ENDO/HEME ONC PACKET 1 Flashcards Preview

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Flashcards in ENDO/HEME ONC PACKET 1 Deck (23)
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1
Q

HASHIMOTOS
TREATMENT
• Hypothyroidism: ______ should be given in usual replacement doses
• Goiter
• may shrink with doses of levothyroxine that drives the serum TSH below the reference range while maintaining clinical euthyroidism (normal thyroid gland function)
• Suppressive doses of __ tends to shrink the goiter.
• Dietary supplementation with ______ reduces the levels of TPO ab

A

levothyroxine
T4
selenium

2
Q

SUBACUTE THYROIDITIS

TREATMENT
• Disease is ______
• Does not require long-term therapy
• During acute painful phase, use _______ agents (ASA, NSAIDS, steroids); ___ is the drug of choice
• Hyperthyroidism treated with ______ (Bilivist) or iopanoic acid (Telepaque)
• Brief periods of____ for symptoms of hyperthyroidism à HR fast, BP goes up (s/s of hyperthyroidism à so BB calms it all down)
• Transient hypothyroidism if symptomatic is treated with T4 orally

A
self limiting
anti inflammatory
ASA
ipodate sodium
b-blockers
3
Q

INFECTIVE SUPPORITIVE THYROIDITIS

TREATMENT
• Treatment is with _____ and possible _____ drainage
• Surgical ______ may be required

A

antibiotics
surgical
thyroidectomy

4
Q

RIEDAL THYROIDITIS

TREATMENT
• ______ 20 mg BID often indefinitely. Steroids can be used short-term to control symptoms

A

TAMOXIFEN

5
Q

hypothyroidism

• Most hypothyroid pts: oral ______(75-150 ug/d) is sufficient replacement therapy
o Use same prep at same time of day à very important
• Verify if dose is enough: need normal ___ and a normal free __ level
o TSH, T4 and T3 monitored monthly and dose is adjusted to normalize the TSH within 2 months of initiating therapy
• Don’t give too much!! Can cause ______ & cardiac arrhythmias
• T4 has long half-life (7 days)
• A change in levothyroxine dosage does NOT produce a new steady state for 4-5 weeks
• After tmt stopped, return of hypothyroidism: slow, insidious; pt may have no discomfort
• THINGS TO NOTE:
o Increased levothyroxine dosage requirements can occur with drugs that increase the hepatic metabolism of levothyroxine
o May treat T4, T3 or symptomatically in patients that have a normalized TSH
o Can use desiccated natural porcine thyroid preps with T4 and T3 (Armour thyroid, Nature-Throid, NP Thyroid)
o IF the TSH is suppressed or low, can mean _______ and patient can have symptoms of hyperthyroidism, atrial fibrillation, osteoporosis

A

levothyroxine
TSH, T4
osteoporosis
overtreatment

6
Q
MYXEDEMA COMA
MANAGEMENT
- ICU monitoring
_- respiratory SUPPORT
- general supportive care
- IV \_\_\_\_\_\_
-\_\_\_\_\_\_\_ therapy as prophylaxis against adrenal crisis
TREATMENT
•	Passive \_\_\_\_\_ (blankets)
•	Preferred over heated blankets (avoid vascular collapse)
•	All meds \_\_\_ Treat underlying illness
A

levothyroxine
glucocorticoid
warming
IV

7
Q

hyperthyroidism and thyrotoxicosis

THERAPY FOR HYPERTHYROIDISM
• ________: DESTROYS THYROID TISSUE
• Drugs that inhibit thyroid hormone synthesis
• Surgery
• Thyrotoxic symptoms from any cause of hyperthyroidism: helped w/______

