Week 3 endo Flashcards
hypercalcemia: possible etiologies
RHINOS
R: renal insufficiency
H: hyperparathyroidism
I: immobilization and iatrogenic
N: neoplasms
O: other endocrinopathies (MEN 1 and 2)
S: sarcoidosis
symptoms of hyperparathyroidism
groans stones thrones bones psychiatric overtones
“Groans” - constipation and muscle weakness from decreased contractility
“Stones” - calcium based kidney/gallbladder stones
“Thrones” - (refers to a toilet) polyuria due to impaired sodium, water absorption
“Bones” - pain from chronic demineralization
“Psychiatric Overtones” - depressed mood, confusion
secondary hyperthyroidism
parathyroid gland is normal/abnormal usually caused by \_\_\_\_\_\_\_ \_\_\_\_ calcium \_\_\_\_ phosphate \_\_\_\_ vit D
parathyroid normal chronic kidney disease low calcium high phosphate low vit D
In secondary hyperparathyroidism the parathyroid gland is normal, but chronic hypocalcemia causes excess PTH to be released to try to correct the low calcium levels
what kind of foods are high in purine?
what food increases purine production?
red meat
shellfish
anchovies
organ meat
high fructose corn syrup INCREASES purine production
ALLOPURINOL
drug class?
MOA?
indication?
xanthine oxidase inhibitor
XO is enzyme that breaks down purine –> uric acid
LOWERS uric acid level
used in chronic gout to prevent future attacks
(tophi, >3 attacks/year, kidney stones, hyperuricemia)
-do not stop taking during/after flare
gout risk factors?
which meds?
Positive Family History Older Age Male Overweight CKD, Hypothyroidism, HTN, CV disease Post-surgery DEHYDRATION Medications (thiazide diuretics, low dose ASA) Alcohol (BEER) chemo, radiation
COLCHICINE
MOA?
side effects?
binds to neutrophils to disrupt function
neutrophils cannot travel to site of injury to cause inflammation
- nausea
- abdominal pain
- diarrhea
what is a common complication of chronic gout?
tophi
**destructive and deforming joint disease
nephrolithiasis (kidney stones) and chronic urate nephropathy
DDX gout
Septic arthritis, trauma
pseudogout (CPPD), cellulitis, rheumatoid arthritis, dactylitis, osteomyelitis
Gout
diagnostic test
JOINT ASPIRATION
monosodium urate crystals and WBC
labwork:
CBC, Cr, urate, CRP, ALT, glucose, RF, ANA
*do urate >2 weeks after gout attack
*urate levels often normal during acute attack, not helpful for diagnosis
urate level >6.8 is supportive but not diagnostic or required for diagnosis
Gout lifestyle counselling
weight loss ETOH decrease screen for HTN and DM AVOID ASA stay well hydrated
colchicine
dosing?
contraindications?
0.6 mg BID - start within first 36 hours, stop when symptoms resolve for 2-3 days
contraindicated if severe renal/hepatic impairment
eGFR <30
treatment options for acute gout?
CNS
-colchicine 0.6 mg BID until attack subsides
-NSAIDS
naproxen 250-500 mg BID
-steroids (po or intraarticular)
prednisone 30 mg po OD x 5 days
*steroids safer in elderly than NSAIDS or colchicine
indications for urate lower therapy?
target serum urate?
- 2-3 acute attacks in 1-2 years
- Radiographic evidence of joint damage
- tophi
- CKD stage 2 or worse
- urate renal stones
URATE <360
<300 if tophi
allopurinol
caution?
most common drug interaction?
RASH, RASH, RASH
fever, decreased platelets, elevated liver enzyme (must stop ASAP if allopurinol rash)
HLA-B58:01 testing for asian pts
azathioprine
also warfarin, thiazide
food and drug precipitants of gout?
Drugs are FACT
Foods are SALT
Furosemide
ASA (low)
Cyclosporine
Thiazide
Seafood
Alcohol
Liver and kidney
Turkey
pseudogout is caused by precipitation of what type of crystals?
calcium pyrophosphate dihydrate
consequence of pseudogout?
acute inflammatory arthritis
inflammatory and degenerative chronic arthropathies
radiographic cartilage calcification
risk factors for pseudogout
- age!
