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
Acute setting SIADH
Acute setting:
3% hypertonic saline
Loop diuretics (furosemide) w/ saline
Vasopressin-2-R antagonists (conivaptan)
(prod water excretion w/o electrolyte excretion)
Water restriction (500-1500mL/d)
Vasopressin-R antagonist: inhib AVP V2-R and causes ↓ number of aquaporin-2 water channels in collecting duct → ↓water permeability of duct
Conivaptan - parenteral V1a AND V2-R antagonist
Tolvaptan - selective oral V2-R antagonist
Avoid in hypovolemic hyponatremia
conivaptan (antagonist of vasopressin 2R)
salty sally’s fury, with Con captain V1V2 and Toll V2 captain.
(a situation that everyone hates)
Chronic setting SIADH
Chronic setting:
Fluid restriction and V2-R antagonist
Referral to nephrologist for chronic vaptan use
tell them to stop drinking water and put them on toll captain
refer if they want the con captain V1V2
VR2 agonists
Conivaptan - parenteral V1a AND V2-R antagonist
Tolvaptan - selective oral V2-R antagonist
Avoid in hypovolemic hyponatremia
con captain and toll captian
find reason for con captain having both V1 and V2 while TOLL just has V2
Diabetes Insipidus
Mild: supportive tx (fluids)
Central and Vasopressinase-induced DI:
Desmopressin acetate
(incr water permeability in renal tubular cells → decr urine volume and incr Uosm) - concentrates urine!
SE: agitation, emotional changes, SI
Desmopressin (desmond miles the time traveler)
Desmond miles is moody because his family got murdered
Pituitary Adenoma
**Transsphenoidal surgery - most effective
Radiation- primary tx or adjunct to surgery
Slow onset of action → good for post-op mgmt
Meds:
Prolactinomas - DA agonists (DOC)
Acromegaly - somatostatin analogs and GH-R antagonists
TSH-secreting tumors - somatostatin analogs
ACTH-secreting tumors and non-fxnal tumors are gen not responsive to meds and req surgery or radiation
Hypercalcemia
Severe (symptomatic or Ca > 14mg/dL)
Rehydration - IV NS 500-1000mL/h x 2-4hrs
+/- loop diuretics - IV furosemide (Lasix) → ↑ calcuria and diuresis
SE: hypoK or hypoMg
+/- corticosteroids (prednisone, hydrocortisone) - ↓ conversion of inactive to active vit/ D (esp w/ excess calcitriol is present)
**
+/- Bisphosphonates, Calcitonin:
↓ release of Ca from bone, esp in chronic cases
Hypocalcemia
Replacement of lost Ca (PO +/- Vit D);
Severe hypocalcemia: (Ca >14)
IV Calcium: 10% Ca gluconate 10-30 mL IV over 10-20min (can cause VD or ischemia)
+/- IV magnesium
+/- Vit. D
replace lost Calcium! can use vit D too. easy.
severe: IV Ca, Mg, D (Ivy green CAMD’)
Primary hyperparathyroidism Asymptomatic
Adequate hydration: 6-8 glasses of water/d
(↓ effects of hypercalcemia, ↓ nephrolithiasis)
Physical activity - avoid bed rest
(↓ osteoporosis risk )
Avoid meds like thiazides, lithium, high dose of Vit A
Mod intake of calcium or vit. D supplement
flush out the stones, run your bones
Avoid slides, batteries, Retinol
Add Ca + D to neg. feedback on the PTH
Primary hyperparathyroidism symptomatic
Parathyroidectomy rec for pts w/:
Symptomatic hyperparathyroidism
Kidney stones, bone dz
Persistence urinary Ca >400mg/dL
SerCa > 1mg/dL above ULN
< 50 y/o
surgery for bones and stones dz
or 400 Ca in urine. Ca in blood above 1 ULN or
less than 50y/o
Hyperparathyroidism monitoring
Annual labs (SerCa, Vit D, PTH, renal fxn, 24hr urine for Ca)
DEXA scan every 2yrs
Spinal X-ray or CT, abd US or CT
Definitive tx is Surgery
once a year -3 C’s: (SerCa, Uri24h Ca, Cr/BUN) + D (e) PTH,
Deep 3 C’s 1/yr
Dexa/2
Spine Xray/CT, abd CT/US
high PTH Symptomatic, non-surgical:
Cinacalcet (Sensipar): pref esp if bone density is WNL
Does NOT improve bone density or reduce calciuria
Recheck SerCa 1 wk after initiating
Bisphosphonates - pref w/ osteoporosis
PO Bisphosphonates - alendronate (Fosamax), ibandronate (Boniva)
Can improve bone density
Do NOT sig impact hypercalcemia or hypercalciuria
IV Bisphosphonates - pamidronate (Aredia), zoledronic acid (Reclast)
Temporarily treats hypercalcemia
Good for sx prep w/** severe hyperCa**
other - estrogen replacement, decreased bone loss. Risk of CA, TE
Raloxifene- decr. reabs in bone. decrease CA risk in uterus and breast
WNL = within normal limits
Sinna is normal, Alen’s got holes, IVY pam&zols got ever bigger holes
Raloxifene
Cinacalcet (sensipar)
Cinacalcet (Sensipar): pref esp if bone density is WNL
MOA: binds to CaSRs in PT and ↓ PTH secr
SE: N/D, arthralgia, myalgia, paresthesia
Does NOT improve bone density or reduce calciuria
Recheck SerCa 1 wk after initiating
Sinna ‘s normal.
