Block 1 Flashcards
(308 cards)
1
Q
For pregnant women, what Rx should you give for hyperthyroidism?
A
Start w/ PTU for the first trimester, then use MMI for the remainder of pregnancy
2
Q
Low probability of HPA suppression include…
A
Any dose for less than 3 wks Prednisone alternating day regimen ≤10mg QOD
3
Q
Mitotane AE?
A
Teratogenic (stored in fat for up to 5 yrs) Induces CYP3A4
4
Q
When should you choose dopamine agonists initially for pituitary issues?
A
- Poor 2. Inability to handle inj. 3. IGF-1 values only modestly elevated and mild signs/symptoms
5
Q
What are some counseling points on radioactive iodine?
A
- Do NOT exchange saliva for 5 days 2. AVOID contact with youngling and pregnant women for 5 days 3. NO breast-feeding 4. Flush toilet twice
6
Q
What are some pros of GH receptor antagonist for pituitary issues?
A
Most effective at normalization of just IGF-1
7
Q
When can you use iodides during the time you’re taking taking radioactive iodine?
A
3-7 days AFTER
8
Q
What is the function of oxytocin?
A
Contract smooth muscles in breast during lactation and plays a role in uterine contraction during parturition
9
Q
Pegvisomant should be based on (GH/IGF-1) values
A
IGF-1 values
10
Q
Which beta blockers can partially block the conversion of T4 to T3?
A
Propranolol Nadolol Metoprolol
11
Q
What is the first line Tx for Bilateral Primary Aldosteronism? Lifestyle modifications?
A
- Aldosterone antagonist (like spironolactone) 2. Potassium-sparing diuretic (like Amiloride) Surgery is TOC for unilateral Limit Na+ <100mEq/day, avoid EtOH
12
Q
Primary adrenocortical insufficiency differs from secondary by…?
A
Primary = destruction of adrenal gland Secondary = hormonal regulation
13
Q
Radioactive Iodine Uptake test is contraindicated in whom?
A
Pregnant or breastfeeding patients
14
Q
Which hypercortisolism condition allows for any pharmacologic therapy option?
A
Cushing’s Disease You can use block and replace, normalization, steroidogenesis inhibitors, adrenolytics, pituitary-targeted** **only one with this Rx group
15
Q
Pharmacodynamics of GH?
A
*Stimulates Liver *Produces insulin-like growth factors *Increase protein levels *Increase release of FA from fat tissues *Increase conversion of FA to acetyl-CoA for energy *ELEVATES BLOOD GLUCOSE Overall effect: encourage burning of fat for energy and increase muscle/bone growth
16
Q
No doses of glucocorticoids should be given to a patient within _____ hrs within bedtime
A
4 to 6 hrs
17
Q
What is the only GH receptor antagonist?
A
Pegvisomant (Somavert)
18
Q
When should you consider checking your GH levels when on Somatostatin LAR?
A
3 months
19
Q
What is Type I and II hyperthyroidism?
A
I = occurs to those w/ underlying risk factors for thyroid disease II = results form destruction of thyroid which releases thyroid hormones
20
Q
AE of Pegvisomant (Somavert)?
A
Hypoglycemia, N/V, Increased LFTs, Flu-like symptoms
21
Q
What are some side effect due to doses of >7.5mg/day of prednisone or equivalent?
A
CV issues Monitor by having a lipid panel after 1 month and then every 6 to 12 months
22
Q
What is therapeutic use of Etomidate?
A
FDA approved = for anesthesia Off-label = rapid control of hypercortisolism at 0.3mg/kg/hr
23
Q
If dopamine agonists activate dopamine D2 receptors in the substantia nigra, what happens?
A
Relieves symptoms of Parkinson’s Disease
24
Q
How is GH dosed and given?
A
QD SubQ 25-50mcg/kg monthly or every 2 wks @ bedtime
25
Iodine deficiency is called...
Goitrous hypothyroidism
26
What are the basic steps into the ACTH Stimulation Test?
To detect primary or secondary adrenal insufficiency 1. Draw plasma cortisol at 8 2. Give Cosyntropin 250mcg IM or IV 3. Check cortisol at 30 min and 60 min 4. Cortisol \>18 = normal, No change = Addison's
27
What are some cons to GH receptor antagonist for pituitary issues?
Expensive and is an injection
28
What are the monitoring for all patients on Recombinant GH?
Thyroid function, glucose, IGF-1, lipid panel Height, weight, BMI
29
What are some other causes for hyperprolactinemia?
\*CNS lesions \*Increase in TRH in hypothyroidism \*Renal/hepatic impairment
30
AE of dopamine agonists?
GI effects, CNS effects, hypotension
31
Onset for hyperthyroidism Thiourea? Iodides? Adrenergic blockers?
Wks Days Hours
32
Which Rx for aldosteronism is contraindicated if CrCl \<30?
Eplerenone
33
What are some indications of d/c corticosteroids?
Steroid-induced psychosis unresponsive to antipsychotics Herpes virus-induced corneal ulceration (lead to blindness)
34
What kind of substrate is Bromocriptine?