A

radioactive iodine

b blockers

8
Q

GRAVES DISEASE

• A _____ (Propranolol) is started to control symptoms (tachycardia, tremor, diaphoresis, anxiety) until the hyperthyroidism is treated.
• Propranolol ER 60 mg (titrate up to max 320 mg to control sxs)
• Beta-blocker does nothing to control hormone secretion
• Thiourea Drugs
o ________ (mostly use this one) or ______ (PTU)
 Methimazole is used primarily, except in the ____ trimester of pregnancy
o Patients with _____ thyroid disease, or who cannot tolerate radioactive iodine
o Can be used in patients who are planning surgery until their surgery is scheduled
o Side effects: pruritus, allergic dermatitis, nausea and dyspepsia
o Thioureas can cause agranulocytosis/pancytopenia
 ½ the cases are discovered because of fever, pharyngitis, bleeding
 ½ from routine CBC
• Iodinated Contrast Agents
o _______ relief of thyrotoxicosis symptoms, if not controlled by Propranolol alone
o In Graves Disease, Dose first with Methimazole, then give Iopanoic acid (Telpaque) or ipdodate sodium (Bilivist)
o These drugs are for symptoms relief, do not cure underlying process
• Lithium Carbonate à not used much bc low therapeutic window
o May be used in cases of Methimazole or PTU induced hepatic toxicity or leukopenia
o Not used during pregnancy
• Radioactive iodine (RAI, 131I)
o Destroys overactive thyroid tissue
o Cannot give before or during pregnancy
o Can worsen Grave’s ophthalmopathy
• Thyroid surgery
o Removal of one total lobe, and most of other lobe
o Pre-operatively dosed with thiourea until they are euthyroid
o Propranolol dosed to control cardiac sxs

A
beta blocker
methimazole, propylthiouracil
first
milder
temporary
9
Q

THYROID STORM

  • Treat with ______ drug to block iodine uptake and hormone synthesis
  • ________ if begun 1 hour after the first dose of thiourea
  • _____ is given 1 hour later as potassium iodide
  • ______ IV or orally
  • Prescribe ____ (inhibit T4 to T3) – steroids inhibit t4 conversion to t3 **ON EXAM
  • Plasmapheresis can be effective in refractory cases
  • Acute MI may be precipitated
A
thiourea
ipodate sodium
iodide
propranolol
steroids
10
Q

SOLITARY NODULE

  • Can treat as you do for Graves Disease: Propranolol and ______
  • 131 I (radioactive iodine) and surgery
  • Almost always benign; rarely malignant; can do ___
A

thiourea

FNA

11
Q

MULTINODULAR GOITER

  • TREATMENT: Can treat with ______ and thioureas
  • ______ is the definitive treatment; can do RAI (radioactive iodine)
  • If RAI, avoid Iodine in diet to increase uptake of RAI
A

propranolol

surgery

12
Q

HYPOPARATHYROIDISM

TREATMENT
EMERGENCY TREATMENT FOR ACUTE HYPOCALCEMIA (HYPOPARATHYOID TETANY)
1. ___ maintenance
2. IV calcium ____ given slowly until the tetany ceases
3. ____ calcium (liquid calcium carbonate)
4. ______ preparations à started with oral calcium
______ = the active metabolite of vitamin D, 1,25-dihydroxycholecalciferol
Can use Calcitriol (form of vitamin D) – helps to reabsorb dietary calcium
5. Magnesium deficiencies must be corrected
MAINTENANCE TREATMENT OF HYPOTHYROIDISM
- Required for patients with symptomatic hypocalcemia or serum calcium levels below 8.0 mg/dL
- _____ , calcium and ____ therapy:
o Pts have a reduced renal tubular reabsorption of calcium and are thus prone to hypercalciuria (excess calcium in urine) and kidney stones if serum calcium is normalized with calcium and vitamin D therapy
o Maintain serum calcium in a slightly low but asymptomatic range of 8-8.6 mg/dL
- ____ supplementation 800-1000 mg orally daily: calcium carbonate or citrate
o Calcium carbonate is best absorbed at the low gastric pH that occurs with meals
o Calcium citrate with or without meals and better choice for pts on PPIs or H2 blockers
- Vitamin D daily: _____ (active metabolite of vitamin D) or ergocalciferol (vitamin D2 derived from plants) for recurrent hypocalcemia
o Ergocalciferol gives stable serum calcium level
- Monitor serum calcium every 3 months or more
àOTHER
- PTH – restricted to patients whose hypocalcemia cannot be adequately treated with calcium and vitamin D analogs
- Hypoparathyroidism in pregnancy is a challenge à can adversely affect the developing skeleton of the fetus causing compensatory hyperparathyroidism
- CAUTION:
o Phenothiazine drugs should be administered with caution because they may precipitate EPS
o Furosemide should be avoided since it may worsen hypocalcemia

