Endocrine Thyroid, Adrenal, Osteoporosis Flashcards
Hypothyroidism
=
- Primary Hypothyroidism =
- Secondary Hypothyroidism =
A clinical condition of reduced or absent thyroid hormone production
- Primary Hypothyroidism = Primary hormone deficit = Low T4 with High TSH
- Secondary Hypothyroidism = Secondary hormone deficit = Low T4 with Low TSH (or inappropriately normal TSH)
Secondary hypothyroidism = pituitary or hypothalamus damage
Thyroid Testing
(1) = Master test - very sensitive, to be done with a measure of peripheral hormone…. (very useful EXCEPT if problem is central hypothyroidism)
(1)= unbound portion (most useful measure of biologically active hormone in most circumstances)
(1) = binding protein dependent (used in pregnancy)
(1) = sometimes useful for assessing thyroid dysfunction in acute illness
TSH = Master test - very sensitive, to be done with a measure of peripheral hormone…. (very useful EXCEPT if problem is central hypothyroidism)
Free T4 = unbound portion (most useful measure of biologically active hormone in most circumstances)
Total T4 = binding protein dependent (used in pregnancy)
Total T3 = sometimes useful for assessing thyroid dysfunction in acute illness
Tests of Autoimmunity
(4)
TPO
TgAb
TSI
TBII
Thyroid Imaging
(1) – assess for echogenicity, nodularity, vascularity
(1) – _____ anatomical testing (usually for _____thyroidism) helps differentiate thyroiditis, graves disease, toxic adenoma and toxic MNG as well as ”cold nodules”
Ultrasound – assess for echogenicity, nodularity, vascularity
Uptake and Scan – functional anatomical testing (usually for hyperthyroidism)helps differentiate thyroiditis, graves disease, toxic adenoma and toxic MNG as well as ”cold nodules”
Primary Hypothyroidism
(1) common autoimmune hypothyroid disease
Diagnosis (2) positive
Hashimotos Thyroid Disease
Autoimmune TPO antibodies (thyroperoxidase antibodies) + and TgAb (thyroglobulin antibodies)
Primary Hypothyroidism Etiology
- Iatrogenic
- Total _______
- ____ I131 therapy
- Cancer-related i______therapy*
- I_____ deficiency
- Infiltrative diseases
- External rad_______ for other disorders
- Inability to repair the gland after a thyroid____
- Medications
- Am_____
- L_____
- Con_______ (Dyshormonogenesis) (1/4000 births, screened at birth)
- Iatrogenic
- Total thyroidectomy
- RAI I131 therapy
- Cancer-related immunotherapy*
- Iodine deficiency
- Infiltrative diseases
- External radiation for other disorders
- Inability to repair the gland after a thyroiditis
- Medications
- Amiodarone
- Lithium
- Congenital (Dyshormonogenesis) (1/4000 births, screened at birth)
Secondary Hypothyroidism Etiology
- ________ disease
- T____
- Trauma
- Infiltrative disorders
- _____ based disease
- T_____
- Infiltrative disorders
- Radiation damage
- Surgery
- Sh________ syndrome
*More prevalent as ______ inhibitors become standard of care for several cancer types (ie Pembrolizumab, Nivolumab)
- Hypothalamic disease
- Tumors
- Trauma
- Infiltrative disorders
- Pituitary based disease
- Tumors
- Infiltrative disorders
- Radiation damage
- Surgery
- Sheehan’s syndrome
*More prevalent as PdL-1 inhibitors become standard of care for several cancer types (ie Pembrolizumab, Nivolumab)
Hypothyroidism Symptoms
- ______ intolerance
- Proximal muscle _____ness
- F______ and listlessness
- Weight ____– usually with a poor appetite
- GI =
- ____ness– accumulated fluid in the vocal cords
- ______ mentation
- Menorrhagia, Irregular menses or _____hea
- __creased sweating
- Cold intolerance
- Proximal muscle weakness
- Fatigue and listlessness
- Weight gain – usually with a poor appetite
- Constipation
- Hoarseness – accumulated fluid in the vocal cords
- Slowed mentation
- Menorrhagia, Irregular menses or amenorrhea
- Decreased sweating
Hypothyroidism Physical Exam
- Skin moisture?
