Endocrine disorders

Question 1

Diabetes screening recommendations

Answer 1

Testing should be considered in adults who are overweight (BMI >25) and have risk factors

• In the absence of risk factors, testing should begin at age 45 and then every 3 years thereafter

Question 2

Lab indicators of DM

Answer 2

• Fasting plasma glucose (8 hour fast) = >126
• Random plasma glucose = >200
• OGTT at 2 hours = >200
• Hgb A1c = >6.5%

Question 3

When is repeat A1c indicated for patients with DM?

Answer 3

If asymptomatic, A1c repeated with glucose <200

Repeat not needed in presence of DM symptoms and/or glucose levels >200

Question 4

DM laboratory tests

Answer 4

• A1c every 3-6 months
• Fasting blood glucose (as indicated)
• Lipid profile (annual)
• Urine microalbumin/creatinine (annual)
• Serum creatinine with GFR (annual)

Question 5

DM treatment (lifestyle modifications)

• Prediabetes

Answer 5

• Target weight loss of 7% body weight
• Increase physical activity to 150 minutes/week
• Consider adding metformin
• Smoking cessation
• Mediterranean diet
• Eat frequent, small, high fiber meals and foods with low glycemic index
• Calorie deficit

Question 6

Metformin therapy contraindications

Answer 6

Can lead to lactic acidosis

• Renal impairment (GFR <45)
• Concurrent IV contrast dye use
• HF
• Age 80+ years

Question 7

Sulfonylurea → glipizide, glyburide, glimepiride

• MOA
• Comments

Answer 7

MOA: insulin secretagogue

Comments:

• Hypoglycemia risk
  
  • Caution in ASCVD
• Require functioning pancreatic beta cells

Question 8

Metformin MOA

Answer 8

• Reduces hepatic glucose production and intestinal glucose absorption
• Insulin sensitizer via increased peripheral glucose uptake and utilization

Question 9

Example of TZDs

Answer 9

• Pioglitazone
• Rosiglitazone

Question 10

GLP-1 agonist → eventide, liraglutide, dulaglutide (incretin mimetic)

• MOA
• Comments

Answer 10

MOA: stimulates insulin production in response to increase in plasma glucose, inhibits postprandial glucagon release, slows gastric emptying

Comments:

• N/V
• Contraindicated with gastroparesis
• Use with caution in patients with mild-moderate renal impairment

Question 11

DPP-4 inhibitor → -gliptin

• MOA
• Comments

Answer 11

MOA: increases levels of incretin, increasing synthesis and release of insulin from pancreatic beta cells, decrease release of glucagon from pancreatic alpha cells

Comments:

• Monitor for development of pancreatitis

Question 12

SGLT-2 inhibitor → -gliflozin

• MOA
• Comments

Answer 12

MOA: lowers renal glucose threshold, increased urinary glucose excretion

Comments:

• Increased risk of ketoacidosis, hyperkalemia
• Weight neutral

Question 13

When is insulin therapy indicated for T2DM management?

Answer 13

• At time of diagnosis to help achieve initial control (especially if glucose greater than 250-300)
• Acutely ill (should be kept at 140-180)
• When >2 insulin secretagogues (sulfonylureas, GLP-1 agonist, DPP-4 inhibitor) at optimized use are inadequate

Question 14

What is the somogyi effect in DM management?

Answer 14

An insulin-induced hypoglycemia triggers excess secretion of glucagon and cortisol → hyperglycemia

• Lower dinnertime dose of intermediate acting insulin (NPH, novolin or humuling)

Question 15

What is the dawn phenomenon in DM management?

Answer 15

Result of reduced insulin sensitivity developing between 5-8am

• Caused by earlier spikes in GH → cortisol release → hepatic glucose secretion → early morning hyperglycemia
• Split evening intermediate insulin dose between dinner and bedtime OR switch to bedtime dose of basal insulin (glargine)

Question 16

Clinical presentation of T1DM and associated ketoacidosis

Answer 16

• Severe dehydration
• Abdominal pain
• Vomiting
• Altered LOC

Question 17

Diagnostic criteria for metabolic syndrome

Answer 17

Insulin resistance (T2DM or impaired fasting glucose) plus 2+ of the following:

• Abdominal/central obesity
• Hypertriglyceridemia (150 or greater)
• Low HDL
  
  • <35 for men
  • <40 for women
• High BP (>140/90) or documented use of antihypertensives
• Microalbuminuria (glucose intolerance)

Question 18

True/false: A 10% body weight loss yields nearly immediate improvements of death rates from heart disease and stroke

Answer 18

True

Question 19

Obesity labs

Answer 19

• Fasting lipid panel
• LFTs
• Thyroid function tests
• Fasting plasma glucose
• A1c

Question 20

Obesity pharmacotherapy

Answer 20

D/c if patient has not achieved 5% weight loss by week 12 of treatment

• Orlistat → reduces dietary fat absorption
  
  • Taken with or within 1 hour of a meal that contains fat
• Phentermine and topiramate (Qsymia)
  
  • Need negative pregnancy test before starting b/c of topiramate
• Naltrexone and bupropion (Contrave)
  
  • Black box warning for neuropsychological symptoms
• Liraglutide → GLP-1 agonist

Question 21

How soon after levothyroxine therapy is initiated for hypothyroidism treatment, should TSH levels be checked again?

