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Endocrine Flashcards

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1
Q

Thyroid cancer risk is increased by

A
  • history of radiation therapy during childhood for Wilm’s tumor, lymphoma, neuroblastoma
  • low-iodine diet
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2
Q

Hyperprolactinemia can be a sign of

A

-pituitary adenoma

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3
Q

Hyperprolactinemia presentation

A
  • slow onset
  • amenorrhea
  • galactorrhea in both males and females
  • serum prolactin elevated
  • if large tumor, c/o HA and vision changes
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4
Q

Prolactin purpose

A

-stimulate breast milk production after childbirth

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5
Q

Hormones from anterior pituitary

A 
FSH
LH
TSH
GH
ACTH
MSH
Prolactin
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6
Q

Hypothalamus stimulates what

A

anterior pituitary

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7
Q

Posterior pituitary secretes

A 
antidiuretic hormone (vasopressin)
oxytocin
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8
Q

Thyroid gland uses what to produce T3 and T4

A

iodine

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9
Q

Parathyroid gland is responsible for

A
  • PTH

- for calcium balance from bones, kidneys, and GI

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10
Q

Pineal gland produces

A

melatonin

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11
Q

Primary hyperthyroidism (Thyrotoxicosis) findings

A

-very low TSH with elevated free T4 and T3

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12
Q

Most common cause of primary hyperthyroidism in US

A

Grave’s disease

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13
Q

Grave’s disease presentation

A
  • middle aged women
  • rapid weight loss
  • anxiety
  • insomnia
  • Cardiac: palpitations, HTN, afib, PAC
  • warm and moist skin, diaphoretic
  • opthalmopathy and lid lag
  • diarrhea
  • amenorrhea
  • heat intolerance
  • goiter
  • pretibial myxedema: thickened skin over ankles, orange-peel look
  • brisk DTR
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14
Q

Grave’s disease labs

A
  • Low TSH
  • elevated free T3, T4
  • Positive thyrotropin receptor antibodies (TSI)
  • Thyroid peroxidase antibody (TPO): positive with graves and hashimoto’s
  • palpable thyroid
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15
Q

Grave’s disease treatment

A
  • Thyroid ultrasound

- refer to endocrinologist

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16
Q

Grave’s disease medications

A

PTU: shrink thyroid, decrease hormone production
Methimazole: same

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17
Q

Grave’s disease medication side effects

A
  • skin rash
  • aplastic anemia
  • thrombocytopenia
  • hepatic necrosis
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18
Q

Medication to manage symptoms of hyperstimulation in Grave’s

A

beta blockers

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19
Q

Thyroid storm

A

need hospitalization

-look for decreased LOC, fever, abdominal pain

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20
Q

Diagnostic test for thyroid cancer

A

fine-needle biopsy

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21
Q

Monitoring response to treatment of thyroid disease

A
  • recheck TSH every 6-8 weeks
  • TSH goal is less than 5
  • when stable, recheck every 6-12 months
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22
Q

Primary hypothyroidism findings

A
  • high TSH with low free T4

- common causes: Hashimoto’s thyroiditis, postpartum thyroiditis, thyroid ablation with radioactive iodine

