answer 34

Amylin is co- secreted with insulin and has effects similar to those of glp-1.

Pramlintide can be used in either type one or type two inpatients receiving insulin.

For type 1 dosing is 15 µg subcutaneously immediately before main meals. Reduce short acting or combination insulin products by 50%. Maximum 60 µg with each meal. Titrate every three days.

For type two dose is 60 µg subcutaneously immediately before mean meals. Decrease short acting insulin’s by 50%. Maximum dose is 120 µg with each meal.

Blackbox warning for severe hypoglycemia especially type one patients. Contraindications gastroparesis. A-1 C greater than 9. History of poor adherence. Hypoglycemia unawareness.

Question 35

What is the duration of each type of insulin?

Answer 35

Short acting is regular and duration is 4 to 6 hours. Rapid acting is aspart or lispro and duration is 3 to 5 hours.
Intermediate acting is nah and duration is 10 to 20 hours.
Long acting is detemir or glargine and duration is 6 to 24 hours.

Question 36

Dosing for type one diabetes weight-based is how many units per kilogram per day? And how much is given when? What is the correctional equation?

Answer 36

0. 3 to 0.6 units per kilogram per day.
   - And nph and regular two thirds is given before morning meal one third is given before evening meal of each goes to third is nph and one third is regular
   - basal bolus therapy is 50% bolus and 50% basal. Basal is divided intothree ways before meals.

The correctional equation is 1800/TDI = # mg/dL of glucose lowering per one unit of rapid acting insulin.

Question 37

In what situations do we use initial insulin therapy?

Answer 37

A-1 C greater than 10%, random glucose greater than 300 mg or fasting greater than 250 mg. Presence of urine ketones, or hypoglycemic symptoms.

Question 38

What is treatment for severe hypoglycemia?

Answer 38

Glucagon 1 mg IM. IV dextrose if patient does not respond to glucagon. Also raise glucose targets for several weeks.

Question 39

What is treatment for diabetic ketoacidosis?

Answer 39

Fluid replacement
-half normal saline to normal saline.
-Change to 5% dextrose with half normal sailing when glucose is less than 200.
-Insulin bolus of 0.1 unit per kilogram.
-Insulin infusion of 0.1 units per kilogram per hour or 0.14 units per kilogram per hour if no bolus.
-goal is to decrease serum glucose by at least 10% in first hour. If not give 0.14 units per kilogram bolus. Lower infusion rate when glucose reaches 200. Keep glucose above 150 until DKA resolves.
Interrupt insulin treatment if baseline serum potassium is less than 3.3 until corrected.

• Potassium 20 to 30 minute equivalents per liter of IV fluid if baseline is greater than 3.3 but less than 5.3. -Hold if 5.33 or greater initially.
• Potassium 20 to 30 mEq per hour if baseline is less than 3.3 Milliequivalents. Hold insulin.
• IV bicarbonate if serum pH is less that 6.9.

-resolution when sugars less than 200 and pH greater than 7.3 or bicarb of 15 or more or anion gap of 12 or less.

Question 40

How do we screen for diabetic nephropathy? What do the results tell us? What is recommended?

Answer 40

Urine albumin/creatinine ratio: Less than 30 µg per milligram or milligrams per gram is normal.

• Ace inhibitors are recommended with increased albumin excretion.
• Dietary protein restriction as renal function declines

Question 41

What else is monitored yearly in diabetes?

Answer 41

Nephropathy, retinopathy, neuropathy.

Question 42

What are treatments for gastroparesis?

Answer 42

Metoclopramide 10 mg before meals (eps) and erythromycin 40 to 250 mg before meals.

Question 43

When are statins recommended in diabetes? What are LDL triglycerides and HDL goals in diabetes?

Answer 43

Over 40 and one cardiovascular risk other than diabetes, or establish cardiovascular disease. Are you 30 to 40% reduction in LDL or less than 100 LDL.
Triglyceride less than 150
HDL greater than 50 for women and 40 for men

Question 44

Who is antiplatelet therapy in diabetes recommended for?

Answer 44

For primary prevention if 10 year risk is greater than 10%, which includes most men older than 50 and women older than 60 who have at least one cardiovascular risk.
-Also patient with existing cardiovascular disease. —Clopidogrel for those intolerant to aspirin.

Question 45

What vaccines are recommended in diabetic patients?

Answer 45

Flu vaccine, pneumococcal vaccine, hepatitis B vaccine.

Question 46

What class is PTU what is the dose and what is it used for?

Answer 46

PTU is for Graves’ disease. It inhibits iodination and synthesis of thyroid hormones. It is a thiourea. It is dosed 100 mg three times a day and max of 400 mg three times a day.