Endocrinology Flashcards
recall
OGTT positive values in pregnancy (24-28 weeks)
FBS 92
1 hr 180
2hr 153
(Any 1 positive = GDM)
WHR and waist circumference cut off to be a clinical risk factor for T2DM
WHR >/= 1 in males
WHR >/= 0.85 in females
Waist circum >/= 90cm in males
Wast circum >/= 80cm in females
(Unite Guidelines)
Target pre prandial CBG in nonpregnant adults
80-130mg/dL
*Postprandial <180mg/dL
Target pre prandial CBG in older/high risk adults
90-140mg/dL
*Postprandial <200mg/dL
Consider Metformin in these individuals with IFG and IGT who are very high risk for progression to DM
Age <60 yes
BMI >35
Women with history of GDM
(HPIM)
Antidiabetic agents that act in a glucose dependent manner
GLP1 receptor agonists
DPPIV inhibitors
Hallmark of proliferative diabetic retinopathy
Neovascularization in response to retinal hypoxemia
Definition of albuminuria in DKD
Urinary albumin to creatinine (UACR)
>30mg/g on a spot specimen
Two FDA approved oral agents used for pain associated with diabetic neuropathy
Duloxetine, pregabalin
May also respond to TCAs, venlafaxine, carbamazepine, tramadol, or topical capsaicin products (patch)M
Most common pattern of dyslipidemia in DM
Hypertriglyceridemia and reduced HDL
Antidiabetic agents that promote weight gain
TZD, SU, Insulins
Antidiabetic agents that promote weight loss
SGLT2 inhibitors, GLP1 receptor agonist, Amylin agonist
*Metformin - moderate weight loss / weight neutral
Maximum dose for Metformin
2grams/day
Target glycemic goals for hospitalized patients
(1) in critically or non–critically ill patients: glu- cose of 7.8–10.0 mmol/L or 140–180 mg/dL
(2) in selected patients: glucose of 6.1–7.8 mmol/L or 110–140 mg/dL with avoidance of hypoglycemia
(3) perioperative period should be 80–180 mg/dL (4.4–10.0 mmol/L)
Monitoring of thyroid function in maternal hypothyroidism
Every 4-6 weeks during first half of pregnancy then 6-8 weeks after 20 weeks AOG
*Increase LT4 to once a day to NINE DOSES / WEEK
Management of myxedema coma
IV levothyroxine is initially given as single IV bolus at 200-400mcg/IV followed by daily oral dose of 1.6ug/kg/day
Hydrocortisone 50mg/IV every 6 hours
External warming if Temp < 30C
If severe hyponat - hypertonic saline
If severe hypogly - IV glucose
Avoid hypotonic solutions
Antithyroid meds starting dose
Methimazole 10-20mg every 8 or 12 hours (half life of 6h)
PTU 100-200mg every 6-8 hours ((90m half life, shorter, hepatotoxic hence indications are only: 1st trim of pregnancy, thyroid storm, and patients with minor adverse rx to methimazole. Monitor LFTs if on PTU)
*TFTs repeated after 4-6 weeks
Dose is titrated based on FT4 levels Euthryoidism after 6-8 weeks of
TSH is often suppressed for several months
Management of thyrotoxic crsis
Large doses of PTU 500-1000mg loading and 250mg every 4 should be given orally or by NGT/Rectum
If no PTU –> methimazole 20mg q6h
1 hour after PTU –> SSKI 5 drops every 6h to block thyroid hormone synthesis via Wolff- Chaikoff
Propanolol 60-80mg q4h or 2mg IV every 4h
Hydrocortisone 300mg IV bolus then 100mg q8h
Management of severe ophthalmopathy with optic nerve involvement
Pulse therapy with IV methylpred (500mg onc a week for 6 weeks then 250mg once a week for 6 weeks)
Orbiatl decompression via transantral route
Teprotumumab – 10mg/kg IV and 20mg/IV every 3 weeks for 21 weeks for active thyroid eye disease
Management of silent thyroiditis
-Brief course of propranolol 20-40mg 3-4x a day
-LT4 replacement may be required but should be withdrawn after 6-9 months once recovered
*Glucocorticoids not indicated
Antithyroid not indicated
Types of amiodarone induced thyrotoxicosis (AIT)
Type 1 - associated with underlying thyroid abnormality (preclinical Graves’ disease or nodular goiter)
Type 2 - in individuals with no intrinsic thyroid abnormalities
Management of subacute thyroiditis (thyrotoxic, hypothyroid, recovery)
Aspirin 600mg every 4-6 hours of NSAIDS
Glucocorticoids if inadequate or with marked local/systemic symptoms (Prednisone 15-40mg dependending on severity, tapered over 6-8 weeks)
LT4 replacement may be needed if hypothyroid phase is prolonged * but only. Low dose 50-100 ug/daily
*Antithyroid not indicated
Effects of Amiodarone on thyroid function (4)
(1) acute, transient suppression of thyroid function
(2) inhibition of T4 to T3 conversion causing either euthyroid hyperthyroxinemia or increased dosage requirement in LT4-treated hypo- thyroid patients
(3) hypothyroidism in patients susceptible to the inhibitory effects of a high iodine load; and
(4) thyrotoxicoMainstaysis that may be caused by either a Jod-Basedow effect from the iodine load, in the setting of MNG or incipient Graves’ disease, or a thyroiditis-like condition due to a toxic effect on thyroid follicular cells
Maintstay of thyroid canccer treatment
LT4 suppression of TSH
Target normal TSH 0.5-2.0miU/L
If at intermediate/high risk of recurrence target lower!!
