how can you establish a dx. of DM?
- FPG > 126 mg/dL (7 mmol/L)
- random PG > 200 mg/dL (11.1 mmol/L)
and symptoms OR - OGTT > 200 mg/dL (11.1 mmol/L)
- HbA1c > 6.5%
impaired fasting glucose
fasting plasma glucose 100-125 mg/dL (5.6-6.9 mmol/L)
impaired glucose tolerance
OGTT at 2 hrs is 140-199 mg/dL (7.8 to 11.0 mmol/L)
diagnosis of metabolic syndrome
- BP > 130/85
- TG > 150, HDL < 40
- FPG > 110
- waist circumference > 40 in
Tx. for pt with impaired fasting glucose or impaired glucose toleracnce
intensive lifestyle change - 30 minutes of exercise daily and calorie-restricted diet
first line agent for newly diagnosed type II DM
metformin
in whom is metformin contraindicated in?
renal insufficiency pts
- Cr > 1.4 mg/dL for women and > 1.5 in men
side-effects/cons of rosiglitazone/pioglitazone
edema, weight gain
increased fracture risk in women
increased CV morbidity
high costs
what is exenatide approved for?
combination regimens with oral agents (tx. of DM 2) - inappropriate as monotherapy
hospitalized pt with uncontrolled diabetes - what should you tx with?
basal bolus insulin regiment consisting of long-acting insulin and rapid-acting insulin before meals
diabetic pt presents to eye doctor; on exam, hard exudates, microaneurysms and minor hemorrhages are seen; when questioned, the patient does not report any decline in vision
non-proliferative diabetic retinopathy
diabetic pt presents to eye doctor with loss of vision; on exam, cotton wool spots and neovascularization are visible - dz?
proliferative diabetic retinopathy
- fibrosis causes retinal detachment and vision loss
macular edema
new vessels in the eye become more permeable and leak serum (diabetic retinopathy)
what two interventions can decrease incidence and progression of diabetic retinopathy?
tight glycemic control
BP control
Tx. of proliferative diabetic retinopathy and macular edema
timed laser photocoagulation
what is the ideal insulin regimen to reduce episodes of hypoglycemia?
long acting basal insulin + rapid-acting insulin
long acting basal insulins
glargine
detemir
NPH - intermediate acting; 2x daily dosing
rapid acting preprandial insulins
lispro
aspart
glulisine
tests to establish dx. of DKA?
serum glucose, electrolytes, ketones and arterial blood gases
diagnostic criteria for DKA (4)
- blood glucose < 250 mg/dL
- anion gap metabolic acidosis (ph < 7.30)
- serum HCO3 < 15
- positive serum or urine ketones
diagnostic criteria for hyperosmolar hyperglycemic syndrome (5)
- blood glucose > 600 mg/dL
- arterial pH > 7.30
- serum HCO3 > 15
- serum osmolarity > 320
- absent serum or urine ketones
first step in management of hyperglycemia hyperosmolar syndrome
IVF with normal saline
- once volume status is restored, switch to hypotonic solutions for maintenance therapy
most effective Tx. of DKA (After IVF)
insulin drip (IV) - measure plasma glucose every 1-2 hours and adjust dose accordingly
can xanthelasma occur w/o hyperlipidemia?
yes, but it is mostly assoc with familial dyslipidemias
clusters of erythematous papules typically on extensor surfaces associated with extremely high TG levels (> 3000)
eruptive xanthomas
tendon xanthomas
subcutaneous nodules on extensor tendons; assoc with familial hypercholesterolemia
plane xanthomas
yellow-red plaques found in skin folds of neck and trunk; assoc with familial dyslipidemias and hematologic malignancies
which endocrine disorder is assoc with elevated lipid levels?
hypothyroidism
first step in management of patients with isolated low HDL cholesterol
lifestyle interventions - exercise, tobacco cessation, weight reduction
non-HDL cholesterol goal
30 mg/dL above the patients LDL goal (so. approx 160)
what does the LDL-cholesterol goal depend on? (5)
smoking HTN older age (> 45 men, > 55 women) low HDL ( < 40) family hx of CAD
LDL-goal when pt has 0-1 risk factors?
LDL < 160 mg/dL
- if below this, then repeat fasting lipid levels sometime in the future (every 5 years or shorter if closer to threshold)
indications for fibrate therapy
hypertriglyceridemia (TG > 200) in the setting of elevated non-HDL cholesterol levels
statin therapy in a pt with no-risk factors
LDL > 190 warrants tx. with statin in low risk patient
LDL cholesterol goal in pts with DM or previous MI?
