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Endocrine Flashcards

1
Q

Danger Signals

(5)

A

HYPOGLYCEMIA

TYPE 1 DIABETES MELLITUS

THYROID CANCER

PHEOCROMOCYTOMA

HYPERPROLACTINEMIA

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2
Q

Hypoglycemia

Hypoglycemia refers to blood glucose that is

Patient complains of ____ness, hand _____, and anxiety and feels like p_____ out. Difficulty concentrating. More common in people with type __ diabetes mellitus (DM; only 5%–10% of DM is type 1, average of two episodes per week). If severe hypoglycemia is uncorrected, it will progress to ___.

A

Hypoglycemia refers to blood glucose that is <50 mg/dL.

Patient complains of weakness, hand tremors, and anxiety and feels like passing out. Difficulty concentrating. More common in people with type 1 diabetes mellitus (DM; only 5%–10% of DM is type 1, average of two episodes per week). If severe hypoglycemia is uncorrected, it will progress to coma.

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3
Q

Hypoglycemia

Nondiabetic hypoglycemia is rare and is either reactive (diet related) or fasting (disease related).

For diabetic individuals, the American Diabetes Association (ADA) defines

  1. Level 1 hypoglycemia (glucose alert) as fasting blood sugar (FBS) of ≤___ mg/dL.
  2. Level 2 hypoglycemia is blood glucose of ≤___ mg/dL. A blood glucose of this level is sufficiently low to indicate serious, clinically important hypoglycemia.
A

Nondiabetic hypoglycemia is rare and is either reactive (diet related) or fasting (disease related).

For diabetic individuals, the American Diabetes Association (ADA) defines

  1. Level 1 hypoglycemia (glucose alert) as fasting blood sugar (FBS) of ≤70 mg/dL.
  2. Level 2 hypoglycemia is blood glucose of ≤54 mg/dL. A blood glucose of this level is sufficiently low to indicate serious, clinically important hypoglycemia.
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4
Q

Type 1 Diabetes Mellitus

School-age child with recent onset of persistent thirst (______) with frequent urination (_____) and weight ____. Feeling of hunger even though eating an increased amount of food; weight loss. May be accompanied by _____ vision (osmotic effect on the lens). Breath has a “____” odor. Large number of _____in urine.

Children may present with diabetic _______ (DKA) and neurologic symptoms, such as drowsiness and leth____, which can progress to ____. May report a recent viral-like illness before the onset of symptoms. Diagnosis peaks from ages __ to __ years and again from ages __ to __ years.

A

School-age child with recent onset of persistent thirst (polydipsia) with frequent urination (polyuria) and weight loss. Feeling of hunger even though eating an increased amount of food; weight loss. May be accompanied by blurred vision (osmotic effect on the lens). Breath has a “fruity” odor. Large number of ketones in urine.

Children may present with diabetic ketoacidosis (DKA) and neurologic symptoms, such as drowsiness and lethargy, which can progress to coma. May report a recent viral-like illness before the onset of symptoms. Diagnosis peaks from ages 4 to 6 years and again from ages 10 to 14 years.

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5
Q

Thyroid Cancer

A single thyroid nodule, usually located on the ____ half of one lobe in a patient, may be accompanied by enlarged _____ lymph node lump, swelling, or pain. May complain of h____ness and problems with sw______ (dysphagia, dyspnea, or cough).

  • Higher incidence in the ____ race. ______ therapy during childhood for certain cancers (Wilms’s tumor, lymphoma, neuroblastoma) and/or a low-iodine diet increases risk.
  • Higher prevalence in what gender (1) (3:1).
  • Highest incidence from age__ to __ years. Positive _____ history of thyroid cancer. Metastasis is by ____ route.
A

A single thyroid nodule, usually located on the upper half of one lobe in a patient, may be accompanied by enlarged cervical lymph node lump, swelling, or pain. May complain of hoarseness and problems with swallowing (dysphagia, dyspnea, or cough).

  • Higher incidence in the Asian race. Radiation therapy during childhood for certain cancers (Wilms’s tumor, lymphoma, neuroblastoma) and/or a low-iodine diet increases risk.
  • Higher prevalence in women (3:1).
  • Highest incidence from age 20 to 55 years. Positive family history of thyroid cancer. Metastasis is by lymph route.
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6
Q

Pheochromocytoma

=

  • It generally occurs in persons aged __ to __ years but can appear at any age.
  • Random episodes of ____ache (can be mild to severe), dia______, and _____ cardia accompanied by (1).
  • Episodes resolve _________. In between attacks, patient’s vital signs are normal.
A

A pheochromocytoma is a rare hormone-releasing adrenal tumor.

  • It generally occurs in persons aged 20 to 50 years but can appear at any age.
  • Random episodes of headache (can be mild to severe), diaphoresis, and tachycardia accompanied by hypertension.
  • Episodes resolve spontaneously. In between attacks, patient’s vital signs are normal.
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7
Q

Pheochromocytoma Triggers

  • Physical ex______, anx____, str____, surgery, anesthesia, changes in body _____, or labor and delivery.
  • Foods high in ______ (some cheeses, beers, wines, chocolates, dried or smoked meats)
  • (1) drug class and st______ drugs are other triggers.
A
  • Physical exertion, anxiety, stress, surgery, anesthesia, changes in body position, or labor and delivery.
  • Foods high in tyramine (some cheeses, beers, wines, chocolates, dried or smoked meats)
  • Monoamine oxidase inhibitors (MAOIs) and stimulant drugs are other triggers.
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8
Q

Hyperprolactinemia

Can be a sign of a ______ adenoma.

Serum prolactin is elevated

  • _____ onset.
  • Women may present with ______.
  • _______ in both males and females.
  • When the tumor is large enough to cause a ____ effect, the patient will complain of (2)
A

Can be a sign of a pituitary adenoma.

Serum prolactin is elevated.

  • Slow onset.
  • Women may present with amenorrhea.
  • Galactorrhea in both males and females.
  • When the tumor is large enough to cause a mass effect, the patient will complain of headaches and vision changes.
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9
Q

Normal Findings

The endocrine system works as a “_______feedback” system. If a ____ level of “_____” hormones occurs, it stimulates production. Inversely, if the level of hormones is high, it _____ production.

  1. (1) stimulates the
  2. (1) into producing the “_______ hormones” (such as follicle-stimulating hormone [FSH], luteinizing hormone [LH], thyroid-stimulating hormone [or thyrotropin; TSH]). These stimulating hormones tell the
  3. (1) (e.g., ovaries, thyroid) to produce “_____” hormones (e.g., estrogen, thyroid hormone).

High levels of these “active” hormones work in reverse. The hypothalamus directs the anterior pituitary into stopping production of the stimulating hormones (e.g., TSH, LH, FSH).

A

The endocrine system works as a “negative feedback” system. If a low level of “active” hormones occurs, it stimulates production. Inversely, if the level of hormones is high, it stops production.

  1. Hypothalamus stimulates the
  2. Anterior pituitary gland into producing the “stimulating hormones” (such as follicle-stimulating hormone [FSH], luteinizing hormone [LH], thyroid-stimulating hormone [or thyrotropin; TSH]). These stimulating hormones tell the
  3. Target organs (e.g., ovaries, thyroid) to produce “active” hormones (e.g., estrogen, thyroid hormone).

High levels of these “active” hormones work in reverse. The hypothalamus directs the anterior pituitary into stopping production of the stimulating hormones (e.g., TSH, LH, FSH).

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10
Q

Hypothalamus Releasing Hormones

(5)

A
  1. Thyroid Releasing Hormone (TRH)
  2. Gonadotropin Releasing Hormone (GnRH)
  3. Corticotropin Releasing Hormone (CRH)
  4. Growth Hormone Releasing Hormone (GHRH)
  5. Somatostatin

Somatostatin inhibits release of GH from pituitary gland

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11
Q

Anterior Pituitary Stimulating Hormones

(7)

A
  1. Thyroid Stimulating Hormone (TSH)
  2. Follicle Stimulating Hormone (FSH)
  3. Luteinizing Hormone (LH)
  4. Growth Hormone (GH)
  5. Adrenocorticotropic Hormone (ACTH)
  6. Melanocyte Stimulating Hormone (MSH)
  7. Prolactin
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12
Q

Posterior Pituitary Stimulating Hormones

(2)

A

Antidiuretic Hormones (ADH)

Oxytocin

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13
Q

Target Organs and Effects

  1. Thyroid (TSH) =
  2. Ovaries/Testes (FSH/LH) =
  3. Adrenal Cortex (ACTH) =
  4. Body (GH) =
  5. Uterus (Oxytocin) =
  6. Kidneys (Vasopressin (ADH)) =
  7. Pineal (melatonin) =
  8. Breast (Prolactin) =
A
  1. Thyroid (TSH) = T3 and T4
  2. Ovaries/Testes (FSH/LH) = Estrogen, Progesterone, Androgens, Testosterone
  3. Adrenal Cortex (ACTH) = Glucocorticoids, Mineralcorticoids
  4. Body (GH) = Somatic growth
  5. Uterus (Oxytocin) = Uterine contractions, bonding
  6. Kidneys (Vasopressin (ADH)) = Blood volume
  7. Pineal (melatonin) = Circadian rhythm
  8. Breast (Prolactin) = Milk production
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14
Q

Endocrine Glands

These glands form the (1) axis

Hypothalamus

Coordinates the n____ and end______ system by sending signals via the ______ gland. The gland interacts to form the HPA axis. Produces neurohormones that stimulate or stop production of pituitary hormones.