CYP3A4; dont mix with CYP3A4 inhibitors
35
When should you choose somatostatin analogs initially for pituitary issues?
Moderate - severe disease First, Octreotide Use Lanreotide if refractory to octreotide and pasireotide if refractory to both
36
When is surgery the treatment of choice for Cushing's Syndrome? What kind of surgery will they need?
When it is Non-iatrogeneic (not caused by surgery or Rx) Unilateral adrenalectomy Transsphenoidal surgery = disease only, not syndrome
37
If you suspect Cushing's Syndrome, what should you do? When should you administer RX and draw serum levels? What do you test for if abnormal?
24-hr cortisol collection, midnight salivary cortisol level, 1 mg of dexamethasone overnight Give RX @ 11pm to 12am Draw serum cortisol at 8am Cortisol \<1.8 = normal 1.8 to 5mcg/dL = likely abnormal \>5 = abnormal If abnormal, test for plasma ACTH Low = ACTH-independent Normal/High = ACTH-dependent and must have inferior petrosal sinus sampling Central\>peripheral = pituitary tumor Central
38
Somatostatin is released by what?
Hypothalamus and pancreas
39
When should you consider checking your GH levels when on Somatostatin IR?
1 month
40
What kind of RX should you not take with Bromocriptine?
Ritonavir, Indinavir, Ketoconazole, Itraconazole, Clarithyromycin
41
What hormones are produced in the adrenal cortex?
1. Glucocorticoids 2. Androgen precursors 3. Mineralocorticoids
42
What enzyme oxidizes iodide?
Thyroid peroxidase
43
High probability of HPA suppression include..
Prednisone \>20mg/day for 3+ wks Bedtime prednisone 5mg/day for 2+ wks Cushingoid appreanace
44
What are the 2nd-Gen alpha adrenergic antagonists for BPH and their initial/usual dose?
1. Alfuzosin (10 and 10) 2. Doxazosin (1 IR and 8 /// 4 ER and 4 to 8) 3. Terazosin (1 and 10-20) 4. Prazosin (0.5 and 1-5)
45
Of the steroidogenesis inhibitors for Cushing's, which one has a rapid onset?
Etomidate (IV) and Metyrapone Ketoconazole is the slowest
46
What parts make up monoiodotyrosine (MIT) and diiodotyrosine (DIT)?
Oxidized iodide + Thyroglobulin
47
What is a typical manner in which GH is secreted?
In a pulsatile manner Low during waking hours and peaks in the first 1-2 hours of sleep Increases after meals, exercise or periods of stress
48
What are some contraindications for dopamine agonists?
Valvulopathy, Ischemic heart disease, peripheral vascular disease, uncontrolled HTN
49
Which Rx for hypercortisolism is a prodrug?
Mitotane
50
What is the Wolff-Chaikoff Effect?
Excessive Iodide (I-) blocks the thyroid function (synthesis and release)
51
How is BPH ranked in regards to severity?
Mild - AUA ≤7 - asymptomatic, peak urine flow \<10, PVR volume \>25-50ml Moderate - AUA 8 to 19, above + LUTS Severe ≥20, above + one or more BPH complication
52
Which dopamine agonist is used for Hyperprolactinemia?
Bromocriptine (Parlodel®) Cabergoline (Dostinex®)
53
What are the equivalent doses for hydrocortisone, prednisone, and methylprednisolone?
Hydrocortisone - 20mg Prednisone - 5mg Methylprednisolone - 4mg
54
Before tapering steroids, what could you do beforehand? How would you taper it?
Switch to a shorter-acting agent Taper by 10-20% of total daily dose every 1-2 weeks (not to exceed 5mg reduction)
55
Propylthiouracil MOA?
Inhibits peroxidase and blocks synthesis of T3 and T4 Also blocks peripheral conversion of T4 to T3
56
What are some cons of using dopamine agonists for pituitary issues?
Not always efficacious
57
Contraindication of PDE-5 inhibitors?
Nitrate medications; risk of hypotension
58
If you inhibit CYP11A1, you block the synthesis of what?
Cortisol, androgen, and aldosterone
59
How is Levothyroxine initially dosed?
1.6 to 1.7 mcg/kg/day
60
What are the IGF-1 Rx?
Mecasermin + Mecasermin rinfabate
61
What are some side effects due to prolonged dose (1-2 months) or high dose?
Iatrogenic Cushing's Syndrome; weight gain
62
What are some lab tests of excess GH?
GH \>1 mcg/L and elevated IGF-1 levels
63
Endocrine Society recommends what in regards to combination therapy for pituitary issues?
Add pegvisomant or cabergoline in pts w/ inadequate response to a somatostatin analog
64
What are some AE of the 3rd Gen alpha adrenergic antagonists for BPH?
Silodosin - needs to be renally adjusted (CrCl \<30), ejaculatory disorders Tamsulosin - do not crush, floppy iris syndrome, sulfa allergy Both need to be taken 30 min before meals
65
What are the prostaglandin E1 Rx for ED?