- Skin temperature?
- Periorbital _____ - GAGs
- De_____ affect
- _____tension (diastolic)
- _____cardia
- Decreased myocardial ______ (EKG changes)
- Le_____
- Ed____ (nonpitting)
- B_____ nails and hair
- Dry skin
- Cold skin
- Periorbital edema - GAGs
- Depressed affect
- Hypertension (diastolic)
- Bradycardia
- Decreased myocardial contractility (EKG changes)
- Lethargy
- Edema (nonpitting)
- Brittle nails and hair
Myxedema Coma
causes (2)
- VERY _____ (but life-threatening)
- Most people with profound hypothyroidism do NOT have myxedema coma
Infection, Injury
- VERY RARE (but life-threatening)
- Most people with profound hypothyroidism do NOT have myxedema coma
Hypothyroidism Treatment
Rx (1)
- High dose IV ___ and for myxedema coma ***IF CENTRAL HYPOTHYROIDISM IS SUSPECTED NEED TO GIVE WITH _____!!**
- 1.6 mcg/kg body weight administered orally = full replacement
- _____ replacement for at risk populations
- El______
- C___ or CAD equivalent patients (DM, etc.)
- Long half life – __ days
Levothyroxine – LT4
- High dose IV T4 and T3 for myxedema coma ***IF CENTRAL HYPOTHYROIDISM IS SUSPECTED NEED TO GIVE WITH STEROIDS!!**
- 1.6 mcg/kg body weight administered orally = full replacement
- Slow replacement for at risk populations
- Elderly
- CAD or CAD equivalent patients (DM, etc.)
- Long half life – 7 days
Subclinical Hypothyroidism
TSH =
FT4 =
- _________ whom to treat
- Most agree that one should treat if TSH >__ [normal <4.5 mIU/L]
- ALWAYS _____ a TSH and FT4 (especially if between 5-10)
- 30-40% _______ if followed
- TSH curve changes with age: TSH of 5.5 may be _____ in ones 80s
- You may otherwise be giving someone a lifetime of unneeded medication
TSH elevated
FT4 normal
- Controversial whom to treat
- Most agree that one should treat if TSH >10 [normal <4.5 mIU/L]
- ALWAYS repeat a TSH and FT4 (especially if between 5-10)
- 30-40% normalize if followed
- TSH curve changes with age: TSH of 5.5 may be normal in ones 80s
- You may otherwise be giving someone a lifetime of unneeded medication
- Generally, subclinical hypothyroidism is overtreated - potential to overmedicate with synthroid and potentiate afib and osteoporosis*
- the only time i am aggressive with treating subclinical hypothyroidism is in pregnancy bc fetus cannot make its own thyroid hormone - prevent miscarriage and malformation in baby - goal TSH of 1-2 especially if there is TPO antibodies*
Hypothyroidism Lab Parameters for Follow Up
When should you repeat labs after starting treatment or a dose change?
- Goal – Primary hypothyroidism =
- Goal – Secondary hypothyroidism =
Wait 6 weeks to repeat TFTs after any dose change
- Goal – Primary hypothyroidism – normal TSH and FT4
- Goal – Secondary hypothyroidism – mid-level of normal FT4 range
Hyperthyroidism
=
- Primary Hyperthyroidism =
- Secondary Hyperthyroidism =
A medical condition of excess thyroid hormone levels..