Pituitary Gland

Located at the sella turcica (_____of the brain). Stimulated by the hypothalamus into producing the ______ hormones such as FSH, LH, TSH, adrenocorticotropic hormone (ACTH), and growth hormone (GH).

A

These glands form the Hypothalamic-Pituitary-Adrenal (HPA) axis

Hypothalamus

Coordinates the nervous and endocrine system by sending signals via the pituitary gland. The gland interacts to form the HPA axis. Produces neurohormones that stimulate or stop production of pituitary hormones.

Pituitary Gland

Located at the sella turcica (base of the brain). Stimulated by the hypothalamus into producing the stimulating hormones such as FSH, LH, TSH, adrenocorticotropic hormone (ACTH), and growth hormone (GH).

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15
Q

Anterior Pituitary Gland (Adenohypophysis)

It has two lobes (anterior and posterior). The _____ pituitary gland produces hormones that directly regulate the target ____ (e.g., ovaries, testes, thyroid, adrenals).

A

It has two lobes (anterior and posterior). The anterior pituitary gland produces hormones that directly regulate the target organs (e.g., ovaries, testes, thyroid, adrenals).

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16
Q

FSH:

  • Stimulates the ______ to enable growth of follicles (or ____)
  • Production of _______

LH:

  • Stimulates the ovaries to ______
  • Production of _______ (by corpus luteum)
  • In males, LH stimulates the testicles (____cells) to produce ______
A

FSH:

  • Stimulates the ovaries to enable growth of follicles (or eggs)
  • Production of estrogen

LH:

  • Stimulates the ovaries to ovulate
  • Production of progesterone (by corpus luteum)
  • In males, LH stimulates the testicles (Leydig cells) to produce testosterone
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17
Q

TSH:

  • Stimulates ____ gland
  • Production of _______ (T3) and _____ (T4)
  • GH*:
  • Stimulates (1) of the body
A

TSH:

  • Stimulates thyroid gland
  • Production of triiodothyronine (T3) and thyroxine (T4)
  • GH*:
  • Stimulates somatic growth of the body
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18
Q

ACTH:

  • Stimulates the ______ glands (two portions of gland: _____ and _____)
  • Production of glucocorticoids (_____) and mineralocorticoids (______)
A
  • Stimulates the adrenal glands (two portions of gland: medulla and cortex)
  • Production of glucocorticoids (cortisol) and mineralocorticoids (aldosterone)
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19
Q
  • Prolactin:*
  • Affects lactation and ____ production
  • Melanocyte-stimulating hormone:*
  • Production of ______ in response to UV light; highest levels at night between __ p.m. and __ a.m.
A
  • Prolactin:*
  • Affects lactation and milk production
  • Melanocyte-stimulating hormone:*
  • Production of melatonin in response to UV light; highest levels at night between 11 p.m. and 3 a.m.
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20
Q

Posterior Pituitary Gland

Secretes ________ hormone (vasopressin) and _____, which are made by the hypothalamus but st____ and sec______ by the posterior pituitary.

A

Secretes antidiuretic hormone (vasopressin) and oxytocin, which are made by the hypothalamus but stored and secreted by the posterior pituitary.

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21
Q

Thyroid Gland

A butterfly-shaped organ (two lobes) located below the prominence of the thyroid _____(Adam’s apple). It is __inches long, and the lobes are connected by the _____. Uses _____to produce T3 and T4.

A

A butterfly-shaped organ (two lobes) located below the prominence of the thyroid cartilage (Adam’s apple). It is 2 inches long, and the lobes are connected by the isthmus. Uses iodine to produce T3 and T4.

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22
Q

Parathyroid Glands

Located _____ the thyroid glands (two glands behind each lobe). Produces (1) hormone, which is responsible for the _____ balance of the body by regulating the calcium loss or gain from the b____, k_____, and G______ tract (calcium absorption).

A

Located behind the thyroid glands (two glands behind each lobe). Produces parathyroid hormone (PTH), which is responsible for the calcium balance of the body by regulating the calcium loss or gain from the bones, kidneys, and gastrointestinal (GI) tract (calcium absorption).

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23
Q

Pineal Gland

Pea-sized gland located inside the ____ that produces _____. Melatonin regulates the sleep–wake cycle. _____ stimulates melatonin production, and ____ suppresses it.

A

Pea-sized gland located inside the brain that produces melatonin. Melatonin regulates the sleep–wake cycle. Darkness stimulates melatonin production, and light suppresses it.

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24
Q

Thyroid Gland Tests

  • (1)* Used to detect goiter (generalized enlargement of gland), multinodular goiter, single nodule, and solid versus cystic masses
  • (1):* Used as a diagnostic test for thyroid cancer
  • (1):* Shows metabolic activity of thyroid gland
A
  • Thyroid gland ultrasound:* Used to detect goiter (generalized enlargement of gland), multinodular goiter, single nodule, and solid versus cystic masses
  • Fine-needle biopsy:* Used as a diagnostic test for thyroid cancer
  • Thyroid scan (24-hour thyroid scan with RAIU):* Shows metabolic activity of thyroid gland
  • RAIU = Radioactive iodine uptake test*
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25
Q

Laboratory Findings of Thyroid Disease

  • _____ spot: Not metabolically active (more worrisome; rule out thyroid cancer); next step is to do?
  • ____ spot: Metabolically active nodule with homogeneous uptake; usually benign; helpful in diagnosing recurrent disease
A
  • Cold spot: Not metabolically active (more worrisome; rule out thyroid cancer); fine-needle aspiration biopsy
  • Hot spot: Metabolically active nodule with homogeneous uptake; usually benign; helpful in diagnosing recurrent disease
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26
Q

TSH (thyroid-stimulating hormone or thyrotropin):

  • Normal range: TSH of ____ to ____ mU/L (third-generation test).
  • TSH is used for both screening and monitoring response to treatment.
    • Recheck TSH every ___ to __ weeks. Dose of levothyroxine (Synthroid) is based on the TSH level. Goal is a TSH __ 5.0 mU/L.
    • When TSH is stable, recheck every __ to __ months.
A
  • Normal range: TSH of 0.5 to 5.0 mU/L (third-generation test).
  • TSH is used for both screening and monitoring response to treatment.
    • – Recheck TSH every 6 to 8 weeks. Dose of levothyroxine (Synthroid) is based on the TSH level. Goal is a TSH <5.0 mU/L.
    • – When TSH is stable, recheck every 6 to 12 months.
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27
Q

What Thyroid Disorder do these labs show?

  • TSH > 5.0
  • Free T4 = Low
  • T3 = Low
A

Hypothyroidism

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28
Q

What Thyroid Disorder do these labs show?

  • TSH < 0.05
  • Free T4 High
  • T3 High
A

Hyperthyroidism

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29
Q

What Thyroid Disorder do these labs show?

  • TSH >5.0
  • Free T4 Normal
  • T3 Normal
A

Subclinicial Hypothyroidism

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30
Q

What Thyroid Disorder do these labs show?

  • TSH <0.05
  • Free T4 Normal
  • T3 Normal
A

Subclinical Hyperthyroidism

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31
Q

Primary Hyperthyroidism (Thyrotoxicosis)

(1) Disease =

The classic finding is a very ____ (or undetectable) TSH with _______ in both serum-free T4 and T3 levels.

A

Graves Disease

Chronic autoimmune disorder that is the most common cause for hyperthyroidism (60%–80%) in the United States

The classic finding is a very low (or undetectable) TSH with elevations in both serum-free T4 and T3 levels.

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32
Q

Graves’ Disease

Graves’ disease accounts for __% to __% of all types of hyperthyroidism. An ________ disorder causing hyperfunction and production of ______ thyroid hormones (T3 and T4).

  • Higher incidence in what gender? (7:1 ratio).
  • These women are also at higher risk for other autoimmune diseases such as rheumatoid arthritis (RA) and pernicious anemia (PA) and for osteopenia/osteoporosis due to increased metabolism.
A

Graves’ disease accounts for 60% to 80% of all types of hyperthyroidism. An autoimmune disorder causing hyperfunction and production of excess thyroid hormones (T3 and T4).

  • Higher incidence in women (7:1 ratio).
  • These women are also at higher risk for other _____ diseases such as (1) and (1) and for ____penia/porosis due to increased metabolism.
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33
Q

Classic Case of Graves Disease

______-aged woman ____ a large amount of weight rapidly with anxiety and insomnia. Cardiac symptoms (due to overstimulation) are pal_____, hypertension, atrial ______, or premature atrial contractions. W____ and m______ skin with increased pers______. May present with ________ and lid lag (Graves’ ophthalmopathy). More ______ bowel movements (looser stools). ____orrhea and (1) temperature intolerance. Enlarged thyroid (g_____) and/or thyroid nod______ present. May be accompanied by pretibial myx_____ (thickening of the skin usually located in the shins and gives an orange-peel appearance).

A

Middle-aged woman loses a large amount of weight rapidly with anxiety and insomnia. Cardiac symptoms (due to overstimulation) are palpitations, hypertension, atrial fibrillation, or premature atrial contractions. Warm and moist skin with increased perspiration. May present with ophthalmopathy and lid lag (Graves’ ophthalmopathy). More frequent bowel movements (looser stools). Amenorrhea and heat intolerance. Enlarged thyroid (goiter) and/or thyroid nodules present. May be accompanied by pretibial myxedema (thickening of the skin usually located in the shins and gives an orange-peel appearance).

