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Clinical Year 4 > Endocrinology > Flashcards

Endocrinology Flashcards

1
Q

All hormones are controlled by which type of feedback?

A

Negative

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2
Q

What are the two main parts of the pituitary gland?

A

Anterior pituitary

Posterior pituitary

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3
Q

What hormones are secreted from the anterior pituitary gland?

A 
ACTH
GH
MSH
TSH
Gonadotropins (FSH, LH)
Prolactin
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4
Q

What hormones are secreted from the posterior pituitary gland?

A

ADH (aka Desmopressin)

Oxytocin

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5
Q

Pituitary Tumours

A

Rare

Usually benign

Occassional are metastases (e.g. from breast cancer)

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6
Q

How do pituitary tumours usually present?

A

Pressure effects from the tumour

Pituitary failure

Hypersecretion of one or more hormones (this is what causes the real problems)

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7
Q

How are non-functioning pituitary tumours usually treated?

A

These make up 90% of pituitary tumours

No pharmacological treatment
Surgery is used

Treatment goals

  • Protect eyesight
  • Restore pituitary function
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8
Q

How are functioning pituitary tumours usually treated?

A

Pharmacological treatments

Most common are Prolactinomas

Much less common are

  • GH = Acromegaly
  • ACTH = Cushing’s disease
  • TSH = TSHoma (thyrotoxicosis but with raised TSH)
  • FSH = FSHoma (menstrual and fertility issues)
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9
Q

Features of a Proclactinoma

A

Secrete prolactin

Pressure effects
- Headache, loss of peripheral vision

Hormone effects

  • Women = Absent periods, infertility, galactorrhoea
  • Men = Erectile dysfunction, hypogonadism
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10
Q

How are Prolactinomas treated?

A

Dopamine receptor agonists

  • Prolactin is inhibited by release of dopamine form the hypothalamus
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11
Q

Which dopamine receptor agonists are ergot derived?

A

Cabergoline and Bromocriptine

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12
Q

Which dopamine receptor agonists are non-ergot derived?

A

Quinagolide

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13
Q

Which dopamine receptor agonist should be used in pregnant women?

A

Bromocriptine as it has a history of use in pregnancy

It has a shorter half life than cabergoline

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14
Q

What is acromegaly?

A

Excess of growth hormone

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15
Q

What are common symptoms of acromegaly?

A

The lower jaw can continue to grow

  • Underbiting
  • Interdental seperation

Shoe size increase

Rings no longer fit

Diabetes
- too much growth hormone can counteract insulin

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16
Q

How is acromegaly treated?

A

First line is often surgery

Somatostatin analogues (not in the endocrine section of BNF!)

  • Monthly injection
  • Tumour shrinkage in 30% of patients

Pegvisomont (GH receptor antagonist)

  • however daily injections compared to monthly
  • No tumour shrinkage
  • Monitored by IGF-1 (metabolite of GH, more stable)
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17
Q

What is Cushing’s disease?

A

Caused by excess secretion of ACTH

Stimulates testosterone production
- can lead to acne

Not to be confused with Cushings SYNDROME
- Cushing’s disease is caused by a pituitary tumour

Has same symptoms of cushing’s syndrome

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18
Q

How is Cushing’s disease normally treated?

A

Surgery

Metyrapone in preparation for surgery
- Blocks hydrocortisone synthesis

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19
Q

What does a lack of ADH/Desmopressin lead to?

A

Diabetes Insipidus (inability to concentrate urine)

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20
Q

What are the main symptoms of adults with not enough growth hormone?

A

Weight gain, less muscle mass

Fatigue

Lipid profile and cardiovascular dysfunction

Bone mineral density

Quality of life

Life expectancy

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21
Q

What criteria do you have to meet as an adult to receive growth hormone replacement?

A

Must have a proven underlying pathology

Stimulation test must prove GH deficiency

Low QoL AGDA score

3-9 month trial with definite improvement in QoL AGDA

  • AGDA score = quality of life score
  • unless there is a significant increase we may take it away
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22
Q

What is the difference between primary and secondary hypothyroidism?

A

Primary = Problem with the thyroid gland

Secondary = problem with pituitary or something other than the thyroid gland

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23
Q

What monitoring is necessary in secondary hypothyroidism?

