Endocrine Diseases Flashcards
(153 cards)
1
Q
diabetes is related to:
A
lack of beta cell pancreatic production of insulin
2
Q
insulin is needed for:
A
sugar absorption into cells
3
Q
a lack of insulin leads to:
A
increased serum glucose aka hyperglycemia
4
Q
hyperglycemia results in:
A
undernourished tissues which have multiple effects on systemic health
5
Q
gestational diabetes occurs in what percentage of pregnancies
A
2-10%
6
Q
is type I diabetes insulin dependent, another name for it and what percentage of diabetics have it
A
- aka juvenile diabetes
- insulin dependent
- 10-20% of diabetics
7
Q
describe type 1 diabetes and who it affects
A
- autoimmune disease
- destruciton of pancreatic Beta cells -> insulin deficiency
- non-obese children and adults less than 40 years old
8
Q
what stage of type 1 diabetes do symptoms occur
A
stage 3
9
Q
what are the effects of diabetes
A
- microvascular
- macrovascular
- impaired wound healing and susceptibility to infection
10
Q
what are the microvascular effects on diabetes
A
- neuropathy- extremities, impotence, bladder dysfunction, gastroparesis
- retinopathy- cataracts, blindness
- nephropathy
11
Q
what are the macrovascular effects of diabetes
A
- peripheral vascular disease, congestive heart failure- hypertension
- myocardial infarction- diabetes accelerates atherosclerosis
- stroke
12
Q
what are the impaired wound healing and susceptibility to infection effects of diabetes
A
- neutrophilic dysfunction, increased M1:M2 ratio
- increased pro-inflammatory cytokines and increased MMPs
- impaired angiogenesis and endothelial dysfunction
12
Q
describe type 2 diabetes
A
- aka adult onset diabetes; non insulin dependent
- pancreas produces insulin but it is in low titers or it does not work properly
- 80-90% of diabetics
12
Q
what is the normal, pre-diabetes and type 2 DM fasting plasma glucose
A
- less than 100mg/dl
- 100-135 mg/dl
- greater than 126 mg/dl
12
Q
what is the normal, pre-diabetes and type 2 DM 2 hour plasma glucose
A
- less than 140 mg/dl
- 140-199 mg/dl
- greater than or equal to 200mg/dl
13
Q
what is HbA1C levels for normal, pre diabetes, and type 2 DM patients
A
- less than 5.7%
- 5.7-6.4%
- greater or equal to than 6.5%
14
Q
describe what A1C measures
A
- measures the glycosylation of HbA aka HBA1C
- glycated hemoglobin test
- glycosylated hemoglobin test
- glycohemoglobin test
- a stable measure not affected by every day glucose fluctuation
- can be tested every 3 months
- biannual testing is recommended for prediabetes and susceptible pateints
15
Q
what is the goal for capillary plasma glucose prior to meals
A
- 80-130 mg/dl
16
Q
what is the goal for the capillary plasma glucose 1-2 hour after a meal
A
less than 180 mg/dl
17
Q
what is the goal for hemoglobin A1C in patients without kidney disease or other significant comorbidities
A
less than 7%
18
Q
what is the goal for hemoglobin A1C in pateints on dialysis less than 50 years of age
A
7-7.5%
19
Q
what is the goal for hemoglobin A1C in pateints greater than 50 years old
A
7.5-8%
20
Q
what HbA1C is associated in perio disease in poorly controlled diabetics
A
over 9%
21
Q
is there a correlation between severity of periodontitis and retinopathy
A
yes
22
periodontitis + diabetes ->
more renal complications and cardiovascular complications
23
severe periodontitis has an association in diabetes with:
neuropathic foot ulceration
24
what are the types of medications that are prescribed for diabetes
- decrease in gluconeogenesis
- increase in insulin secretion
- sensitization to insulin
- decrease in glucagon secretion
- intestinal and renal absorption of glucose
25
what are the medications that cause a decrease in gluconeogenesis
- biguanide- metformin
- insulin - rapid- lispro, short - novolin, long acting- glargine
26
what are the medications that cause an increase in insulin secretion
- sulfonylureas- glipizide, chlorproamide, tolbutamide
- glucagon- like peptide (GLP1) receptor agonist- exenatide, liraglutide
27
what are the meds that cause a sensitization to insulin
-thiazolidinediones- pioglitazone
28
what are the medications that cause a decrease in glucagon secretion
- dipeptidyl peptidase 4 (DPP4) - sitagliptin
- GLP1 receptor agonist - exanatide, liraglutide
29
what are the meds that are prescribed for intestinal and renal absorption of glucose
- sodium glucose cotransporter 2 inhibitors - canaglifozin
- alpha- glucosidase inhibitor- acarbose
30
what are the most common type of medication prescribed in diabetes
meds that cause a decrease in gluconeogenesis
31
what are the side effects of diabetes meds