- Primary Hyperthyroidism = Primary Hormone Excess = High T4 with Low TSH
- Secondary Hyperthyroidism = Secondary Hormone Excess = High T4 with High TSH
Thyrotoxicosis Types
- (1) – autoimmune stimulation of the thyroid
- (1) (adenoma – Plummer’s disease)
- Toxic ___nodular goiter
- (1) – many types, release of preformed thyroid hormone from damage to the gland
- (1) (thyrotoxicosis factitia or iatrogenic)
Rare causes
- TSH producing p_____ adenoma
- (1) mediated hyperthyroidism in pregnancy
- Drugs – (1) or (1) administration (Jod-Basedow effect)
- Graves’ Hyperthyroidism – autoimmune stimulation of the thyroid
- Toxic nodule (adenoma – Plummer’s disease)
- Toxic multinodular goiter
- Thyroiditis – many types
- Excess levothyroxine administration (thyrotoxicosis factitia or iatrogenic)
Rare causes
- TSH producing pituitary adenoma
- HCG mediated hyperthyroidism in pregnancy
- Drugs – amiodarone or iodine administration (Jod-Basedow effect)
Hyperthyroidism Symptoms
- P________
- N_____ness
- Ag_____ or irritability
- ____ intolerance
- Tr_____
- Easy Fatigue
- Muscle ____kness
- Weight _____ with _____ appetite
- _____ or Double Vision
- GI =
- ____menorrhea
- Palpitations
- Nervousness
- Agitation or irritability
- Heat intolerance
- Tremor
- Easy Fatigue
- Muscle weakness
- Weight loss with good appetite
- Blurry or Double Vision
- Frequent bowel movements
- Oligomenorrhea (infrequent menstrual periods)
Hyperthyroidism Physical Exam
- G______
- _____ycardia (ST most commonly)
- Eye lid re_____
- Atrial arrhythmias – esp. (1)
- Skin moisture (1), temp (1)
- Proximal myopathy
- Gynecomastia (rare)
- Systolic _____– high output CHF
- ____ pulse pressure
- Goiter
- Tachycardia (ST most commonly)
- Eye lid retraction
- Atrial arrhythmias – esp. A Fib
- Warm, moist skin
- Proximal myopathy
- Gynecomastia (rare)
- Systolic Murmur – high output CHF
- Wide pulse pressure
Thyrotoxicosis-Consequences of Untreated Hyperthyroidism
- Atrial _____
- Sinus _____cardia
- (1) – High Output
- _____ pectoris
- O_____ and O______
- Thyroid _____
- D_____
- Atrial fibrillation
- Sinus tachycardia
- Congestive heart failure – High Output
- Angina pectoris
- Osteopenia and Osteoporosis
- Thyroid Storm
- Death
Hyperthyroidism
(1) Disease
60-80% of thyrotoxicosis. More common in females.
(3) antibodies
Graves Disease
- Thyroid Stimulating Immunoglobulin (TSI)* stimulates the TSH-Receptor and mimics the action of TSH
- TPO + in many cases also seen
- TBII – Thyroid Binding Imunoglobulin
Pathognomonic Findings in Graves Disease
- o______mopathy (cytokines)
- br____/th_____ in thyroid gland
- pretibial _______ (NOT that myxedema)
- ophthalmopathy (cytokines)
- bruit/thrill in thyroid gland
- pretibial myxedema (NOT that myxedema)
Graves Disease the Antibodies
- (1)
- Not so specific
- Very sensitive for auto-immune related thyroid disease
- Have a low threshold for ordering when considering any thyroid disease
- (1)
- Very specific
- Not so sensitive
- Can take a week for lab to result (depends upon your lab)
- (1)
- Can be an antagonist to the TSH-Receptor
- Can be the term used for a group of antibodies to the TSH-Rec
- Pretty specific for Graves’ disease
- Can come back within a day or as much as a week (depends upon lab)
- Anti-TPO – anti-peroxidase antibody
- Not so specific
- Very sensitive for auto-immune related thyroid disease
- Have a low threshold for ordering when considering any thyroid disease
- TSIg – Thyroid stimulating immunoglobulin*
- Very specific
- Not so sensitive
- Can take a week for lab to result (depends upon your lab)
- TBII – Thyrotropin binding inhibitory immunoglobulin (aka TRAb – Thyroid Receptor Ab)
- Can be an antagonist to the TSH-Receptor
- Can be the term used for a group of antibodies to the TSH-Rec
- Pretty specific for Graves’ disease
- Can come back within a day or as much as a week (depends upon lab)
Graves Disease - Infiltrative Ophthalmopathy
