Treatments

Question 1

Acromegaly

Answer 1

If pituitary adenoma: Surgery

• Transphenoidal resection of pituitary

If surgery contraindicated or not a pituitary adenoma: Medical

• 1st line: Somatostatin analogues (octereotide, lanreoride) - suppress GH release
• GH antagonists (Pegvisomant)
• Dopamine agonists (bromocriptine, Cabergoline)
• Radiotherapy

NOTE: Physiologically, growth hormone should be suppressed by somatostatin.

Question 2

Adrenal insufficiency (& Addisonian crisis)

Answer 2

• Patient education on ‘sick day’ rules, carrying a steroid card, and wearing a medical alert bracelet
• Doubling the regular steroid medication dose during any intercurrent illness
• Replacement of both glucocorticoids (typically with hydrocortisone) and mineralocorticoids (typically with fludrocortisone)
• Regular screening for complications including an adrenal crisis and osteoporosis

Addisonian crisis: a life-threatening condition characterized by severe hypotension and electrolyte imbalances, should be managed with:

• Aggressive fluid resuscitation
• Administration of intravenous/IM (if no access) steroids STAT
• Glucose administration if hypoglycaemia is present

Question 3

Amiodarone-induced thyrotoxicosis

Answer 3

A recognized adverse effect of the anti-arrhythmic agent, amiodarone, which is rich in iodine, a component of thyroid hormone.

The condition manifests in two types:

• AIT type 1, a direct toxic effect of amiodarone on the thyroid gland causing thyroiditis
• AIT type 2, where amiodarone triggers underlying thyroid autoimmunity.

Question 4

Cushing’s Syndrome

Answer 4

Depends on underlying cause:

• Medical management: aim to decrease cortisol levels e.g. 1st line: Metyrapone, Others: Ketoconazole, Mifepristone and Pasireotide (a somatostatin analogue)
• Surgical: resection of pituitary tumour
• Radiotherapy: if hypercortisolaemia persists post-surgery, or if no surgery for whatever reason

NOTE: need steroid replacement post-op

Question 5

Hypothyroidism

Answer 5

Hormone replacement therapy with Levothyroxine

• review TSH levels every 3 months and adjust dose accordingly
• after 2 similar measurements 3 moths apart check TSH annually

NOTE: During pregnancy, the dose of levothyroxine is usually increased by 25-50mcg due to increased metabolic demands