Flashcards in Final Deck (36):
Ant Pit/Hypothalamic Hormones-Receptors
GH and Prl activate?
GH and Prl activate JAK-STAT
TSH/FSH/LH/ACTH activate GPCR
Explain regulation of pituitary and hypothalamic hormones
TRH, TSH, T3/4
GnRH, FSH/LH, E/P
CRH, ACTH, cortisol
GHRH, GH/IGF1, somatostatin
Thyrotrophin-RH, secretin, glucagon, VIP, GIP, Prl, and dopamine
TRH stim TSH which stim T3/4 which inhibits TRH and TSH
GnRH stim FSH/LH which stim E/P which inhibit GnRH and FSH/LH
CRH stim ACTH which stim cortisol which inhibits CRH and ACTH
GHRH stim GH and IGF1 which inhibit GHRH; SST inhibits GHRH
ThyrotrophicRH, secretin, glucagon, VIP, and GIP stim Prl which is inhibited by dopamine
GH Drug- Somatropin
AE? (Kids and adults)
Kinetics- somatropin is a rhGH, metabolized by liver, and induces p450
MOA- binds GH-R, activates JAK-STAT, leads to IGF1 mediated affects
Uses- GH deficiency (make short children nml size and reverse symptoms seen in adults like obesity and loss of m mass); short stature assoc w/ Prader Willi, Turners, or Noonan; wasting in AIDS pt; pt w/ short bowel syndrome
AE- kids- intracranial HTN, scoliosis, otitis media in Turners, hypothyroidism, gynecomastia, and pancreatitis
AE- adults- edema, myalgia, arthralgi, and carpal tunnel
What is it made of?
How is it given?
AE? How to prevent
Used in children w/ growth failure whohave severe IGF1 deficiency not responsive to exogenous GH
Complex made of rhIGF1 and rhIGFBP3 (inc half life of rhIGF1)
AE- hypoglycemia (eat 20 min before injection)
What are the 2 classes
What is the use?
SST Analogs (reotides) and Pegvisomant
used for somatotroph adenomas
What are the 2 drugs and their uses
MOA- inhibit GH, glucagon, insulin, and gastrin
Octreotide- give subQ, use for acromegaly, carcinoid syndrome, gastrinomas, glucagonomas, VIPomas
Lanreotide- use for acromegaly
AE- GI, gallstones, b12 deficiency, and bradycardia
MOA- GH-R antagonist, binds GH-R but doesnt activate JAK-STAT
Dopamine Agonists (2)
AE (when do you discontinue)
Bromocriptine and Cabergoline
MOA- D2R agonist
AE- NV, HA, hypotension, fatigue
Discontinue if prego w/ microadenoma
Induce labor, limit post partum bleeding, and elicit milk ejection
ADH Agonists (2)
AE (use caution with which one in pt with what condition?)
Vasopressin and Desmopressin
Kinetics- desmopressin has longer half life and minimal V1 activity
MOA- activate GPCR V1R and V2R; V1 vasoconstricts; V2 inc water reabsorption
Uses- Central DI (desmo) and hemophilia A or von willebrand disease (desmo)
AE- HA, NV, abdominal pain, hyponatremia, seizure; use vasopressin w caution in pt with CAD
Vaptans (T and C)
T vaptan is v2 selective; metabolized by cyp3A4
MOA- inc water excretion w/o changing electrolyte excretion
Uses- hyponatremia and CHF (T vaptan dec wt and dec dyspnea; C vaptan inc water excretion w/o affecting vascular resistance)
Explain effects of hyper/hypothyroidism on T3/4 clearnace and T3/4 half life
Hyperthyroid- inc clearance and dec half life
Hypothyroid- inc half life and dec clearance
What agents prevent the conversion of T4 into T3?
Iopanoic acid, ipodate, amiodarone, b-blockers, and corticosteroids
What agents dec T4 absorption?
Antacids, ferrous sulfate, cholestyramine, and colestipol
What agents induce cyp450 to inc metabolism of T4/3?
What are thyroid hormone drugs MOA?
T4/3 enter cell -> T4 converted to T3 -> T3 enters nucleus and binds TR -> complex binds RXR ->gene transcription -> effects after a lag period
What is the 1st line choice for T4 replacement?
Kinetics (kinetics of each then explain their use during pregnancy)
AE (when do you discontinue)
Propylthiouracil and methimazole
Kinetics- PTU- radpily absorbed, fast acting, 1st pass effect, requires multi doses
Kinetics- methimazole- completely absorbed, take once a day
Kinetics- can cross placenta and accumulate in fetal thyroid; take PTU in 1st trimester; methimazole in 2nd and 3rd trimester
MOA- inhibit thyroid peroxidase and iodide organification; inhibit thyroid hormone synthesis/release; PTU blocks conversion of t4 to t3; DOES NOT block iodide uptake
AE- maculopapular rash, urticarial rash, vasculitis, LAD, hepatitis (PTU), and jaundice (methimazole); agranulocytosis-reverse by discontinuing
Lugols Iodide Solution
Lugols Iodide Solution
MOA- inhibit organification and hormone release; dec size and vascularity of thyroid
Uses- thyroid storm, preop reduction of hyperthryoid gland, and block uptake of radioactive isotopes
AE- acneiform rash, swollen salivary glands, ulcers, conjunctivitis, and metallic taste
Uses and kinetics
Used for thyrotoxicosis; give PO, rapidly absorbed; destroys parenchyma
CI- prego or breast feeding
B-Blockers for thyroid
Propranolol, metoprolol, atenolol
Uses- improve symptoms, reduce T3 (propranolol) by preventing conversion of T4 to T3
Explain the treatment of Hypothyroidism
Drug of choice? How do you give it?
