Endocrinology Flashcards
(168 cards)
1
Q
What are two antibodies to measure to confirm T1DM?
A
GAD65 and IA-2
*Will be negative especially in African or Asian ancestry
2
Q
If you have nocturnal hypoglycemia, what type of insulin is too much?
A
basal
3
Q
What is an autosomal dominant form of T2DM that presents before 25 years old?
A
MODY-maturity onset diabetes of youth
4
Q
When do you screen for T2DM? USPSTF vs ADA
A
USPSTF: 40-70 yo in patients who are overweight or obes. Can consider screening earlier with 1+ risk factors (positive family history, h/o gestational diabetes or PCOS, ethnic groups)
ADA: overweight BMI >25 or >23 in Asian Americans with at least 1 additional risk factor`
5
Q
What are 3 ways to screen for T2DM?
A
fasting plasma glucose, 2 hour postprandial glucose during oral glucose tolerance test, A1c
If 1 of 2 is abnormal, repeat the abnormal test
If 2/2 is abnormal, then diagnose
6
Q
T/F: if random plasma glucose >200 and have hyperglycemic symptoms–>diagnosis as DM
A
T
7
Q
What is the cut off for prediabetes in:
1) fasting glucose
2) random glucose
3) 3 hour glucose during OGTT
4) hemoglobin A1c
A
1) 100-125
2) 140-199
3) 140-199
4) 5.7-6.4
8
Q
What is the cut off for diabetes in:
1) fasting glucose
2) random glucose
3) 3 hour glucose during OGTT
4) hemoglobin A1c
A
1) >126
2) >200 with symptoms
3) >200
4) >6.5
9
Q
When should blood glucose be measured if preprandial readings look good, but the a1c is still elevated?
A
postprandial blood glucose levels
10
Q
What is a1c goal for diabetic?
A
7-8%
11
Q
What 3 situations will the a1c be falsely low?
A
1) hemolytic anemia
2) EPO
3) kidney injury
12
Q
What is a contraindication to metformin?
What is a vitamin deficiency with metformin?
A
1) eGFR<30
2) vit B12
13
Q
What is the 3 side effects of sulfonylureas?
When do you avoid using it?
A
3 side effects: weight gain, hypoglycemia, rash
avoid using in renal failure
14
Q
What are 3 side effects of metformin?
When do you avoid it?
A
3 side effects: diarrhea, abdominal pain, lactic acidosis, (also vit B 12 deficiency)
avoid: eGFR<30
15
Q
What is a side effect of alpha glucosidase inhibitors (acarbose, miglitol, voglibose)
When do you avoid it?
A
abdominal pain
avoid in kidney injury
16
Q
What are 6 side effects of thiazolidinediones (rosiglitazone, pioglitazone)
When do you avoid it?
A
6 side effects: weight gain, edema, HF, macular edema, osteoporosis, bladder cancer risk
avoid if have CV events (especially with rosiglitazone)
17
Q
What are 2 side effects of meglitinide (reaglinide, nateglinide)
When do you avoid it?
A
2 side efects: weigth gain, hypoglycemia
avoid in renal failure
18
Q
What are 2 side effects of amylinomimetics (pramlintide)
What caution do you need to take with prescribing with insulin?
A
2 side effects: nausea, vomiting
increased risk of hypoglycemia with insulin
19
Q
What are 2 side effects with GLP-1 mimetics (exenatide, liraglutide)
What are 2 things you are at risk of?
A
2 side effects: nausea, vomiting
increased risk of pancreatitis and kidney failure
20
Q
What are 3 side effects of DPP-4 inhibitors (sitagliptin, saxagliptin, vildagliptin, linagliptin, alogliptin)
What 2 things are you at risk of?
A
3 side effects: nausea, skin rash, infections
increased risk of pancreatitis, HF exacerbation
21
Q
What are 2 side effects of SGLT2 inhibitors (dapagliflozin, empagliflozin, canagliflozin)
What medical history would you caution you to use this?
