Adrenal and Thyroid

Question 1

What are the symptoms of diabetes insipidus?

Answer 1

Main symptoms are polyuria and polydipsia
If left untreated can lead to shock like symptoms, hypotension, tachycardia and tachypnea, dehydration, hypernatrena (increase sodium)

Question 2

What are the treatment for diabetes insipidus?

Answer 2

Vasopressin injection
Desmopressin injection/tab/nasal spray

Question 3

What causes nephrogenic diabetes insipidus?

Answer 3

Collecting ducts don’t respond to ADH
Can be used by drugs e.g Lithium, genetic or intrinsic kidney disease and electrolyte imbalance

Question 4

What is cranial diabetes insipidus?

Answer 4

Hypothalamus doesnt produce ADH
Can be caused by brain tumours, infections or idiopathic

Question 5

How do you test for both types of diabetes insipidus?

Answer 5

Measure urine osmolality without fluid or food for 8 hours, then give desmopressin, then measure urine osmolality 8 hours after
Cranial DI- higher urine osmolality
Nephrogenic DI- same (low) urine osmolality
Primary polydipsia (no DI) after initial 8 hour deprivation there should still be a high osmolality so no diabetes insipidus so don’t give desmopressin

Question 6

What is the treatment for GH deficiency?

Answer 6

Potential risk of cancer
Treatment is somatotropin (recombinant GH)
Given for short stature
Also somatorelin, a 44a.a can be given if relevant
Also Mecasermin (recombinant IGF-1) where is growth failure in children lacking adequate IGF-1

Question 7

What is the treatment for a pt having GH excess?

Answer 7

Surgery
Medicines- somatostatin analogues given as an adjunct to surgery
Somostatinn acts on all the SST1-5 receptors
Different analogues acts on specific set receptors:
-octreotide -lanreotide -pasireotide
Other drugs:
-dopamine agonists, bromocriptine
-GHRH antagonists, pegvisomant

Question 8

What is the treatment for aldosterone hypersecretion?

Answer 8

Usually surgery to remove a tumour and spironolactone

Question 9

State and describe the symptoms of Cushing’s syndrome:

Answer 9

Results in glucose excess and protein shortage, abnormal fat distribution resulting in ‘buffalo hump’ and ‘moonfaced’
Fragile thin skin- from muscle breakdown leading to tiredness and weakness
Inhibits immune system- adequate protein production for wound healing
osteoporosis, hirsutism, hypertension, psychosis and depression, hyperglycaemia

Question 10

State and describe the treatment for Cushing’s syndrome:

Answer 10

Surgery or radiotherapy for tumours
Corticosteroid inhibitors:
-metyrapone- a competitive inhibitor of 11B hydroxylation in the adrenal cortex
-ketoconazole- acts as a potent inhibitor of cortisol and aldosterone synthesis by inhibiting the activity of a17-hydroxylase, 11 hydroxylation steps and at higher doses the cholesterol sidechain cleavage enzyme, may have direct effect on corticotropic tumour cells in patients with Cushing’s disease
-mitotane- inhibits glucocorticoid synthesis by an unknown direct effect on the adrenal gland
-carbenexone- inhibits hydrocortisone conversion to cortisone

Question 11

Describe Addison’s disease:

Answer 11

Deficiency in glucocorticosteroids and in mineralcorticoids
Due to atrophy in the adrenal cortex

Question 12

What are the symptoms of Addison’s disease?

Answer 12

Lethargy, depression, anorexia and weight loss

Question 13

What is Addison’s crisis?

Answer 13

Where it can first present as a severe adrenal deficiency and is a medical emergency
Symptoms of vomiting, abdominal pain, weakness, hypertension, hyperpigmentation and eventually coma

Question 14

What is a treatment for Addison’s disease?

Answer 14

Lifelong steroid replacement
Hydrocortisone- replaces cortisol, 20 to 30 mg daily and divided dose, larger dose in morning to mimic diurnal rhythm of cortisol secretion
Fludrocortisone- replaces aldosterone, 50 to 300 µg daily

Question 15

What is a treatment for Addison’s crisis?