A

TSH is NOT useful

Need to check FT4 (Free Thyroxine 4) only

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24
Q

Hydrocortisone in pituitary failure

A

Most closely mimics natural diurnal rhythm

Theoretical less risk osteoporosis

10mg on waking
5mg at lunch
5mg early evening

Can be adjusted using day curves or urine cortisol

NB Fludrocortisone NOT required in pituitary failure

25
Q

Why is hydrocortisone important in pituitary failure?

A

Not getting cortisol is the most dangerous part of the disease

We use hydrocortisone (orally) because it is short acting and so we can replicate the natural daily cycle of cortisol production

Prednisolone is long acting and so would NOT be given

26
Q

What are the hydrocortisone ‘sick day rules’?

A

Double dose if febrile illness

Double dose if fractured limb

Surgery: IV hydrocortisone then double dose

Gastroenteritis: Double dose, IM hydrocortisone

Dental extraction: 20mg

Severe shock: double dose

Long haul flight: double dose

27
Q

Desmopressin

A

Acts on kidney collecting ducts and tubules (ADH) to allow water reabsorption into the bloodstream

Sublingual, subcutaneous, oral

Give at night then according to symptoms during the day

Aim: control of polyuria then treatment should wear off for an hour prior to next dose to excrete free water load

Check U+E to ensure Sodium is normal

28
Q

What are the main SIGNS of hypothyroidism?

A 
Facial swelling
Hair loss
Dry skin
Reduced heart rate
Husky voice
Hypothermia
Goitre
29
Q

What are the main SIGNS of hyperthyroidism?

A 
Tremor
Warm skin
Agitation
Goitre
Exophthalmous (protusion of the eyeballs)
Atrial fibrillation
30
Q

What are the main SYMPTOMS of hypothyroidism?

A 
Fatigue
Constipation
Weight gain
Depression
Menorrhagia
Psychosis
Hearing loss
31
Q

What are the main SYMPTOMS of hyperthyroidism?

A 
Palpitations
Diarrhoea
Weight loss
Sweating 
Heat intolerance
Hunger & Thirst
Anorexia
32
Q

What are the main aims of treatment of thyroid dysfunction?

A

Restore wellbeing and to return TSH levels to normal

Relieve symptoms

Manage any underlying condition

33
Q

What monitoring is required in thyroid dysfunction?

A

TSH, T4, T3

Patient symptoms

34
Q

What drugs can induce thyroid disease?

A

Amiodarone
Lithium

Iodine
Cholestyramine
Ferrous sulphate
Glucocorticoids

35
Q

How does amiodarone affect thyroid function?

A

Contains 40% iodine, can cause both hypo and hyper

It inhibits the conversion of T4 to T3 and the iodine can directly inhibit thyorid gland function (HYPO)

Can also cause HYPER via an inflammatory process that causes increased release of thyroid hormones

36
Q

Which patients should be screen for thyroid dysfunction?

A

Patients taking amiodarone or lithium

Patients with diabetes

Patients with AF

Patients with hyperlipidaemia

Patients with

  • Down’s syndrome
  • Turner’s syndrome
  • Addison’s disease
37
Q

How can thyroid function affect a patient’s lipid profile?

A 
HYPOthyroidism = high lipids
HYPERthyroidism =  lower lipids
38
Q

What are the cardiovascular signs and symptoms of HYPERthyroidism (to help with differential diagnosis)

A 
o	Palpitations 
o	Anginal chest pain 
o	Exercise intolerance 
o	Atrial fibrillation
o	Exertional dyspnea 
o	Cardiac hypertrophy 
o	Systolic hypertension 
o	Peripheral edema
o	Hyperdynamic precordium 
o	Congestive heart failure
39
Q

What are the main cardiovascular risks associated with HYPOthyroidism?

A
  • Impaired cardiac contractility and diastolic function
  • Increased systemic vascular resistance
  • Decreased endothelial-derived relaxation factor
  • Increased serum cholesterol
  • Increased C-reactive protein
  • Increased homocysteine
40
Q

How do you tell if something is caused by CV or thyroid dysfunction?

A

Restoration of normal thyroid function would reverse the CV symptoms if caused by thyroid dysfunction

41
Q

What is adrenal insufficiency?

A

The clinical manifestation of deficient production or action of glucocorticoids, with or without deficiency also in mineralocorticoids and adrenal androgens.

42
Q

What are the adrenal glands?

A

Adrenal cortex

  • Aldosterone, Cortisol and Androgens
  • Steroids (Mineralo-, Gluco- and Gonado-corticoids)

Adrenal medulla

  • Epinephrine
  • Norepinephrine
43
Q

What are the main functions of cortisol?