A
2 side effects: genital candidal infections and UTIs
medical history: peripheral vascular idsease, previous amputations, diabetic ulcers or neuropathy
can have hypoglycemia with insulin, DKA, canagliflozin is associated with lower extremity amputation
22
Q
What are 3 DM meds that can help with weight loss?
A
GLP-1 mimetics , pramlintide, SGLT2 inhibs
23
Q
When should screening for complications begin for T1DM? T2DM?
A
T1DM: 5 years after diagnosis and annually
T2DM: at diagnosis and annually
24
Q
What is the BP goal for DM?
1) ACC/AHA
2) ADA
A
1) <130/80
2) <140/90
25
When do you start a statin (and what) in a diabetic:
1) >40 yo, diabetes, ASCVD risk <7.5%
2) CAD, peripheral vascular disease or ASCVD risk >7.5% (AHA/ACC)
3) 40-75 yo, diabetes and ASCVD >10% (USPSTF)
1) moderate intensity
2) high intensity
3) moderate to high intensity
26
When do you start ACE/ARB when measuring urine albumin excretion of acreatinine?
>30
27
What are 3 treatments for diabetic retinopathy?
1) excellent blood glucose and BP control and smoking cessation
2) panretinal laswer photocoagulation
3) intraocular injections of bevacizumab or ranibizumab for severe or macular edema
28
How can you treat diabetic peripheral neuropathy?
amitriptyline, venlafaxine, duloxetine, paroxetine, pregabalin, gabapentin, valproate or capsaicin cream
29
T/F: Treat diabetic mononeuropathy (like a 3rd nerve palsy)
False, it was resolve spontaneously
30
What do you need to think about when there is a patient with AMS, hypovolemia, normal pH and bicarb?
HHS
glucose >600
plasma osmolality >320
management: NS to replenish extracellular space, then switch to hypotonic solution. Give IV insulin after expansion of intravascular space. Then subQ insulin once eating and glucose <200
31
How do you manage DKA?
NS then switch to 1/2NS if sodium level is high or normal. Then give insulin (delay if K <3.3), replace K when K is <5.5, glucose infusion when glucose level is <250, continue until AG is closed
32
When do you screen pregnant women for gestational diabetes?
24-28 weeks with 75 gram 2 hour OGTT
continue screening for T2DM with annual screening after delivery
33
What are the glycemic targets in pregnancy for:
1) premeal plasma glucose
2) 1 hour postprandial values
3) 2 hour postprandial values
1) <95
2) <140
3) <120
34
What meds are used during pregnancy for diabates?
insulin
| stop ACE/ARBs, statins
35
When should comprehensive eye exam be done during pregnancy for diabetes?
once per trimester
36
Which antihypertensives can be used in pregnancy?
methyldopa, BB (NOT atenolol), CCB, hydralazine
37
What is whipple triad?
neuroglycopenic sx, hypoglycemia <55, resolution of sx with glucose ingestion
38
What is a common cause of postprandial hypoglycemia?
previous gastrectomy or gastric bypass surgery
meals of simple CHO is the cause
39
What is C peptide level if surreptitious use of oral hypoglycemic agents?
elevated during hypoglycemia
| urine screen for sulfonylurea and meglitinide metabolites
40
What is C peptide level if surreptitious use of insulin?
low during hypoglycemia
41
What is seen with a 72 hour fast if insulinoma is suspected?
1) fasting plasma glucose
2) serum insulin
3) C peptide
1) <45
2) >5-6
3) high
schedule abdominal CT
42
What can present as hyperparathyroidism, pituitary neoplasms, pancreatic neuroendocrine tumors (gastrinomas and insulinomas)
MEN1
43
What dx is suspected with sudden headache, visual change, ophthalmoplegia and AMS associated with hypopituitarism?
pituitary apoplexy 2/2 hemorrhage or infarction
44
What dx is suspected with postpartum amenorrhea, inability to lactate and fatigue?
postpartm pituiary necrosis (Sheehan syndrome)
45
What dx is suspected with hypopituitarism and mass lesion but during pregnancy?
lymphocytic hypophysitis
46
Which hormone deficiency is seen with:
1) amenorrhea, loss of libido, ED
2) fatigue, n,v, weight loss, abdominal pain
3) cold intolerance, weight gain, constipation
4) loss of muscle mass
5) polydipsia, polyuria, nocturia
1) FSH/LH
2) ACTH
3) TSH
4) GH
5) DI 2/2 ADH deficiency
47
How do you test for the following hormone deficiency?
