USMLE Endocrine Flashcards
Acromegaly
Cancer
High risk of esophageal , gastric, colon cancer, Pt to under go colonoscopy on dx and q3-4 yrs.
Adrenal Incidentaloma
Hormone studies
- Pheochromocytoma
- Cushings syndrome
- primary aldosteronism
- Adrenocortical carcinoma
Imaging
Pheochromocytoma
- HTN, palpitation, HA, Diaphoresis, Tremor
- Epinephrins / metanephrines
Cushings
- Cortisol (am / pm), Dexamethasone suppres
Primary aldosteronism
- Rrenin/Aldostrone : 20 times
Imaging ( if > 4 Cm / housefield > 10, retension of contrast > 50% after 10 mins) :
- Consider FNA / surgery follow up
Amiodarone induced thyrotoxicosis
Type I
Type II
- discontinuing Amio wont help / stays in adipose tissue with half life of 100 days
- RAI upatake low in both
- Amiodarone has 6 mg Iodine in 200 mg tablet
Type I
- Increase synthesis of T4 and T3
- preexisting MNG or latent graves
- US Increased Vascularity
- Tx: Antithyroid medications (methimazole) Thryroidecdtomy for refractory cases
- Incrase MMI
Type II
- Release of preformed T4/T3
- US Decreased Vascularity
- Tx: Corticosteriods
- Decreased _C_orticosteriods _CD_
ATP III Guidlines
- CHD or CH risk equivalent (DM / Carotid, PAD, AAA) > 20%
- > 2 risk factors (10 yr risk
- 0-1 risk factors
Total Cholestrol - HDL
LDL goals / Non-HDL goals
- < 100 mg/dL
- < 130 < 160
- < 160 < 190
Causes of hyperprolactinemia
Physiologic
- Pregnancy / Breast feeding / Stress
Pathologic
- Pituitary adenoma / macroprolactinoma
- Hypothalamic dz with low dopamin
- Drugs: Antidepresants, antipsychotics, metoclopramid,
- Hypthyroidism
- Chest wall injury (herpes zoster)
- CKD
Causes of Low TSH and low T4
Central Hypothyroidism
- LOW TSH/T4/T3
- Pituitary hormonal Deficiencies
Subclinical Thyrotoxicosis
- Low TSH / T4 and high T3 (seen in pt taking t3)
- Radioactive iodine uptake and scan helpful
Euthyroid sick syndrome
- Sick pt / Normal to low TSH/T4/T3
Medications
- Dopamin, octerotide, steriods
Causes of secondary hTN
- Renal artery stenosis
- OSA
- CKD
- Pheochromocytoma
- Cushing syndrom
- Coarctation of aorta
- Primary Hyperaldosteronism
50% of patients with hyperaldosteronism have normal K levels
- Central hypothyroidism
- Subclinical thyrotoxicosis
- Euthyroid Sick syndrome
- low TSH FT4 and FT3
- Low TSH and FT4 with high FT3
- Low TSH / FT4/FT3
CKD and hyperprolactinemia
Usually increased by 3 folds and decreased in clearance by 30 %
Comparative steriod potencies
- Hydrocortisone (cortisol)
- Prednisone
- Prednisolone
- Methylprednisolone
- Dexamethasone
- Betamethasone
- Triamcinolone
- Beclometasone
- Fludrocortisone
Glucocorticoid potency / Mineralcorticoid potency / Durations
- Hydrocortisone 1 / 1 / 8 hrs
- Prednisone 3.5-5 / 0.8 / 16-36
- Prednisolone 4 / 0.8 / 16-36
- Methylprednisolone 5-7.5 / .5 / 18-40
- Dexamethasone 25-80 / 0 / 36-54
- Betamethasone 25-30 / 0 / 36-54
- Triamcinolone 5 / 0 / 12-36
- Beclometasone 8 buffs 4 X daily same as 14 mg oral prednisone once a day
- Fludrocortisone 15 / 200 / 24
Criteria for Parathyroidectomy in asymptomatic PHPT
Asymptomatic means
- no Fractures
- no Osteoprosis
- no kidney stones ect
- Serum **C**a > 1 mg/dL above normal
- Cr clearance < 60 ml/min
- Bone mineral density with T score < 2.5 at any site
- Age < 50
Cushing’s syndrome (test to stablish)
Flow chart after stablished.
