Endocrine Disorders Flashcards
(54 cards)
1
Q
Pathophysiology of Diabetes in the Elderly
A
- Age associated decline in beta cell function
- Age associated insulin resistance
- Increased body fat, decreased muscle mass
- Decreased physical activity
- Increased hepatic glucose production
- Progression from impaired glucose tolerance to diabetes mellitus
2
Q
Risk Factors for Diabetes in the Elderly
A
- Obesity
- Family history
- Increased age
- Co-morbid conditions - hypertension, hyperlipidemia (metabolic syndrome)
- Medications: Corticosteroids
3
Q
Describe the signs and symptoms of diabetes in the elderly
A
- Traditional signs of polydipsia, polyuria and polyphagia occur less frequently in the elderly
- Dehydration with confusion and delirium as presenting symptoms are more common in the elderly
- Incontinence due to glycosuria
- Weight loss and anorexia more common in the elderly
4
Q
What are the goals of therapy of treating diabetes ? in the elderly?
A
Prevention of microvascular complications
• Prevention of macrovascular complication
• Prevention of short term complications
• Prevention of hypoglycemia
5
Q
What are microvascular complications that can happen?
A
- retinopathy
- nephropathy
- neuropathy
6
Q
What are macrovascular complication that can happen?
A
- CHD
- CVD
- PVD
7
Q
What are short term complications that can happen?
A
- Blurred vision
- weakness
- HHNC (hyperosmolar hyperglycemic nonketotic syndrome; will not see this unless blood sugar is 700-900)
8
Q
Summarize the concerns about hypoglycemia in the elderly diabetic
A
- Elderly are at greater risk of hypoglycemia during treatment
- Greater morbidity from hypoglycemia in the elderly
- Hypoglycemia presents atypically in the elderly
- Symptoms can include: confusion, delirium, dizziness, weakness, falls
9
Q
Which medication has the greatest reduction in A1C?
A
metformin
10
Q
Prioritize the use of oral agents in the treatment of diabetes in the elderly
A
- metformin first
- secondary: SGLT-2 inhibitors or TZD’s because they have CV benefits
- try to avoid sulfonylureas b/c of risk of hypoglyemia; avoid glyburide at all cost
- try to avoid insulin b/c of administration and compliance
11
Q
Which SGLT-2 inhibitors has CV benefits?
A
- canaglifozin
- empaglifozin
12
Q
Which TZD’s has CV benefits?
A
pioglitazone
13
Q
Consideration for the use of Metformin?
A
- Do not use if CrCl < 30 ml/min
- Monitor B12
- GI side effects common
14
Q
Consideration for the use of Pioglitazone?
A
- Edema, do not use in CHF patients
* Increased fracture risk
15
Q
Consideration for the use of SGLT-2 Inhibitors?
A
- UTI risk
- Fracture risk
- Black Box warning about increased risk of amputation
16
Q
Consideration for the use of DPP – 4 Inhibitors?
A
Risk of acute pancreatitis
17
Q
Consideration for the use of GLP-1?
A
GI (N,V)
18
Q
Discriminate signs and symptoms of hypothyroidism in the young versus older patient
A
• Signs and symptoms develop insidiously and typical signs of hypothyroidism (cold intolerance, lethargy, fatigue, constipation, etc) are often attributed to “normal aging”
19
Q
Thyroid tests in the elderly
A
- Abnormal thyroid function tests are common in the elderly but the clinical significance varies
- Abnormal thyroid function tests may be diagnostic of overt disease or represent subclinical dysfunction
- Patients with markedly abnormal TFTs are often asymptomatic or have atypical symptoms
- TFTs can be influenced by non-thyroidal illness or medications
20
Q
prevalence of hypothyroidism
A
Prevalence of chemically overt hypothyroidism in the elderly is 2.5 to 3%
21
Q
Describe laboratory parameters that are used to diagnose hypothyroidism in the elderly
A
Characterized by normal T4 but elevated TSH
22
Q
What is the most common cause of hypothyroidism?
A
Hashimoto’s thyroiditis
23
Q
Treatment of Hypothyroidism in the Elderly
A
- Levothyroxine starting at 0.025mg/d in the elderly and increase by 0.025 mg/d every four to six weeks until euthyroid
- Take on an empty stomach
- Too aggressive dosing may precipitate angina
24
Q
Subclinical Hypothyroidism
A
- 6% in patients 70 to 79 and 10% in patients over the age of 80 have elevated TSH and normal T4
- 17% of these patients progress to overt hypothyroidism
- To treat or not to treat?
25
prevalence of hyperthyroidism
Prevalence of hyperthyroidism in the elderly varies from 0.5 to 2.3%
26
What is the most common cause of hyperthyroidism?