- xerostomia/dry mouth
- oral burning
- infections (bacterial, fungal, viral)
- poor wound healing
- increased carries
- increased severity risk of perio disease
32
which type of infection is an indicator that diabetes isnt being controlled well
fungal
33
what are the concerns with diabetics
- if 2 hour after meal glucose, or fasting glucose reading less than 70 or more than 200mg/dl or hba1c over 8%
- if patient is not being closely followed by physician or more than 6 months seeing physician
- prophylactic antibiotics is context dependent
- defer elective tx
- if emergency or active infection refer to hospital or specialist
- send med consult
34
what comorbidities with diabetes need to be controlled
- HTN
- HLD
- other cardiovascular disease (angina, MI, CHF, stroke)
- renal impairment
35
what medications need to be avoided in diabetes and what do they cause
- tetracycines (including doxycyclines) with insulin - hypoglycemia
- fluoroquinolones - ciprofloxacin (cipro), levofloxacin (levaquin) with insulin - hypoglycemia
- aspirin with sulfonylureas - hypoglycemia
- sulfonylureas may cause thrombocytopenia
36
what should early morning appointments with diabetics consider
- eat normal meal and take meds prior to appointment
- be aware of and have patient communicate symptoms of hypoglycemia
- have high concentrations sugar products readily available- orange juice, cake icins, soft drinks
37
is oral sedation recommended with diabetics , why or why not
- no because fasting is necessary
38
which questions should you ask once you know your patient is diabetic
- previous hospitalizations
- drug interactions/side effects
- disease control
- ability to tolerate care
- comorbidities
- infection
- disease duration
- disease complications
39
what percentage of pregnancies does gestational diabetes occur in and when does it present
- 2-10% of pregnancies
- presents at mid-term ~24-28 weeks
- unknown etiology
40
how long is each trimester of pregnancy
- first trimester: 0-12 weeks
- second trimester: 13-28 weeks
- third trimester: 29-40 weeks
41
what is early term, full term, late term and post term
- early: 37-38 weeks and 6 days
- full: 39-40 weeks
- late: 41 weeks - 41 weeks and 6 days
- post: 42 weeks and after
42
dental procedures could harm the developing fetus through the effects of:
-ionizing radiation
- drugs: continues post partum from transmission of drugs via breast milk
- stress
43
what are the common pregnancy discomforts
- nausea and vomiting
- indigestion
- headaches
- polyuria
- lumbar pain
- perspiration
- breast tenderness
44
what are nausea and vomiting caused by in pregnancy
- hormonal imbalances
- stress (physical and emotional)
- hyperacidity
45
what is indigestion in pregnancy
difficulties digesting foods rich in fats, sugars, acids can lead to nausea and vomiting
46
what should be the considerations for pregnant women and what trimesters can receive tx
- maintain optimal oral health
- avoid elective dental care during the first trimester
- second trimester is the best time to perform dental tx
- after the middle of the third trimester, postpone elective care
- dental treatment can be safely performed in all trimesters
- avoid drugs known to be harmful to the fetus
- lack of proper oral health care during pregnancy could harm the developing fetus and affect the time of delivery
47
what are the considerations with radiation for women of childbearing age
inquire if the patient could possibly be pregnant
48
what is the gonadal/fetal dose incurred with 2 PA images when a lead apron is used
700 times less than that for 1 day exposure to natural background radiations in the US
49
when should radiographs be taken in pregnancy
radiographs are contraindicated in all but emergency situations. when taken lead shielding is mandatory
50
what are the radiographs recommendations for new and recall pregnant dental patients
- radiographs should be postponed until post partum
- long term benefit to the health of mother from new patient or recall exam radiographs
- but no benefit to the health of the developing child
- unborn child faces greater helath risks from the radiation exposure than the mother without any benefit to their health
51
what does the national council on radiation protection and measurements recommend for pregnant radiation workers
radiation exposure thresholds for pregnant radiation workers is lowered to the same thresholds as the general population
52
what is the SoD dental radiograph recommendation guidelines for pregnant patients
same as NCRP recommendations
53
what is the protocol with radiographs in emergency pregnant dental patients