Must have 2 out of 3
- 24 hr urinary cortisol
- Late night salvary cortisol
- Low dose dexamethasone suppression test
First Check ACTH
- If low Adrenal CT ( ACTH< 5)
- If high ACTH> 5 - MRI of pituitary
- **Pituitary < 6 mm **Inferior petrosal sinus sampling
- Pituitary > 6 mm Hight dose dexamethason suppression
DDP-4 inhibitors (Gliptons)
Sitagliptin (januvia), Saxagliptin, Linagliptin
Decrease blood blucose by increase the endogenous incretin hormone GLP1 and GIP.
Safe with CKD
Diabetes Neuropathy
- Topical capasiacin Cream
- Antidepressants (amitriptyline) (younger pt)
- Anticonvulsants(pregabalin, Valporic acid) (older)
- Alpha lipoic acid
Diagnose postexercise hyperglycemia.
Hypoinsulinemia causes increased hepatic glucose output and decreased peripheral glucose uptake, which results in a higher blood glucose level and, ultimately, a higher hemoglobin A1c value; prolonged exercise, which further stimulates hepatic glucose release, exacerbates this condition.
Diagnose thyroid lymphoma.
Thyroid lymphoma occurs most frequently in older patients with a history of Hashimoto thyroiditis and typically presents as an enlarging neck mass, often with local and systemic symptoms.
Diagnose thyroid storm
- Thyroid storm can be differentiated from other forms of thyrotoxicosis by the presence of temperature elevation, significant tachycardia, heart failure, abdominal discomfort, diarrhea, nausea, vomiting, and (sometimes) jaundice.
- Treatment typically consists of a combination of antithyroid drugs (propylthiouracil or methimazole), iodine solution, high-dose corticosteroids, β-blockers, and (rarely) lithium. Even with aggressive therapy and supportive measures, mortality rates are as high as 15% to 20%.
DM start with meds …
Metformin(M) + Lifestyle changes (LC)
LC + M + Sulfas if failed
LC + M + Lantus
Or LC + M + Pioglitazone or LC + M + Exenatide
LC + M + C + sulfas
Else
LC + M + Basal insulin
Endocrine causes of carpal tunner syndrome:
Acromegaly
DM
Hypothyroidism
ESS
Euthyroid Sick Syndrome
- Due to Decreased conversion of T4 to T3
- Decreased T4 production and clearance
- Altered T4 protien bining
- Suppresion of TSH
- Also meds like Steriods / dopamine will suppress TSH levels block T4 - > T3 conversion
- Long term T4 will become suppressed
Features of anabolic steriod abuse
- Acne and gynecomastia
- Increased muscle mass
- Psychiatric problems
- Erythropoiesis
- Hyperlipidemia
- Normal Libido and Erectile function
- Atrophic testes w low testrone and FSH/SH levels
Gestational DM
- fasting BG 105 compare to 75 is 4X likely to have complications
Need better control then avg person
NPH idealy
-
Metformin / glyburide not CI but not enough studies
- Category C
GLP 1 Receptor agonist (Exenatide)
- Weight loss
- Low hypoglycemia risk
Granulomatous disorders causing hypercalcemia
Non infectous
- Sarcoidosis
- Berylliosis
- Crohn’s
- Lymphomas
Infectious
- TB
- Leprosy
- Coccidioidomycosis
- Histo
- PCP
Non PCO Disorders causing hirsutism
Ovarian tumors - Often sever
- Elevated Androgen
Non classic CAH - Significant
- increase 17 hydroxyprogesterone
Cushings syndrome - Significant
- Overnight dexamethasone / 24 hr urinary cortisol / late evening salivary cortisol
Hypothyriodism - Mild
- Elevated TSH
Hyperprolactinemia - Mild
- Elevated prolactin
Drugs - Mild
- Anabolic steriods, valproic cid, Danazol, cyclosporin
Hungary bone syndrome
- Patients with hyperparathyroidism have increased bone formation and resorption with increase flow of calcium out of the bone. However when PTH adenoma removed the Ca flows in the the bone formation which will cause decrese calcium and phosphorus, magnesium levels.