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34
Q

Objective Findings of Graves Disease

  • Thyroid: ______ enlarged gland (goiter), toxic ad_____, or multi______r goiter. May be tender to palpation or asymptomatic
  • Extremities: Fine _____ on both hands, _____ palms, pretibial ______
  • Eyes: Lid ___; ________in one or both eyes
  • Cardiac: ______cardia, atrial ______, congestive heart failure, cardiomyopathy
  • Integumentary: ____ hair, _____ skin
  • Neurologic: _____ deep tendon reflexes
A
  • Thyroid: Diffusely enlarged gland (goiter), toxic adenoma, or multinodular goiter. May be tender to palpation or asymptomatic
  • Extremities: Fine tremors on both hands, sweaty palms, pretibial myxedema
  • Eyes: Lid lag; exophthalmos in one or both eyes
  • Cardiac: Tachycardia, atrial fibrillation, congestive heart failure, cardiomyopathy
  • Integumentary: Fine hair, warm skin
  • Neurologic: Brisk deep tendon reflexes
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35
Q

Graves Disease Labs

Look for very low ___(

  • If Graves’ disease, will have positive (1) antibodies, which is also known as the (1) immunoglobulins
  • The (1) antibody is positive with Graves’ disease as well as Hashimoto’s disease.
A

Look for very low TSH (<0.05 mU/L) with elevated serum-free T4 and T3.

  • If Graves’ disease, will have positive thyrotropin receptor antibodies (TRAb), which is also known as the thyroid-stimulating immunoglobulins (TSIs)
  • The thyroid peroxidase antibody (TPO) is positive with Graves’ disease as well as Hashimoto’s disease.
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36
Q

Graves Disease Workup

  1. Check (1).
  2. If low, order thyroid _____. Look for very ___ TSH (<0.05 mU/L) with ______ serum-free T4 and elevated T3. (In some patients with very low TSH, only either the serum T4 or the serum T3 will be elevated.)
  3. Next step is to order ______ tests to confirm whether Graves’ disease is present ( (1) and (1) or (1)).

If thyroid has a single palpable mass/nodule, order thyroid ______. Refer to ________for management.

A
  1. Check TSH.
  2. If low, order thyroid panel. Look for very low TSH (<0.05 mU/L) with elevated serum-free T4 and elevated T3. (In some patients with very low TSH, only either the serum T4 or the serum T3 will be elevated.)
  3. Next step is to order antibody tests to confirm whether Graves’ disease is present (TRAb and TPO or TSI).
  • If thyroid has a single palpable mass/nodule, order thyroid ultrasound. Refer to endocrinologist for management.
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37
Q

Graves Disease Imaging Studies

  • Thyroid ______
  • (1) (RAIU) shows diffuse uptake (goiter).
  • If solitary toxic nodule, shows warm or “__” nodule or “____” nodule. Absolute contraindications for this test are pr_____ and breast_______.
A
  • Thyroid ultrasound
  • 24-hour radioactive iodine uptake (RAIU) shows diffuse uptake (goiter).
  • If solitary toxic nodule, shows warm or “hot” nodule or “cold” nodule. Absolute contraindications for this test are pregnancy and breastfeeding.
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38
Q

Graves Treatment

  • Rx (1)**:* Shrinks thyroid gland/decreases hormone production.
  • Rx (1)**:* Shrinks thyroid gland/decreases hormone production.

Which one is the preferred treatment for moderate to severe hyperthyroidism? (can cause _____ failure).

A
  • Methimazole (Tapazole):* Shrinks thyroid gland/decreases hormone production.
  • Propylthiouracil (PTU)**:* Shrinks thyroid gland/decreases hormone production.

PTU is preferred treatment for moderate to severe hyperthyroidism (can cause liver failure).

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39
Q

Side Effects of Methimazole and Propylthiouracil (PTU)

What 2 labs are important to monitor?

Skin ____

granulocyto____/aplastic ____, ______cytopenia - check (1)

______ necrosis - check (1)

A

Skin rash, granulocytopenia/aplastic anemia, thrombocytopenia (check complete blood count [CBC] with platelets), hepatic necrosis (monitor CBC, liver function tests [LFTs]).

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40
Q

If a pregnant woman has hyperthyroidism? What is the preferred medication? Can you take care of this patient by yourself?

A

For hyperthyroidism, PTU is preferred treatment, if needed. For high-risk pregnancy, refer to obstetrician.

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41
Q

Graves Disease Adjunctive Treatment

Rx (1)-(3)

Given to alleviate the symptoms of hyperstimulation (i.e., anxiety, tachycardia, palpitations

A

Betablockers are effective (e.g., propranolol, metoprolol, atenolol).

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42
Q

When using Radioactive Iodine to treat Graves - what conditions is it contraindicated to give radioactive iodine? What does radioactive iodine do to the thyroid gland? What will the person need for life?

A

Contraindicated during pregnancy or lactation. Permanent destruction of thyroid gland results in hypothyroidism for life (needs thyroid supplementation for life).

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43
Q

(1)

Complication of Graves Disease where an individual’s heart rate, blood pressure, and body temperature can soar to dangerously high levels. Acute worsening of symptoms due to stress or infection. Look for decreased level of consciousness (LOC), fever, abdominal pain. Lifethreatening. Immediate hospitalization needed.

A

Thyroid Storm (Thyrotoxicosis)

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44
Q

Primary Hypothyroidism

(1) Most common disease in the US

The classic lab finding for hypothyroidism is a ____ TSH with ____free T4 levels (do not confuse with total T4). Diagnosis is based on the lab findings.

Some of the most common causes are ______ thyroiditis, post_____ thyroiditis, and thyroid ablation with (1) (to treat hyperthyroidism).

A

Hashimoto’s Thyroiditis

The classic lab finding for hypothyroidism is a high TSH with low free T4 levels (do not confuse with total T4). Diagnosis is based on the lab findings.

Some of the most common causes are Hashimoto’s thyroiditis, postpartum thyroiditis, and thyroid ablation with radioactive iodine (to treat hyperthyroidism).

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45
Q

Hashimoto’s Thyroiditis

A chronic ______ disorder of the thyroid gland. There is generally no ____ with this thyroid swelling. The body produces destructive antibodies (1) against the thyroid gland that gradually destroys them. Almost all patients (90%) with Hashimoto’s thyroiditis have elevated TPOs. Most patients have developed a goiter. More common in (1) gender with ratio of 8:1.

A

A chronic autoimmune disorder of the thyroid gland. There is generally no pain with this thyroid swelling. The body produces destructive antibodies (TPOs) against the thyroid gland that gradually destroys them. Almost all patients (90%) with Hashimoto’s thyroiditis have elevated TPOs. Most patients have developed a goiter. More common in women with ratio of 8:1.

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46
Q

Classic Case of Hashimoto’s Thyroiditis

A middle-aged-to-older woman who is overweight complains of f____, weight ____, ____ intolerance, cons______, and menstrual abnormalities. May have alopecia on the outer one-third of both eyebrows. Serum ch______ is elevated. May have a history of another ______disorder (e.g., RA, PA).

A

A middle-aged-to-older woman who is overweight complains of fatigue, weight gain, cold intolerance, constipation, and menstrual abnormalities. May have alopecia on the outer one-third of both eyebrows. Serum cholesterol is elevated. May have a history of another autoimmune disorder (e.g., RA, PA).

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47
Q

(1)

Severe hypothyroidism is an endocrine emergency that is now rare (mortality rate 30%–40%). Patient presents with cognitive symptoms such as slowed thinking, poor short-term memory, depression (or dementia), hypotension, and hypothermia

A

Myxedema - Myxedema Coma

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48
Q

Hashimoto’s Thyroiditis Labs

  1. Order _____ first (TSH >___ mU/L).
  2. If elevated, order TSH again with (1) (free thyroxine).
  3. If TSH is ___ and serum-free T4 is ___, the diagnosis is hypothyroidism.
  4. Next step is to order (1): If elevated, confirms Hashimoto’s thyroiditis (gold-standard test for diagnosing Hashimoto’s thyroiditis).
A
  1. Order TSH first (TSH >5.0 mU/L).
  2. If elevated, order TSH again with free T4 (free thyroxine).
  3. If TSH is high and serum-free T4 is low, the diagnosis is hypothyroidism.
  4. Next step is to order TPOs: If elevated, confirms Hashimoto’s thyroiditis (gold-standard test for diagnosing Hashimoto’s thyroiditis).
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49
Q

(1)

Diagnosis If TSH is >5 mU/L (elevated), but serum-free T4 is within normal range, person is (asymptomatic to mild symptoms of hypothyroidism).

Decision to treat with Synthroid should be individualized. Some choose not to treat but recheck same labs again in 12 months.

A
  • Subclinical Hypothyroidism*
  • (nonpregnant adults)*
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50
Q

Hashimoto’s Thyroiditis Treatment

Rx (1)

Dose Range __-__ mcg/day

Increase Synthroid dose every few weeks until TSH is normalized (

Recheck TSH every __ to __ weeks until TSH is normalized (TSH <5.0 mU/L). When under control, check TSH every __ months.

A

Levothyroxine (Synthroid)

Dose Range 25-50 mcg/day

Increase Synthroid dose every few weeks until TSH is normalized (<5.0 mU/L).

Recheck TSH every 6 to 8 weeks until TSH is normalized (TSH <5.0 mU/L). When under control, check TSH every 12 months.

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51
Q

Levothyroxine Side Effects

Advise patient to report if pal_____, n_____ness, or tr______ because this means that Synthroid dose is too high (decrease dose until symptoms are gone and TSH is in normal range).

Start with _____ dose for older adults or patients with history of heart disease (watch for ang______, acute ____, atrial _______)

A

Advise patient to report if palpitations, nervousness, or tremors because this means that Synthroid dose is too high (decrease dose until symptoms are gone and TSH is in normal range).