- necessary radiogrphs are part of the standard of care to treat and diagnose a condition that threatens the health of the mother an dunborn child
- lack of radiographs compromises the emergency care diagnosis and treatment, this will directly impact the health of the unborn child
- primary beam is not directed toward the child bearing area
54
what is the protocol for emergency dental treatment during pregnancy
- may be provided as needed any time during pregnancy
- pain control and elimination of infections should be preformed
- emergency dental tx may require a consult with the obstetrician if there is a concern about medications or effect of emergency tx on fetus
- untreated dental infections may pose a risk to the developing fetus
- dental radiographs as needed to establish dx
55
what might untreated dental infections cause in pregnant patients
- fever and sepsis may precipitate a spontaneous abortion
56
when should you avoid supine position in pregnant patients and why
- in late third trimester
- supine hypotension syndrome- due to compression of the IVC that results in impaired venous return to the heart
57
what does supine hypotension syndrome manifest as
- fall in BP
- bradycardia
- sweating
- nausea
58
what can patient do to decrerase the effects of supine hypotension syndrome
patient can rotate to their LEFT side to allow venous return to recover
59
what drugs should be avoided in pregnant patients
- all if possible
- most dental drugs can be safely used in pregnant patients but do not exceed max dose of LA- lido with or without epi is safe
- avoid aspirin and other NSAIDs
- opiods should be avoided
60
why should aspirin and NSAIDs be avoided
- closure of the ductus arteriosus
- risk of post partum hemorrhage and delayed labor
61
what is the analgesic of choice in pregnant patients
acetominophen
62
what is the opioid of choice in pregnant patients when discussed with the physician
codeine with acetominophen (APAP)
63
what antibiotics are okay to prescribe in pregnant patients
- amoxicillin
- clindamycin
- azithromycin
- metronidazole
- erythromycin
64
what antibiotics are contraindicated in pregnant pateints and why
- tetracyline and doxycylcine
- they are teratogenic
65
what are the sedation recommendations for pregnant patients
- no pharmacologic sedation is prefered
- if necessary, NO may be used for less than 30 minutes and with at least 50% O2
66
what are the considerations when using NO on a pregnant patient
- pt should not have multiple appointments or extended appointment with NO sediation because cumulative effects are a point of concern
- avoid during first trimester
- appropriate oxygenation after nitrous is necessary to avoid diffusion hypoxia
- benzodiazepines should be avoided because of respiratory depression
67
what are the protocols with NO for pregnant workers and why
women of child bearing age should not be chronically exposed to nitrous in occupational capacity for more than 3hours per week without scavenging equipment
- risk for decreased fertility and greater rates of spontaneous abortion
68
what is the occupational dose limit for pregnant workers and what are they given to measure this
- personal dosimeter monitoring devices
- less than or equal to 1mSv/year
69
what is the maximum permissible dose definition
the amount of ionizing radiation which in the light of present knowledge will not produce any serious, harmful or deleterious effects on the individual receiving it
70
average dental occupational exposure for pregnant dental workers is:
0.2 mSv/year
71
what perentage of pregnant dental workers have readings below the threshold of detection
68%
72
what are the considerations for lactating mothers
- most drugs are of little pharmacologic significance to lactation
- do not prescribe drugs known to be harmful
- medications should be taken just after breat feeding
73
what might be the periodontal effects seen in pregnant or lactating mothers
- periodontium- can range from mild inflammation to severe overgrowth, the hormonal increase can exaggerate the gum tissues response to bacterial plaque
- tooth moility may be present
- prevention, good oral health and perio maintenance is important for your pregnant patients or those considering becoming pregnant
74
what are the oral complications in pregnancy
- exacerbation of underling periodontal disease
- increased risk of pyogenic granuloma
- gingivitis is the most common oral condition in pregnancy -60-75% of pregnant women
75
pregnancy gingivitis and exacerbated periodontitis affected by:
- lack of attention to OH