A
airway 
gluconate
oral
vitamin d
calcitriol

vitamin d, magnesum
calcium
calcitriol

13
Q

HYPERPARATHYROIDISM

  • Medical treatment:
    o Large ___ intake
    o _______ calm bone pain
    o CaSr activators
     _______ (Sensipar) is a calcimimetic agent that binds to receptor sites in parathyroid, blocking PTH production
    o Vitamin D replacement in deficient pts
    o Denosumab for pts with severe hypercalcemia due to parathyroid carcinoma
    o Avoid thiazide diuretics and dietary phosphate
  • Surgical _________:
    o Recommended for symptomatic patients, kidney stones, bone disease, and pregnancy
    o Young pts (under 50-60)
    o Complications to surgery:
     Serum PTH levels fall below normal in 70% of pts post-surgery (hours)
     Can cause hypocalcemic paresthesias or ___
     Hyperthyroidism occurs immediately post-surgery, but calms down over several days (may need a beta blocker during that time)
  • Parathyroid hyperplasia is common in chronic renal failure – because hypocalcemia from CKD which can stimulate and cause parathyroid hyperplasia
    o 3 1/2 glands removed
    o Metal clip left to mark residual parathyroid tissue
A
fluid
bisphosphonates
cinacalcet
parathyroidectomy
tetany
14
Q

HYPERALDOSTERONISM

TREATMENT
• ______ (Spironolactone) or Eplerenone (no antiandrogen activity)
o But why? Increases __
o What is a physical side effect to look out for?
o Is this a primary or secondary cause of hypertension?
o This is not going to cure hyperaldosteronism, but is strictly used to control the symptoms
o If there is an adrenal mass contributing to the symptoms, then _______ may be necessary.
• Glucocorticoids (cortisol)
o Stress hormone
o Reduces bone formation, thus increasing your risk for osteoporosis
 What test should patients on chronic steroids get to help monitor this?
o Immune system
 B-cell-mediated antibody response
 Used for allergies, RA, inflammation
o Glucose regulation through gluconeogenesis
 Where does this happen?

A

aldactone
K+
surgical intervention

15
Q

ACUTE ADRENAL INSUFFICIENCY

• Treat patient with IV ______ (IV hydrocortisone) and symptoms should improve

A

solu-cortef

16
Q

CHRONIC ADRENAL INSUFFICIENCT (ADDISONS) (COMBINED FROM 2 PLACES ON FR)

TREATMENT
• _______ is the drug of choice.
o Glucocorticoid: secreted from the zona fasciculate
• ______ (Florinef) has a potent sodium retaining effect, thus is given to patients that have significant postural hypotension, hyponatremia, or hyperkalemia
o Mineralcorticoid: secreted from the zona glomerulosa
• Patients who have AI (or are on chronic steroids) and will be having surgery will need stress dose steroids (IV solucortef 100 mg 1 hour before surgery, then 100 mg q8 hour x 2 doses after)

TREATMENT
• General Measures
o Wear a medical alert _____ or medal saying “takes hydrocortisone”
o Provide dose escalation schedule for increased corticosteroids for illness, accidents or prior to minor surgical procedures
o Increased fludrocortisone for hot weather or prolonged strenuous exercise
o Prescribe with refills so patient does not run out; _______ for nausea; parenteral hydrocortisone for self injection if vomiting.
• Specific therapy
o Hydrocortisone orally daily in 2 or 3 divided doses; 15-30 mg daily
o Some may respond better to prednisone or methylprednisolone 3-6 mg in divided doses daily
o Additional corticosteroid must be given during stress (infection, trauma, surgical procedures); IV for severe illness, trauma or major surgical stress
o Monitor patients closely; clinical improvement; WBC: relative neutrophilia and lymphopenia can indicate corticosteroid over replacement and vice versa
• Mineralocorticoid replacement therapy
o Fludrocortisone acetate: potent sodium-retaining effect
o 0.05-0.3 mg orally daily or every other day
o Increased in the presence of postural hypotension, hyponatremia or hyperkalemia
o With edema, hypokalemia or hypertension, dose is decreased
o _____is given to some women with adrenal insufficiency
o 50mg orally improved well0being, increased muscle mass and a reversal in bone loss