1) GH
2) FSH/LH
3) TSH
4) ACTH
5) prolactin
1) IGF decreased, decreased resonse to insulin tolerance test
2) FSH, LSH, estradiol/testosterone levels low
3) decreased T4 and TSH
4) low cortisol and ACTH, depressed response of 11 deoxycortisol and cortisol to metyrapone; positive cortisol resonse to ACTH
5) elevated prolactin
48
What is treatment for adrenal insufficiency?
hydrocortisone
49
What is treatment for pituitary apoplexy
glucocorticoids until adrenal insufficiency has been r/o
50
How do you titrate thyroxine dose for central hypothyroidism?
based off T4 and NOT TSH
treat after hypoadrenalism has been r/o or treated
51
When is pituitary gland enlarged w/o mass? (2)
1) untreated primary hypothyroidism
| 2) pregnancy
52
Where does pituitary adenoma come from?
anterior
53
How do you test for cushing disease? (proximal muscle weakness, facial rounding, centripetal obesity, purple striae, DM, HTN)
24 hoururine cortisol excretion, dexamethasone suppression test or late night salivary cortisol level (ELEVATED), serum ACTH level (ELEVATED or "NORMAL")
54
What meds can cause hyperprolactinemia?
TCAs, antiseizure meds, metoclopramide and domperidone, CCB, methyldopa, opiates, protease inhibs
55
T/F: hypothyroidism can cause hyperprolactinemia
T
56
What is tx for sx prolactinoma?
cabergoline >bromocriptine (dopamine agonist therapy)
57
What is tx for pituitary adenomas that secrete hormones?
surgery
58
What hormone deficiency causes central DI?
ADH
59
What electrolyte can also cause polyuria?
hypercalcemia
60
What will confirm dx of DI?
urine osm <200 and inabilit to increase urine concentration during water deprivation test
then do desmopressin challenge test to differentiate between central and nephrogenic forms (if urine concentrates -->positive-->central DI-->order MRI of pituitary gland)
(if urine doesn't concentrate-->negative-->peripheral DI-->order kidney US)
61
TX for DI
1) DI after neurosurgery or head trauma
2) chronic central DI
3) lithium-induced peripheral DI
4) non-drug induced peripheral DI
1) D51/2NS if can't drink + desmopressin if UOP high or hyperNa develops
2) desmopressin
3) stop lithium OR add amiloride
4) thiazide diuretic and salt restriction
62
What 3 hormones need to be measured if you see empty sella syndrome?
cortisol, TSH, T4 (if asx)
| all hormones if sx
63
What are 3 types of destructive thyroiditis?
subacute (de Quervain), post partum, silent (painless)
64
Which thyroidtoxicosis presents as a nonautoimmune inflammation that has a firm and painful thyroid gland?
subacute
65
T/F: Permanent hypothyroidism can follow destructive thyroiditis
T
66
What occurs when ou have hyperthyroidism associated with cardiac decompensation, fever, delirium and psychosis?
thyroid storm
can follow surgery, infection, iodine load (contrast) and untreated Graves
67
What is the next step if TSH is suppressed but T4 is normal?
measure T3 to see if there is a T3 toxicosis
68
What hyperthyroid do you see with this:
1) decreased TSH, increased T4
2) decreased TSH, increased T3, normal free T4
3) decreased TSH, normal T3 and free T4 w/o symptoms
4) increased TSH, increased T3, increased T4
1) primary hyperthyroidism
2) primary hyperthyroidism with T3 toxicosis
3) subclinical hyperthyroidism
4) secondary hyperthyroidism from pituitary tumor (central hyperthyroidism
69
What is the treatment for toxic multinodular goiter or toxic adnoma?
iodine therapy or surgery
70
What is the first line medical treatment for hyperthyroidism?
methimazole
71
Which medication is used for hyperthyroidism in the first trimester of pregnancy or during tyroid storm?
propylthiouracil
72
What are 3 side effects of methimazole? What is side effects of propylthiouracil?