Start with lowest dose for older adults or patients with history of heart disease (watch for angina, acute myocardial infarction [MI], atrial fibrillation).

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52
Q

Exam Tips

  • Learn to diagnose (1) (TSH elevated with normal free T4).
  • If patient has elevated TSH (>5.0 mU/L), workup needed for ________ (e.g., order ___, free ___).
  • Start older patients at low dose of Synthroid (___–___ mcg/day) and gradually increase to avoid adverse ______ effects from overstimulation (palpitations, angina, MI).
  • Patient with normal free T4 but with elevated TSH—do ___ treat (subclinical hypothyroidism). Recheck TSH in about __ months.
A
  • Learn to diagnose subclinical hypothyroidism (TSH elevated with normal free T4).
  • If patient has elevated TSH (>5.0 mU/L), workup needed for hypothyroidism (e.g., order TSH, free T4).
  • Start older patients at low dose of Synthroid (12.5–25 mcg/day) and gradually increase to avoid adverse cardiac effects from overstimulation (palpitations, angina, MI).
  • Patient with normal free T4 but with elevated TSH—do not treat (subclinical hypothyroidism). Recheck TSH in about 6 months.
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53
Q

Exam Tips

  • Check TSH every __ to __ weeks (do not order earlier than 6 weeks) to monitor treatment response. If TSH is ___ to ____ mU/L, it is within normal limits and the patient is at the right dose (Synthroid).
  • (1) treatment results in hypothyroidism for life. Supplement with thyroid hormone for life.
  • If TSH is suppressed (TSH <0.05 mU/L), workup needed for _______.
  • Chronic amenorrhea and hypermetabolism result in ______. Supplement with (1) and (1) 1,200 mg; engage in weight-bearing exercises.
A
  • Check TSH every 6 to 8 weeks (do not order earlier than 6 weeks) to monitor treatment response. If TSH is 0.05 to 5.0 mU/L, it is within normal limits and the patient is at the right dose (Synthroid).
  • Radioactive iodine treatment results in hypothyroidism for life. Supplement with thyroid hormone for life.
  • If TSH is suppressed (TSH <0.05 mU/L), workup needed for hyperthyroidism.
  • Chronic amenorrhea and hypermetabolism result in osteoporosis. Supplement with calcium and with vitamin D 1,200 mg; engage in weight-bearing exercises.
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54
Q

Clinical Pearls

  • Many patients with subclinical hypothyroidism will eventually develop?
  • Advise patient to _____ Synthroid tablets with teeth before swallowing with ____for better absorption. These tablets are synthetic T4 (levothyroxine).
  • Alternative medicine practitioners are more likely to prescribe _____ thyroid tablets (desiccated thyroid glands from pigs), which contain _____ T3 and T4 for hypothyroidism.
  • All _____thyroid patients should be referred to an endocrinologist as soon as possible.
A
  • Many patients with subclinical hypothyroidism will eventually develop overt hypothyroidism.
  • Advise patient to crush Synthroid tablets with teeth before swallowing with water for better absorption. These tablets are synthetic T4 (levothyroxine).
  • Alternative medicine practitioners are more likely to prescribe Armour thyroid tablets (desiccated thyroid glands from pigs), which contain natural T3 and T4 for hypothyroidism.
  • All hyperthyroid patients should be referred to an endocrinologist as soon as possible.
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55
Q

(1)

A chronic metabolic disorder affecting the body’s metabolism of carbohydrates and fat. The result is microvascular and macrovascular damage, neuropathy, and immune system effects.

A

Diabetes Mellitus

56
Q

(1) Damage

Retinopathy, nephropathy, and neuropathy

(1) Damage

Atherosclerosis, heart disease (coronary artery disease, MI)

A

Microvascular Damage

Retinopathy, nephropathy, and neuropathy

Macrovascular Damage

Atherosclerosis, heart disease (coronary artery disease, MI)

57
Q
  • Target organs in Diabetes Mellitus*
  • (4)*

DM is the most common reason for (2) in the United States

A

Eyes, kidneys, heart/vascular system, peripheral nerves (especially in the feet)

DM is the most common reason for chronic renal failure requiring dialysis and lower limb amputations in the United States.

58
Q

Type 1 Diabetes Mellitus

=

  • If uncorrected, body ___ will be used for fuel.
  • ______, the metabolic product of fat breakdown, build up in the body until the result is diabetic ketonic acidosis (ketoacidosis) and coma.
  • Most patients are juv_____; occasionally occurs in adults (maturity onset diabetes of the young [MODY]). The Centers for Disease Control and Prevention (CDC) reports 5% to 10% of U.S. cases.
A

The massive destruction of B-cells in the islets of Langerhans results in an abrupt cessation of insulin production.

  • If uncorrected, body fat will be used for fuel.
  • Ketones, the metabolic product of fat breakdown, build up in the body until the result is diabetic ketonic acidosis (ketoacidosis) and coma.
  • Most patients are juveniles; occasionally occurs in adults (maturity onset diabetes of the young [MODY]). The Centers for Disease Control and Prevention (CDC) reports 5% to 10% of U.S. cases.
59
Q

Type 2 Diabetes Mellitus

=

  • Has strong g____component.
  • Type 2 DM represents __% to __% of U.S. cases.
  • ______ epidemic is increasing rates of type 2 DM in younger patients.
A

Progressive decreased secretion of insulin (with peripheral insulin resistance) resulting in a chronic state of hyperglycemia and hyperinsulinemia.

  • Has strong genetic component.
  • Type 2 DM represents 90% to 95% of U.S. cases.
  • Obesity epidemic is increasing rates of type 2 DM in younger patients.
60
Q

Risk Factors for Type 2 Diabetes Mellitus (Screen These Patients)

  • (1) (body mass index [BMI] 25 or greater)
  • _______ obesity; sedentary lifestyle
  • _______ syndrome
  • Ethnicities?
  • History of ______ diabetes or infant weighing >__ lb at birth
  • Impaired (1) (IFG) or (1) (IGT) is considered at higher risk for type 2 DM (prediabetes)
A
  • Overweight or obese (body mass index [BMI] 25 or greater)
  • Abdominal obesity; sedentary lifestyle
  • Metabolic syndrome
  • Hispanic, African American, Asian, Pacific Islander, or American Indian ancestry or positive family history
  • History of gestational diabetes or infant weighing >9 lb at birth
  • Impaired fasting blood sugar/glucose (IFG) or impaired glucose tolerance (IGT) is considered at higher risk for type 2 DM (prediabetes)
61
Q
  • Serum Blood Glucose Norms: Nondiabetic Adults*
  • FPG:* __ to 100 mg/dL
  • Peak postprandial plasma glucose:*
  • Glycosylated hemoglobin (A1C*
  • Definition of A1C =*
A
  • FPG:* 70 to 100 mg/dL
  • Peak postprandial plasma glucose:* <180 mg/dL
  • Glycosylated hemoglobin (A1C <6.0%):*
  • A1C =* the average blood glucose levels over previous 3 months; no fasting required; test measures excess glucose that attaches to the hemoglobin of the red blood cells
62
Q

Metabolic Syndrome
Other names are insulin-resistance syndrome and syndrome X

Affected people have higher risk of type 2 DM and cardiovascular disease

Presence of any ____ of the following four traits:

  • Obesity, abdominal obesity. Waist size:
    • Male: >__ inches (102 cm)
    • Female: >__ inches (88 cm)
  • Hypertension: BP >___/___ mmHg
  • Dyslipidemia: Triglycerides >___ mg/dL, high-density lipoprotein (HDL)
  • Hyperglycemia: Fasting plasma glucose (FPG) >____ mg/dL or type 2 DM
A

Presence of any three of the following four traits:

  • Obesity, abdominal obesity. Waist size:
    • Male: >40 inches (102 cm)
    • Female: >35 inches (88 cm)
  • Hypertension: BP >130/85 mmHg
  • Dyslipidemia: Triglycerides >150 mg/dL, high-density lipoprotein (HDL) <40 in males or <50 in females
  • Hyperglycemia: Fasting plasma glucose (FPG) >100 mg/dL or type 2 DM
63
Q

Increased Risk of Diabetes Mellitus (Prediabetes)

Glycosylated hemoglobin (A1C) between ____% and ____%

or

Fasting glucose of ____to ____ mg/dL (impaired FPG)

or

Two-hour oral glucose tolerance test (OGTT; 75 g load) of ____to ____mg/dL

A

Glycosylated hemoglobin (A1C) between 5.7% and 6.4%

or

Fasting glucose of 100 to 125 mg/dL (impaired FPG)

or

Two-hour oral glucose tolerance test (OGTT; 75 g load) of 140 to 199 mg/dL

64
Q

Diagnostic Criteria for Diabetes Mellitus

A1C ≥___%

or

FPG ≥_____mg/dL (fasting is no caloric intake for at least 8 hours)

or

Symptoms of hyperglycemia (3) plus random blood glucose ≥____mg/dL

or

Two-hour plasma glucose ≥____mg/dL during an OGTT with a 75-g glucose load

A

A1C ≥6.5%

or

FPG ≥126 mg/dL (fasting is no caloric intake for at least 8 hours)

or

Symptoms of hyperglycemia (polyuria, polydipsia, polyphagia) plus random blood glucose ≥200 mg/dL

or

Two-hour plasma glucose ≥200 mg/dL during an OGTT with a 75-g glucose load

65
Q
  • Diabetes Labs*
  • Newly diagnosed diabetics:* Check A1C every __ months until blood glucose controlled or when changing therapy, then check ___ a year
  • _____ profile at least once a year with 9- to 12-hour fasting
  • Random or “on-spot” urine for _______ at least once a year
    • Urine (1) better than microalbumin test (spot urine sample) for evaluating microalbumin (the earliest sign of diabetic renal disease)
    • If positive, order (1) for protein and creatinine
A