- Symptoms
- ___ness, dryness, itching
- _____tosis (only found in graves disease), Corneal exposure
- Ed____
- Bl____ vision or loss of vision
- Often times also need to bring in ophthal to help address eyes and potentially ______
- ymptoms
- Redness, dryness, itching
- Proptosis (only found in graves disease), Corneal exposure
- Edema
- Blurry vision or loss of vision
- Often times also need to bring in ophthal to help address eyes and potentially decompress
Thyrotoxicosis - Anatomic Imaging
(1) = identifies nodules, vascularity
(1) = helps differentiate cause of hyperthyroidism
Thyroid US = identifies nodules, vascularity
NM (nuclear medicine) Uptake and Scan = helps differentiate cause of hyperthyroidism
Thyroiditis
Many different forms of Thyroiditis - this pattern is most common course for any patient (independent of etiology)
- Subacute – painful - post-v____ (de Quervain), Giant cell or Granulomatous
- Acute thyroiditis – fluctuance, severe pain, fever, marked ____ rise – bacterial
- Painless (silent) thyroiditis – most common - post-_____ (TPO+)
- Drug induce - Am_____, IFN-α, _____ inhibitors (cancer therapy), post-iodinated contrast load, post-RAI-131 – usually painless
- Reidel thyroiditis – fibrosis (usually leads to hypothyroidism) which can invade local structures. Very firm gland. Usually painless
- Subacute – painful - post-viral (de Quervain), Giant cell or Granulomatous
- Acute thyroiditis – fluctuance, severe pain, fever, marked ESR rise – bacterial
- Painless (silent) thyroiditis – most common - post-partum (TPO+)
- Drug induce - Amiodarone, IFN-α, PdL-1 inhibitors (cancer therapy), post-iodinated contrast load, post-RAI-131 – usually painless
- Reidel thyroiditis – fibrosis (usually leads to hypothyroidism) which can invade local structures. Very firm gland. Usually painless
Hyperthyroidism
Treatment
Rx (2) first line therapy
Rx (1) for symptomatic relief
Methimazole, Propylthiouracil
Beta Blockers for symptomatic relief
Methimazole, Propylthiouracil (Thionamides)
MOA
SE (1)* precautions for high dose
PTU - 3rd most common cause of _____ toxicity by medication, rarely indicated
Only inhibits production of new hormone, does not interfere with pre-formed hormone release
Directly interferes with the first step in thyroid hormone biosynthesis in the thyroid gland.
AGRANULOCYTOSIS* precautions for high dose
PTU - 3rd most common cause of liver toxicity by medication, rarely indicated
Beta Blockers
in ____ doses, are the drugs of choice for ______ relief and suppression of ________
in high doses, are the drugs of choice for symptomatic relief and suppression of tachyarrhythmia
Thyroiditis Treatment
JUST TREAT SYMPTOMS
What should you use? (2)
What should you not use? why?
JUST TREAT SYMPTOMS
Beta Blockers and Pain medication PRN
Do not use thionamides (methimazole/PTU) because will only lengthen the hypothyroid phase and cause confusion in interpreting TFTs
Hyperthyroidism Treatment Definitive Therapy
- (1)– relatively safe, though some studies suggest small 2/2 cancer risk. May exacerbate exophthalmos.
-
(1)
- ____ thyroidectomy for Graves’ or TMNG
- ____thyroidectomy for toxic adenoma
- RAI – I-131 – relatively safe, though some studies suggest small 2/2 cancer risk. May exacerbate exophthalmos.
-
Surgery
- Total thyroidectomy for Graves’ or TMNG
- Hemithyroidectomy for toxic adenoma
Thyroid Storm/Thyrotoxic Crisis
- Precipitated by an acute (1) or (1)
- Increased risk in poorly treated or inadequately treated thyrotoxicosis
- Avoid point scoring systems - it is a _____ diagnosis!
- Patient presentation where it is almost assuredly NOT storm?
- Patient presentation of storm likely?
- High mortality from ______ causes
- These patients require the ICU
- Precipitated by an acute insult or illness
- Increased risk in poorly treated or inadequately treated thyrotoxicosis
- Avoid point scoring systems - it is a clinical diagnosis!