Alprostadil Injection or urethral suppository Used also as a diagnostic test for ED
66
What are the basic classes used for Acromegaly?
1. Somatostatin analogs 2. GH receptor antagonist 3. Dopamine agonist
67
What are the 3rd-Gen alpha adrenergic antagonists for BPH and their initial/usual dose?
1. Silodosin (8) 2. Tamsulosin (0.4, maybe 0.8)
68
Cleavage of angiotensinogen to angiotensin I occurs where?
Liver
69
What is a regular prolactin level in non-pregnant females?
\<25mcg/L
70
What RX can cause GH deficiency?
Glucocorticoids Methylphenidate Dextroamphetamine
71
How is Mecasermin dosed ?
BID SubQ +/- 20min of a meal
72
Which dopamine agonist is used for Parkinson's?
Bromocriptine (Parlodel®)
73
What are the RX classes used for Cushing's Syndrome?
1. Steroidogenesis inhibitors 2. Pituitary targeted therapy 3. Glucocorticoid receptor antagonist 4. Adrenolytic agent
74
Primary Adrenocortical Insufficiency is also known as...?
Addison's Disease
75
How is Levothyroxine titrated?
25mg increments q6-8wks Check TSH 6-8wks after each dose change
76
How is the thyroid hormone regulated?
Hypothalamus produces TRH which stimulates the anterior pituitary to make TSH which allows the thyroid gland to produce thyroid hormones TSH inhibits the hypothalamus Thyroid hormones inhibit both hypothalamus and anterior pituitary
77
Propylthiouracil vs Methimazole, which is longer acting?
Methimazole
78
What CYP protein does Ketoconazole inhibit?
CYP17 Higher dose = CYP11A1
79
When is prednisolone give over hydrocortisone for glucocorticoid replacement?
Pts w/ poor compliance. It is given 3-5mg ONCE daily compared to 15-25mg/day divided BID or TID
80
Use of Pasireotide?
Cushing's Disease + Acromegaly
81
The most important pharmacotherapy plan in treating aldosteronism is...?
\*\*Titrating dose to normal K+\*\* Monitor K+ every 4wks and monitor BP daily
82
Primary hyperaldosteronism is also known as...
Conn's Disease
83
What are some AE of Thiourea Rx?
Rash, GI problems, hepatotoxicity (worse with propylthiouracil)
84
What kind of neurotransmitter effect does Cushing's Syndrome have?
Depression
85
What effect does Dopamine have on the anterior pituitary?
Inhibits PRL (prolactin)
86
What hormones do the anterior pituitary gland produce?
Growth hormone (somatotropin) Prolactin ACTH TSH FSH LH
87
What CYP protein does Etomidate inhibit?
CYP11B1 Same as Metyrapone
88
What is Adrenal Crisis?
1. Adrenal cortex doesnt respond to stress 2. Cortisol reserves are used up 3. Hypovolemic shock and coma 4. High K+ and Low Na+ and Low BP
89
What Rx can store in adipose tissue for up to 5 years?
Mitotane (Adrenolytic Rx)
90
Metyrapone AE?
Increase androgen production (more acne, hirsutism, counters antiandrogenic effect of Ketoconazole) Increases 11-deoxycortisol
91
What effect does GHRH have on the anterior pituitary?
Promotes GH (growth)
92
What are the RX classes used for hyperaldosteronism?
1. Aldosterone receptor antagonists 2. K-sparing diuretic
93
Subclinical hyperthyroidism TSH T3/T4 TSI RIUT
TSH = down T3/T4 = normal TSI = - RIUT = - Not an autoimmune disorder, so TSI = -. Normal T3/T4 = RIUT is -
94
What is the clinical presentation of Primary Aldosteronism?
1. High BP 2. Hypokalemia 3. Metabolic alkalosis 4. Edema 5. Muscle weakness
95
What cleaves angiotensin I to II?
ACE
96
AE of Lanreotide?
N/D, stomach problems Gallstones
97
Anticholinergic agent AE?
Anti-SLUD Dry mouth, dry eyes, confusion, dilated pupils, urinary retention
98
Spironolactone AE?
Androgen antagonist Progesterone agonist Hyperkalemia, heart issues, gynecomastia
99
With hyperprolactinemia, how does that affect the hypothalamus?
Positive effect
100
What are the steroidogenesis inhibitor RX used for Cushing's Disease?
1. Ketoconazole 2. Metyrapone 3. Etomidate 4. Aminoglutethimide \*\*\*1-3 are not FDA approved for Cushing's
101
What are some drug interactions with Recombinant GH?
Corticosteroids Estrogen Antidiabetic agents
102
Most common hypothyroid state in the US is called...
Hashimoto's Thyroiditis
103
Coupling of DIT and DIT form (T3/T4)
T4
104
What is the difference between micro and macroadenomas?
Micro = \<10mm in diameter and do not increase in size Macro = \>10mm in diameter and will continue to grow and invade other tissues
105
How is thyroglobulin secreted?
From the ER of a thyroid follicle cell
106
What are the main classes to help with BPH?