Newly diagnosed diabetics: Check A1C every 3 months until blood glucose controlled or when changing therapy, then check twice a year (every 6 months)

  • Lipid profile at least once a year with 9- to 12-hour fasting
  • Random or “on-spot” urine for microalbuminuria at least once a year
    • Urine albumin-to-creatinine ratio better than microalbumin test (spot urine sample) for evaluating microalbumin (the earliest sign of diabetic renal disease)
    • If positive, order 24-hour urine for protein and creatinine
66
Q

Diabetes Labs

Rx (3) with tighter control of blood glucose/A1C decreases progression and lowers mortality from kidney disease

Check electrolytes (3)), l_____ function panel, and (1) hormone

A

ACEI/ARBS/ARNIS with tighter control of blood glucose/A1C decreases progression and lowers mortality from kidney disease

Check electrolytes (potassium, magnesium, sodium), liver function panel, and TSH

67
Q

Diabetes Treatment Plan

  • Every visit:* Check B__, f___, w____ and BMI, blood ____.
  • Vibration sense (128-Hz tuning fork):* Place on bony prominence of the __ toe at the ____ joint; if unable to sense vibration or asymmetry, patient has (1)
  • Light and deep touch, numbness:* Place at right angle on plantar surface, push into skin until it buckles slightly (_______ tool)

Check pedal ____, ankle reflexes, and skin for acanthosis _______, insulin injection or insertion sites, l___dystrophy

A
  • Every visit:* Check BP, feet, weight and BMI, blood sugar.
  • Vibration sense (128-Hz tuning fork):* Place on bony prominence of the big toe (metatarsophalangeal [MTP] joint); if unable to sense vibration or asymmetry, patient has peripheral neuropathy
  • Light and deep touch, numbness:* Place at right angle on plantar surface, push into skin until it buckles slightly (monofilament tool)

Check pedal pulses, ankle reflexes, and skin for acanthosis nigricans, insulin injection or insertion sites, lipodystrophy

68
Q

Preventive Care Recommendations

The CDC recommends adults >___ years be given ______ vaccine in two doses, 2 to 6 months apart.

_______ immunization every year.

____________ polysaccharide vaccine: If vaccinated before 65 years of age, give one-time revaccination in __ years; if age 65 years, give one dose of the vaccine only.

Prescribe ____ __mg if high risk for MI, stroke (if <30 years, not recommended).

  • (1):* Yearly ______ eye exam needed. If type 2, eye exam at diagnosis; if type 1 DM, first eye exam needed 5 years after diagnosis.
  • (1):* Refer to ____ or twice a year, especially with older diabetics.
  • BP:* Goal is ___/___ mmHg.
  • (1) care:* Important (poor oral health associated with heart disease).
A

The CDC recommends adults >50 years be given Shingrix in two doses, 2 to 6 months apart.

Influenza immunization every year.

Pneumococcal polysaccharide vaccine: If vaccinated before 65 years of age, give one-time revaccination in 5 years; if age 65 years, give one dose of the vaccine only.

Prescribe aspirin 81 mg if high risk for MI, stroke (if <30 years, not recommended).

  • Ophthalmologist:* Yearly dilated eye exam needed. If type 2, eye exam at diagnosis; if type 1 DM, first eye exam needed 5 years after diagnosis.
  • Podiatrist:* Refer to once or twice a year, especially with older diabetics.
  • BP:* Goal is 130/80 mmHg.
  • Dental/tooth care:* Important (poor oral health associated with heart disease).
69
Q

Dietary and Nutrition Recommendations (or Macronutrients)

Alcohol: Advise females not to exceed ___ drink per day and males ___ drinks per day.

Monitor carbohydrate intake (i.e., carbohydrate ______).

______ fat (animal fats, beef fat) intake should be <7% of total calories.

Reduce intake of ____ fats (will lower low-density lipoprotein [LDL] and increase HDL), such as most fr____ foods and “j____foods.”

Refer patient to a _____ at least once or more often if problems with diet.

Routine vitamin supplementation of antioxidants?

A

Alcohol: Advise females not to exceed one drink per day and males two drinks per day.

Monitor carbohydrate intake (i.e., carbohydrate counting).

Saturated fat (animal fats, beef fat) intake should be <7% of total calories.

Reduce intake of trans fats (will lower low-density lipoprotein [LDL] and increase HDL), such as most fried foods and “junk foods.”

Refer patient to a dietitian at least once or more often if problems with diet.

Routine vitamin supplementation of antioxidants is not yet advised.

70
Q

Hypoglycemia

High risk:

  • Level 1 hypoglycemia (glucose alert): FBS ≤___ mg/dL
  • Level 2 hypoglycemia: Blood glucose ≤___mg/dL

Look for what symptoms?

What medication can mask hypoglycemia symptoms?

A

High risk:

  • Level 1 hypoglycemia (glucose alert): FBS ≤70 mg/dL
  • Level 2 hypoglycemia: Blood glucose ≤54 mg/dL

Look for: Sweaty palms, tiredness, dizziness, rapid pulse, strange behavior, confusion, and weakness;

If patient on beta-blockers, the hypoglycemic response can be blunted or blocked.

71
Q

Hypoglycemia Treatment

(1)= preferred for conscious patients

  • Other options are 4 oz of ____juice, regular____ drink, hard c_____.
  • Think of the “__-__ Rule”: 15 g of ______ to raise blood sugar, _____ in __ minutes.
  • When blood glucose is normalized, do what afterward?

(1) = for patients at significant risk for severe hypoglycemia (BG <54 mg/dL)

A

Glucose (15 g) preferred for conscious patients

  • Other options are 4 oz of , orange juice, regular soft drink, hard candy.
  • Think of the “15-15 Rule”: 15 g of carbohydrates to raise blood sugar, recheck in 15 minutes.
  • When blood glucose is normalized, eat a meal or snack afterward (complex carbohydrates, protein).

Glucagon: Prescribe for patients at significant risk for severe hypoglycemia. Severe hypoglycemia is defined as blood glucose <54 mg/dL.

72
Q

Illness and Surgery

Should you stop taking antidiabetic medication during illness?

Requires ______ self-monitoring of blood glucose.

Eat _____ amounts of food every __ to __ hours to keep FBG as normal as possible.

Contact healthcare provider if: Dehy____, v_____, or di____ for several hours; blood glucose is >____mg/dL; changes in L _ _ (feel sleepier than normal/cannot think clearly; urine with 1+ or higher _______).

A

Do not stop taking antidiabetic medicine. Keep taking insulin or oral medications as scheduled unless fasting blood glucose (FBG) is lower than normal.

Requires frequent self-monitoring of blood glucose.

Eat small amounts of food every 3 to 4 hours to keep FBG as normal as possible.

Contact healthcare provider if: Dehydrated, vomiting, or diarrhea for several hours; blood glucose is >300 mg/dL; changes in LOC (feel sleepier than normal/cannot think clearly; urine with 1+ or higher ketones).

73
Q

Hypoglycemia and Exercise

What happens to blood sugar when you exercise? What should you do to your medicine dosage? or do what afterwards to compensate?

  • If patient does not compensate (_____ the dose of insulin, _____ caloric intake, sn_____ before and after), there is an increased risk of hypoglycemia within a few hours.
  • Example: If patient exercises in the afternoon, high risk of hypoglycemia at ____/bedtime if they do not compensate by eating snacks, eating more food at dinner, or lowering insulin dose.
A

Increases glucose utilization by the muscles. Patients may need to reduce their usual dose of medicine (or eat snacks before the activity and afterward to compensate).

  • If patient does not compensate (reducing the dose of insulin, increasing caloric intake, snacking before and after), there is an increased risk of hypoglycemia within a few hours.
  • Example: If patient exercises in the afternoon, high risk of hypoglycemia at night/bedtime if they do not compensate by eating snacks, eating more food at dinner, or lowering insulin dose.
74
Q

Snacks for Exercise

  • Eat _____ carbohydrates (2) before or during exercise.
  • Eat ______carbohydrates ((1) bars) after exercise (avoids postexercise hypoglycemia).
A
  • Eat simple carbohydrates (candy, juices) before or during exercise.
  • Eat complex carbohydrates (granola bars) after exercise (avoids postexercise hypoglycemia).
75
Q

Dawn Phenomenon

=

A

Daily surge of fasting blood glucose levels between 4-8am

Normal physiologic event due to a hormonal surge, without normal insulin responses, diabetics experience rising FBG levels - healthy people can produce the insulin to combat this phenomenon

76
Q

Somogyi Effect

=

A

(Rebound Hyperglycemia)

Severe nocturnal hypoglycemia stimulates counterregulatory hormones, such as glucagon, to be released from the liver. The high levels of glucagon in the systemic circulation result in high FBG by 7 a.m. The condition is due to overtreatment with the evening and/or bedtime insulin (dose is too high). More common in people with type 1 DM.