- PS – if the patient is calm, afebrile and can take PO without nausea or emesis, it is almost assuredly NOT storm
- If they are agitated, febrile and cannot take PO – treat as storm until proven otherwise
- High mortality from cardiovascular causes
- These patients require the ICU
Thyroid Storm Treatment Algorithm
(4) Rx
- High doses of Propranolol 40 – 60 mg PO q4H (or i.v. beta-blocker)
- High doses of Methimazole (PO, NG, PR enema) or PTU (T4->T3 effect)
- 1 hour after Thionamide dose can give Iodine solution (avoids Jodbasedow effect)
- High dose steroids +/-
Thyroid Nodules and Cancer
Categories of Goiter
(3)
- May be ____ (excess thyroid hormone) or ____ (normal FT4/TSH)
- Thyroid nodules are more common with ___
- Prevalence of palpable thyroid nodules: 2-6%
- Prevalence on thyroid U/S: 19-35%
- CT, MRI imaging = increased detection of likely ____ nodules (____diagnosis)
Diffuse, Multinodular, Uninodular
- May be Toxic (excess thyroid hormone) or Non-toxic (normal FT4/TSH)
- Thyroid nodules are more common with age
- Prevalence of palpable thyroid nodules: 2-6%
- Prevalence on thyroid U/S: 19-35%
- CT, MRI imaging = increased detection of likely benign nodules (overdiagnosis)
Primary Adrenal Insufficiency
ACTH levels =
Mineralocorticoid levels =
ACTH levels = Excess ACTH (negative feedback)
Mineralocorticoid levels = Mineralocorticoid deficiency
Secondary Adrenal Insufficiency
CRH/ACTH levels =
Mineralocorticoid levels =
Deficiency in CRH or ACTH
Mineralocorticoid intact
Main difference is glomerulosa that makes aldosterone remains intact in secondary AI
Specific Primary AI Manifestations
(1) from increased ACTH stimulation
(1) from absence of aldosterone
Skin pigmentation from increased ACTH stimulation
Salt craving from absence of aldosterone
(skin pigmentation from increased melanin on palms, dorsal surface of hands, buccal mucosa, sun-exposed areas)
Cosyntropin Stimulation Test (Synthetic ACTH)
Most common test? What result rules out AI?
Whom to test?
Most common test: 250mcg short (60 minutes) stimulation
Cortisol >15 mcg/dL after 60 min rules out AI (unless evaluating for acute pituitary injury)
Patients with indeterminate basal cortisol levels, All patients for whom time is of the essence
Osteoporosis
Systemic skeletal disease characterized by
- Low bone ____→ degree of mineralization
- Low bone _____→ macroarchitecture, microarchitecture, microdamage accumulation, rate of bone turnover
- Consequently - there is an increase in bone fragility and risk of ______
- Low bone mass → degree of mineralization
- Low bone quality → macroarchitecture, microarchitecture, microdamage accumulation, rate of bone turnover
- Consequently - there is an increase in bone fragility and risk of fracture
Metabolic Bone Disease
Peak Bone Mass and Rate of Bone Loss
Intrinsic Factors
- G______, ___pathway
Extrinsic Factors
- Es____ Status
- XRC/Nut_____
- To_____
- C____/Vitamin __ status
- Chronic Diseases
- Medications
Intrinsic Factors
- Genes, wnt pathway
Extrinsic Factors
- Estrogen Status
- XRC/Nutrition
- Tobacco
- Calcium/Vitamin D status
- Chronic Diseases
- Medications
The Wnt signaling pathway is an ancient and evolutionarily conserved pathway that regulates crucial aspects of cell fate determination, cell migration, cell polarity, neural patterning and organogenesis during embryonic development**.
Antifracture Pharm Therapy
Antifracture Pharm Therapy
Effect of osteoporosis therapy after a fragility fracture?
Anti-Osteoporotic Therapy After Fragility Fracture Lowers Rate of Subsequent Fracture
- All patients 50 and older who sustained a fragility fracture
- Treatment group: received anti-resorptive within 6 month with possession ration >80%
- No treatment group
- Outcome: 3 year rate of subsequent fracture