- IV Calcium given when patient has Ca < 7.5 mg/dl or Tetany, respiratory distress
- Do not administer phosphorus unless levels < 1 mg/dl as it may worsen the hypocalcemia
Hypercalcemia with Eelvated to normal PTH
Which lab to order next
Urinary Calcium 24 hr collection
- > 100
- Primary and tertiary hyperparathyroidism
- < 100
- Familial hypercalcemic hypocalciuria
Hypercalcemia with Suppressed PTH
- Elevated PTHrP
- Elevated D3
- Elevated D2
- Normal labs
- Elevated PTHrP - Tumor has no feed back
- Elevated D3 - Sarcoid, lymphoma (CXR)
- Elevated D2 - Vit D toxicity
- Normal labs - Hyperthyroid / MM / Adrenal tumor / acromegaly / Immobilization
Hypercalcemia
Tx: IVF +
- Calcitonin
- Cinacalcet
- Prednisone
- Zoledronate
- Calcitonin for Ca > 14 in cancer patients
- Cinacalcet: Calcium mimetic drug - works on ca sensors on PTH cells to lower PTH (used in CKD and primary PTH)
- Prednisone: Sarcoidosis and lymphoma as they produce 1-hydroxylase with excess conversion of active Vit D
- Zolendronate is good in dz that cause excess bone resorption
Hyperglycemia and TAGs how to treat it
150-199
200-499
>500
150-199:
- Weight reduction / activity
200-499
- _Primary _target **LDL **(statin)
- _Secondary _target: **non HDL **(increase statin dose and add fibrates)
>500
- _Primary goal _is to prevent pancreatitis with fibrates/niacin
Hyperthyroidism
- B-Blocker
- Steriods
- Methamezole
- Radioactive iodine ablation
B-Blockers
- Symptom control / painless thyroiditis / preformed hormones
Steriods
- Type II amiodarone thryroiditis-CD Corticosteriors for Decreased vaslcular
Methimezole
- Graves
Radioactive iodine abliation
- Graves / toxi nodular goiter
Subclinical hypothyroidism / females
If TSH < 10
- and Anti TPO if so then must treat with levothroxine
- Else if patient is pregnent has a goiter, is symptomatic, ovulatory dysfunction, hypercholesterolemia must be treated.
Hypothyroidism and elevated transaminases
Muscle injury could increase transaminases - watup
Indications for MRI in patinets with central hypogonadism
-
Testostrone levels
- < 150 > 65 yrs old
- < 200 Age < 65
- Mass effect / HA or visual field defects
- Multiple pituitary hormone def
- Hyperprolactinemia
Indications for treating prolactinoma
Females
- Presence of classic symptoms / amenorrhea and glactorrhea
- Infertility without classic symptoms
- Osteoprosis and risk of bone loss
- Acne and hirsutism
Males
- Hypogonadism and gynecomastia
- Osteoprossis
Both sexes
- Enlarged adenoma
Interpret thyroid function studies in an older patient.
- Older patients generally should not be given levothyroxine solely for an elevated thyroid-stimulating hormone level.
- elevated serum TSH level in older patients is not associated with detrimental medical outcomes (such as depressive symptoms and impaired cognitive function) but, in fact, is associated with a lower mortality rate
LADA - Latent autoimmune diabetes of adulthood
- Age of onset > 35 < 50
- Acute onset of symptoms
- BMI < 25 kg/m2
- Personal or family history of autoimmune dz
- Check GAD
Levothyroxine drug intractions
Lower Levothyroxin absorption (increase dose)
- Bile acid binding agents / Iron / ca / PPI
Increase TBG concentration (increase dose)
- Estrogen, tamoxifen raloxifene / heroin, methadone
Decrease TBG concentration (decrease dose)
- Androgens, steriods, anabolic steriods
Increase Thryoid Hormone (decrease dose)
- Rifampicin, Phenytoin, Carbamazepine
Manage an asymptomatic incidental adrenal mass.
ncidentally discovered adrenal masses that are small, are associated with no clinical or biochemical features suggestive of excess hormonal secretion, and have no imaging features suggestive of possible malignancy should be followed with observation and repeat testing in 6 to 12 months.
Neither the size (
Manage hirsutism in polycystic ovary syndrome.
Initial treatment for hirsutism in women with polycystic ovary syndrome is an oral contraceptive.
Spironolactone can be very useful for the treatment of hyperandrogenism in PCOS but is added only if an oral contraceptive does not adequately improve symptoms.