77
Q

Somogyi vs. Dawn Effect

  • If the blood sugar level is low at 2 a.m. to 3 a.m., suspect the ______ effect.*
  • If the blood sugar level is normal or high at 2 a.m. to 3 a.m., it’s likely the _____ phenomenon.*
A
  • If the blood sugar level is low at 2 a.m. to 3 a.m., suspect the Somogyi effect.*
  • If the blood sugar level is normal or high at 2 a.m. to 3 a.m., it’s likely the dawn phenomenon.*
78
Q

Somogyi Effect

  • Diagnosis*
  • Treatment*
A
  • Diagnosis:* Check blood glucose very early in the morning (3 a.m.) for 1 to 2 weeks.
  • Treatment:* Eat a snack before bedtime or eliminate dinnertime intermediate-acting insulin (NPH) dose or lower the bedtime dose for both NPH and regular insulin.
79
Q

Diabetic Retinopathy

  • (1) = new growth of fragile arterioles in retina)
  • (1) = dot and blot hemorrhages due to neovascularization
  • (1) spots or soft exudates (nerve fiber layer infarcts), and hard exudates.
A
  • Neovascularization = new growth of fragile arterioles in retina
  • Microaneurysms dot and blot hemorrhages due to neovascularization
  • Cotton-wool spots or soft exudates (nerve fiber layer infarcts), and hard exudates.
80
Q

Diabetic Retinopathy Screening

When to screen

  • Patients with type 1 DM:*
  • Patients with type 2 DM:*
A
  • Patients with type 1 DM:* Screen after age 10 years.
  • Patients with type 2 DM:* Refer to ophthalmologist shortly after diagnosis; then eye exam needed every 6 to 12 months.
81
Q

Diabetic Foot Care

Patients with peripheral neuropathy should avoid excessive running or walking to minimize the risk of foot injury.

  • Patients with type 2 DM screening?
  • Wear shoes that ___properly. Never go ______.
  • Check feet ____, especially the soles of the feet (use _____).
  • Trim nails _____ (not rounded) to prevent ingrown toenails.
  • Report ___ness, skin breakdown, or trauma to healthcare provider immediately (main cause of lower leg _______ in the United States).
A

Patients with peripheral neuropathy should avoid excessive running or walking to minimize the risk of foot injury.

  • Patients with type 2 DM: Refer to podiatrist at least once a year.
  • Wear shoes that fit properly. Never go barefoot.
  • Check feet daily, especially the soles of the feet (use mirror).
  • Trim nails squarely (not rounded) to prevent ingrown toenails.
  • Report redness, skin breakdown, or trauma to healthcare provider immediately (main cause of lower leg amputations in the United States).
82
Q

Deformity of the foot that is caused by joint and bone dislocation and fractures due to neuropathy and loss of sensation to the foot and ankle. May affect only one foot or both feet. If severe, foot deformity includes collapse of midfoot arch (rocker-bottom foot;

A

Charcot’s Foot and Ankle (Neuropathic Arthropathy)

83
Q

Biguanides

(1)

MOA

A

Metformin (Glucophage)

Decreases gluconeogenesis and decreases peripheral insulin resistance

84
Q

Metformin

Incidence of hypoglycemia?

Effect on weight loss?

Side effects?

A

Rarely causes hypoglycemia

Neutral for weight change and has potential for modest weight loss - preferred for obese patients

Side effects: diarrhea, nausea, vitamin B12 deficiency (supplement)

85
Q

Metformin Contraindications

  • R_____ disease
  • H______ disease ac_____
  • Al______, hy_____

What labs should you monitor? (2)

A
  • Renal disease
  • Hepatic disease acidosis
  • Alcoholics, hypoxia

Monitor renal function (Cr, GFR, UA) and LFTS

86
Q

Metformin Adverse Effects

Increased risk for (1) during hypoxia, hypoperfusion, renal insufficiency

Usually inpatient - metformin should be held on day of this procedure (1) and for 48 hours after? What should you check beforehand?

A

Increased risk for lactic acidosis (pH <7.25) during hypoxia, hypoperfusion, renal insufficiency

IV contrast dye testing - hold metformin on day of procedure and 48 hours after - check baseline creatinine and recheck after procedure - if SrCr remains elevated after procedure, do not restart metformin, Cr must be normalized before drug resumed

87
Q

Sulfonylureas

Why are they not commonly used anymore? (2)

A

High risk of severe hypoglycemia

Increased risk of cardiovascular mortality (based on studies of older sulfonylurea tolbutamide)

88
Q

Sulfonylureas

MOA

  • First generation (1)*
  • Second generation (3)*

Half life =

A

Stimulates Beta cells of pancreas to secrete more insulin

First generation

  • Chlorpropamide (Diabinese)

Second generation

  • Glipizide (Glucotrol, Glucotrol XL)
  • Glyburide (Diabeta)
  • Glimepiride (Amaryl)

Long half life = 12 hours

89
Q

Sulfonylureas

Incidence of hypoglycemia?

Cardiovascular risk?

Effect on weight?

  • Increased risk of _____sensitivity (use sunscreen)
  • Blood ______ (monitor ___)
  • Avoid if impaired (2) function (monitor (3))
A

High risk of severe hypoglycemia

Increased risk of cardiovascular mortality

Weight gain (monitor weight and BMI)

  • Increased risk of photosensitivity (use sunscreen)
  • Blood dyscrasia (monitor CBC
  • Avoid if impaired hepatic and renal function (monitor LFTs, creatinine, UA)
90
Q

Thiazolidinediones

(1)

MOA

A

Pioglitazone (Actos)

Enhances insulin sensitivity in muscle tissue (decreases peripheral tissue resistance) and reduces hepatic glucagon production (gluconeogenesis).

91
Q

Thiazolidinediones

When should you take it?

Can it be combined with other anti-diabetics?

A

Take daily with breakfast

Can be combined with metformin, sulfonylureas, glucagonlike peptide 1 (GLP-1), sodium-glucose cotransporter-2 (SGLT2) inhibitors, dipeptidyl peptidase-4 (DPP-4) inhibitors, insulins.

92
Q

Thiazolidinediones Contraindications

(Pioglitazone)

  • Black Box Warning =
  • Causes (2) that can aggravate or precipitate CHG
  • Effect on weight =
  • Avoid if history of (1) - rare
  • Active ____ disease, Type 1 DM, pregnancy
  • Labs to check (1)
A
  • Black Box Warning = DO NOT USE with class III/IV heart disease, symptomatic HF (CHF)
  • Causes water retention and edema that can aggravate or precipitate CHG
  • Causes weight gain
  • Avoid if history of Bladder Cancer- rare
  • Active liver disease, Type 1 DM, pregnancy
  • Labs: Check LFTs
93
Q

Bile Acid Sequestrants

MOA

(3)

A

Reduces hepatic glucose production and may reduce intestinal absorption of glucose

Cholestyramine (Questran)

Colesevelam (Welchol)

Colestipol (Colestid)

94
Q

Bile Acid Sequestrants SE

How to take, what can it lower?

SE mostly ___ related =

SE are a common reason for? So what should you do?

Can effect (2), so check what labs?

A

Take with meals, lowers LDL

SE mostly GI related = Nausea, bloating, constipation, increased triglycerides

SE are a common reason for noncompliance, start patients on low dose and titrate up slowly

Kidney and liver effects (check Cr, GFR, LFTs)

95
Q

Meglitinide (Glinides)

(2)

MOA

A

Repaglinide (Prandin)

Nateglinide (Starlix)

Stimulates pancreatic secretion of insulin

96
Q

Meglitinides

Indicated for type 2 diabetics with (1)

Effect on weight =

Incidence of hypoglycemia?

  • Half life =
  • How to take?
  • If skipping a meal?
  • SE =
A

Indicated for type 2 diabetics with postprandial hyperglycemia

Weight neutral

May cause hypoglycemia

  • Rapid acting with very short half life (<1 hour)
  • Take before meals or up to 30 minutes after a meal
  • Hold dose if skipping a meal
  • SE = bloating, abdominal cramps, diarrhea, flatulence
97
Q

Rapid Acting Insulin

(3)

  • Onset =
  • Peak =
  • Duration =
A

Insulin Aspart (Novolog)

Insulin Lispro (Humalog)

Insulin Glulisine (Apidra)

  • Onset = 15 minutes
  • Peak = 30 min - 2.5 hr
  • Duration = 4.5 hr
98
Q

Short Acting Insulin

(1)

  • Onset =
  • Peak =
  • Duration =
A

Humulin R (Regular)

  • Onset = 30 min
  • Peak = 1-5 hour
  • Duration = 6-8 hours
99
Q

Intermediate Acting Insulin

(1)

  • Onset =
  • Peak =
  • Duration =
A

Insulin NPH

  • Onset = 1 hour
  • Peak = 6-14 hr
  • Duration = 18-24 hr
100
Q

Long Acting (basal) Insulin

(2)

  • Onset =
  • Peak =
  • Duration =
A

Insulin Glargine (Lantus)

Insulin Detemir (Levemir)

  • Onset = 1 hour
  • Peak = no peak
  • Duration = 24 hour
101
Q

Premixed Insulin

Humulin 70/30 = (____/_____)

Humulin 50/50

Other types available

  • Onset =
  • Peak =
  • Duration =
A

Humulin 70/30 = (NPH/Regular)

Humulin 50/50

Other types available

  • Onset = 30 min
  • Peak = 4.4 hr
  • Duration = 24 hours
102
Q

Basal Insulin

  • Peaks in (1) and then _____ level for most of the day
  • Humulin __
  • ____ (insulin glargine), _____ (insulin detemir)
    • Give ___ a day at the ____ time
A
  • Peaks in 1 hour and then steady level for most of the day
  • Humulin N
  • Lantus (insulin glargine), Levemir (insulin detemir)
    • Give once a day at the same time
103
Q

Insulin Mixtures

Humulin 70/30 (70% NPH ____, 30% ____insulin)

If mixing NPH and regular insulin, use the mixture immediately

Rapid-acting insulin can be mixed with NPH, but it should be used ___ minutes before a meal

A

Humulin 70/30 (70% NPH insulin, 30% regular insulin)

If mixing NPH and regular insulin, use the mixture immediately

Rapid-acting insulin can be mixed with NPH, but it should be used 15 minutes before a meal

104
Q

Insulin Pumps

Insulin pumps require in_____ training; they are expensive. Can be used for ___ type 1 and type 2 diabetics. Patients should remove pump when sw_____ or sh______.