A

Helping to regulate blood pressure.

Helping to regulate the immune system.

Helping the body to respond to stress.

Helping to balance insulin in regulating blood sugar level

44
Q

How do the adrenals work?

A

The hypothalamus receives input from the body (when more cortisol is needed) and produces corticotropin-releasing hormone (CRH)

CRH stimulates the pituitary to secrete ACTH

ACTH travels to the adrenal glands and stimulates the adrenal cortex to make more cortisol.

45
Q

What are the two main consequences of Adrenal dysfunction?

A

Cushing’s syndrome

  • Most commonly drug induced
  • High ACTH secretion as the anterior pituitary becomes insensitive to the negative feedback
  • Excess cortisol

Addison’s disease

  • Destruction of adrenal gland
  • Autoimmune most common cause
  • Low cortisol
  • Lack of cortico and mineralo corticoids
  • High ACTH as less negative feedback from cortisol
46
Q

What are the main cardinal symptoms of Adrenocortical insufficiency (aka Addison’s Disease)

A

Weakness

Fatigue

Anorexia

Abdominal pain

Weight loss

Orthostatic hypotension

Salt craving

Hyperpigmentation (caused by increased ACTH)

47
Q

What are the main biochemical abnormalities associated with Addison’s Disease?

A

LOW

  • Sodium
  • Blood sugar

HIGH

  • Potassium
  • Urea
  • Calcium
  • Serum TSH
48
Q

What is the ADDISONS Pneumonic for Addison’s Disease Symptoms?

A

A = ALWAYS TIRED

D = DIZZY WHEN STANDING

D = DROP IN BLOOD PRESSURE ON STANDING

I = INEXPLICABLE WEIGHT LOSS

S = SKIN COLOUR CHANGES

O = ONLY EATING SPARINGLY / ANOREXIA

N = NO STRENGTH IN HANDGRIP OR LIMBS

S = SICK OR NAUSEOUS

49
Q

How is Addison’s Disease managed?

A

Hydrocortisone (Glucocorticoid replacement)

Fludrocortisone (Mineralocorticoid replacement)

50
Q

What do you do in an acute adrenal crisis?

A

Dial 999!

Parenteral hydrocortisone and IV fluids

51
Q

What are the complications from adrenal crisis?

A

Cardiac arrest
Stroke
Hypoglycaemic shock
Hypoxia

52
Q

Are adults taking corticosteroids for adrenal insufficiency at risk of osteoporosis?

A

Evidence from observational studies indicates that some adults taking corticosteroids for adrenal insufficiency (AI) have decreased bone mineral density (BMD).

  • Ensure good vitamin D and calcium intake.
  • Stop smoking and limit alcohol intake
53
Q

What monitoring is needed for patients with Addison’s?

A 
Blood pressure
Blood glucose
Adrenal function
Thyroid function
U&E
Signs & symptoms
- Patient wellbeing
54
Q

What are the ‘sick day rules’ for patients with Addison’s disease?

A

Fever
37.5 degrees or more = double normal dose
39 degrees or more = triple normal dose

Serious injury
- Take 20mg immediately in addition to normal doses

Vomit once
- Take 20mg immediately in addition to normal doses
Vomit twice or more
- Emergency injection of hydrocortisone

55
Q

What other advice should be given to addison’s disease patients taking hydrocortisone?

A

If you go on holiday
- ensure to take ample supplies

If you take part in strenuous exercise
- Will need extra hydrocortisone, speak to your doctor

If you work shifts or at night
- You dosing schedule will probably need to be changed to match your work schedule. Speak to your doctor/prescriber.

56
Q

What are the main symptoms of adrenal crisis?

A 
Vomiting
Abdominal pain
Myalgia
Joint pains
Severe hypotension
Hypovolemic shock

Emergency hydrocortisone injection!

57
Q

What is the pharmacists role in the management of patients with addison’s?

A

Timing of steroid doses
- Morning and lunchtime

Doubling doses if patient is unwell

Education on ‘Sick Day Rules’

Management of adrenal crisis

Drug interactions

  • Oestrogen
  • Liquorice root interacts with fludrocortisone (check cough meds)
58
Q

Differences in amounts of T3 and T4

A

There is 20 times more T4 than T3

T3 is 3-4 times more potent than T4

T4 is converted to T3 by the liver and muscles

Clinical Year 4 (12 decks)

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