• TREATMENT OF ADRENAL CRISIS
o Without established adrenal insufficiency diagnosis: emergency lab tests, blood cultures and serum cortisol and ACTH levels
o Without waiting for results; immediate treatment:
 _________ or hydrocortisone sodium succinate 100-300 mg IV along with saline solution
 Thereafter, hydrocortisone is continued as IV infusions of 50-100 mg every 6 hours for the first day
 Broad spectrum ___ empirically
 Treat ______ abnormalities
 When able to switch to oral hydrocortisone, 10-20 mg q 6 hours; then reduced to maintenance dosing
 Mineralocorticoid replacement is not needed when large amounts of hydrocortisone are being given but when the dose is reduced it is usually necessary to add fludrocortisone acetate 0.05-0.2 mg orally daily.

A

hydrocortisone
fludrocortisone

bracelet
ondansetron
DHEA

hydrocortisone phosphate
ABX
electrolyte

17
Q

CUSHINGS

TREATMENT
• Treatment for cortisol-dependent comorbidities including osteoporosis, psychiatric disorders, DM, HTN, hypokalemia, muscle weakness and infections
• _____
o Pituitary Cushing Disease: transsphenoidal selective resection of the pituitary adenoma
o Ectopic ACTH secreting tumors should be surgically resected; if it can’t be localized or is metastatic, laparoscopic bilateral dis usually recommended
o Benign Adrenal Adenomas: resected laparoscopically if they are smaller than 6 cm
o Adrenocortical carcinomas are resected surgically
• MEDICAL THERAPY
o ______ 2-5 years postoperatively; can cause hypogonadism, suppress TSH and cause hypothyroidism; can also cause primary adrenal insufficiency.
o Replacement hydrocortisone or prednisone started when mitotane doses reach 2 g daily
o ______ is an oral drug that reduces cortisol synthesis by blocking the adrenal enzyme 11B-hydroxylase.
o Medical therapy for people that refuse surgery is aimed at treated the symptoms of hypercortisolism.

A

surgical therapy
Mitolane
osilodrostat

18
Q

PRIMARY ALDOSTERONISM

TREATMENT
•	Unilateral Adrenal Adenoma
o	Conn syndrome: laparoscopic \_\_\_\_\_\_
o	Second trimester in pregnancy 
o	Long term medical therapy is an option
•	Bilateral adrenal hyperplasia
o	Best treated with medical therapy 
o	\_\_\_\_\_\_\_ diuretic (spironolactone, eplerenone or amiloride) 
o	\_\_\_\_\_\_\_ is the most effective; antiandrogen activity; men get breast tenderness, gynecomastia, reduced libido
A

adrenolactomy
potassium sparing
spironolactone

19
Q

anterior hypopituitarism

LIFELONG HORMONE REPLACEMENT THERAPY
- _______ replacement (for ACTH deficiency)
- _____ replacement (for TSH deficiency)
- ______ replacement (for LH/FSH deficiency)
o hCG equivalent to LH for men (for men with oligospermia, or low sperm count)
o With continued low sperm count à follitropin beta (synthetic recombinant FSH) or urofollitropins (urine derived FSH)
o An alternative is ____ (GnRH analog)
o Clomiphene can stimulate men’s own gonadotropins, increasing testosterone and sperm production
 Induction of ovulation in women
- hGH (human growth hormone) replacement with rhGH, somatropin (recombinant human growth hormone

A

glucocorticoid
thyroid
gonadotropin
leuprolide

20
Q

SIADH

TREATMENT
- Identify and treat underlying cause
- Fluid ______ don’t give a lot of free water
- Correct underlying _______ –> BUT if I give you too much salt too quickly, water follows salt (draws water from cells) à causes osmotic demyelination (pulls myelin off those nerve fibers)
o Do not correct severe hyponatremia too ____ à causes central pontine myelinolysis (rapid correction of sodium pulls water from the cells, causing osmotic demyelination within the central basis pontis)
- _______ – a tetracycline abx that causes renal tubules to develop resistance to ADH
- vaptans – ADH receptor antagonists (not widely used for clinical practice)