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23
Q

Most common cause of hypothyroidism in US

A

Hashimoto’s

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24
Q

Hashimoto’s patho

A
  • chronic autoimmune disorder of thyroid gland

- body produces destructive antibodies (TPO) against thyroid gland

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25
Hashimoto's presentation
- overweight - fatigue - weight gain - cold intolerance - constipation - menstrual abnormalities - alopecia - serum cholesterol elevated - history of autoimmune disorders
26
Myxedema
- severe hypothyroidism - endocrine emergency - cognitive symptoms
27
Hashimoto's labs
- TSH, if elevated, order again with free T4 | - Order TPO to confirm Hashimoto's thyroiditis
28
Gold standard for diagnosing Hashimoto
TPO
29
Subclinical hypothyroidism
- TSH >5 but serum free T4 WNL - asymptomatic to mild symptoms - recheck again in 6 months
30
Hypothyroidism treatment
- Levothyroxine start 25-50 mcg/day - start with lowest dose for elderly with CVD history (12.5) - Increase every few weeks until TSH normal - recheck every 6-8 weeks until normal, then check every 12 months when stable
31
Radioactive treatment for hyperthyroidism results in
hypothyroidism for life
32
Levothyroxine is synthetic ___
T4
33
Which thyroid hormone is more active
T3
34
Subclinical hypothyroidism with TSH >10
treat to prevent conversion to primary hypothyroidism
35
Subclinical hypothyroidism with TSH 4.5-10
- treatment not recommended | - recheck in 6-12 months unless they are symptomatic
36
Major risks of prescribing levothyroxine
- accelerated bone loss | - afib
37
Suggested Synthroid starting dose for young (<50) patients
1.6 mcg/kg/day
38
Suggested Synthroid starting dose for middle (50-60) patients
50 mcg
39
Suggested Synthroid starting dose for older or with CVD, or multiple comorbidities
25 mcg
40
T1DM patho
- destruction of B-cell sin islets of Langerhans - abrupt cessation of insulin production - ketone buildup--> DKA and coma
41
Ketone
-byproduct of fat breakdown
42
T2DM patho
- progressive decreased secretion of insulin resulting in chronic state of hyperglycemia and hyperinsulinemia - genetic component
43
Other names for metabolic syndrome
- insulin-resistance syndrome | - syndrome X
44
Metabolic syndrome increases risk for
CVD | T2DM
45
Prediabetes labs
- A1C: 5.7-6.4 - Fasting glucose: 100-125 - 2 OGTT: 140-199
46
Diagnostic criteria for DM
- A1C: >6.5 - FPG: >126 - hyperglycemia symptoms: polyuria, polydipsia, polyphagia + random glucose >200 - 2 hour OGTT >200
47
Normal serum blood glucose
- FPG: 70-100 - Peak postprandial glucose: <180 - A1C: <6 - Elderly may have A1C <8 if tolerable
48
Newly diagnosed diabetic labs
- A1C every 3 months until normal - A1C every 6 months once stabilized - lipid panel once a year - random urine for microalbuminuria once a year - CMP, TSH, LFT's
49
LDL goal for DM
<100
50
A1C goal for DM
<7
51
BP goal for DM
<140/80
52
Preprandial plasma glucose goal
70-130
53
DM what to check every visit
- BP, feet, weight, BMI, blood sugar - vibratory sense - light and deep touch - pedal pulses, reflexes
54
DM preventative care
- >50: Shingrix, 0, 2-6 months - flu shot annually - pneumococcal vaccine - ASA 81 mg if risk for MI, stroke (not rec in <30) - Yearly dilated exam - T2DM: eye exam at diagnosis - T1DM: first exam 5 years after diagnosis - podiatry: once to twice a year - BP goal: 130/80 - Dental health
55
Level 1 hypoglycemia
FBS < 70
56
Level 2 hypoglycemia
FBS < 54
57
What medication can blunt hypoglycemic response
beta blockers
58
A1C goal for T1Dm and most pregnant patients
<6
59
A1C goal for older adults with T2DM comorbids
<8-8.5
60
A1C goal for T2DM and healthy older adult
<7.5
61
A1C goal for T2DM for most adults
<7
62
Screening for T2DM
- annual for BMI> 25 and one or more risk factors for DM | - entire population >45 every 3 years if screening is normal
63
Hypoglycemia treatment
- glucose 15-20 g for conscious patients - orange juice, soft drink, candy - recheck in 15 minutes - glucagon for severe hypoglycemia (<54)
64
Exercising and DM
- may need to decrease medication before | - increased risk of hypoglycemia if they do not compensate
65
Dawn phenomenon
- normal physiological event - FBG elevation between 4-8 am - normal people have insulin to combat this
