Treatments only, Endo Flashcards
Chronic Addisons Disease treatment
- 1st line Hydrocortisone 15-30 mg, 2/3 dose in AM and 1/3 in PM
- 2nd line prednisone or methylprednisone
PRN for stressful events:
increase dose of steroids up to 50%
if using low dose GC, + Mineralcorticoids
if still having ortho hypotension, hyponatremia, hyperkalemia = Fludrocortisone
Monitor w/ PRA - if PRA (plasma renin activity) increases, fludrocortisone dose needs to be upped
see notability for medication names
1st line Hydracort lady walks to the gym with her (2nd line) packed-n-ready prenisone bag or her methylprednisone metal-packed’n’ready bag
you go to the gym chronically (on a weekly basis for a longtime) = connection to chronic
If drinking very little water its not enough so you need The Rock to help w/ your workout (mineral)
If we still have problems at the gym, drown with some fluid (fludrocortisone)
To monitor all the fluid shes getting, she beings an umbrella(it’s renin umbrella from picmonic). If PRA plasma renin activity increases, increase fludrocortisone
If you are going through something stressful you take more (thats easy to remember as it is)
Acute adrenal crisis
If no prev dx - order sercortisol and ACTH and start tx immediately w/ HYDROcortisone
- Loading dose IV hydrocortisone 100-300 mg in NS
- IV hydrocortisone 50-100 mg Q6h x 24 h then taper.
- switch to PO hydrocortisone once pt tolerates oral intake (10-20 mg Q6H then reduce)
Broad spectrum antibiotics and send for culture
Treat all electrolytes, glucose, volume abnormalities
cortisol = coffee
ACTH, start immediately with hydra court lady
When hydracourt lady needs to go to the gym BAD, she grabs coffee, and lifts TONS of weight ASAP!!!
First she lifts 100-300 lbs w/ NS
Then she lifts green IVY 50-100 lbs every 6 hours for one day
Then to get by she lifts little dumbells everywher she goes 10-20 lbs every 6 hours (PO)
abx and cx b/c a fever occurs and you want to make sure and treat
Monitoring for Addisons disease
WBC diff, electrolytes, renal fnx
DEXA scan: screens for osteoporosis –> b/c steroids inhibit bone formation
Refer to an endocrinologist
Pt education - medical alert bracelet - adrenal insuff
Take home injectible hydrocortisone
DEXA = Xray vision goggles
Hydracourt lady goes home from the gym with take home equipment. She has a special alert bracelet like the apple watch steps counter & Xray vision goggles w/ White gatorade (whitebloodcell + electrlytes) and new BUNS for renal fxn (from working at the gym)
Exogenous cushings (iatrogenic, from meds given by doctors)
Exogenous: Slowly titrate down exog GC/ACTH therapy
Prolonged tx can suppress the HPA axis → rapid withdrawal → in acute adrenal insuff
HPA recovery in 6-12mo
Use** short-acting GCs to** help w/ recovery of HPA axis → hydrocortisone (DOC)
Hydracourt lady journies for 6-12 mo by riding a buffalo (hump for Cushings)
Cushings
adrenalcortical carcinoma
Sx removal + lifelong GC replacement
or pituitary replacement therapy
While awaiting surgery,
Hypercortisolism: 11β-hydroxylase inhib - blocking cortisol steroidogenesis (metyrapone and osilodrostat)
Ketoconazole - inhibits early steps of steroidogenesis (monitor LFTs)
ACTH sec Adrenocortical carcinoma: mitotane - blocks cortisol sec
Surgery + GC replace or pituitary replacement therapy
while awaiting surgery: “me tired of waiting for surgery. oh sigh, drop that.” Key tone (of sad violin)
Buffalo is a mighty tank, needed to kill the cancer
metyrapone and osilodrostat
11β-hydroxylase inhib - blocking cortisol steroidogenesis (metyrapone and osilodrostat)
a whiney 11 year old Boy is tired of making cortisol all day. “Me tire” “O sigh, drop that (BS)”.aka stfu
Mitotane
mitotane - blocks cortisol sec
mitotane = mitigate secretion
Mighty tank
Think of him as having shields around him and blocking explosions of cortisol
Ketoconazole
Ketoconazole - inhibits early steps of steroidogenesis (monitor LFTs)
Key tone (music) w/ blue
Congenital Adrenal Hyperplasia
Hydrocortisone TID
Intial and maint dose; monitoring 17-hydroxy.
need stress dosing.
fludrocortisone daily. monitor BP and plasma renin activity.
hydracourt lady three times a day
monitors 17 babies
water daily! use umbrella while watering
Primary aldosteronism
Unilateral adrenal adenoma - unilat adrenalectomy, medical mgmt while waiting for surgery
Bilat adrenal hyperplasia - medical mgmt Adrenal
carcinoma - refer to onc
Monitor BP and K!