A

restriction
hyponatremia
rapidly
demeclocycline

21
Q

DIABETES INSIPIDUS

TREATMENT
- Mild cases? Require no treatment – just ensure adequate fluid intake (GIVE THEM _____, MAKE SURE THEY HAVE ACCESS TO WATER) and avoid steroids
- Central DI? _______ acetate nasal spray every 12-24 hours
o Desmopressin is also available orally and by IV.
- Nephrogenic? Manage underlying disease (ex. end stage renal disease), remove _____ agent if there is one (ex. lithium), make sure they have access to water to ensure they do not become hypernatremic

A

WATER
desmopressin
offending

22
Q

HYPERPITUITARISM

TREATMENT
PITUITARY MICROSURGERY
- Transphenoidal pituitary ______ removes the adenoma while preserving anterior pituitary function
- Complications in 12% = infection, CSF leak, hypopituitarism
- POST-OPERATIVELY:
o GH levels fall immediately with diaphoresis and CTS improves 1 day post-op
o Fluid and electrolyte disturbances post-op – DI 2 days post-op, but usually mild and self-limiting
o hyponatrema 4 days post-op – nausea, vomiting, headache, malaise, seizure à treated with free water and hypotonic fluid restriction
- Corticosteroid perioperatively à tapered to replacement doses over 1 week
o 6 weeks post-op à hydrocortisone is discontinued; cosyntropin test done
o Screen for hypothyroidism and hypogonadism (6 weeks post-op)
MEDICATIONS – incomplete biochemical remission after pituitary surgery (did surgery and pituitary not in complete remission OR cannot do surgery à BUT, surgery > meds)
Include dopamine agonists, somatostatin analogs, tamoxifen, or pegvisomant
- _______: dopamine agonists of choice (oral)
o Best for GH/PRL tumors; shrinks tumors and safe in pregnancy
o Side effects: nausea, fatigue, constipation, abdominal pain, dizziness
- ______ LAR and LANREOTIDE: long-acting somatostatin analogs (monthly subq injection)
- RALOXIFENE: selective estrogen receptor modulator (SERM) (oral)
o May be useful for persistent acromegaly in men or women with hx of breast cancer
o Does not reduce GH levels but reduces IGF-1 and may normalize it
o Testosterone levels increase in men à used for osteoporosis (selective for bones, not going to affect other organs)
- PEGVISOMANT: GH receptor antagonist (daily subq )
o Blocks hepatic IGF-1 production, but does not shrink tumors
o Monitor patients for tumor growth
àSTEREOTACTIC ______
- For pts that do not go into remission with transsphenoidal surgery or meds
- May be treated with one or a combination of three types of stereotactic radiosurgery:
o Linear accelerator: x-rays to the tumor
o Gamma knife radiosurgery: gamma rays to the tumor
o Proton beam: charged particles to the tumor
- Normalizes serum IGF-1 in up to 80% of treated patients
- Take lifelong ASA because of increased risk of small vessel stroke
- Monitor for anterior pituitarism for 5 years

A

microsurgery

CABERGOLINE
OCTREOTIDE
radiosurgery

23
Q

HYPERPROLACTINEMIA

TREATMENT
- Stop meds known to induce prolactinemia
- Hypothyroidism should be corrected
- Amenorrhea à OCPs with microprolactinemias (give ____s to maintain cycle)
- Infertility = ______ agonist
- Pregnancy = dopamine agonists throughout pregnancy
- No treatment –> at risk for ______– because suppressing estrogen or testosterone, at risk for imbalance and thus osteoporosis
- Macroprolactinomas –> higher risk of progressive especially during estrogen, testosterone HRT or during pregnancy – if you get testosterone or estrogen HRT, tumor can get bigger because stimulating pituitary
àDOPAMINE AGONISTS = _____ and _______
- ______: most tolerated and most effective; for those desiring normal sexual function and fertility
- Taken at bedtime to minimize side effects of nausea, dizziness, orthostatic hypotension
- Psychiatric side effects
- Restores fertility à pregnancy possible and no increased risk of teratogenicity
SURGERY – if candidate for surgery DO _____! Instant results, less side effects, life-long results
- Transphenoidal surgery
o Complications: CSF leakage, meningitis, stroke, visual loss (3%), sinusitis, nasal septal perforation, or infection; DI, hyponatremia
- Stereotactic radiosurgery
*Chemotherapy for small percentage of pts

A
OCPS
DOPAMINE
osteoporosis
cabergoline, bromocriptine
cabergoline
surgery