66
Somogyi effect
- aka rebound hyperglycemia - severe nocturnal hypoglycemia stimulates counterregulatory hormones (glucagon) from liver - results in high fasting blood glucose by 7am - due to overtreatment with evening and or bedtime insulin - more common with T1DM
67
How to diagnose Somogyi effect
-check blood glucose early in morning (3am) for 1-2 weeks
68
Somogyi effect treatment
- eat snack before HS | - or remove dinnertime NPH or lower dose
69
Diabetic retinopathy findings
- neovascularization (new growth of fragile arterioles) - microaneurysms (dot and blot hemorrhages d/t neovascularization) - cotton-wool spots or soft exudates (nerve fiber layer infarcts) - hard exudates
70
T/F Patients with diabetic neuropathy should avoid excessive running or walking
True: avoid risk of foot injury
71
Charcot's foot and ankle
- aka neuropathic arthropathy - deformity of foot caused by joint and bone dislocation and fractures due to neuropathy - midfoot arch collapse (rocker bottom foot)
72
First line medication for T2DM
Metformin (glucophage)
73
Metformin (glucophage) mechanism
- biguanide - decrease gluconeogenesis - decrease peripheral insulin resistance - rare hypoglycemia
74
Metformin side effects
-diarrhea | nausea
75
Metformin contraindications
- renal disease - hepatic disease acidosis - alcoholics - hypoxia
76
Metformin labs
- renal function | - LFTs
77
Metformin has increased risk for
- lactic acidosis | - occurs with hypoxia, hypoperfusion, renal insufficiency
78
Metformin and IV contrast dye
-hold on day of procedure and 48 hours after
79
Sulfonylurea mechanism
-stimulate beta cells of pancreas to secrete more insulin
80
Sulfonylurea examples
glipizide Glyburide Glimepiride
81
Sulfonylurea adverse effects
- increased risk of CV mortality - hypoglycemia - increased risk of photosensitivity - blood dyscrasias - avoid if impaired hepatic or renal function (monitor LFTs, creatinine, UA) - Causes weight gain
82
Thiazolidinediones examples
-Pioglitazone (Actos)
83
TZD mechanism
-enhance insulin sensitivity in muscles and reduce hepatic glucagon production
84
TZD can be combined with
-metformin -sulfonylurea -GLP-1 -SGLT2 -DPP-4 -insulins ...so any diabetic med
85
TZD contraindications
- BBW: NYHA class 3 and 4, symptomatic heart failure - water retention and edema ' - avoid with bladder cancer or history - active liver disease - Type 1 DM - pregnancy
86
Bile-acid sequestrant example
-Cholestyramine
87
Bile-acid sequestrant mechanism
reduce hepatic glucose production and reduce intestinal absorption of glucose -take with meals, lower LDL
88
Meglitinide (Glinides) examples
- Repaglinide (Prandin) | - Nateglinide (Starlix)
89
Meglitinide mechanism
- stimulate pancreatic secretion of insulin | - For T2DM with postprandial hyperglycemia
90
Meglitinide side effects
- weight neutral - may cause hypoglycemia - take before meals or 30 minutes after - Hold if skipping a meal - bloating, abdominal cramps, diarrhea, farting
91
Rapid acting insulins
- Lispro - Aspart - Glulisine
92
Basal insulins
- Glargine (lantus) | - Detemir (Levemir)
93
alpha glucosidase inhibitors mechanism
Acarbose (Precose) - slow intestinal carb digestion and absorption - no hypoglycemia - modest effect on A1C - GI s/e: farting, diarrhea
94
Incretin mimetics or glucagonlike peptide mimetics examples
- Exenatide (Byetta) | - Liraglutide (Victoza) injections
95
GLP-1 mechanism
-stimulate GLP-1 -increase in insulin production and inhibit postprandial glucagon release increase satiety
96
GLP-1 may cause
- weight loss - appetite suppression - NO hypoglycemia - Pancreatitis - medullary thyroid tumors
97
GLP-1 contraindication
-personal or fam hx of medullary thyroid carcinoma, multiple endocrine neoplasia syndrome type 2
98
SGLT2 inhibitor examples
- Canagliflozin (Invokana) - Dapagliflozin (Farxiga) - Empagliflozin (Jardiance)
99
SGLT2 inhibitor mechanism
-blocks glucose reabsorption by kidney and increases glucosuria
100
SGLT2 is effective for
T2DM in any stage | -no hypoglycemia
101
SGLT2 FDA warning
- may lead to DKA | - weight loss, hypotension
102
SGLT2 renal s/sx
- polyuria - increased creatinine - increase in UTIs - PN
103
SGLT2 increased risk for
leg and foot amputations
104
DPP-4 inhibitor examples