3: agranulocytosis, drug rash, hepatotoxicity
PPU: more hepatotoxicity but same as above
73
What is the definitive treatment for severe Graves ophthalmopathy?
What treatment needs to be AVOIDED?
thyroidectomy
radioacive iodine (can make ophthalmopathy worse)
74
What is the treatment for subclinical hyperthyroidism?
methimazole if TSH <0.1
75
What 4 medications can cause hypothyroidism?
amiodarone, lithium, interferon alfa, interleukin-2
76
```
What can the following labs look like with hypothyroidism?
prolactin
sodium
CK
AST
cholesterol
```
```
prolactin high
sodium low
CK elevated
AST elevated
cholesterol elevated
```
77
How do you treat subclinical hypothyroidism?
levothyroxine if TSH >10
78
What 4 things can decrease levothyroxine absorption?
celiac disease
calcium supplements
iron supplements
PPIs
79
What happens to hypothyroidism in pregnancy?
thyroid demand increases by 50%
80
What is the treatment for myxedema coma?
levothyroxine and hydrocortisone (until adrenal insufficiency is r/o)
81
When is FNA biopsy indicated?
1) all thyroid nodules >__cm with suspicious sonographic features and normal TSH
2) nodules
1) >1 cm
| 2) <1cm
82
When is calcitonin measured in a thyroid nodule?
if have hypercalcemia or fhx of thyroid cancer of MEN2
83
When is surgery indicated for a thyroid nodule?
if continued nodule growth despite normal FNA
If malignant cytology
if large multnodular goiters associated with compressive symptoms
84
What will ACTH levels look like in Cushing syndrome if:
1) ACTH dependent
2) ACTH independent
1) ACTH normal/elevated
| 2) low or normal
85
What are 2 causes of:
1) ACTH dependent
2) ACTH indepdent
1) ACTH secreting pituitary adenomas (Cushing disease) and ACTH secreting carcinomas and carcinoid tumors
2) adrenal adenomas; adrenal carcinomas
86
What are 3 first line tests for cushing disease?
1) 1 mg overnight dexamethasone suppresion test (positive is if failure to suppress serum cortisol to <3)
2) 24 hour urine cortisol level (positive is elevated)
3) late night salivary cortisol level (positive is elevated)
87
What is the next test to order if cortisol level is elevated or is not suppressible?
order ACTH level
88
If morning ACTH is elevated (over 20), then what is the next step?
If morning ACTH is suppressed or normal (<5), then what is the next step?
1) pituitary imaging
| 2) adrenal CT
89
What is the next step if ACTH is elevated, but no pituitary tumor is visualized?
order 8 mg dexamethasone suppression test to differentiate between pituitary and ectopic tumor ACTH production
- if it doesn't suppress cortisol production-->ectopic tumor releasing ACTH such as SCLC, bronchial carcinoid, pheochromocytoma, medullary thyroid carcinoma-->chest and abdmen CT
- if it suppreses pituitary ACTH production and adrenal cortisol secretion-->is pituitary and will need intrapetrosal sinus sampling
90
What can cause false positives (failure to suppress cortisol) with the 1mg dexamethasone suppression test?
alcohol, obesity, psychological disorders
91
What are the treatments for cushing syndrome?
surgery and bisphosphonates for the low bone density from hypercortisolism
92
What is the next step after finding an adrenal incidentaloma ?
1mg overnight dexamethasone suppression test and 24 hour urine metanephrines/catecholamines
If having HTN or hypokalemia, also measure plasma aldosterone-plasma renin activity ratio
93
What characteristic of the adrenal mass makes it more likely that it is malignant?
size >6cm
94
What is the treatment for adrenal masses?
surgery if >4cm or functional tumors
masses <4cm are monitored radiographically in 6-12 months and repeat screning for hormonal hypersecretion
95
What hormones are deficient in Addison's disease?
cortisol, aldosterone, adrenal androgens
96
What hormones are deficient in secondary adrenal insufficiency?
cortisol and adrenal androgens
97
What symptoms are unique to primary adrenal insufficiency?
hyperpigmentation, hyponatremia and hyperkalemia
98
What is the most comon cause of primary insufficiency
autoimmune adrenalitis
99
What morning cortisol level diagnosis cortisol deficiency?