Answer 21

6-8 weeks after initiation

• Once levels are stable, check again after 6 months then at 12 month intervals

Question 22

What foods and/or medications should be avoided, or separated by at least several hours, when on levothyroxine therapy?

Answer 22

• Medications
  
  • Iron
  • Calcium
  • Aluminum containing antacids
  • Rifampin
  • Phenytoin
  • Carbamazepine
  • Phenobarbital
  • Sucralfate
• Cow or soy milk

Question 23

How should levothyroxine be taken?

Answer 23

Same time every day on empty stomach with water only

• If taken in morning, no food should be eaten for 1 hour
• If taken after eating, wait 4 hours after eating with 1 hour wait postdose

Question 24

Subclinical hypothyroidism diagnostic testing

Answer 24

Add test for TPO antibodies - clinical marker of autoimmune thyroid disease

Question 25

Is treatment necessary for subclinical hypothyroidism?

Answer 25

Yes if… * TSH levels increase to more than 10 * Increase in LDL * Increased CVD risk * Infertility * Pregnancy * Plans to become pregnant in the near future

Question 26

Hyperthyroidism treatment

Answer 26

* Methimazole and PTU (if pregnant, PTU in first trimester) * Hepatotoxicity warning * Once euthyroid state achieved, radioactive iodine for thyroid ablation next step

Question 27

Dyslipidemia diagnostic testing recommendations

Answer 27

Begin lipid screening (TC, HDL, LDL, TG) for adults ages 20-78 years without ASCVD every 4-6 years * If non fasting and TGs are \>400, repeat profile in fasting state

Question 28

When is repeat testing of lipid profiles indicated for patients on drug therapy and those focusing on lifestyle modifications?

Answer 28

If on drug therapy, check after 6 weeks of therapy If not on drug therapy, monitor every 3-6 months

Question 29

Four groups for the prevention of ASCVD risk reduction (indication for statin therapy)

Answer 29

* LDL 190 or higher (high intensity) * DM who are aged 40-75 years (moderate intensity) * Older than 75 years * Aged 40-75 years who have LDL between 70-189

Question 30

Statin therapy considerations before initiation

Answer 30

* Check baseline hepatic enzyme levels * Causes LDL reduction * High intensity statin → atorvastatin 40-80, rosuvastatin 20-40 * Moderate intensity statin → simvastatin, atorvastatin 10-20, pravastatin, rosuvastatin)

Question 31

When is a repeat lipid profile indicated after statin therapy?

Answer 31

After 4-12 weeks then repeated every 12 months

Question 32

Primary vs secondary adrenal insufficiency

Answer 32

Primary - adrenal gland is damaged and hinders production of hormones (autoimmune, infection, hemorrhage, tumor, anticoagulant) Secondary - pituitary gland is diseased, those who have taken systemic corticosteroids for a chronic condition and then abruptly stop taking them

Question 33

Addison's disease clinical presentation

Answer 33

* GI upset (chronic diarrhea, N/V, loss of appetite) * Weight loss * Paleness * Darkening of skin, patchy appearance * Muscle wasting, fatigue * Slow or sluggish movement * Hypoglycemia * Low BP

Question 34

Addison's disease diagnostic testin

Answer 34

* Serum potassium, sodium, cortisol, ACTH * ACTH stimulation test * Inject synthetic ACTH and compare level of cortisol before and after * Damage to adrenal gland will show no response to synthetic ACTH * Abdominal CT scan

Question 35

Addison's disease treatment and management

Answer 35

* Corticosteroid replacement therapy * Increase salt intake before heavy exercise, hot climates, during GI upset (diarrhea)

Question 36

Cushing's syndrome clinical presentation

Answer 36

* Progressive weight gain * Altered fatty tissue deposits (mid section and upper back) * Moon face * Buffalo hump * Pink or purple stretch marks * Fragile skin that bruises easily * Slow healing cuts * Fatigue * High BP * Glucose intolerance * Hirsutism * Menorrhagia

Question 37

Cushing's syndrome diagnostic testing

Answer 37

* Without history of long term corticosteroid use * Urine, blood, saliva tests to evaluate cortisol levels * MRI or CT scan to determine any abnormality of pituitary

Question 38

Cushing's syndrome treatment and management

Answer 38

* For endogenous Cushing's syndrome or Cushing's disease → surgery * Mifepristone for patients with endogenous Cushing's syndrome and T2DM or glucose intolerance

Question 39

PALM-COEIN classification system for abnormal uterine bleeding (heavy menstrual bleeding or intermenstrual bleeding)

Answer 39

PALM (structural) * Polyp * Adenomyosis * Leiomyoma * Malignancy and hyperplasia COEIN (non structural) * Coagulopathy * Ovulatory dysfunction * Endometrial * Iatrogenic * Not yet classified

Question 40

Abnormal uterine bleeding diagnostic testing

Answer 40

* CBC * Pap smear (if due) * Pregnancy test * Endometrial sampling via biopsy (for hyperplasia or cancer) * Thyroid function (hypothyroid) * Prolactin (pituitary function) * LFT * Coagulation studies * Pelvic US

Question 41

Abnormal uterine bleeding treatment and management

Answer 41

* Up to age 39 years → COCs, LNG IUD * Pre or perimenopause (40+ years) → cyclic *progestin* therapy, low dose COC, LNG IUD, cyclic hormone therapy