LDL < 100 mg/dL
first line tx for elevated LDL cholesterol
statin, such as simvastatin
colestipol
interrupts bile acid reabsorption and reduces LDL by 10-15%; used as a second line drug with statins bc it acts synergistically to induce LDL receptors
ezetimibe
reduces LDL cholesterol by reducing its absoprtion in small intestine; reserved as adjunct to other meds if goal is not achieved or pt is allergic/intolerance to other meds
LDL goal in pts who have had stroke or transient ischemic attack
LDL < 100 mg/dL
- first line tx is with a statin
what tests should be done before initiating therapy for hypothyroidism?
aside from TSH and free T4, you don’t need anything to make dx of Hashimotos i.e. anti-TPO abs are not necessary for dx
RAIU in thyrotoxicosis
above normal or high normal uptake (inappropriate in context of suppressed TSH level)
RAIU in thyroiditis or exposure to exogenous thyroid hormone
RAIU will be below normal
thyroglobulin levels are elevated in..
hyperthyroidism
destrustive thyroiditis
what causes a decreased thyroglobulin level?
exogenous intake of thyroid hormones
thyroidectomy/ radioactive iodine ablation
when should you do a FNA biopsy of a thyroid nodule?
any nodule > 1 cm in diameter
small nodules in pts with cancer risk factors
risk factors for thyroid cancer
extremes of age male sex history of head/neck irradiation family hx nodule > 1 cm (or rapid growth) hoarseness
when do you perform a thyroid scan and RAIU for a thyroid nodule?
in content of nodule and low TSH } may be a toxic nodule or multinodular goiter
appropriate management of hypothyroidism in pregnancy
check TSH and total T4 levels throughout pregnancy - may require an increase in levothyroxine dosage in first trimester
most appropriate medical regimen for pt with Graves’ disease
atenolol (BB) and methimazole
diagnosis of post-partum thyroiditis
measurement of TSH and free-thyroxine levels
low TSH
low free T3
low-normal free T4
elevated reverse T3
euthyroid sick syndrome
- pt usually has history of recent severe illness
next step after you diagnosed euthyroid sick syndrome
repeat thyroid function tests in 6-8 weeks
basic screening tests that should be done in everyone with a newly discovered adrenal incidentaloma
plasma catecholamine levels
overnight dexamethasone suppression test
aldosterone levels - if pt has HTN or hypokalemia
metastatic lesions to adrenal glands
high attenuation (Hounsfield units > 20) bilateral
primary adrenocortical carcinoma
large (>6 cm) with irregular borders and areas of necrosis
best screening test for primary hyperaldosteronism
serum aldosterone:renin ratio
- ratio > 20, when serum aldosterone is > 15 is consistent with primary hyperaldosteronism
partial suppression on high dose dexamethasone suggests?
ACTH secreting pituitary microadenoma
- high dose dexamethasone is usually not succesful in suppressing ACTH production
when is adrenal imaging indicated for hypercortisolism?
when you have high cortisol but normal/low ACTH level –> CT scan often shows a tumor
cosyntropin stimulation test
determines adrenal reserve
- used to detect adrenal insufficiency
next step in pt with partial suppression to dexamethasone test?
pituitary MRI
test of choice for diagnosing pheochromocytoma (in pt with symptoms and elevated catecholamine levels?
abdominal CT scan or MRI
in patient with signs of pheochromocytoma, but abdominal CT scan shows no masses - what do you do?
metaiodobenzylguandine (MIBG) scan
- reserved for pts with equivocal CT results, extra-abdominal catecholamine secreting tumor or suspected malignancy
suppressed ACTH and cortisol levels, with clinical findings of excess glucocorticoids
secondary adrenal insufficiency due to exogenous steroids
tx. of adrenal insufficiency in times of increased physiologic stress
stress dosage (10-time normal replacement dose) of IV hydrocortisone
Tx of acute adrenal insufficiency
IV fluids
IV hydrocortisone
prevention and tx. of osteoporosis
vitamin D and calcium supplementation
screening for osteoporosis
DEXA scan beg. at age 65 in women
- women age 60-64 should be screened if they are at higher risk (i.e. weight below 70 kg)
indications for pneumococcal vaccine
people age 65 yo or older
people under 65 who live in long-term care facilities, have chronic illnesses or who are alaskan natives/american indians
MOA of bisphosphonates
pyrophosphate derivatives that bind to bone surface and inhibit osteoclastic bone resorption; lower fracture risk in osteoporosis patients
calcitonin for tx. of osteoporosis
nasal spray - increases bone mass in spine and decreases vertebral fractures (no effect on hip fractures)
- 2nd line to bisphosphonates
teriparitide
stimulates osteoblastic bone formation; given as subcutaneous injection, should not be used for more than 2 years
who should teriparitide be avoided in?
increases risk of osteosarcoma; avoid in:
- pts with Paget dz of bone
- unexplained elevations of ALP
- previous radiation involving skeleton
- history of skeletal cancer
next best tx. in pt on alendronate who develops exacerbated symptoms of GERD?
IV zolendronate (once yearly infusion) or IV ibandronate every 3 months
indications for IV zolendronate
- when oral bisphosphonates are unsuccesful
- oral BPs C/I (esophageal achalasia/stricture)
- likely to be poorly absorbed (celiac, IBD)
- pt is unable to remain upright for 30-60 min
who is teriparatide reserved for?
pts with high risk of fracture (T score > -.30) with previous vertebral fracture and contraindications to bisphosphonate use
definition of osteoporosis
presence of fragility fractures OR
bone mineral density T score less than -2.5 in pts w/o fragility fracture
osteopenia
BMD T score between -1 and -2.5