Grave’s disease
27
Treatment of Hyperthyroidism in the Elderly
* Radioactive iodine ablation
* Precede radioactive iodine by symptomatic treatment with betablockers (cautiously) or antithyroid medication for more rapid control of symptoms
28
List the risk factors for osteoporosis
* Postmenopausal
* Early menopause
* Caucasian or Asian ancestry
* Thin, small build
* Family history
* Excessive Alcohol
* Cigarette Smoking
* Drugs - corticosteroids
29
Risk Factors for Falls
* Poor vision
* Co-morbid diseases
* Environmental elements: Throw rugs, Bath tub, Lighting
* Drugs: CNS and antihypertensives
30
Describe the etiology of osteoporosis
* Calcium deficiency and secondary hyperparathyroidism
* Estrogen deficiency in women
* Androgen deficiency in older men
* Decreased osteoblast activity in aging
31
Diagnosis of Osteopenia / Osteoporosis
* Osteopenia is defined as a T score of –1.0 to –2.5
| * Osteoporosis is defined as a T score of less than –2.5
32
Construct a treatment strategy for osteoporosis
* Calcium, Vitamin D
* Raloxifene
* Bisphosphonates
* Teriperitide
* Denosumab (Prolia*)
33
Calcium in treating osteoporosis
* Insufficient evidence that proves prevention of fracture but insufficient evidence to recommend against it
* Inconclusive results in maintenance of BMD
* Safe and well tolerated
* New USPSTF recommendation
* Use with caution in patients with history of kidney stones
34
Calcium dosing
* Dose: supplement dietary intake to achieve 1500 mg elemental calcium in post-menopausal women or patients over 65
* Calcium carbonate is cheapest but requires administration with meals
* Calcium citrate does not require administration with meals
35
Calcium adverse effects
- constipation
| - possible increased risk of cardiac events
36
Calcium drug interactions
```
decreases absorption
• Tetracylines and quinolones
• Alendronate and etidronate
• Phenytoin
• Fluoride
```
37
Vitamin D in treating osteoporosis
* Inconclusive results regarding fracture risk
* Limited studies demonstrate inconsistent effects on BMD in patients without vitamin D deficiency
* Use with caution with patients with a history of renal stones
* Safe and well tolerated
* Consideration to hepatic and renal function should be given
38
Vitamin D dosing
* 800 IU Vitamin D3 (cholecalciferol) -> May be increased to 1200 IU/d
* 20-50 ug 25-OHD3 (calcifediol)
* 25-50 ug 1,25-(OH)2D3 (calcitriol)
39
Estrogen in treating osteoporosis
* Given current evidence that long term risk exceeds benefit.
* Estrogens should never be used for prevention unless there is no other alternative
40
Bisphosphonates in treating osteoporosis
* Bisphosphonates are incorporated into bone, and exhibit an inhibitory effect on osteoclasts
* For prevention and treatment
* Maintain supplemental calcium and vitamin D
* Have demonstrated a reduction in fracture
* Parenteral agents – zoledronic acid
41
Bisphosphonates dosing
* Alendronate (Fosamax*) -> 10 mg daily or 70 mg once weekly
* Risedronate (Actonel*) -> 5 mg daily or 35 mg once weekly or 150 mg monthly
* Ibandronate (Boniva*) -> 150 mg once per month
* Patient should take it first thing in the a.m. with a full glass of water
* No food, beverages, or medication should be taken within 30 minutes of the dose
* Patient must remain upright for 30 minutes
42
Bisphosphonates adverse effects
- abdominal pain
- dyspepsia
- constipation
- diarrhea
- flatulence
- esophageal ulcer
- abdominal distention
- dysphagia
43
Bisphosphonates contraindications
* Patient unable to stand or sit-up
| * Patient with esophageal emptying problems
44
Bisphosphonates: extent of therapy
* Consider drug holiday after three to five years of therapy in appropriate patients
* Consideration should be given to life expectancy
* Increased risk of these with long term use: Spontaneous femur fractures, Bone pain, jaw osteonecrosis, (?)afib
45
Raloxifene (Evista*) in treating osteoporosis
* Selective estrogen receptor modulator (SERM)
* Is indicated for both prevention and treatment
* Effective in preventing fractures
* Has beneficial effects on lipids
46
Raloxifene (Evista*) dosing
Dose: 60 mg daily
47
Raloxifene (Evista*) contraindications
patients with history of thromboembolic disorders
48
Raloxifene (Evista*) adverse effects
* Hot flashes
| * Leg cramps
49
Teriperitide (Forteo*) in treating osteoporosis
* Pen injection device
* Costly, refrigerated
* Caution with digoxin
* Treatment only
50
Teriperitide (Forteo*) dosing
20 mcg SQ every day
51
Denosumab (Prolia*) in treating osteoporosis
* Monoclonal antibody
| * High co-pay
52
Denosumab (Prolia*) dosing
60 mg SubQ as a single dose every six months
53
Calcitonin in treating osteoporosis
* Costly and difficult to administer
* Lack of efficacy data
* Possible risk of cancer
* Not recommended for osteoporosis
* May have utility for managing pain from an acute fracture short term
54
Calcitonin dosing
* Intranasal - 200 IU/d
| * Subcutaneous or IM - 50 to 100 IU 3 to 5 X/wk