- increased systemic fluid levels from increased progesterone and estrogen exacerbate any existing gingival/periodontal condition
76
what are the other names for pyogneic granuloma
- epulise gravidarum
- pregnancy tumor
77
describe pyogenic granulomas
- not an actual granulmona as there is proliferation of vascular tissues as well as proliferation of fibrous tissue
- forms submucosally and takes the shape of nodular growth
- in pregnancy, it is an exacerbated response to plaque and bacteria precipitated by the changes in progesterone and estrogen hormonal levels
78
what is the tx for pyogenic granuloma
- nothing it will resolve after
- keep it clean because it can get affected
79
what are the considerations for patients with gestational diabetes
- high blood sugar affecting pregnant women who have insufficient insulin production relative to metabolic needs
- in some instances, it may also be insulin resistance
- gestational diabetics are at higher risk of developing type 2 diabetes later in life
- generally asymptomatic
80
what are the risks to the fetus with gestational diabetes
- fetus can have excess weight gain
- affects lung development
- delivery may require cesarean section
81
what are the general treatment considerations for gestational diabetes
- daily blood sugar monitoring
- healthy diet
- exercise
- monitoring the baby
82
if conservative measure are not responsive and blood sugar remains high in gestational diabetes then:
- medical intervention like the intervention for type 2 diabetes is indicated
- Intramuscular insulin
- or metformin - preferred method
83
what hormone is secreted from the glomerulosa zone and the action
- aldosterone
- kidneys- distal tubules
- intravascular volume and RAA system
- regulates Na and water balance - affects BP
84
what does the zona fasciculata secrete and what are the actions
- cortisol
- increases contractility and vascular reactivity to vasoconstriction resulting in increased BP
- antagonizes insulin
- activates lipolysis - increased FFA
- stimulates gluconeogenesis- results in increased sugar, insulin intolerance and cholesterol
- muscle catabolism- increases glucose
- decreases calcium absorption and activates osteoclasts- results in osteoporosis
- inhibits PLA2 and mobilization , migration, function of leukocytes - results in decreased immune response
- increases appetite, suppresses sleep, regulates emotion and memory
- increases intraocular pressure
85
what does zona reticularis secrete and what are the actions
- androgens
- gonads
- sexual maturation, growth and development
86
what does norepinephine and epinephrine do
- fight or flight stress response
- increases BP, peripheral resistance, CO
87
what does hyperadrenalism cause
- increased aldosterone, cortisol, androgen, estrogen isolate or in combination
88
what is seen in hyperaldosteronism
- hypertension
- hypokalmemia
- edema
89
what is glucocorticoid excess
- most common
- high levels of cortisol
- cushing disease - pituitary or adrenal tumor
- cushing syndrome- exogenous corticosteroids
90
what are the diseases associated with the adrenal gland
- hyperadrenalism
- hyperaldosteronism
- glucocorticoid excess
91
what are the complications of glucocorticoid excess
- diabetes
- hypertension
- weight gain
- moon facies
- buffalo hump
- hirsutism
- acne
- osteoporosis
- delayed wound healing
- susceptibility to infection
- irregular menses insomnia
- psychiatric disorders
- peptic ulcers
- glaucoma and cataracts
92
what does the acronym CUSHINGOID stand for
-Cataracts
-Ulcers
-Striae and skin thinning
-Hypertension and hirsutism
- Immunosuppression and infections
- Necrosis of femoral heads
- Glucose elevation
- Osteoporosis and obesity
-Impaired wound healing
-Depression and mood changes
93
what are the cutaneous findings in cushing syndrome
- increased central adiposity with thinning of the extremities
- skin thinning and easy bruising
- violaceous striae
- acanthosis nigricans
- increased dermatophyte and candidal skin and nail infections
- hyperpigmentation
94
what are the diseases seen with cushing syndrome
- diabetes
- HTN
- osteoporosis
- irregular menses
95
what is the dx of cushing syndrome
- measurement of 24 hour urinary free cortisol and late night salivary cortisol
- failure to suppress cortisol production with a low dose dexamethoasone suppression test
96
what is the management of cushing disease
- appropriate endocrine and surgical consultation
- surgical removal of pituitary or adrenal tumor
- adrenal enzyme inhibitors
- radiation therapy
97
what are the immediate acting glucocorticoids prescribed for cushings
- prednisone