1. Alpha-antagonists (relax prostatic muscle) 2. Phosphodiesterase inhibitors (see above) 3. 5-alpha-reductase inhibitors (decrease testosterone effect) 4. Anticholinergic agents (relax detrusor muscle)
107
How does Alprostadil work?
1. Activate prostaglandin receptor 2. Decrease Ca influx 3. Relaxation of smooth muscle 4. Erection
108
\_\_\_\_\_\_ production in substantia nigra is reduced in Parkinsons
Dopamine
109
What pharmacologic therapy options exist for ectopic ACTH or CRH secreting tumors?
Steroidogenesis inhibitors + adrenolytics
110
What is used to retard the release of T3 and T4 during a thyroid storm?
KI (Lugol's solution)
111
Etomidate AE?
Venous pain + skeletal muscle movements
112
What is more effective for prolactinomas, Transsphenoidal surgery or dopamine agonists?
Dopamine agonists
113
What are some non-pharmacologic diet Tx of BPH?
Low fat, high intake of fruits + veggies
114
Normal range of TT3?
60 to 181 ng/dL
115
What do recombinant GH hormone products contain?
Somatropin; same AA sequence in human GH
116
What are some metabolic changes in pregnancy + thyroid?
Increases estrogen = higher levels of thyroxine binding globulin which increases transport of thyroid hormones Increase of iodine requirements to 200 to 300mcg/day
117
Which RX group does not affect GH production and therefore does not decrease tumor size?
GH receptor antagonist (Pegvisomant)
118
What are some side effects due to prolonged dose (6-12 months) or high dose?
Osteoporosis Take calcium 1000-1500mg/day + vit D (800IU/day) Regular DEXA/FRAX testing
119
What are the AE of the PDE-5 inhibitors?
All = headache, flushing, nasal congestion, dyspepsia Just Sildenafil (Viagra) = altered or bluish vision
120
PDE-5 inhibitor and Onset/Duration?
All but Tadalafil Onset = 1hr (Avanafil = 0.5hr) Duration = 4hr Tadalafil Onset = 2-12hr Duration = 24-36hr
121
How does Secondary Aldosteronism differ from Primary?
Increase in Renin production which leads to a bunch of CV issues
122
What are the main clinical presentations for BPH?
2 major symptoms: obstructive and irritative
123
What effect does CRH have on the anterior pituitary?
Promotes ACTH (Adrenocorticotropic)
124
How is somatostatin IR and LAR given?
IR = SubQ LAR = IM
125
The adrenal cortex produces what class of corticosteroid hormones?
1. Glucocorticoids 2. Adrenal androgen precursors (EX: DHEA) 3. Mineralocorticoids
126
What are some clinical issues associated with excess GH?
1. Cardiovascular issues 2. Joint issues 3. Respiratory disorders and sleep apnea 4. T2DM 5. GI cancers
127
Normal range of TSH?
0.5 to 4.7
128
What are some signs and symptoms of hyperprolactinemia in males?
Amenorrhea, galactorrhea, infertility
129
When is initiation of recombinant GH started in children?
Prior to puberty is most favorable
130
What are some signs of excess GH?
1. Coarsening of facial features 2. Increased hand volume, ring size, shoe size 3. Enlarged tongue 4. Various skin conditions
131
What is the Tx goal of Recombinant GH in adults?
Increase muscle mass and reduce adiposity
132
What are some pros of somatostatin analogs for pituitary issues?
More effective vs dopamine agonists at normalization of GH AND IGF-1
133
What are some side effects due to doses of \>15mg/day of prednisone or equivalent?
HPA Axis Suppression Prevent this by tapering the dose down
134
Propylthiouracil vs Methimazole, which can cause hypoglycemia?
Methimazole
135
What is the only pregnancy category C Rx for pituitary gland issues?
Mecasermin (Increlex®)
136
When is radiation therapy for someone with excess GH?
Poor surgical candidates or those who refuse it
137
What are some considerations when giving a mineralocorticoid?
Adjust dose for summertime dosing
138
What kind of class is Macimorelin (Macrilen)?
Ghrelin agonist (GH secretagogue agonist)
139
When monitoring for hypercortisolism with Mitotane, what should you look for?
Urine free cortisol because of increase of presence of cortisol binding globulin which falsely increases cortisol levels and decreases efficacy of hydrocortisone
140
IV use of Octreotide is used for what?
Acromegaly or tumor Tx
141
Physiology of erection
1. Neurons reach tissue via cavernosal nerve 2. Relaxation of arterioles and trabecular smooth muscles 3. Pooling of blood in sinusoidal space 4. Compression of subtunical venous plexuses, increasing pressure 5. Length and diameter increase
142
Could you use IGF-1 Rx to replace a GH Rx?
No
143
Bilateral adrenalectomy is reserved for what?
Last resort and only for ACTH-secreting disease. Will need lifelong glucocorticoid and mineralocorticoid replacement
144
What is a counseling point for Levothyroxine?
Take Rx on an empty stomach 30 min to 1 hr before breakfast or at bedtime 4 hrs after evening meal
145
What are some AE of Bromocriptine?