Although early observational trials suggested that metformin may be effective in treating hirsutism in patients with PCOS, subsequent randomized clinical control trials have had mixed results
Dexamethasone For Tx congenital adrenal hyperplasia. This patient’s 17-hydroxyprogesterone must be measured
MEN
MEN 2A
MEN2B
MEN 1
- Pancreatic / Pitiutary /
- _Parathyroid _
MEN IIa
- **Parathyroid, **
- **Medullary Thyroid CA, pheo, **
MEN IIb
- Medullary Thyroid CA, peho,
- marfanoid body hapitus
NOTE
MEN II - Medullary Thyroid and PHEO
Methimazole is associated with an increased risk of fetal abnormalities
- Aplasia cutis and choanal atresia, when used in the first trimester. After fetal organogenesis is complete, methimazole should be used. Methimazole is the antithyroid agent of choice except in the first trimester of pregnancy
- Propylthiouracil is associated with a higher risk of severe hepatotoxicity than methimazole. Close monitoring of pregnant women treated with antithyroid agents is required, as is periodic fetal thyroid
PCOD
Improving hirsutism
- OCs to manage oligomenorrhea and hirsutism ( it increases sex hormone binding protien and results in decrease androgen levels also Lower LH so ovaries dont produce as much androgens)
- if hirsutism not decrease in 6 months will need to start spironolactone
- Metformin not approved for PCOD unless paitent has glucose intolerance
Pertusis Criteria (actually ID)
- cough > 2 weeks with one or more of following
- Paroxysms of cough, inpiratory whoop, posttussive vomiting
Pioglitazone (TZDs)
1-1.5%
- If can not tolerate Metformin** / **sulfas
- Weight gain, edema, CHF, bone fracture, Bladder cancer
- Low risk of hypoglycemia
- Can be used with renal insufficiency
Pituitary apoplexy
Endocrine emergency:
Treatment
- High dose Steriods
- CT of the Head / NSGY consultation
PTH / Vit D / Ca
axis
-
PTH release from parthyroid glands
- (inhibited by 1,25 OH-D and Ca)
- PTH** increase **Ca reabsorption from kidney and bone resorption - also helps increase 1,25 OH D conversion
- 1,25 Vit D increase GI ca** and **po4 absorption
Raloxifene vs tamoxifen
- Raloxifene is specifically approved for the treatment of osteoporosis
- Treat a patient with ductal carcinoma in situ with tamoxifen.
- For premenopausal women with hormone receptor-positive ductal carcinoma in situ or invasive breast cancer, the standard of care is tamoxifen for 5 years to reduce both the risk of recurrence and the development of a new primary tumor in the ipsilateral or contralateral breast.
PHPT
Bsiphosphonates vs Surgery ..
non surgical patients
Bisphosphonates
- Increases bone mineral density in pt with PHPT without decrease ca serum levels
- For pt who do not meet surgery criteria or wish not to have surgery
Primary Hyperparathyroidism without surgical indication
- Can be monitored with annual serum ca and cr with DEXA Q2Y (every 2 yrs because the in order to notice difference in scan need > 5% change in bone)
OSA and bicaronate levels
Hypercarbia will cause increase in Bicarb
Insulin
1.5-3.5%
- A1C > 8.5 Start basal
- IF A1C > 10 Start basal and prandial
- Weight gain and hypglycemia
Risk factors for Thyroid cancer:
- Hx of radiation exposure < 15 (Rx)
- Family history of thyroid cancer
- Other
- Elevated TSH
- Exterme ages < 20 or > 70
- Male sex
- Rapid growth
- Hard and fix nodules
- Elarged neck lymph node
Insulin
Short acting - onset of action / duration
- Regular
- Analogs (aspart/lispro)
- Long Acting
- NPH
- Glargine
- Detemir
- Regular / 2-3 / 8-10
- Analogs (aspart/lispro) 0.5-1 / 4-6
- Long Acting
- NPH 4-8 / 12-18
- Glargine None / 20-14
- Detemir None / 16-20
Risk of hypothalmic pituitary adrenal suppresion after steriod use
High risk : > 20 mg prednisone or equivalent for > 3 weeks / stigmata of Cushing’s syndrome
Intermediate risk : Prednisone 5-20 mg for > 3 weeks / smaller dose < 5 mg prednisone at QHS for a few weeks
Low risk: Prednisone any dose for < 3 weeks / < 5mg dialy
High risk
Stress dose likely to be needed during surgery / ACTH stimulation test to assess steriod requirement maybe needed
Intermediate
ACTH stimulation test to determine whether or not stress dose steriods are needed
Low risk
No testing or stress dose coverage required
Secondary amenorrhea evaluation (b hCG -ve)
- BMI
- Elevated TSH
- Elevated prolactin
- FSH
- Testostrone
BMI
- Low - Eating Disorder
- High - PCOS
Elevated TSH
- Treat hyperthyroidism
Elevated prolactin
- R/O drugs / hypothyroid / CKD
- MRI brain
FSH
- Low with low estrogen Hypothalmic Disorder
- High with low estrogen ovarian fialure
Testostrone
- Elevated > 200 Ovarian hyperandrogenism
- Elevated < 200 Adrenal or ovarian tumor(CT abd)
Sulfonylureas
1-2 %
Metformin failure
weight gain / hypoglycemia
Synthroid dosing based on situation
- Elderly
- Pregnancy
- Estrogen therapy / Oral contraceptives:
- CAD
- Coffee intake:
Elderly :
- Start at 50 increase by 25 every 3-6 weeks
Pregnancy:
- Increase by 30% check TSH Q4weeks
Estrogen therapy / Oral contraceptives:
- TSH Q12Weeks, may need to increase
CAD:
- Start 25 increase 25 q3-6weeks
Coffee intake:
- May lower absorption by 35%
Testostrone Def
How to dx.