just decreases PTH by binding to Ca receptor in PT (sinna flirts with pink ice cream receptionist in panem)
he has joint pain, muscle pain from years of haircutting in Panem
doesn’t change the fact that katniss still has to battle (no effect to bone density).
After the hunger games are over, Ca is rechecked (hunger games over after 1 week)
Bisphosphonates
Bisphosphonates - pref w/ osteoporosis
MOA: bind to hydroxyapatite and imp ability of osteoclasts to reabs bone
(↓ number of active osteoclasts by inhibiting osteoclast progenitor dev and promote apoptosis)
inhibit the people with the axe
PO Bisphosphonates
PO Bisphosphonates - alendronate (Fosamax), ibandronate (Boniva)
Can improve bone density
Do NOT sig impact hypercalcemia or hypercalciuria
alen the drone stops axe people, they use robot legs to jump in big hole
can’t do much to remove pink ice cream
IV Bisphonsphonates
IV Bisphosphonates - pamidronate (Aredia), zoledronic acid (Reclast)
Temporarily treats hypercalcemia
Good for sx prep w/ severe hyperCa
Pam drone and Zole drone can jump down big holes too, but they also have the robot arms to deal with too much pink ice cream
show a surgeon on the scene
Raloxifene
Raloxifene (Evista) - SERM
Estrogen agonist in bone to ↓ reabs
Estrogen antagonist in uterus and breast to ↓ CA risk
Raloxifene is both an agonist and antagonist. Relax and fiend
Estrogen stop osteoporosis. Raloxifene - tells axe guys to relax.
its also an estrogen antagonist in uterus and breast - a “fiend”, antagonist to cancer in uterus and breast. can draw on body where its a fiend and where its not.
Complications of Primary hyperparathyroidism
Weakened bones → osteopenia, osteoporosis, pathologic factors
Eval w/ DEXA scan every 2yrs
Vertebrae at high risk
Tx: bisphosphonates or denosumab (Prolia)
Vit. D def:
Eval w/ serum 25-OH Vit. D
Tx: vit D replacement therapy
Renal effects → nephrolithiasis, nephrocalcinosis, CKD
Refer to nephrology or urology
Secondary Hyperparathyroidism
Refer to nephrology if CKD present
Medical management - mainstay
Vit. D supplement
Dietary restriction of phosphate (if CKD)
Hypoparathyroidism Acute
Acute management:
Maintain airway - risk of laryngospasm or bronchospasm
IV Ca Gluconate 10%
Ind: low SerCa, tetany, seizures, bronchospasms, prolonged QT, HF
PO - Calcitrol and Calcium to wean offf from IV Ca
Vit D therapy (started w/ Ca tx)
Calcitriol (1,25 Vit. D) - faster onset
Magnesium (if low)
Magnesium sulfate IV → Mg oxide PO
Monitor - SerCa, P, Mg, UCa
start IV then PO
IV Ca Gluconate 10% indication is any of the symptoms from the green shelf in the pictures
PO- Calcitrol and Calcium to wean off from IV
Vit D therapy started at same time
Magnesium if low is given IV and then transitioned to Mg oxide PO
Monitor all of these + P
Hypoparathyroidism chronic/maintanence
Chronic management/maintenance:
PO Calcium Supplement:
Ind: **sympt pts **
Monitor SerCa every 3-6mo (“normal” Ca leads to hypercalciuria and renal stones)
Vit. D and Mg supplements: as needed
PTH replacement tx:
Recombinant human PTH, Synthetic PTH, palopegteriparatide (prodrug of PTH)
Ind: pts intolerant of Ca/Vit. D
Long-term lab monitoring: Urine and SerCa, SerCr, P, 25-OH Vit. D every 3-6mo then 6-12mo
Periodic renal imagine (US) if persistent
Recomb human PTH, synth PTH,..
supplements only if symptomatic.