- Sitagliptin (Januvia) - Saxagliptin (Onglyza) - Linagliptin (Tradjenta)
105
DPP-4 inhibitor mechanism
- inhibit DPP-4 activity - increase active incretin concentrations - increase insulin secretion - decrease glucagon - no hypoglycemia
106
DPP-4 inhibitor FDA warning
may cause joint pain that can be severe and disability - occur on day 1 or years later - angioedema - urticaria - acute pancreatitis
107
T/F Incretin mimetics and Incretin enhancers can be combined
False
108
Treatment for mild A1C elevation
-try lifestyle modifications for 3-6 months
109
Metformin starting dose
500 mg daily | max 2000 mg
110
If patient on max metformin and A1C not within range, then what
add sulfonylurea
111
Other choices for adding onto metformin
- any other medication - DPP-4 inhibitor - incretin mimetics - TZD
112
Insulin should not be combined with what
meglitinides | -severe hypoglycemia
113
Which diabetic meds can cause hypoglycemia
- sulfonylureas - meglitinides - rarely metformin
114
If A1C still elevated with metformin and sulfonylurea..
consider adding basal insulin
115
Causes weight loss
- metformin - incretin mimetic - GLT-2 inhibitors
116
Causes weight gain
- insulins - sulfonylureas - TZDs
117
Weight neutral
- meglitinides - bile-acid sequestrants - alpha-glucosidase inhibitors
118
Primary prevention for patients at high risk for T2DM
- encourage weight loss - regular physical activity - increase fiber
119
Metformin dosage increments
- 500mg once daily - 500 mg BID - 1000 mg BID
120
Initial A1C 9, plan
-start basal insulin
121
Diabetics are at risk for which eye problems
- cataracts | - glaucoma
122
With new onset-afib, what endocrine complication should be checked
TSH
123
Insulin sensitivity and labs
-Elevated TG with low HDL
124
What other medications should be started with diabetics
- Statin | - ACEI
125
What second agent should be considered in a patient with DM and ASCVD
- SGLT2-I - empagliflozin (Jardiance) - or Liraglutide (Victoza)
126
Dose to start basal insulin
0.1-0.2 units/kg or 10 units daily adjust 2-4 units once-twice weekly to reach FBG goal if hypoglycemia, reduce by 4 units
127
Postprandial glucose goal
<180
128
Addison's disease
- adrenal insufficiency - deficiency of cortisol and aldosterone - aldosterone: sodium and K balance - cortisol: maintain BP, cardiac function, blood sugars
129
Addison's disease presentation
- dysphagia - fatigue - weight loss - hypotension - abdominal pain - amenorrhea - NV - thin, brittle nail - hyperpigmentation
130
Addison's disease diagnosis
- measure AM serum cortisol level - low cortisol level with normal to high K and low to normal Na - ACTH stimulation test: measure cortisol level before and after injection - CT
131
Addison's disease treatment
- Hydrocortisone (Cortef), prednisone, or methylprednisolone - Fludrocortisone to replace aldosterone - increase salt intake
132
Addisonian crisis treatment
- ED | - IV corticosteroids, saline, dextrose
133
Cushing syndrome
-excess cortisol from adrenal glands
134
Cushing syndrome presentation
- red cheeks - Buffalo hump - abdominal stretch marks - easy brusing - pendulous abdomen - thin arms and legs - thin skin
135
Cushing syndrome diagnosis
- cortisol levels | - CT MRI
136
Cushing syndrome treatment
- reduce corticosteroid use - surgery if due to tumor - Ketoconazole, Mifepristone (if with T2DM) - i guess refer to endocrinology
137
Which diabetic med should be used with caution in patient with severe sulfa allergy
-Glyburide
138
T/F hyperglycemia can occur as a result of aerobic exercise
False
139
Which diabetic medication is helpful for minimizing postprandial hyperglycemia
meglitinide
140
T/F Insulin resistance can contribute to prothrombotic and proatherogenic state
true
141
Prolonged metformin usage increases risk for
Vitamin B12 deficiency
142
GLP-1 agonists increases risk for
pancreatitis
143
At minimum, what interval should TSH be reassessed after Synthroid dosage adjustment?
6-8 weeks
144
Hypercalcemia with suppressed PTH should raise concern for what
malignancy
145
How to distinguish between T1DM and T2DM
T1DM has HLA-DR3 or HLA-DR4
146
Normal free T4
4.6-11.2 mcg/dL
147
Which diabetic medication is contraindicated with history of medullary thyroid carcinoma?
GLP-1 agonists
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