Answer 15

Treat with IV hydrocortisone
100mg every 6-8 hours

Question 16

What are the sequels for long-term steroid use?

Answer 16

Inter-current illness, trauma or surgery- need to temporarily increase days to compensate (temporarily double)

Question 17

Why shouldn’t you withdraw steroids abruptly?

Answer 17

Cause acute adrenal insufficiency as adrenal glands can’t switch back on
Hypotension, confusion, coma, death

Question 18

What is a steroid treatment card?

Answer 18

Blue card- allows healthcare professionals to not stop abrupt withdrawal
Contains the drugs name, dose, strength etc

Question 19

Under which conditions would gradual withdrawal of steroids be needed:

Answer 19

More than 40mg prednisolone OD for more than a week
More than 3 week treatment
Recently received repeated short courses
Needed short course within 1 year of stopping long term therapy

Question 20

What are the rules of infection for patients on prolonged steroid therapy?

Answer 20

Prolonged causes increase susceptibility to infection
If never had chickenpox, avoid contact with people who have had shingles or chickenpox
Avoid exposure to measles
Seek medical advice if exposure occurs

Question 21

What are psychiatric reactions of steroid therapy?

Answer 21

High doses:
-euphoria, nightmares, insomnia, irritability, suicidal thoughts (especially if history)
Usually subside on dose reduction or withdrawal

Question 22

What are other side-effects of corticosteroid treatment?

Answer 22

Mineral corticoid:
- hypertension (Na and water retention)
Glucocorticoid:
-diabetes/ glucose intolerance, osteoporosis, GI disturbances, Cushing’s syndrome, growth suppression in children

Question 23

Give an example of a prophylaxis treatment of corticosteroids:

Answer 23

Bisphosphonates, prophylaxis for osteoporosis

Question 24

What are the symptoms of too much thyroid hormone?

Answer 24

Weight loss, increase heart rate, fatigue etc

Question 25

What are the symptoms of too little thyroid hormone?

Answer 25

Swelling, weight gain etc

Question 26

What is the major presenting symptom of thyroid disease/ dysfunction and give reasons for this:

Answer 26

Goitre= enlargement of the thyroid as swelling in the neck This occurs in: -Thyroid cancer -Hypothyroidism often due to Hashimoto's thyroiditis -Hyperthyroidism often due to Graves disease

Question 27

What is Hashimoto's thyroiditis?

Answer 27

An autoimmune disease where the body makes antibodies to thyroglobulin and causes primary hypothyroidism, preventing thyroid hormone from being made

Question 28

What are the symptoms and signs of hypothyroidism?

Answer 28

Metabolism slows down so everything is slower and weaker resulting in a low metabolic rate, generalised weakness, slow speech, cold and intolerance, memory loss, depression, constipation, weight gain, dry skin, sparse thin hair, growth failure in children, amenorrhea

Question 29

What is myxoedema coma?

Answer 29

A life-threatening complication of chronic thyroid hormone deficiency resulting in brain damage and death if not treated

Question 30

What is the diagnosis for primary hypothyroidism?

Answer 30

Confirm by checking a patient's thyroid function test (TFTs) and testing blood TSH and T3 and free T4 levels Ideally all levels and thyroid antibodies should be checked but not available in all hospitals Hypothyroidism will be confirmed by high TSH levels and low free T4 and T3 levels, raise TSH levels is a gold standard for diagnosis

Question 31

What is the diagnosis for secondary hypothyroidism?

Answer 31

All TSH, T4 and T3 will be low

Question 32

What is the treatment for hypothyroidism?

Answer 32

Levothyroxine (thyroxine) orally, a synthetic form of T4

Question 33

Describe the treatment for hypothyroidism:

Answer 33

Levothyroxine starting dose 50 to 100mcg, 1.6mcg/kg in the morning, 25µg for the elderly Should be taken on an empty stomach Can take a few months to have an effect, the aim is to maintain TSH levels in reference range, can take up to 6 months Initially check levels after 2-3 months, if TSH levels still raised, increase dose by 25-50mcg Usual maintenance dose 100-150mcg daily, very rare to see a dose higher than 200mcg

Question 34

Why do you have to take levothyroxine on an empty stomach?