Recomb human PTH, synth PTH, palopegteriparatide if they can tolerate the supplements.
Labs: Ca Cr D 3, 6, 12
if it keeps going US
HYPOparathyroid prophylaxis
Transplant of cryopreserved PT tissue
Ind: pts undergoing parathyroidectomy
Transplanted in brachioradialis (MC), pectoralis, SCM
Vit D2
Cheaper and plant-based
Ind: vit. D def, osteoporosis, hypoparathyroidism, FHH
MOA: stimulates Ca and P abs in SI; Ca reabs in renal tubule; secretion of Ca from bones to blood
AE: C, AMS, fatigue, arrhythmias
CI: allergy, hypercalcemia, Hypervitaminosis D
Vitamen D3
Animal sources
Ind: vit. D def, osteoporosis, hypoparathyroidism
MOA: stimulates Ca and P abs in SI; Ca reabs in renal tubule; secretion of Ca from bones to blood
AE: C, AMS, fatigue, arrhythmias
CI: allergy, hypercalcemia, Hypervitaminosis D
1,25 vit D calcitriol
Ind: hypoCa in hypoparathyroidism/pseudohypoparathyroidism, secondary hyperparathyroidism (CKD)
MOA: binds and activates Vit.D-R in kidney, PT, intestine, bone (↓ PTH, stimulates Ca abs, promotes bone formation)
AE: related to hypercalcemia - abd pain, N/C, HA, AMS, arrhythmias, polydipsia
CI: allergy, hypercalcemia, hypervitaminosis D
Calcium carbonate
Ind: hypoCa prevention/tx, primary osteoporosis prevention
MOA: prevents or treats negative Ca balance
AE: HA, abd pain, C, acid rebound, flatulence, N/V
CI: hyperCa, hypercalciuria, hypophosphatemia, renal calculi, hx of V-fib
Calcium gluconate
MOA: prevents or treats negative Ca balance
AE: bradycardia, arrhythmias, VD, cutaneous calcification, hyperCa, hypoP
CI: hyperCa, hypercalciuria, hypophosphatemia, renal calculi, hx of V-fib
Magnesium Oxide
MOA: prevents or treats negative Mg balance
AE: D, GI irritation
CI: HyperMg, allergy
Hypothyroidism
First-line - levothyroxine
Combination T3/T4 therapies - dessicated thyroid; liotrix
Synthetic T3 - liothyronine
evaluate clinically for adrenal insufficiency/angina before start
Take on an empty stomach, w/ water
Peak response usually seen in ~4 weeks
BBW - use of TH replacement as obesity tx
Hypothyroidism adjustment criteria
Adjustment of medication based on TSH level
Elevated TSH - inadequate thyroid hormone replacement therapy
Verify how patient is taking medication!
Normal TSH - adequate thyroid hormone replacement therapy
May need high-normal TSH if pt has hx of CAD or a-fib
If still symptomatic → free T3/T4 levels to evaluate adequacy of tx
May consider T3 supplement or changing to combination T3/T4 (controversial)
Low/Suppressed TSH - excess thyroid hormone replacement therapy
Consider severe systemic illness or hypopituitarism
Meds - NSAIDs, opioids, CCBs, steroids
Suppressed TSH (0.03 mIU/L or less) - risk of a-fib, osteoporosis
When do you need to give the patient more thyroid hormone requirements
Increased thyroid hormone requirements
Meds - anticonvulsants, sertraline, bile acid-binding resins, PPIs
Increased estrogen - pregnancy, estrogen-containing medications
GI Disorders - celiac disease, IBD, lactose intolerance, gastritis; wt gain - over 10% body wt
When do you need to give the patient less thyroid medication
Decreased thyroid hormone requirements
Decreased estrogen - cessation of estrogenic meds, postpartum, post-oophorectomy
Increased androgen - testosterone therapy
wt loss - over 10% body weight
LT4 Levothyroxine
synthroid, Levoxyl, Levothroid
Ind: hypothyroidism, TSH suppression (CA/goiter)
Titrate up every 4-6wks; 30-60min before food
SE: similar to effects of hyperthyroidism
Angina, palpitations, tachy, arrhythmia, CHF, flushing, anxiety, fatigue, insomnia, irritability, pseudotumor cerebri
Menstrual irreg, wt loss, abd cramps, D/V, ↑ appetite
CI: hypersensitivity, thyrotoxicosis, acute MI, uncorrected adrenal insuff
Monitor: TSH Q4-6wks then Q6-12mo
LT3 Liothyronine