<3
>18 excludes the diagnosis
100
What test can distinguish between primary and secondary adrenal insufficiency if morning cortisol level is equivocal
morning ACTH
101
What is the next step if evaluating for cortisol deficiency and ACTH level is:
1) morning ACTH is elevated >20
2) morning ACTH is supresse dor normal <5
1) adrenal CT
| 2) pituitary MRI
102
What is the next step if there is a nondiagnostic cortisol value when evaluating for adrena insufficiency?
stimulation testing with synthetic ACTH (cosyntropin)-->stimulated serm cortisol >18 excludes adrenal insufficiency
103
What is the acute adrenal insufficiency treatment immediately?
high dose dexamethasone and IV saline
**dexamethasone doesn't mess up serum cortisol assay
104
What is the treatment after adrenal insufficiency is made?
primary: hydrocortisone and fludocortisone (but not if hydrocortisone >40mg)
secondary: hydrocortisone
105
What can happen during anesthesia if someone has pheochromocytoma?
hypotension
Also gets orthostatic hypotension
106
What 3 diseases are associated with pheochromocytoma?
MEN2, von Hippel-Lindau disease, NF type 1
107
What is the appropriate test to order if the pretest probability of pheochromoctyoma is low? High?
low: 24 hour metanephrine and catecholamine urine
high: serum plasma metanephrine
if positive, then order MRI/CT of A/P-->if negative then iodine or I-MIBG scan can help
108
What medications are used to treat HTN pre/intra-operative pheochromocytoma?
pre: phenoxybenzamine
intra: nitroprusside or phentolamine
109
What are 3 signs that are suggestive of primary hyperaldosteronism? (inrelation to HTN, K, family history)
HTN: difficult to treat
K: difficult to treat or provoked hypokalemia
Fhx: positive for primary hyperaldosteronism
110
What 2 lab values are suggestive of hyperaldosteronism?
1) plasma aldosterone-plasma renin activity ratio
2) plasma aldosterone level
1) >20
2) >15
**spironolactone and eplerenone can antagonize the aldosterone receptor and messes up measurement
111
How is the diagnosis of hyperaldosteronism done?
nonsuppressibility of elevated aldosterone in response to high salt load
112
What is the treatment for hyperaldosteronism?
spironolactone/eplerenone for adrenal hyperplasia. adrenalectomy is indicated if aldosterone producing adenoma (but need to do adrenal vein sampling first), but if need more BP control, then use thiazide diuretic
113
What is the testing for primary amenorrhea?
pregnancy
karyotype
FSH/LH/TSH/prolactin
pelvic US
114
What is the definition of secondary amenorrhea
abscence of menstruation for 3 cycles or 6 consecutive months
115
What medication can cause secondary amenorrhea?
metaclopramide and antipsychotics
116
What are 4 causes of hypogonadotrophic hypogonadism? (low estradiol and low/normal FSH/LH)
hypothyroidism
hyperporlactinemia
hypothalamic (stress, weight loss, exercise)
pituitary
117
What test can be peformed in patients with secondary amenorrhea?
progesterone challenge
if no bleeding, it's because of low estrogen-->hypothalamic hypogonadism
if bleeding-->normal estrogen-->hyperandrogenism
118
What are 3 things that cause hypergonadotrophic hypogonadism
premature ovarian insufficiency (autoimmune)
chemo
pelvic radiation
(low estradiol and elevated FSH/LH)
119
What two hormones are elevated in PCOS?
testosterone and DHEAS (not needed for diagnosis)
120
What is the first hormone deficiency to r/o with hyperprolactinemia?
hypothyroidism
121
What syndrome is caused by h/o dilatation and curettage, amenorrhea caused by fibrous uterine scarring?