- triamcinodone
- methylprednisome
98
what are the long acting glucocorticoids prescribed for cushing disease
- dexamethasone
- betamethasone
99
what is another name for primary adrenal insufficiency
addison disease
100
describe addison disease
- destruction of adrenal cortex
- decreased cortisol and increased ACTH
- cannot tolerate stress: adrenal crisis
101
what is the etiology of addison disease
- most commonly autoimmune
- chronic infectious disease and sepsis: HIV, CMV, fungal infection
- drugs
102
what is the treatment for addisons
- lifelong replacement therapy of glucocorticoids and mineralocorticoids
- requires cortisol replacement
- surgery and stress may require supplemental corticosteroids
- pain control is important
103
what are the cutaneous findings in addison disease
- hyperpigmentation of the skin and mucous membranes
- longitudinal pigmented bands in the nails
- vitilgo
- decreased axillary and pubic hair in women
- calcification of auricular cartilage in men
104
what are the related features in addison disease
- abdominal pain
- electrolyte abnormalities- hyponatremia and hyperkalemai
- postural hypotension
- anorexia and weight loss
- fatigue
- shock, coma and death if untreated
105
how is addison dx
failure to respond adequately to corticotropin test
106
describe secondary adrenal insufficiency
- impaired/destructive pituitary disease
- decreased cortisol and decreased ACTH, aldosterone unchanged
- lower dose replacement therapy
107
describe teriary adrenal insuffiency
- impaired function of hypothalamus
- most commonly a result of chronic exogenous steroid use
- lower dose replacement therapy
108
does hyperpigmentation and adrenal crisis usually occur with tertiary adrenal insufficiency
not usually or it is less likely
109
what should be considered with hyperadrenalism
- BP and glucose levels
- avoid NSAIDs and aspirin -> peptic ulcers and GI bleed
- if osteoporosis and osteopenia->more prone to periodontal bone loss. may have history of bisphosphonate use
110
impaired wound healing in adrenal diseases may be a consequence of:
hyperadrenalism and adrenal insufficiency
111
the necessity for supplemental corticosteroids in adrenal insufficiency depends on
- type
- severity/stability/medical status
- dental proceudre being perfromed (long: greater than 1hr or invasive)/ type of stress/dental infection
112
what are the signs of adrenal crisis
- hypotention- monitor BP - vasopressors, patient position, fluid replacement
- abdominal pain
- myalgia
- fever
- supplement with 100mg of hydrocortisone and send to ED
113
what are the pain control protocols with adrenal insufficiency
- adequate anesthesia, long acting agent at end of procedure
- good post op pain control
114
thyroid function involved in:
developmental and metabolic processes
115
thyroid function depends o:
iodide
116
what hormones does the thyroid produce
- T3 and T4
- calcitonin
117
what are T3 and T4 controlled by
TSH in the pituitary
118
what does calcitonin do and what is it influenced by
- regulates circulating calcium and phosphorus levels
- influenced by actions of PTH and vitamin D
119
what is the effect and mechanism of thyroid hormones on the heart
- chronotropic and inotropic
- increased number of beta adrenergic receptors
- enhanced responses to circulating catecholamines
- increased proportion of alpha myosin heavy chain with higher ATPase activity
120
what is the effect and mechanism of thyroid hormones on adipose tissue
- catabolic
- stimulates lipolysis
121
what is the effect and mechanism of thyroid hormones on muscle
- catabolic
- increased protein breakdown
122
what is the effect and mechanism of thyroid hormones on bone
- developmental
- promote normal growth and skeletal development
123
what is the effect and mechanism of thyroid hormones on nervous system
- developmental
- promote normal brain development
124
what is the effect and mechanism of thyroid hormones on the gut
- metabolic
- increased rate of carbohydrate absorption
125
what is the effect and mechanism of thyroid hormones on lipoprotein
- metabolic
- formation of LDL receptors
126
what is other effects and mechanism of thyroid hormones
- calorigenic
- stimulated oxygen consumption by metabolically active tissues except testes, uterus, lymph nodes, spleen and anterior pituitary
- increased metabolic rate
127
what are the thyroid disroders
- thyroid enlargement- goiter
- thyroid nodules
128
describe thyroid enlargement disorders
- may be functional or non functional
- most are nonfunctional (euthryoid)
- hyperthyroidism goiter- graves disease
- hypothyroidism goiter - hashimoto thryoiditis