A

Insulin pumps require intensive training; they are expensive. Can be used for both type 1 and type 2 diabetics. Patients should remove pump when swimming or showering.

105
Q

Clinical Pearls

____-acting insulins (insulin lispro) are used mostly by type __ diabetics before each ___.

Intermediate-acting insulin (NPH) can be used ___ or ____ a day.

A

Rapid-acting insulins (insulin lispro) are used mostly by type 1 diabetics before each meal.

Intermediate-acting insulin (NPH) can be used once or twice a day.

106
Q

Alpha-Glucosidase Inhibitor

(2)

MOA

Incidence of hypoglycemia?

Effect on A1C?

SE =

A

Acarbose (Precose), Miglitol (Glyset)

Slows intestinal carbohydrate digestion and absorption, a nonsystemic oral drug

Does not cause hypoglycemia

Modest effect on A1C

GI SE = flatulence, diarrhea

107
Q

Glucagon-Like-Peptide Receptor Agonists (GLP-1 RAs)

(4)

A

Exenatide (Byetta)

Liraglutide (Victoza)

Dulaglutide (Trulicity)

Semaglutide (Ozempic)

108
Q

GLP-1 RAs

MOA

A

Stimulate GLP-1, causing an increase in insulin production and inhibiting postprandial glucagon release (will decrease postprandial hyperglycemia); increase satiety

109
Q

GLP-1 RA Effects

Effect on hypoglycemia?

Effect on cardiovascular disease?

Effect on weight loss?

A

Does not cause hypoglycemia

Reduces cardiovascular disease (CVD) events/death and death from kidney disease

Causes weight loss, suppresses appetite

110
Q

GLP-1 RA Side Effects and Contraindications

  • Side Effects
    • _____titis (monitor (2))
    • Medullary (1) in animals
    • C-cell ________
  • Contraindications
    • Personal or family history of (1)*
    • MEN-2 =
A
  • Side Effects
    • Pancreatitis (monitor amylase, lipase)
    • Medullary thyroid tumors in animals
    • C-cell hyperplasia
  • Contraindications
    • Personal or family history of medullary thyroid carcinoma
    • MEN-2 = Multiple endocrine neoplasia syndrome type-2
111
Q

Sodium Glucose Cotransporter-2 Inhibitors (SGLT-2 inhibitors)

MOA

(3)

A

Block glucose reabsorption of glucose by the kidney (proximal nephron) and increase glucosuria

Canagliflozin (Invokana)

Dapagliflozin (Farxiga)

Empagliflozin (Jardiance)

112
Q

SGLT-2 Inhibitors Effects

Effect on hypoglycemia?

Effect on Cardiovascular and Kidney disease?

Effect on weight?

A

No hypoglycemia

Reduces CVD events/death, Helps slow progression of CKD

Causes weight loss/hypotension (volume depletion)

113
Q

SGLT-2 Inhibitor Side and Adverse Effects

Renal signs and symptoms* =

FDA warning =

Warning =

A

Increased risk of urinary tract infections (UTIs) and pyelonephritis (urosepsis), polyurea, increased creatinine

FDA warning = may lead to DKA (symptoms of difficulty breathing, nausea, vomiting, abdominal pain, confusion, and unusual fatigue or sleepiness)

Increased risk of leg and foot amputations

114
Q

Dipeptidyl Peptidase-4 Inhibitors (DPP-4 Inhibitors)

MOA

(3)

A

Blocks action of DPP-4, an enzyme that destroys the hormone incretin, increase active incretin concentrations → increase insulin secretion and decrease glucagon

Sitagliptin (Januvia)

Saxagliptin (Onglyza)

Linagliptin (Tradjenta)

Incretins are gut hormones that are secreted from enteroendocrine cells into the blood within minutes after eating. One of their many physiological roles is to regulate the amount of insulin that is secreted after eating, Incretin effect is reduced in type 2 diabetes

115
Q

DPP-4 Inhibitors Effects

Effect on hypoglycemia?

Effect on Cardiovascular disease?

Effect on Kidneys?

Effect on weight?

A

No Hypoglycemia

CARDIOVASCULAR EFFECTS NEUTRAL: As a class, DPP4i are not associated with any increase or reduction of MACE, all-cause mortality, and heart failure. Saxagliptin seems to be associated with an increased risk of hospitalization for heart failure.

RENOPROTECTIVE effect by delaying kidney disease progression and decreasing albuminuria

WEIGHT NEUTRAL

116
Q

DPP-4 Inhibitors FDA Warning

(3)

A

May cause joint pain that can be severe and disabling (may occur on day 1 or years later)

Angioedema/urticaria

Acute pancreatitis

117
Q

Can you use GLP-1 RAs (glutides) and DPP-4 Inhibitors (gliptins) at the same time?

A

Do not combine incretin mimetics (Exenatide (byetta), Liraglutide (Victoza)) with any incretin enhancers ( Sitagliptin (Januvia), Saxagliptin (Onglyza)). Both act on incretin.

118
Q

Amylin Mimetic/Analog

MOA

(1)

A

Decreases glucagon secretion; slows gastric emptying; leads to feeling satiety early

Symplin

119
Q

Amylin Mimetic (Symlin) Administration

Route, Dosing frequency

Causes hypoglycemia if used with?

A

Route: Injection, frequent dosing that requires patient training

Can cause hypoglycemia if used with insulin (decrease insulin dose)

120
Q

Prescribing Tips: Type 2 Diabetics

  • First step in managing a patient with mild A1C elevation?
  • In addition to lifestyle, Rx (1) is first-line treatment for most type 2 diabetics. Starting dose? Max dose?
    • If metformin dose is at maximum (and blood sugar or A1C is still high), add a Rx (1) (e.g., Glucotrol XL 20 mg/day). OR
    • If patient is on a sulfonylurea at the maximum dose (e.g., Glucotrol XL 40 mg/d) and blood sugar/A1C is still elevated, then add Rx (1).
A
  • Try lifestyle changes (weight loss) for 3 to 6 months if mild A1C elevation.
  • In addition to lifestyle, metformin is first-line treatment for most type 2 diabetics. Start on metformin 500 mg daily (maximum dose is 2,000 mg/dL, or 2 g).
    • If metformin dose is at maximum (and blood sugar or A1C is still high), add a sulfonylurea (e.g., Glucotrol XL 20 mg/day). OR
    • If patient is on a sulfonylurea at the maximum dose (e.g., Glucotrol XL 40 mg/d) and blood sugar/A1C is still elevated, then add metformin.
121
Q

Prescribing Tips: Type 2 Diabetics

Choice of second or third agent is any other drug class used to treat type 2 DM.

  • If on maximal metformin dose (2 g), other choices to add are (1) (Januvia, Onglyza), (1) (Byetta), and/or (1) (TZDs; Actos), others.
  • Do not combine insulins with meglitinides, why?
A
  • If on maximal metformin dose (2 g), other choices to add are DPP-4 inhibitors (Januvia, Onglyza), incretin mimetics (Byetta), and/or thiazolidinediones (TZDs; Actos), others.
  • Do not combine insulins with meglitinides (severe hypoglycemia).
  • Sitagliptin (januvia) = DPP-4i*
  • Exenatide (byetta) = GLP-RA*
122
Q

Prescribing Tips: Type 2 Diabetics

Presence of CVD and/or chronic kidney disease, or heart failure with reduced ejection fraction (HFrEF), start on an (1) and/or (1)

If blood sugar or A1C is still elevated and patient is on both metformin and sulfonylurea, consider starting patient on a (1)

If patient refuses insulin, other options are (1) (Actos), (1) (Byett)a, others. Keep in mind the contraindications for each drug class.

A

Presence of CVD and/or chronic kidney disease, or heart failure with reduced ejection fraction (HFrEF), start on an SGLT-2 inhibitor and/or GLP-1 RA.

If blood sugar or A1C is still elevated and patient is on both metformin and sulfonylurea, consider starting patient on a basal insulin (Lantus SC once a day).

If patient refuses insulin, other options are thioglitazones (Actos), GLP-1 RA Byetta, others. Keep in mind the contraindications for each drug class.

123
Q

Diabetes Medications Effect on Weight

Medications that cause weight loss

Medications that cause weight gain

Medications weight neutral

A

Weight Loss = Metformin, GLP-1 RAs, DPP-4 SGLT-2i

Weight Gain = Insulin, Sulfonylureas, TZDs, Meglitinides

Weight Neutral = Meglitinides? Bile Acid-Sequestrants (Welchol), Alpha-glucosidase inhibitors

124
Q

Diabetes Management Tips

Refer to (1) to learn about ______ counting. The ADA recommends f___and p_____counting as well. _______ changes are first-line treatment.

(1) and (1) protect the heart and kidneys and promotes weight loss.

Eating more f____ and whole _____ (brown rice, whole wheat) may help.

_______ increases cellular glucose uptake in the body.

Type 2 diabetics not well controlled on multiple oral agents and diet and lifestyle changes are good candidates for (1) therapy.