Hallucinations Impulse control Orthostatic hypotension
146
Intermediate probability of HPA suppression include...
Prednisone 10-20mg for 3+ wks Prednisione \<10mg/day
147
Angiotensinogen is cleaved in the liver to...
angiotensin I
148
Which corticosteroids have the highest anti-inflammatory properties?
Dexamethasone (highest) and fludrocortisone
149
How is Lanreotide given?
SubQ in da butt
150
What is the new RX to test for GH deficiency?
Macimorelin (Macrilen)
151
What Rx decreases T4 absorption?
Multivitamins, cholestyramine, and sucralfate
152
What Rx interacts w/ levothyroxine?
Warfarin + Digoxin
153
What Rx elevate prolactin levels?
\*Dopamine agonists (antipsychotics, phenothiazines, Reglan, domperidone) \*Verapamil \*Prolactin stimulators (hormones, antidepressants, opioids, cocaine)
154
AE of Octreotide?
Gallbladder abnormalities, N/D, stomach problems
155
Cushing Syndrome and its major effects?
1. High glucose 2. Central obesity and buffalo hump 3. Immunosuppression 4. High BP, Low K+, Edema 5. Androgen synthesis (acne, infertility, etc) 6. Depression
156
When should you give a steroid to mimic their natural cycle of cortisol?
Around 0830
157
MOA of Iodine?
Use to treat + detect hyperthyroidism Iodine is taken up by gland and deposited in colloid. Beta and gamma radiation destroys parenchymal cells
158
What are some drug interactions with Octreotide?
Cyclosporine, Beta blockers, and calcium channel blockers
159
How long does levothyroxine take to get to steady state?
About 6 wks
160
How should you monitor the efficacy for dopamine agonists?
Improvements in signs/symptoms and GH \<1mcg/L after 4 to 8 wks
161
How is Pasireotide given?
IM
162
How does iodide enter the thyroid follicular cell?
Through a Na/I- symporter
163
What cells in the pancreas produce somatostatin?
Delta cells
164
What is the treatment of choice for most people with excess GH?
Transsphenoidal surgical resection
165
Addison's Disease is also known as...?
Primary Adrenocortical Insufficiency
166
How would you initiate which pharmacotherapy strategy to begin with for hypercortisolism?
1. Start with low dose steroidogenesis inhibitor 2. Titrate until normal cortisol level 3. High variability = block and replace. Low = normalization Block and replace = begin w/ corticosteroid such as dexamethasone or prednisone, then titrate until cortisol is undetectable Normalization = educate patient on glucocorticoids rescue just in case
167
Dopamine agonists are used for what?
Reduce GH production Shorter duration of action when used for hyperprolactinemia
168
What is the only Rx for pituitary issues that is weight-based?
Recombinant GH for GH deficiency Recombinant IGF-1 (Mecasermin)
169
How are thyroid hormones synthesised and released?
Uptake of I- thru thryoid epithelial cells I- is oxidized and incorporated into tyrosine residues bound to thyroglobulin into MIT and DIT
170
Mitotane take _______ for onset
weeks to months
171
What is a regular prolactin level in pregnant females?
34-386mcg/L
172
Males vs Females; who is more likely to get excess GH?
Equal chance
173
What hormones do the posterior pituitary gland produce?
Vasopressin + oxytocin
174
What are the basic classes used for GH deficiency?
1. GH 2. Insulin-like growth factor-1 (IGF-1)
175
Side effects due to Metyrapone cancel out with what RX?
Ketoconazole
176
What is a normal serum cortisol level?
7-20
177
Methimazole MOA?
Inhibits peroxidase and blocks synthesis of T3 and T4, but does NOT inhibit peripheral conversion of T4 to T3
178
How does Somatostatin analogs block GH release?
Bind and activate SST2 and SST5 somatostatin receptors
179
Do the drugs for hyperthyroidism block the release of stored hormones?
Nope, they take 2 days to 2 wks to deplete stored pool of hormones
180
What are some symptoms of excess GH?
Local effects of GH-secreting tumor = headache and visual disturbance Elevated GH and IGF-1 = sweating, neuropathies, joint pain, and paresthesias
181
What are some immediate side effects due to glucocorticoids?
Within 1 wk, behavioral and sleep disturbances Hyperglycemia and Hypertension Dose in the AM to prevent sleep issues A1c 48 hrs after initiation then every 3-6 months BP 1-2 days after initiation then regularly afterwards
182
When are iodides given?
Adjunctive therapy for preparation on Grave's disease surgery
183
Growth-promoting effects of GH are mediated by what?
IGF-1 = before/after birth IGF-2= in utero
184
When can you use a beta-blocker during the time you're taking radioactive iodine?
Any time
185
Which Rx for aldosteronism is a CYP3A4 substrate?
Eplerenone
186
How does amiodarone cause hypothyroidism?
Occurs anytime and is NOT dose-related
187
When should Recombinant GH be administered?
In the evening
188
What are the basic classes used for hyperprolactinemia?