Cytomel, Triostat
Ind: Hypothyroidism, myxedema, goiter suppression
30-60 min before food or other medications
SE: Similar to effects of hyperthyroidism
Arrhythmia, tachycardia, hypotension or HTN, MI, CHF
Twitching, irritability, nervousness
Menstrual irreg, wt loss, abd cramps, D/V, ↑ appetite
CI: hypersensitivity; thyrotoxicosis; acute MI; uncorrected adrenal insuff
Monitoring: TSH Q4-6wks then Q6-12mo
Desiccated Thyroid
Armour Thyroid, Nature-Thyroid, Westhroid
Ind: Hypothyroidism (not rec)
titrate every 6 weeks to euthyroid status
30-60 min before food or other meds
SE: Similar to effects of hyperthyroidism
Angina, palpitations, tachy, arrhythmia, CHF, flushing, anxiety, fatigue, insomnia, irritability
Menstrual irreg, wt loss, abd cramps, D/V, increased appetite
CI: hypersensitivity, beef, or pork; thyrotoxicosis; acute MI; uncorrected adrenal insuff
Monitor: TSH Q4-6wks then Q6-12mo
Thyrotoxicosis
Definitive tx:
RAI - NOT safe in pregnancy
Methimazole can decrease efficacy; may worsen ophthalmopathy → give w/ steroids
Surgery - safe in pregnancy; thionamide drugs pre-op
Thionamide (thiourea) Drugs - inhib prod of thyroid hormone
Ind: mild, elderly, young adults, pts who cannot have more definitive tx, prepare for RAI or sx
No permanent damage to thyroid
SE: agranulocytosis, aplastic anemia, hepatotoxicity
Methimazole - pref in most pts
PTU (Propylthiouracil) - pref if 1st trimester or breastfeeding
Grave’s Disease
Grave’s Disease tx:
Beta blockers (propranolol, atenolol)
Iodine contrast agents (iopanoic acid, ipodate sodium)
Blocks T3→T4 conversion; ind: severe s/s - NOT in US
Tx subclinical thyrotoxicosis
Tx - observation if no s/s
Evaluate and Tx if s/s
Thyrotoxicosis - toxic solidtary nodule
Toxic solitary nodule - eval w/ FNA to r/o CA
s/s - BB + methimazole or PTU (suppress TSH)
Sx - if pt <40y/o or healthy older pt
Alt: RAI if not sx candidate
Thyrotoxicosis - Amiodarone induced
Amiodarone-induced:
s/s - BB + methimazole (adjunct iodinated contrast agent)
Refractory - sx
Thyrotoxicosis - toxic multinodular goiter
Toxic multinodular goiter:
s/s - BB + methimazole or PTU
Sx - definitive tx; thyroidectomy
Alt: RAI
Thyrotoxicosis- Thyroiditis
Thyroiditis:
Thinamides - ineffective; TH prod is low
s/s - BB; severe - iodinated contrast agents
NSAIDs or opioids for pain mgmt
Hashimoto disease
May observe if asympt and minimally enlarged or normal size thyroid
Hypothyroidism - levothyroxine
Large gland/goiter - levothyroxine suppressive tx
Subacute thyroiditis
High dose ASA/NSAIDs +/- corticosteroids (severe/refractory)
BB for acute s/s
Severe thyrotoxicosis - iodinated contrast agents
Suppurative Thyroiditis
Antibiotics
Surgical drainage of abscess
Thyrotoxicosis - Ridel IgG4 thyroiditis
Tamoxifen
+/- steroid therapy
Sx for decompression if needed
Sick Euthyroid Syndrome
Observe w/o adm of thyroid hormone unless pt has hx of pre-existing hypothyroidism or clinical s/s
Correcting underlying dz → returns labs to normal
Thyroid Nodules/Goiters
General follow up
Regular palpation and US Q6 mo initially, then yearly
AVOID excess iodine intake
LT4 suppression
Indicated for nodules > 2cm + normal or high TSH
Reduces emergence of new nodules
Risk: heart dz exacerbation, osteoporosis, hyperthyroidism
Thionamide drugs +/- BB: if s/s of thyrotoxicosis
Surgery – CA, hyperfxning nodules, toxic MNG
Ethanol injection – shrink benign tumor
RAI therapy –toxic thyroid adenomas, toxic MNG, Graves
Risks: hypothyroidism
Thyroid cancer - refer to flowchart made in class
Pasireotide
Pituitary ACTH tumor: pasireotide (Signifor) - inhib ACTH sec
parasite or passthetime
inhibit ACTH like a brain parasite that sucks out the ACTH
or inhibit
or, could inhibit ACTH by meditating, passing the time peacefull and controlling the mind’s stress