How to dx:
- Two low Total testostrone / Usually measure 7-10 am
- Free levels only in Obese or advanced age
Once dx can do LH/FSH levels
- If low means secondary hypogonadism
- if High LH/FSH primary hypogonadism
Threshold size for FNA
- High risk hx and/or U/S features
- Solid hypoechoic nodule
- Solid isoechoic or hyperechoic nodule
- Mixed solid / cystic nodule
- Spongiform nodule
- Purely Cystic nodules
- High risk hx and/or U/S features > 0.5 cm
- Solid hypoechoic nodule >1.0 cm
- Solid isoechoic or hyperechoic nodule > 1-1.5 cm
- Mixed solid / cystic nodule > 1.5-2 cm
- Spongiform nodule > 2 cm
- Purely Cystic nodules not indicated
Thyroid nodule
- If high cancer risk factor or suspicious ultrasound finding -> FNA
- No Cancer risk factor then Measure TSH
- if TSH high or normal -> FNA
- Else I-123 scintigraphy
- if hyperfunctional treat hyperthyroidism
- Cold nodule needs FNA
Thyroiditis Common forms - RAIU Low
Cause / mechanism / pain / Tx / test
- Hashimotos -
- Subacute Lymphocytic -
- Subacute Granulomatous -
- **Hashimotos **- Autoimmune / goiter + hypothyroid / minimal pain / + AntiTPO / Normal ESR / Tx Levothyroxine
- **Subacute Lymphocytic **- Autoimmune / thyrotoxicosis with hypothyroidism / minimal pain / + AntiTPO / Normal ESR / Tx Bblker
- Subacute Granulomatous - Viral / thyroitosicosis with hypothyroidism / tender / - AntiTPO / Elevated ESR / Tx: BBLK + NSAIDs + Steriod
Thyrotoxicosis
RAIU uptake
- If no uptake means there is destruction of tissue and thyroid gets released
- If patient pregnent can use U/S or Thryotropin receptor antibodies
High uptake
- Graves
- Toxic multinodular goiter (TMNG)
- Toxic nodule
Low uptake
- Painless or subacute thyroiditis
- Amiodarone induced thyroiditis
- Surreptitious thyroid hormmone
- Iatrogenic
- Struma ovarii
- Iodine induced
Treat a macroprolactinoma.
•In a patient with a macroprolactinoma, administration of a dopamine agonist, such as cabergoline, is indicated as the initial treatment.
Treatment of Osteoprosis
- Postmenopausal women
- Not to use with Patient Creatnine clearance < 35
- Hypocalcemia in CKD pateints
- Failed Bisphosphonates
- Modestly reduces risk of Fx / not first line
- Post menopausal women intolerant to bisphosphonates and at Increase risk of Breast cancer
- 1200 mg Ca and 800 IU Vit D
- Oral or IV bisphosphonates (alendronate, risedronate and zoledronic acid)
- Dnosumab (risk of skin infection)
- Teriparatide (Recombinant human parathyroid hormone) Have had Fx or reduced BMD (do not give with renal insufficiency / monitor Ca, uric acid and RFP)
- Nasal Calcitonin
- Selective estrogen receptor modulators (Raloxifen)
TSH Low / FT4 high
What is next
Primary hperthyroidism
RAIU scan
High
- Diffused pattern Graves
-
Nodular uptake
- Toxic adenoma
- Mutinodular goiter
Low
- Measure Tg: Decreased :
- Exogenour hormone
- Measure TG:Elevated:
- Thyroiditis
- Iiodinde esposure
- extraglanular production
TSH Low / FT4 Normal
What is next:
measure FT3
Low :
- Subclinical hyperthyroidism
- Early pregnency
- Nonthyroid illness
High
T3 Toxicosis (R/O graves RAIU scan)
TSH Normal / High FT4 High
What is next
MRI pituitary (2nd hyperthyroidism)
Turner’s syndrome
Two elevated FSH valuses
- In a woman with primary ovarian insufficiency, Turner syndrome must be excluded as the cause by obtaining the patient’s karyotype.