1. Dopamine agonists
189
Pathophysiology of Grave's Disease
Continuous stimulation of thyroid gland via Thyroid stimulating antibodies (TSABs) Pituitary TSH secretion is suppressed due to too many thyroid hormones
190
What are some lab tests for GH deficiency?
GH \<10mcg/L during a 2 hr period following a GH provocation test Physical height is \>2 standard deviations below population mean for given age/sex
191
When beginning surgery for Cushing's Syndrome, what Rx will they need for the week?
Glucocorticoid on operative day Mineralocorticoid 5 days after operation Continue Tx until cortisol \>20
192
Posterior pituitary gland is known as (Adenohypophysis//Neurohypophysis)
Neurohypophysis
193
When monitoring for hypercortisolism with Mifepristone, what should you look for?
Clinical signs rather than lab values
194
What are some pharmacological means to induce smooth muscle relaxation?
1. Activate K channel (hyper polarize) 2. Inhibit Ca channel 3. Decrease MLC phosphorylation 4. Increase cGMP (does all of the above)
195
Fludrocortisone has only (glucocorticoid.mineralocorticoid) effects
Mineralocorticoid
196
What are the 5-alpha reductase inhibitors for BPH?
1. Finasteride (inhibits type II) 2. Dutasteride (inhibits type I and II)
197
400mg of amiodarone releases \_\_\_\_mg of iodine
12
198
AE of Pasireotide?
Hyperglycemia, Diarrhea, Gallstones
199
What is the most common cause of Cushing's Syndrome?
Glucocorticoid use
200
In regards to dose, what is something to look out for in recombinant GH for GH deficiency?
Potency is expressed as 1 mg = 2.6 IU of GH
201
When are peeps usually diagnosed with excess GH?
Middle aged
202
When should you administer Macimorelin (Macrilen)?
After 8 hours of fasting
203
PDE-5 inhibitors and CV effects?
All lower BP by 5mmHg; no clinical significance even to those w/ cardiac disease
204
When should you choose GH receptor antagonists initially for pituitary issues?
High IGF-1 levels and refractory to somatostatin analogs.
205
What is the Tx goal of Recombinant GH in kids?
Achieve normal adult height
206
What pharmacologic therapy options exist for adrenal adenoma/carcinoma?
Adenoma = either block and replace or normalization Carcinoma = only palliative normalization Steroidogenesis inhibitors Adrenolytics only if there is an inoperable adrenal carcinoma
207
What should you do if growth rate is less than 2-2.5cm/year when treating with recombinant GH?
Non-responders will get doubled the normal dose If no response from that, d/c therapy
208
What are some other uses of Sildenafil (Revatio) and Tadalafil (Adcirca)?
Pulmonary Arterial HTN
209
What is the function of vasopressin?
Antidiuretic hormone; acts on collecting ducts to conserve water
210
How would you Tx symptomatic prolactinomas?
1. Dopamine agonist 2. Transsphenoidal surgery 3. Radiation w/ surgery
211
PDE-5 inhibitors and food?
High fat meals will slow down absorption except with Tadalafil Metabolized via CYP3A4
212
What are some symptoms of glucocorticoid withdrawal?
Flu-like symptoms Disease flare Mild symptoms? Give supplemental hydrocortisone Severe? Treat as adrenal crisis
213
What effect does SRIF have on the anterior pituitary?
Inhibits TSH (thyroid) + inhibits GH (growth)
214
AE of IGF-1 Rx?
Hypoglycemia
215
What is the difference between Cushing's Syndrome and Disease?
Disease = pituitary tumor that increases ACTH and therefore cortisol as well. CRH is still not produced Syndrome = CRH is not produced, therefore not ACTH and no cortisol
216
What are some monitoring parameters when initiating alpha-adrenergic antagonists for BPH?
Hypotension, ejaculation disorder, floppy iris syndrome
217
Anticholinergics can be used for (obstructive/irritative) symptoms
Only irritative
218
What is found in Pegvisomant (Somavert)?
GH analog w/ PEG
219
What is the overall/specific goal of Tx on BPH?
1. Improve AUA score by at least 3 points 2. Increase urine flow rate 3. Normalization of PVR
220
What are the main Rx that cause drug-induced thyroid disorders?
Lithium - hypo Amiodarone - both Interferone - both
221
What are the dopamine agonists?
Bromocriptine (Parlodel®) Cabergoline (Dostinex®)
222
How does iodide enter the lumen?
Through pendrin
223
Could you use IGF-1 Rx on someone with GH deficiency?
No; Not intended for use in subjects with secondary forms of IGF-1 deficiency, such as GH deficiency, malnutrition, hypothyroidism, or chronic treatment with glucocorticoids
224
What are the main causes of GH deficiency?
Congenital via gene deletion of developmental disorders Acquired via other conditions such as head trauma, CNS infection, or even RX
225
What are the monitoring parameters of Pegvisomant?
Check IGF-1 values every 6-12 months, colonoscopy, and CV risk factors
226
Anterior pituitary gland is known as (Adenohypophysis//Neurohypophysis)
Adenohypophysis
227
Which PDE-5 inhibitor is more selective toward PDE-5?