Answer 34

Food can decrease reabsorption by 40 to 80% and reduced by iron, antacids, calcium containing products and soya milk

Question 35

What is a treatment for severe hypothyroid states including hypothyroid coma?

Answer 35

Liothyronine (T3)- IV Acts rapidly but has a shorter duration of action Need to be monitored in the blood to minimise risk of hyperthyroidism Iodine can also be given in iodine deficiency

Question 36

Give the aetiology of hyperthyroidism:

Answer 36

Most common is Graves' disease (80-90%) Most patients present between 30 to 60 years and is 10% more common in women than men

Question 37

What is Graves' disease?

Answer 37

An autoimmune condition with a genetic predisposition, where the body makes thyroid-stimulating antibodies that mimic TSH, stimulating the TSH receptor

Question 38

What are the symptoms and signs of hyperthyroidism?

Answer 38

The metabolism speeds up with an increase in sympathetic activity, resulting in a higher metabolic rate Palpitations, sweating, trauma, anxiety, diarrhoea, inability to tolerate heat and weight loss In addition patients experience goitre and eye problems: -Exophthalmus (bulging eyes) -swelling of eyelids -irritation, lid retraction -ophthalmoplegia (weakness of eye muscles) -diplopia

Question 39

What is a diagnosis for hyperthyroidism?

Answer 39

Low TSH levels and high free T4 and T3 levels due to too much T4 and T3 produced by thyroid and resulting negative feedback causing anterior pituitary to cut off production of TSH

Question 40

What is exophthalmos and how is it caused?

Answer 40

Causes buldging of eyes due to graves disease due to inflammation, swelling and hypertrophy of muscle behind eyeball, forcing it forward

Question 41

What is pretibial myxoedema?

Answer 41

Deposits of mucin under the skin Discoloured, waxy, oedematous Specific to Grave's disease

Question 42

Describe the first line treatment for hyperthyroidism?

Answer 42

Carbimazole (thioureylenes) Normal thyroid function after 4 to 8 weeks Continue maintaining dose or titrated down to maintain all levels 'titration block' Or block all production of thyroid hormone and replace with levothyroxine 'block and replace' Complete remission after 18 months

Question 43

Describe the second line treatment for hyperthyroidism:

Answer 43

Propylithiouracil Small risk of hepatic reactions- death

Question 44

What can't you do when taking radioactive iodine for hyperthyroidism?

Answer 44

Can't get pregnant Stay away from children Limit contact with anyone few days after treatment

Question 45

What are other drug treatments for hyperthyroidism?

Answer 45

Beta blockers (propranolol, non selective for thyroid storm), doesn't treat hyperthyroidism but blocks adrenaline related symptoms: -tachycarida, anxiety, sweating, tremor Surgery

Question 46

What are side-effects in drugs used for hyperthyroidism?

Answer 46

Rashes (5%) and agranulocytosis, rare but life-threatening in 0.3% of patients- Ab mediated, resulting in complete depletion of neutrophils and increase susceptibility to bacterial infections, as well as the depletion of RBCs so increase risk of bleeding

Question 47

What are the monitoring parameters for drugs used in hyperthyroidism and why?

Answer 47

All patients should be told to report any signs of sore throat, mouth ulcers, fever, malaise, bruising or bleeding due to the risk of agranulocytosis

Question 48

When are high doses of iodine/iodide given in hyperthyroidism?

Answer 48

Lugol's iodine Sometimes given to temporarily inhibit the release of thyroid hormones Given as oral solution Symptoms decrease after 1-2 days Max effect at 10-15 days then effect decreases Sometimes given to patients are waiting for surgery and acute throtoxiccrisis

Question 49

Describe drug induced thyroid dysfunction and what should be the monitoring parameters?

Answer 49

Amiodarone (for cardiac arrhythmias) can cause thyroid dysfunction (hypo/hyper) as molecule contains a significant amount of iodine Patients taking amiodarone should have the baseline TFT's measured at start of treatment and six months thereafter