129
what are the thyroid nodule disorders
- hyperplasia
- adenoma
- carcinoma
130
what are the neoplasms of the thyroid
- adenoma
- carcinoma- papillary and follicular
131
what are the symptoms of hyperthyoidism
- unintentional weight loss
- heat intolerance/ sweating
- palpitations
- agitation/emotional lability
- multiple daily loose stools
- pruritis
- weakness
- oligomenorrhea in women
132
what are the clinical findings and complications in hyperthyroidism
- goiter
- tachycardia
- atrial fibrillation
- high output cardiac failure
- fine tremor
- hot sweaty extremities
- ophthalmopathy
- agitation/confusion
- muscle weakness/wasting
- thyroid storm with fever, confusion, dehydration and eventual death if untreated
133
what is the diagnosis of hyperthyroidism
- increased free T4
- decreased TSH
- best initial test is serum thyroid stimulating hormone - low
- other tests include serum free thyroxine (T4), total triiodothyronine (T3) and thyrotropin receptor antibodies
- radioactive iodide uptake and imaging
134
what is the management of hyperthyroidism
- appropriate surgical and endocrine consultation
- propanolol for symptomatic treatment of tremor, tachycardia and sweating
- proplythiouracil to inhibit hormone metabolism and concentration of T4 to T3
- methimazole to inhibit thyroid hormone synthesis
- radioiodine ablation of the thyroid gland
135
thyroid storm/crisis may be precipitated by:
oral infection or surgical procedure in a patient who is poorly controlled
136
what are the symptoms of hypothyroidism
- unexplained weight gain
- fatigue
- cold intolerance
- constipation
- dry skin
- muscle weakness
- carpal tunnel syndrome
- hoarseness
- decreased body temperature
- facial swelling
- menorrhagia in women
137
what are the clinical findings and complications in hypothyroidism
- goiter
- cold, doughy skin
- bradycardia
- facial and finger swelling
- slowed relaxation of deep tendon reflexes
- hair loss/lateral eyebrow loss
- pericardial effusion
- MI or CHF with aggressive thyroid hormone replacement
- coma and death without treatment
138
what are the related features in hypothyroidism
- macroglossia
- broadened nose, thickened lips, puffy eyelids
- impaired wound healing
- cretinism in patients with congenital hypothyroidism
- myxedema coma
139
what is the dx of hypothyroidism
- decreased free T4
- decreased or increased TSH
- best initial test is serum thyroid stimulating hormone- elevated
- other useful tests include serum free thyroxine (T4), total triiodothyronine (T3), antithyroperoxidase (anti-TPO) antibodies, and lipid panel
140
what is the management of hypothyroidism
- appropriate endocrine consultation
- oral thyroxine replacement - usually in the range of 75-150 micrograms per day
- careful follow up for heart, lung and adrenal disease
141
what is the oral manifestations of hyperthyroidism
- increased periodontal bone loss
- increased susceptibility to caries
142
what are the oral manifestations of hypothyroidism
- delayed tooth eruption and altered bone formation
- macroglossia
- dysgeusia and burning mouth
- salivary gland enlargement
- oral lichen planus
143
patients with both hyper and hypothyroidism may be more susceptible to______ so you need to treat ______
infections; aggressively
144
what is the risk for uncontrolled thyroid disorders
- risk of agranulocytosis from medications used to treat hyperthyroidism
- thyrotoxic crisis/storm in hyperthyroidism
- myxedema coma- hypothyroidism
145
what should you do if there is a thyrotoxic crisis/storm
- CPR and vital signs
- ice packs or wet packs
- administer hydrocortisone 100-300mg
- IV glucose
- administer propylthiouracil
- send to ED
146
what should you do if there is myxedema coma
- CPR and vital signs
- conserve body heat- blanket
- administer hydrocortisone 100-300 mg
- IV saline and glucose
- administer thyroxine
- send to ED
147
what are the warning signs of agranulocytosis
- fever
-sore throat
- oral ulcers
148
what are the drug interactions/side effects in hyperthyroidism
- caution with aspirin and NSAIDS can increase T4
- ciprofloxacin contraindicated- decreases absorption of thyroid hormone
- avoid local anesthetics containing epinephrine and ginvial retraction cord with epi in poorly controlled patients
149
what are the drug interactions/side effects in hypothyroid patients
- avoid CNS depressants such as narcotics, barbituates and sedatives if the patient is poorly controlled
- cytochrome p450 inducers such as phenytoin, carbamazepine, and rifampin should be avoided because it increases metabolism of levothyroxine
150