Cialis (Tadalafil) + Stendra (Avanafil) Cialis is also more potent at PDE11 vs all PDE5 inhibitors
228
What hormones do the hypothalamus produce?
\*CRH (corticotropin) \*TRH (Thyrotropin) \*SRIF (Somatotropin releasing inhibiting factor) \*GnRH (Gonadotropin) \*Dopamine \*GHRH (Growth)
229
What effect does GnRH have on the anterior pituitary?
Promotes FSH + LH
230
What is the issue with using testosterone for ED?
Does NOT correct it Takes days or weeks to see effects
231
What is the place in therapy for 5-alpha reductase inhibitors for BPH?
BPH w/ enlarged prostate gland and elevated PSA Use w/ alpha1-adrenergic antagonist for 6 months before the 5-alpha reductase inhibitors begin to work
232
Subclinical hypothyroidism TSH T3/T4 Antithyroid AB
TSH = up T3/T4 = normal Antithyroid AB = -
233
When can you use thin amides be given during the time you're taking radioactive iodine?
Needs to be withdrawn 4 to 6 days before and reinstituted 4 days after radioactive iodine
234
Liothyronine is (T3/T4)
T3
235
What are the phosphodiesterase inhibitors used for BPH?
Just Tadalafil, however it must be used with an alpha-adrenergic antagonist (make sure to monitor BP for hypotension)
236
Eplerenone AE?
No effect on androgen and progesterone receptors like spironolactone Mild hyperkalemia
237
What are the Rx interactions with propylthiouracil and methimazole?
Anti-Vitamin K activity may increase activity of warfarin Increased clearance of B adrenergic blockers Increase levels of digoxin
238
Which somatostatin analog has a higher incidence of hyperglycemia?
Pasireotide
239
If dopamine agonists activate dopamine D2 receptors in the pituitary, what happens?
Inhibits prolactin secretion In pts w/ acromegaly, it inhibits GH release
240
What disadvantages to block and replace pharmacotherapy strategy have over normalization?
More AE and requires higher dose and multiple agents
241
Pathophysiology of Primary Aldosteronism?
AKA Conn's Disease 1. Aldosterone is secreted by an adrenal adenoma 2. Na+/Water retention 3. Increases BP 4. Decreases Renin 5. Decreases Angiotensin
242
What should you monitor when initiating dopamine agonist therapy for prolactinomas?
Check prolactin level every 3 to 4 wks
243
T3 vs T4, which is more potent? Efficacy?
Both = T3
244
What is the FDA black box warning for thyroid hormones?
Don't use them alone or with another Rx for weight loss
245
What is the best tolerated and most effective Rx that inhibits steroidogenesis in hypercortisolism?
Ketoconazole
246
What is another name for Lugol's solution?
Potassium Iodide
247
Alpha-adrenergic antagonists can be used for (obstructive/irritative) symptoms
Bof
248
What is the clinical presentation of Primary Adrenocortical Insufficiency?
1. Hypoglycemia due to decreased cortisol 2. Low BP, Low Na+, High K+ due to decreased aldosterone 3. Skin bronzing due to increased melatonin-stimulating hormone because of up-regulation of ACTH production
249
Which phosphodiesterase enzymes are relevant to the penis?
PDE 5 + 11 PDE 6 - retina (AE)
250
What is the 1st line therapy Rx for hyperaldosteronism?
Aldosterone receptor antagonists such as spironolactone and eplerenone
251
Explain the pharmacodynamics behind Mifepristone.
Progesterone antagonist (terminates early pregnancy) Higher dose = glucocorticoid receptor antagonist which blocks effects of hypercortisolism
252
What disorder can cause skin bronzing?
Addison's Disease
253
What are some AE of Cabergoline?
Depression Nasal congestion Increased LFT
254
Levothyroxine is (T3/T4)
T4
255
Cortisol activates steroids within what organ? Inactivated where?
Liver Kidney inactivates cortisol
256
Could you use IGF-1 Rx on someone with primary IGF-1 deficiency?
Yes for primary No for secondary forms
257
AE of GH in children?
Intracranial HTN w/ papilledema, visual changes, H/N/V
258
What is the Beer's Criteria of using Recombinant GH?
Avoid use unless it is used as a replacement following pituitary gland removal
259
Which Thiourea RX is first-line for first trimester of pregnancy?
Propylthiouracil
260
The dopamine agonists are derived from what?
Ergot
261
What drugs are classified as Somatostatin analogs?
-reotides Octreotide, Lanreotide, Pasireotide
262
What CYP protein does Metyrapone inhibit?
CYP11B1 Same as Etomidate
263
What are some signs and symptoms of hyperprolactinemia in females?
Decreased libido, infertility, visual loss
264
What is the first step in determining etiology of hyperthyroidism?
Radioactive Iodine Uptake Test
265
How would you Tx drug-induced prolactinomas?
\*D/c offending agent \*Administer therapeutic alternative \*If no alternative exists, consider dopamine agonist or sex-steroid replacement
266
What are the 3 main causes of erections?