If drug induced?
Myxedema and CAD?
Mgmt of Hypothyroidism
Levothyroxine is 1st choice; give on empty stomach
Drug induced- remove drug or add levo
Myxedema coma- large loading dose of levo followed by IV dosing
Myxedema and CAD-use levo w/ caution to avoid arrhythmia or MI
Prego- maintain nml level for fetal brain development
Explain mgmt of Graves
When do you use drugs? What drug is preferred?
When do you perform thyroidectomy?
When do you use radioiodine?
What are the adjuvant therapies?
Use methimaxole in young pt
Thyroidectomy in pt w/ large thyroid or multinodular goiter
Use radioiodine in pt over 21 unless pt has heart disease or if elderly w/ thyroid storm
Adjuvant therapy- beta blockers for cardiac effects
Explain multidrug therapy of thyroid storm
B-blockers for arrhythmias
K iodine to prevent thyroid hormone synthesis
PTU or methimazole to prevent synthesis
Hydrocortisone to prevent shock and block conversion of t4 to t3
Plasmapheresis or dialysis to dec t4
Menopause transition- variations in cycle w/ skipped cycles
Post menopause- 12 months complete amenorrhea
Symptoms- hot flash, night sweats, sexual dysfunction, dec QoL
Comorbidities- osteoporosis and fractures and CV events
Treatment- estrogen w/ or w/o progestin (women w/ intact uterus REQUIRE E and P)
Menopause Hormone Therapy (MHT)
What are the estrogenic forms? (4)
What are the progestinic forms? (3)
Estradiol, conjugated estrogen CE (many estrogen derivatives), esterified estrogen EE (Na esterone sulfate and Na equilin sulfate), estropipate (crystalline estrogen solubilized with sulfate and stabalized w/ piperazine)
Medroxyprogesterone MPA (MPA alone or w/ CE), methyltestosterone (alone or with EE), and progesterone
MOA- mimics effects of endogenous hormone by binding target R
Estrogen only MHT effects
Dec LDL, antithrombin 3, and osteoclast activity
Inc HDL, TAGS, clotting factors, platelet aggregation, Na retention, and TBG
What are the goals of the Womens Health Initiative study with regards to MHT?
The goals were to examine MHTs effects on heart disease, osteoporosis, and risk of cancers
What were the findings of the Womens Health Initiative study with regards to E/P therapy and E therapy alone; harms and benefits? What did they find with regards to age and therapy?
Estrogen and Progesterone
Harms- breast cancer, CAD, dementia, gall bladder disease, stroke, thromboembolism, and incontinence
Benefits- dec DM, fractures, and colorectal cancer
Harms- dementia, gallbladder disease, stroke, thromboembolism, and incontinence
Benefits- dec breast cancer, fractures ,and DM
Benefits better in 50 > 60 > 70 yo
What were the summary findings and recommendations from the Womens Health Initiative with regards to MHT?
-what does it effectively treat
-what should it not be used to treat
-benefits vs risks for bone and colon cancer
MHT effectively treats vasomotor symptoms and vaginal change
MHT should not be used to treat CAD or dementia
Benefits of bone and colon cancer are outweighed by other risks
List the 5 MHT Agreements
-acceptable to treat?
-what is preferred treatment for vaginal symptoms only
-what treatment is preferred in women with uterus to prevent cancer
-MHT inc risk of what?
-MHT inc risk of what where the risk dec if MHT is stopped
MHT is acceptable to treat mod-severe menopause symptoms for women under 60 or w/in 10 years of menopause
Low dose topical estrogen is preferred treatment for women w/ vaginal symptoms alone
Women with uterus need combo E and P therapy to prevent uterine cancer
MHT inc risk of blood clots and stroke
MHT inc risk of breast cancer, risk dec if MHT is stopped
What are SERMs? What do they do? What are the drug examples?
Selective Estrogen R Modulators
Have pro-estrogenic actions in select tissues and anti-estrogenic actions in others
Drugs- ospemifene, clomiphene, and “fenes”
What are TSECs? What are they made of? What is the drug example?
Tissue selective estrogen complexes
Combo SERM and estrogen compound
Drug- Bazedoxifene (use in combo w/ CE)
Use to treat dyspareunia caused by vulvovaginal atrophy assoc w/ menopause
MOA- agonist at vaginal ER; antagonist in breast; inc superficial cell growth and vaginal secretions, dec pH and pain during sex
SE- hot flash, night sweats, inc risk of stroke and thromboembolism, endometrial thickening and hyperplasia
CI- unexplained vaginal bleeding, CV disease, or estrogen assoc neoplasia
Anti-estrogen SERM used to treat infertility in anovulatory women
MOA- induce ovulation by blocking actions of estrogen on GnRH, FSH, and LH; inc gonadotropin rlease and occyte follicle development
SE- multi-births, ovarian cysts, hot flash, blurred vision, and luteal phase dysfunction (dec progresterone)