0.1-0.5mIUmL (intermediate)
<0.1mIU/L if high risk and with mets
Drugs used in tx of Cushing’s disease
Pasireotide - somatostatin receptor ligand; SE: hyperglycemia
Osilodrostat - oral 11beta hydroxylase inhibitor, SE: GI symptoms, hypokalemia, hypertension, QTc prolongation
Ketoconazole - SE hepatic transaminases, gynecomastia, impotence, GI upset, edema
Mifepristone - for hyperglycemia, does not target pituitary tumor
Metyrapone - acne, hirsutism
Mitotaine - suppress cortisol hypersecretion
Definition of diabetes insipidus
24h urine vol >40mL/kg body weight and
24h urine osm <280mosm/L
Initial hormonal tests when suspecting pituitary adenoma (5)
(1) basal prolactin (PRL)
(2) insulin-like growth factor (IGF)-1
(3) 24-h urinary free cortisol (UFC) and/or overnight oral dexamethasone (1 mg) suppression test
(4) α subunit, follicle-stimulating hormone (FSH), and luteinizing hormone (LH)
(5) thyroid function tests
Indications for bone mineral density testing
- Women age >65, men >70
- Younger postmenopausal women,
women in menopausal transition, men
50-69 with clinical risk factors for fx 3. Adults who have a fracture at or after
age 50 - Adults with condition (e.g. RA) or taking
medication (e.g. steroids at daily dose of >5mg pred or euivalent for >3 months associated with low bone mass or bone loss
Treatment for mineralocorticoid excess from unilateral adrenal mass
<40 yrs, laparoscopic adrenalectomy
> 40 years, adrenal vein sampling
if positive proceed to unilateral adrenalectomy
if negative, Drug treatment (spironolactone/ epleronone/amiloride)
Difference between primary and secondary adrenal insufficiency
Primary - loss both glucocorticoid and mineralocorticoid secretion
Secondary - loss of glucocorticoid only
*adrenal androgen secretion impaired in both
Characteristic biochemical feature of primary adrenal insufficiency
Hyponatremia
Most common cause of primary adrenal insufficiency
Autoimmune adrenalitis
Treatment of acute adrenal insufficiency
Immediate initiation of rehydration – saline infusion at 1L/h with continuous cardiac monitoring
Glucocorticoid replacement – bolus hydrocortisone 100mg then 200mg hydrocortisone x 24h
Mineralocorticoid replacement initiated once daily hydrocortisone dose has been reduced to <50mg (Fludrocortisone 100-150ug)
Initial tests screen for hormone excess in investigating adrenal mass (4)
Plasma metanephrines or 24-h urine for metanephrine excretion
Dexamethasone 1 mg overnight test; if positive; also perform plasma ACTH, midnight salivary cortisol (≥2x), 24-h urine for free cortisol excretion (≥2x)
Plasma aldosterone and plasma renin in patients with hypertension and/or hypokalemia
If tumor >4 cm: Serum 17-hydroxyprogesterone, androstenedione, and DHEAS
Dx of adrenal insufficiency using short cosyntropin test
Cutoff for failure is usually defined at cortisol levels of <450–500 nmol/L (16–18 μg/dL) sampled 30–60 min after ACTH stimulation
Treatment for chronic adrenal insufficiency
Administer at dose that replaces physiologic daily cortisol production
Oral hydrocortisone 15-25mg in 2-3 divided dose
at least half of the dose should be given in the morning