1. Psychogenic - audiovisual stimuli or fantasy 2. Reflexogenic - tactile stimuli 3. Nocturnal - during REM sleep
267
Ketoconazole AE?
1. Hepatic levels may rise 2. Gynecomastia + hypogonadism in males 3. Teratogenicity 4. Inhibits CYP3A4
268
What is a regular prolactin level in males?
\<15mcg/L
269
What accounts for \>90% of excess GH?
GH-secreting pituitary adenoma; BENIGN tumor of epithelial origin
270
What are some pros of using dopamine agonists for pituitary issues?
Cheap and oral route
271
When can you use iodides + RAI treatment?
Use iodides 3 to 7 days AFTER RAI treatment
272
What is used to block the synthesis of T3 and T4 during a thyroid storm?
Propylthiouracil
273
Graves Disease TSH T3/T4 TSI RIUT
TSH = down T3/T4 = up TSI = + RIUT = up Autoimmune disorder makes TSI + If T3/T4 go up, RIUT goes up
274
What kind of receptor is a GH receptor?
Reception Tyrosine Kinase
275
What Rx increases T4 metabolism?
Phenytoin, phenobarbital, rifampin, and sertraline
276
Hashimoto's disease TSH T3/T4 Antithyroid AB
TSH = up T3/T4 = normal or down Antithyroid AB = +
277
What should you monitor on recombinant GH?
Blood glucose and BP
278
What are some cons to somatostatin analogs for pituitary issues?
Expensive and is an injection
279
Besides suppressing GH release, what other system do Somatostatin analogs affect?
Suppresses release of GI hormones (reduce secretion and motility)
280
Androgen replacement is important to whom for Addison's Disease?
Women with depression and libido DHEA 25-50 mg daily in AM for about 6 months
281
GH counteracts the effects of what?
Insulin Pts walk in with hyperglycemia due to glycogenolysis and decreased uptake of glucose into muscles
282
Coupling of MIT and DIT form (T3/T4)
T3
283
AE of GH in adults?
Increased % of diabetes
284
What should you monitor when prolactin levels are reaching normal levels when treating prolactinomas?
Check prolactin levels every 6 to 12 months
285
Normal range of FT4?
0.8 to 2.7
286
What are the monitoring parameters for kids on Recombinant GH?
Growth curve, Tanner staging, bone age every 6 to 12 months \*\*specific for kids only
287
Adenomas are symptomatic prolactinomas that are NOT drug-induced. How would you further classify the adenomas?
Macro or Micro
288
How is Mecasermin rinfabate dosed?
QD SubQ (morning or evening)
289
What are some AE of the 5-alpha reductase inhibitors for BPH?
1. Takes 6-12 months to show effect 2. More sexual dysfunction vs alpha adrenergic antagonists 3. Pregnancy category X
290
Use of Lanreotide?
Gastroenteropancreatic Neuroendocrine Tumors (GEN-NET) + Acromegaly
291
Which dopamine agonist is used for Acromegaly?
Bromocriptine (Parlodel®)
292
What are some side effects due to doses of \>10mg/day of prednisone or equivalent?
Glaucoma Monitor by having regular eye exams
293
What is the regular fasting prolactin level?
\>25mcg/L
294
Normal range of TT4?
4.5 to 10.9
295
What is the black box warning for propylthiouracil?
Severe liver injury and acute liver failure have been reported with this Rx Reserve propylthiouracil for those who cant tolerate methimazole
296
Which dopamine agonist is used for Cushing's Disease?
Cabergoline (Dostinex®)
297
Which dopamine agonist is preferred for pregnant women?
Bromocriptine Cabergoline has a superior efficacy though
298
What effect does TRH have on the anterior pituitary?
Promotes TSH (thyroid)
299
If you inhibit CYP17, you block the synthesis of what?
Cortisol and androgen
300
SubQ use of Octreotide is used for what?
Acromegaly
301
Which corticosteroid has only mineralocorticoid effects?
Fludrocortisone
302
What are the signs of GH deficiency?
Reduced growth velocity and delayed skeletal maturation
303
When Angiotensin II binds w/ AT1 receptors, what happens to sodium and potassium?
Sodium retention and potassium excretion
304
What is the recommended dose of iodide for adults and pregnant women?
150mcg - adults 200mcg - pregnant women
305
What Rx can be useful who pts w/ severe diarrhea due to metastatic carcinoid tumors?
Octreotide (helps suppress GI stuff)
306
Which corticosteroids have the highest mineralocorticoid activity with glucocorticoids?
Cortisone and Hydrocortisone Both have short duration of action and allows patients to take just 1 pill rather than 2 (like prednisone and fludrocortisone)
307
How should you prevent Adrenal Crisis?
There are 2 kinds of conditions 1. Fever/"kinda" sick, ABx use, small outpatient procedure = double oral dose 2. Severe sickness, fasting for procedure, during surgery = hydrocortisone 100mg immediately then 50mg q6hrs. Then 1-3 Liters of D5NS or NS and Tx hyperkalemia as needed
308
Recombinant GH AE?
Fluid retention Hyperglycemia Carpal tunnel syndrome