A

Refer to dietitian to learn about carbohydrate counting. The ADA recommends fat and protein counting as well. Lifestyle changes are first-line treatment.

SGLT-2 inhibitors and GLP-1 RAs protect the heart and kidneys and promotes weight loss.

Eating more fiber and whole grains (brown rice, whole wheat) may help.

Exercise increases cellular glucose uptake in the body.

Type 2 diabetics not well controlled on multiple oral agents and diet and lifestyle changes are good candidates for basal insulin therapy.

125
Q

Diabetes Complications

  • Eyes:* C_____, diabetic ______, _____ness
  • Cardiovascular:* Hyper_____, _______artery disease, M_, ______tension
  • Kidneys:* Renal disease, renal ______
  • Feet:* Foot ul______, skin in______, peripheral n______, amp______
  • Gynecologic/genitourinary:* _______ (candidal infection of the glans penis), c______ vaginitis
A
  • Eyes:* Cataracts, diabetic retinopathy, blindness
  • Cardiovascular:* Hyperlipidemia, coronary artery disease, MI, hypertension
  • Kidneys:* Renal disease, renal failure
  • Feet:* Foot ulcers, skin infections, peripheral neuropathy, amputation
  • Gynecologic/genitourinary:* Balanitis (candidal infection of the glans penis), candidal vaginitis
126
Q

Primary Prevention of Diabetes

For individuals at high risk of type 2 DM

Encourage how much weight loss?

How much exercise?

Increase in dietary (2)

A

Encourage weight loss (7% of body weight)

Regular physical activity 150min/week

Increase dietary fiber and whole grains

127
Q

Solving an Insulin Related Question

The nurse practitioner certification exams are based on the primary care model of care. In general, it is not necessary to memorize specific doses. Keep in mind some broad concepts, such as the peak and duration of each type of insulin. For example:

Rapid-acting insulin covers =

Regular insulin lasts =

NPH insulin lasts =

Lantus is =

A

Rapid-acting insulin covers “one meal at a time”

Regular insulin lasts “from meal to meal”

NPH insulin lasts “from breakfast to dinner”

Lantus is “once a day”

128
Q

Case Scenario

A patient with type 1 DM is on regular insulin and NPH insulin (not premixed but separate) injected twice a day. The first dose is injected before breakfast, and the second dose is injected at bedtime. The blood sugar results from the patient’s diary (fasting, before lunch, dinner, and bedtime) show that the lunchtime values are higher than normal. Which insulin dose should be increased or decreased?

A

In this case, the NPH component of the morning dose should be increased. Regular insulin peaks between breakfast and lunch (most of it is gone by lunchtime). In contrast, NPH insulin peaks between 6 and 14 hours. Therefore, it will cover the postprandial spike after lunch.

129
Q

Exam Tips

First-line medication for type 2 DM is (1)

  • If patient on metformin 500 mg daily and A1C is high (>7%), increase dose to?
  • If A1C is still high (>7%) and on metformin 500 mg BID, increase dose to?
  • If taking maximum dose of metformin (1 g BID), can use several drug classes with it such as a
    • (1) like glipizide (Glucotrol XL) 5 mg PO daily (do not exceed maximum dose of glipizide 20 mg/day)
    • (1) (Januvia, Onglyza)
    • (1) (Actos), others.
A

First-line medication for type 2 DM is metformin (Glucophage).

  • If patient on metformin 500 mg daily and A1C is high (>7%), increase dose to metformin 500 mg BID.
  • If A1C is still high (>7%) and on metformin 500 mg BID, increase dose to metformin 1,000 mg BID (or 1 g BID).
  • If taking maximum dose of metformin (1 g BID), can use several drug classes with it such as a
    • Sulfonylurea like glipizide (Glucotrol XL) 5 mg PO daily (do not exceed maximum dose of glipizide 20 mg/day)
    • DPP-4 inhibitor (Januvia, Onglyza)
    • TZDs (Actos), others.
130
Q

Exam Tips

At what A1C do you need to start on basal insulin?

HbA1C is the average blood glucose level over how long?

Important contraindication of Pioglitazone (Actos) =

(1) foot and ankle is more common in diabetics.

A

If a patient’s A1C is ≥9, start on basal insulin. Or if on two oral drugs and A1C is ≥9, start on basal insulin.

Hemoglobin A1C is the average blood glucose level in previous 3 months (12 weeks).

Pioglitazone (Actos) can cause water retention, which may precipitate CHF. Contraindicated if history of heart failure or NYHA class III or IV (moderate to severe heart failure).

Charcot’s foot and ankle is more common in diabetics.

131
Q

Exam Tips

Microvascular complications of diabetes are (3)

Macrovascular complications are (3)

Diabetic Retinopathy findings are (4)

Hypertensive retinopathy findings are (2)

(Photographs of fundi appear on the exam. Search for photographs online)

A

Microvascular complications of diabetes are retinopathy, nephropathy, and neuropathy.

Macrovascular complications are coronary artery disease, peripheral arterial disease, and stroke.

Diabetic Retinopathy findings are cotton-wool (soft exudates), neovascularization, microaneurysms with dot, and blot hemorrhage.

Hypertensive retinopathy findings are silver wire/copper wire arterioles, arteriovenous nicking.

(Photographs of fundi appear on the exam. Search for photographs online, learn what cotton wool spots look like)

132
Q

Exam Tips

Lid Lag is a symptom of?

Alopecia on outer third of eyebrow and myxedema are symptoms of?

When should a patient disconnect from their insulin pump?

A

Lid lag is a symptom of Graves’ ophthalmopathy (hyperthyroidism).

Alopecia of outer one-third of eyebrow and myxedema are symptoms of hypothyroidism.

Tell patient to disconnect insulin pump if swimming, bathing, or showering. Certain sports (e.g., wrestling) require that an insulin pump be disconnected during activity.

133
Q

Clinical Pearls

People with subclinical and overt hyperthyroidism are at higher risk of bone (1) and cardiac (1) complications.

New-onset atrial fibrillation, check (1).

  • Keep TSH between ___ and ____ mU/L as goal for thyroid hormone supplementation.

Diabetics are at higher risk for (2) ophthalmologic conditions

In morbidly obese patients, _________ surgery can result in remission of type 2 diabetes.

A

People with subclinical and overt hyperthyroidism are at higher risk of bone (osteopenia/osteoporosis) and cardiac (atrial fibrillation) complications.

New-onset atrial fibrillation, check TSH. - Keep TSH between 1.0 and 4.0 mU/L as goal for thyroid hormone supplementation.

Diabetics are at higher risk for cataracts and glaucoma.

In morbidly obese patients, bariatric surgery can result in remission of type 2 diabetes.

134
Q

Exam Tips

Subclinical Hypothyroidism TSH and T4 level =

If patient has elevated TSH (>5.0 mU/L), workup needed for _______ (e.g., order(2)).

Start older patients at ____ dose of Synthroid (12.5–25 mcg/day) and gradually increase to avoid adverse ______ effects from overstimulation (palpitations, angina, MI).

Patient with normal free T4 but with elevated TSH—do you treat? what should you do?

A

Subclinical Hypothyroidism TSH and T4 level = TSH elevated, normal free T4

If patient has elevated TSH (>5.0 mU/L), workup needed for hypothyroidism (e.g., order TSH, free T4).

Start older patients at low dose of Synthroid (12.5–25 mcg/day) and gradually increase to avoid adverse cardiac effects from overstimulation (palpitations, angina, MI).

Patient with normal free T4 but with elevated TSH—do not treat (subclinical hypothyroidism). Recheck TSH in about 6 months.

135
Q

Exam Tips

When do you recheck TSH to monitor treatment response? If TSH is 0.05 to 5.0 mU/L, it is within normal limits and the patient is at the right dose (Synthroid).

Radioactive iodine treatment results in _____thyroidism for life. Needs (1) for life.

If TSH is suppressed (TSH <0.05 mU/L), workup needed for _____thyroidism.

Chronic amenorrhea and hypermetabolism result in ______. Supplement with c_____ and with ______ 1,200 mg; engage in (1) exercises.

A

Check TSH every 6 to 8 weeks (do not order earlier than 6 weeks) to monitor treatment response. If TSH is 0.05 to 5.0 mU/L, it is within normal limits and the patient is at the right dose (Synthroid).

Radioactive iodine treatment results in hypothyroidism for life. Supplement with thyroid hormone for life.

If TSH is suppressed (TSH <0.05 mU/L), workup needed for hyperthyroidism.

Chronic amenorrhea and hypermetabolism result in osteoporosis. Supplement with calcium and with vitamin D 1,200 mg; engage in weight-bearing exercises.

136
Q

Clinical Pearls

Many patients with subclinical hypothyroidism will eventually develop?

Advise patient to _____ Synthroid tablets with teeth before swallowing with ____ for better absorption. These tablets are _____ T4 (levothyroxine).

Alternative medicine practitioners are more likely to prescribe _____ thyroid tablets (desiccated thyroid glands from pigs), which contain natural T3 and T4 for hypothyroidism.

All ____thyroid patients should be referred to an _______ as soon as possible.

A

Many patients with subclinical hypothyroidism will eventually develop overt hypothyroidism.

Advise patient to crush Synthroid tablets with teeth before swallowing with water for better absorption. These tablets are synthetic T4 (levothyroxine).

Alternative medicine practitioners are more likely to prescribe Armour thyroid tablets (desiccated thyroid glands from pigs), which contain natural T3 and T4 for hypothyroidism.

All hyperthyroid patients should be referred to an endocrinologist as soon as possible.

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