- hemochromatosis
- hyperparathyroidism
- gout
- hypomagnesemia
- joint trauma
- genetics
acute CPPD arthritis
triggers?
trauma
surgery
(esp parathyroidectomy)
severe medical illness
acute CPPD pseudogout arthritis
signs and symptoms?
location?
-1 or several joints
intense pain, redness, warm, swelling (like acute gout)
may also have inflammation of adjacent joints (cluster attacks)
tends to be larger joints
KNEE affected in >50% acute attacks
-wrist, shoulders, elbows, ankles, feet
chronic CPPD arthritis
AKA
signs and symptoms?
AK pseudorheumatoid arthritis
morning stiffness
fatigue
synovial thickening
localized edema, and restricted joint motion
often symmetric, multiple peripheral joints of upper and lower extremities
diagnosis of pseudogout?
synovial fluid analysis:
CPPD crystals
imaging:
chondrocalcinosis (cartilage calcification)
how is hyperuricemia defined?
serum UA >404-416 mmol/L
concentration >420 mmol abnormal
CV symptoms in hypothyroidism
hyperthyroidism
HYPO
- bradycardia
- isolated diastolic HTN
HYPER
- palpitations, tachy
- afib
- isolated systolic HTN
thermoregulation in hypothyroidism
hyperthyroidism
HYPO
- decreased sweating
- cold intolerance
HYPER
- increased sweating
- heat intolerance
menstrual bleeding changes in hypothyroidism
hyperthyroidism
HYPO
-menorrhagia
HYPER
- amenorrhea
- oligomenorrhea
risk factors for thyroid dysfunction
Risk factors:
- men: age ≥ 60 years
- women: age ≥ 50 years
- personal history or strong family history of thyroid disease
- diagnosis of other autoimmune diseases
past history of neck irradiation
- previous thyroidectomy or radioactive iodine ablation
- drug therapies such as lithium and amiodarone
- dietary factors (iodine excess and iodine deficiency in patients from developing countries)
- certain chromosomal or genetic disorders (e.g., Turner syndrome, Down syndrome and mitochondrial disease).
HYPOTHYROIDISM
TSH will be high/low?
T4 will be high/low?
when to recheck TSH?
high TSH
low T4
recheck 6 weeks after changing dose/starting med
subclinical HYPOthyroidism
TSH?
T4?
when to treat?
high TSH (<10) normal T4
treat if:Treat:
TSH >10 OR
= 10 with hypothyroid symptoms, ↑TPO antibodies, evidence of CVD/HF/risk of CVD or HF, or preggers
Treatment of subclinical hypothyroidism can shorten survival rates for older adults
subclinical HYPERthyroid
TSH?
T4?
when to screen?
when to treat?
TSH <0.1
normal T3
SCREEN if afib or osteoporosis
*increase risk of bone loss
treat if TSH <0.1
what medications can affect thyroid function?
lithium
amiodarone
hyperthyroidism
TSH will be high/low?
T4 will be high/low?
TSH low
T4 high
how often to check TSH?
6 weeks after dose change
once stable annual
if on lithium/amiodarone:
check q3-6 months
TRH (thyrotropin releasing hormone) is created in _____ and acts on _____ to stimulate release of _____
TRH
- created in hypothalamus
- acts on anterior pituitary
- release of TSH
in normal functioning, TSH stimulates thyroid to make 90% T4 and 10% T3
which one is more active?
99% of thyroid hormones is bound to_____?
T3 +++active
T3 is active hormone
T4 is pro hormone
99% bound to plasma proteins (thyroxine-binding globulins
what is the starting dose of levothyroxine?
if CVD hx?
generally 50 mcg dose
CVD: 12.5-25 mcg
what is the target TSH for age 60-70?
>75?
TARGET TSH
3-4 age 60-70
4-6 age >75
overtreating hypothyroidism can lead to what 2 sequelae?
afib bone loss (postmenopausa women)
patient teaching for hypothyroidism?
take med on empty stomach (1 hour before eating)
avoid taking with calcium
recheck labs in 6 weeks