Asherman syndrome (uterine synechiae)
122
What are 3 criteria needed for PCOS diagnosis (you only need 2 of the 3)
1) ovulatory dysfunction
2) lab or clinical evidence of hyperandrogenism
3) US evidence of polycystic ovaries
123
What are typical labs in PCOS:
1) testosterone
2) DHEAS
3) LH/FASH ratio
1) elevated
2) elevated
3) >2:1
124
What is the treatment of hirsutism?
fertility not desired: OCP, spironolactone if hirsutism is still a problem
fertility desired: ovulation induction with clomiphene or letrozole
125
What is the next step in measurement if the two testosterone morning measurements or euivocal?
measure free testosterone level by equilibrium dialysis or mass spectrometry
126
What is the next step in labs after testosterone level is low?
measure LH, FSH, prolactin
127
What are 5 examples of primary testicular failure (elevated LH/FSH)
1) Klinefelter
2) atrophy 2/2 mumps orchitis
3) autoimmune destruction
4) previous chemo or pelvic irradiation
5) hemochromatosis
128
What are 4 examples of secondary hypogonadism (low/normal LH/FSH)
1) sleep apnea
2) hyperprolactinemia
3) hypothalamic or pituitary disorders (hemochromatosis, pituitary/hypothalamic tumor)
4) use of opiates, anabolic steroids, glucocorticoids
129
What two labs should be monitored during testosterone therapy?
hematocrit and PSA
130
What is the most common cause of hypercalcemia?
outpatient vs inpatient
outpatient: primary hyperparathyroidism
Less common presentations: kidney stones, osteooprorosis, pancreatitis, fractures
inpatient: malignancy
131
What are 2 medications than can cause hypercalcemia?
thiazides and lithium
132
What syndrome presents as PTH suppressed, P, Cr and CO2 elevated. Can be caused by ingestion of calcium-containing antacids
milk-alkali syndrome
133
What imaging should be done if hyperparathyroidism is confirmed and surgery is indicated?
sestamibi paraythyroid scan to look for adenoma
134
What is the most common manifestation of MEN1?
primary hyperparathyroidism
135
What is the treatment of hypercalcemia?
volume with NS, IV bisphosphonates and serum calcitonin, oral glucocorticoid if caused by multiple myeloma or sarcoidosis
136
What are the 3 diseases under MEN1? Which is the most common?
1) multigland hyperparathyroidism (most common)
2) pituitary neoplasm (prolactinoma, acromegaly, Cushing disease)
3) pancreatic NETs (gastrinoma, insuinoma, vasoactive intestinal polypeptide-secreting tumor, carcinoid syndrome)
DIAMOND
137
What are the 3 diseases under MEN2? Which is the most common?
1) multigland hyperparathyroidism (least common)
2) medullary thyroid cancer (most common)
3) pheochromocytoma
138
T/F: You should measure vit D in all patients with hyperparathyroidism.
T
139
What is indicated if patients have primary hyperparathyroidism and hpercalcemic complications like with kidney stones, bone dsiease or previous hypercalcemic crisis?
parathyroidectomy
140
At what threshold are asymptomatic hyperparathyroid patients needing surgery?
1) serum calcium level
2) eGFR
3) reduced bone mineral density
4) age
1) >1 above normal
2) <60mL/min/1.73m2
3)
141
What is the treatment for hyperparathyroidism if patients are not candidates for surgery?
cinacalcet or bisphosphonates
142
What is the adjustment for Calcium in the setting of low albumin?
Ca decreases by 0.8 for each 1 g/dL decrease in albumin
143
What are 4 physical findings for hypocalcemia?
1) circumoral and acral paresthesia
2) carpal-pedal spasm
3) Trousseau sign (carpopedal spasm induced by ischemia secondary to the inflation of a cuff)
4) Chvostek sign (contraction of facial muscles provoked by lightly tapping over the facial nerve anterior to the ear as it crosses the zygomatic arch. )
144
What is the syndrome that including mucocutaneous candidaisis, adrenal insufficiency, hypogonadism, malabsorption and hypoparathyroidism?
polyglandular autoimmune syndrome type 1
145
What are 6 differentials for hypocalcemia?