- Turner syndrome is associated with several cardiovascular malformations, including aortic valve disease, aortic dilation, and aortic coarctation; renal malformations, most commonly horseshoe kidney; and autoimmune disorders, such as thyroid disease.
What to do after Medullary thyroid dx
- Evaluate for Metastic Dz
- Calcitonin levels corolate with extend of Dz and local lymph nodes / if Calcitonin > 400 need CT of abd/pelv
- Coexisting tumors
- RET mutation identification
Diagnosis of Diabetes
• A1c>6.5%
or
• FPG>126
or
• 2-hr glucose > 200 on 75 gm OGTT
or
• Random glucose > 200** and **symptoms
Hypoglycemia
A. Insulinoma
B. Surreptitious use of insulin
C. Surreptitious use of Oral meds
Tests
- Drug levels
- if sugar is low and insulin is low its most likely normal
- C-peptide levels / insulin levels after fasting 72 hrs once drops > 50 need to do levels
Hyperosmolar Nonketotic State
- Glucose > 600
- pH>7.3, CO2>15
- Minimal ketonemia/ketonuria
- Correct Na for hyperglycemia (for each 100 mg/dL glucose > 100 add 1.6 mg to serum sodium)
- If K is < 3.3, hold insulin and give K
DKA
IVF
K Keep > 3.3
IV insulin once K > 3.3
Once glucose 200 can reduce IV insulin 50% and change to d5W1/2
Adjunct KCL / Vasopressors / Bicarb / phosphate (no definite benefit found)
Laboratory Diagnosis of Hypocalcemia
• Hypoparathyroidism (autoimmune)
low Ca, high PO4, low PTH
• Hypomagnesemia (alcohol)
low Ca, high P04, low PTH
Paget Disease
- Usually asymptomatic
- high Bone turnover -> structurally weak bone
- very high Alkaline phosphatase 100’s
- Treat if pain is severe, pagetic lesions in_ weight-bearing_ areas, or _lytic lesions_
So do not treat if not symptomatic / first step to go to NSAIDs then Bisphosphonates/Calcitonin
Familial Hypocalciuric Hypercalcemia
- Rare
- Lower Sensitivity of Ca-sensing receptor and higher Ca levels are needed to suppress PTH
- Familial /Autosomal Dominnant
- 24-hr urine calcium < 100
Will have a very low urine calcium | Ca / ratio < 0.01
Treatment not recommended
tuberculosis-induced hypercalcemia.
excessive production of 1,25-dihydroxyvitamin D by the tuberculous granulomas. The granulomas of tuberculosis (and other granulomatous diseases, such as sarcoidosis, Crohn disease, and leprosy) are composed of macrophages that possess the 1α-hydroxylase enzyme needed to convert 25-hydroxyvitamin D to its active form, 1,25-dihydroxyvitamin D.
Low PTH, PO4 high
with Malignancy Hypercalcemia High PTH /prPTH and low PO4
Woman with low bone mass. How to treat?
The NOF recommends antiosteoporotic therapy for persons whose risk of major osteoporotic fracture over the next 10 years is 20% or greater or whose risk of hip fracture over the next 10 years is 3% or greater.
Denosumab, osteoclast formation, reserved for patients with a high risk of fracture, including those with multiple risk factors for fracture or a history of previous fractures.
Estrogen is contradicted in this patients with dx of breast cancer.
Raloxifene, a selective estrogen receptor modulator, approved for osteoporosis prevention by the FDA. However, significant hot flushes.
Teriparatide (recombinant human parathyroid hormone) is also contraindicated in persons with malignancy involving bone, Paget disease, or existing hyperparathyroidism or hypercalcemia.
Bispho alendronate is the most appropriate drug to use for osteoporosis prevention in patients with osteopenia and a history of radiation therapy