Primary aldosterone management
Low sodium diet K+ sparing diuretic - Spironolactone (DOC), eplerenone
Additional BP med: ACEI, HCTZ,
2nd line K+sparing (amilorid, triamterene)
Spyro pleads, gets an ACE fountain
2nd line gets AT
Pheochromocytoma
Tumor resection
Post-sx assess ACTH level - risk of post-OP adrenal insuff
Mgmt prior to sx: BP needs to be consistently <160/90 𝛼-adrenergic blockers ≥ 14d prior to sx (doxazosin, prazosin, terazosin) +/- BB’s, CCB’s, ACEI
Diet - high salt and ↑ water intake
Start 3d after 𝛼-adrenergic blockade d/t risk of orthostasis
before surgical . terazosin is an a 1 blocker
Houdini zones in before surgery for 14 d +/- ACE BB CCB (ABC)
3d after zoned in, drink salt water
Adrenal Carcinoma
Stage the malignancy → TNM staging (Tumor, Nodes, Metastasis) Refer to surgeon for complete resection
Hydrocortisone
tablet, injection, 20mg short acting.
PK 2-3 hrs
Hydra court lady 20 mg
Short acting!
Blue tablet and blue injection w/ a 20 mg
Methylprednisolone
tablet, injection
4 mg
intermediate HL 2-3 hours
metal pack n sow - metal vial and metal tablet
Prenisone
Tablet, **delayed release **tablet, solution
comes in liquid form! for kids
5 mg
imtermediate
pack n sow - Tab & Tab DR, Soln (for those slow to leave the house w/ purse), its a solution
Prenisolone
Tablet, solution, ODT (oral disintegrate), syrup
comes in liquid for for kids!
5 mg
intermediate acting
pre pack n sow (aka the person who is type A and prepared for leaving). This person, who is type A, can orally disintegrate in mouth(instant result because they are fast out the door!), a great solution for type A.
Pre pack maple syrup for the kiddies
Dexamethasone
Injection, tablet
0.75 mg
long acting, LONGEST HALF LIFE 6.5 hrs
Dexamethasone is thel longest acting one
Decks of stone (playing a game of cards, and rock does NOT move for very long time)
Stone injection vial and tablet
Glucocorticoids properties
decrease chemotaxis of inflam cells, depress migration of PMN, lympholysis, less capillary permeability, less phagocytic killing ability of neutrophils and macrophages
take with food
indicated for inflam conditions. always titrate down if using for at least 7 days.
DI w/ live vaccine, inactive vaccine.
Caution: peptic ulcer dz, CVD, HTN w CHF, varicella, TB, acute psychosis, DM, osteoporosis, glaucoma
CI: hypersensitivity, coadmin w/ live vaccines, systemic fungal infection
SE: osteoporosis. ICP incr in eye. insomnia. depression. mania. psychosis. HYPOkalemia
Leukocytosis, neutrophillia, lymphopenia, eosinophilia, monocytopenia
think white cars (leukocytes) are at stop lights. Neutrophils lose their 2nd amendment right. They get angry about that so they aggregate to protest.
After 7 d titrate down.
peptic ulcers are caused by stress so CI. can’t use w/ a bad heart or pipes since stress makes those worse. stress causes hyperglycemia to run from the bear so we don’t want that for DM. glaucoma gets worse from a1 receptors so CI. Osteoporosis b/c it stops bone builders.
Stress makes emotions worse.
Eosinophils go UP during stress because the opposite reaction (antihistamines) makes them go down. epi is the opposite of antihistamine
Hyperprolactinemia
ID causes
Normalize PRL levels to alleviate suppressive effects on gonadal fxn, halt galactorrhea, and preserve bone mineral density
Tx micoPRLomas (<1cm) w/ estrogen, estrogen/progesterone, or testosterone replacement tx
w/ macroPRLomas → DA agonist instead
DA agonists - Cabergoline and Bromocriptine - suppress PRL secr and synth/lactotroph cell proliferation
If visual fields affected → Sx
Microadenoma - safe to have DA agonist and conceive and breastfeed
Macroadenoma - if DA agonist is stopped, monitor SerPRL and visual-field testing
Estrogen upregulates prolactin production.
Prolactin down regulates estrogen production.
Cabergoline
Cabergoline - long-acting DA agonist that suppressed PRL for > 14d after single PO dose
Caroline long acting DA agonist (old creepy doll)
Think about it like she takes over someone’s body, like a demon. An agonist. Makes the person stronger when they are possessed.
Bromocriptine
short-acting and pref when pregnancy is desired
broom cript. we don’t like sweeping for all that long.
I guess we want pregnant women to sweep idk.