1) hypoparathyroidism (hyperphosphatemia, low PTH)
2) pseudohypoparathyroidism (hyperphos, elevated PTH, normal vit D)
3) CKD (hyperphos, elevated PTH and low 1, 25OH vit D)
4) vit D deficiency (hypophos, bone tenderness/fibromyalgia, weakness, gait difficulty, osteomalacia)
5) impaired PTH secretion and resistance (Mg deficiency)
6) hungry bone syndrome (recent parathyroidism)
146
What is the acute treatment of hypocalcemia?
IV calcium gluconate and vit D
147
When does USPSTF recommend DEXA scan?
>65 yo or under if have risk factor using FRAX >8.4%
148
What is the recommended repeat DEXA scan for normal/slightly low bone density and no risk factors?
10-15 years
149
What is the definition of osteopenia vs osteoporosis?
1) osteopenia -1.0 to -2.4
| 2) osteoporosis
150
What are secondary causes of osteoporosis related to the following things:
1) hormones
2) GI disease
3) meds
(other secondary causes are rheumatoid arthritis, multiple myeloma, CKD, chronic liver disease, vit D deficiency)
1) hyperthyroidism, hyperparathyroidism, Cushing syndrome
2) malabsorption with Crohn disease, interstinal resection, celiac disease
3) thyroid hormone, glucocorticoids, phenobarbital, phenytoin, thiazolidinediones
151
When is FRAX is indicating antiresorptive treatment? (major osteoporotic fracture % and risk of hip fracture %)
major osteoporotic fracture: >20%
| risk of hip fracture: >3%
152
When denosumab indicated?
stage 4 CKD or intolerant of bisphosphonates
Not effective when stopped
153
When is teriparatide indicated in osteoporosis?
postmenopausal women, glucocorticoid-induced osteoporosis at high risk, men with hypogonadism related osteoporosis at high risk
Use only for 2 years
154
When is calcitonin indicated in osteoporosis?
pain from osteoporotic fractures
155
When are oral bisphosphonates contraindicated?
When are IV bisphosphonates contraindicated?
oral: if have CKD or esophageal disease
(then use IV zoledronate as alternative--once a year)
IV: severe hypocalcemia and CKD
156
What is adverse effects of:
1) oral bisphosphonates?
2) IV bisphosphonates?
3) denosumab?
4) teriparatide
1) erosive esophatitis and atypical hip fracture
2) osteonecrosis of jaw
3) osteonecrosis of jaw
4) osteosarcoma
157
When do you do a follow up DEXA after starting therapy for osteoporosis?
2 years
158
What do Looser zones indicate? (bands perpendicular to bone surface visible on XR)
osteomalacia
159
What is osteomalacia caused by?
vit D and sometimes deficiencies of calcium or phosphate
160
What is the treatment for osteomalacia?
ergocalciferol and elemental calcium
161
What will prolonged and severe vit D deficiency cause?
secondary hyperparathyroidism, osteomalacia, sx of bone pain, muscle weakness and fracture
162
What do you measure to eval status of vit D?
25 OH vit D
aim for >30
163
What 4 populations will have lower vit D due to medical conditions or meds?
1) obesity
2) glucocorticoids
3) orlistat
4) malaborption disorders like bariatric surgery
164
How do you treat vit D deficiency?
acute treat with 50,000 U of ergocalciferol or cholecalcicerol then maintenance therapy of 1500 to 2000
165
What is a focal disorder of bone remodeling that leads to greatly accelerated rates of bone turnover and therefore disrupts normal architecture of bone leading to gross deformities?
Paget disease
166
What lab value is abnormal in Paget disease?
alk phos
167
What are 4 sx/signs of Paget disease?
1) bone pain, fractures
2) CN compression syndromes, spinal stenosis, nerve root syndromes
3) high output cardiac failure
4) angioid retinal streaks
168
What is the treatment for Paget disease?
bisphosphonates