Bromocriptine and cabergoline combined SE
MC - C, congestion, dry mouth, nightmares, insomnia, vertigo (try ↓ dose)
Pt’s w/ Parkinson’s receiving ≥ 3mg/d of cabergoline - at risk for cardiac valve insuff
creepy doll Caroline sweeping a crypt. nightmares and insomnia b/c scary as fuck. Dries mucous membranes out - crypt in a desert. dries out GI. dries out nose.
Heart w/ a valve and a 3 for risk of cardiac valve insuff
Hypoprolactinemia
DA antagonist - oppose DA in those who want to breastfeed
Many antipsychotics - Haloperidol, Olanzapine, Metoclopramide
Surgery
these drugs are dopamine antagonists
Metal Claw + halo + lancer
Angel lancer on a horse w/ metal claws racing towards milk (bc he had none)
GH deficiency in children
Recombinant GH restores growth velocity in GH-def children to ~10cm/yr
Somatropin (Genotropin, Humatrope, Norditropin, Nutropin, Omnitrope, Saizen)
In pts w/ GH insuff and growth retardation d/t mutations of GH receptors, tx w/ IGF-1 bypasses the dysfxnal GH receptor
TROPIN grows
self explanatory
Growth Hormone Deficiency in Adults
Recombinant GH injections (rhGH, somatotrophin)
CI: active neoplasm, intracranial HTN, uncontrolled DM or retinopathy
Monitor: fundoscopic exam (intracranial HTN)
Adults: IGF-1 every 1-2mo during titration then semiannually
Children: growth curve and PE w/ skeletal assessment each visit
SE: fluid retention, joint pain, carpal tunnel, myalgia, paresthesia, hyperglycemia, DM
flooded tunnel, high sugar, aches, HTN
IGF-1 every 1 to 2 months then semi annual
Acromegaly
Transsphenoidal Surgery resection - pref tx (hypopituitarism dev in ~15% of pts)
RT (radiation) - adjunct tx for acromegaly
(req 8yrs for max GH suppression)
Somatostatin analogues (adjunct) - ↓ GH
Lanreotide
Octreotide
Pasireotide
Sandostatin (LAR)
Signifor
Somatuline Depot GH receptor antagonists (Pegvisomant)
Blocks GH-R sites; $$$
DA agonist:
Bromocriptine and Cabergoline - mod suppress GH secr (high dose)
**Octreotide + Cabergoline **
TIDE inhibits - TIDE pods challenge was killing people. TIDE pods were the ultimate inhibitor.. of life.
Somatostatin analogues
Well tolerated in most patients and adverse effects are short-lived and mostly relate to drug-induced suppression of gastrointestinal motility and secretion.
Nausea, abdominal discomfort, fat malabsorption, diarrhea, and flatulence occur in one-third of patients, and these symptoms usually remit within 2 weeks.
Octreotide suppresses postprandial gallbladder contractility and delays gallbladder emptying; up to
30% of patients develop long-term echogenic sludge or asymptomatic cholesterol gallstones.
somatostatin = stop sign
a stop light is short lived. (2 weeks long)
GI side effects. a stop light guy who brown pants for D, with a green face and grimace light in pain. flatulence (green smoke behind him) 1/3.
Jar of green stones. lots of sludge around him.
Hypogonadism females
Cyclical replacement of estrogen and progesterone - maintain secondary sex characteristics and prevent osteoporosis
Gonadotropin or LH - ovulation induction
Human menopausal gonadotrophin (hMG) or recombinant FSH - Follicular growth and maturation
Pulsatile GnRH tx can be used to treat hypothalamic causes of infertility
LH/gonadotropin = ovulate,
hMG/reFSH = follicular growth,
GnRH for infertility
est & prog for every day and to keep away spongy bone
Hypogonadism for males
Testosterone replacement (IM or patch)
For infertility d/t oligospermia - human chorionic gonadotropin (hCG) - IM
Alt for pts w/ intact pituitary: leuprolide (GnRH analog)
Clomiphene PO - stimulates men’s own pituitary gonadotrophins → ↑ testosterone and sperm prod
SIADH emergency setting
3% hypertonic saline
(monitor SerNa+ and neuro s/s)
Furosemide - increases excretion of free water (adjunct)
(limits tx-induced volume expansion)
salty sally’s fury crying
salty sally= hypertonic saline
excretion of water= crying
SIADH non emergency settings. What is importance of acute vs chronic?
Depends on acute (<48hr) vs chronic
Consult nephrology
Correcting hyponatremia too quickly → central pontine myelinolysis (CPM) w/ permanent neurology s/s (paralysis, dysphagia, dysarthria)
Want daily rise of Na+ (10-12mEq/d)
10-12 rise of salt is good
48 hour cutoff
