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MKSAP Endocrine Flashcards

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1
Q

What are the indications for treatment of osteoporosis?

A
  1. Osteoporosis-related fracture 2. T score 2.5 or less 3. T score between -1 and -2.5 + 10 year risk of hip fracture >3% or major osteoporotic fracture >20%
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2
Q

What are the indications for anabolic agents (synthetic PTH) in osteoporosis tx? What are 2 examples of these agents? What is the max length of time this drug should be used? What cancer is it associated with?

A
  1. Steroid induced osteoporosis, T score less than -3.5, T score less than -2.5 + fragility fracture
  2. Teriparatide, Abaloparatide
  3. 2 years
  4. Osteosarcoma
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3
Q

What is the MOA for Denosumab? What are the side effects? What happens when you stop it?

A
  1. RANKL inhibitor, inhibits osteoclast activation
  2. Hypocalcemia, cellulitis, bronchitis; rare osteonecrosis of jaw and atypical femur fracture
  3. Increased bone resorption, so IF it needs to be stopped need to start bisphosphonate
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4
Q

What two drugs have been approved by the FDA for patients with DM and CVD, to reduce CV events and all cause mortality? What drug has shown reduction in CV events but not death? What were the trials that showed this?

A
  1. Empaglifozin (EMPA-REG) and Liraglutide (LEADER)

2. Canaglifozin (CANVAS)

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5
Q

What are the side effects of GLP-1 agonists?

A

Nausea, vomiting, pancreatitis, weight loss, gallbladder disease, medullary thyroid cancer

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6
Q

What are the side effects of DPP-4 inhibitors? Which 2 meds are associated w/ increased HF hospitalizations?

A
  1. Increased risk of infection, pancreatitis, derm reactions

2. Saxagliptin (SAVOR-TIMI), Alogliptin

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7
Q

What are the side effects of SGLT2 inhibitors?

A

AKI, increased UTIs, increased candida infections, fournier’s gangrene, euglycemic DKA, weight loss, improved BP control, fractures (canagliflozin), increased amputations (canagliflozin), bladder cancer (dapaglifozin)

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8
Q

How often should pregnant women be screened for diabetic retinopathy?

A

Pre-pregnancy, every trimester, then closely for 1 year post partum

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9
Q

What is the progesterone withdrawal test? What happens if the woman bleeds vs. doesn’t bleed?

A

Progesterone is given for 7-10 days. If woman bleeds within 7 days she has a normal estrogen state, so consider hyperandrogenism (measure testosterone & SHBG). If she does not bleed consider premature ovarian failure, HPA axis issues, or uterine outflow tract issues.

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10
Q

In men type of cells does LH affect, and what hormones are produced? What about for FSH? What inhibits FSH?

A

LH -> Leydig cells -> testosterone -> dihydrotestosterone, estradiol
FSH -> Sertoli cells -> spermatogenesis
Inhibin B inhibits FSH

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11
Q

What is the preferred dopamine agonist in pregnancy? In non-pregnancy?

A
  1. Bromocriptine 2. Cabergoline
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12
Q

How does the glucose tolerance test work and what is it used for?

A

Give 75 g of oral glucose and measure GH at 0, 30, 60, 90, 120, and 150 minutes. Normal response is GH <0.2. If >1 this is diagnostic of acromegaly

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13
Q

What is a common complication of pituitary surgery? What lab should be checked in 1 week?

A

SIADH

Sodium

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14
Q

What are the characteristics of adrenal malignancy or pheochromocytoma? (size, density, contrast washout)

A

> 4 cm, >10 hounsfield units, <50% at 10 minutes

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15
Q

What is the testing for Cushing’s disease? Which is preferred in patients taking estrogen and/or with odd sleep patterns?

A
  • 24 hour urine free cortisol - avoids issues related to binding proteins; false negative in CKD; preferred in estrogen and odd sleeping patterns
  • Late night salivary cortisol test - if not low as suspected the test is positive
  • 1 mg dexamethasone suppression test - given at 11 PM, if AM cortisol >5 test is positive
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16
Q

How to do you diagnose aldosteronism? How do you localize the source of high aldosterone?

A
  1. Aldosterone: renin ratio >20 with aldosterone concentration at least 15 ng/dl; typically then confirm w/ oral sodium load or saline infusion test (if persistent aldosterone production dx is confirmed) however if spontaneous hypoK, undetectable renin, or PAC >30 do not need this confirmation
  2. Dedicated adrenal CT then adrenal vein sampling
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17
Q

What drugs are associated w/ false positive results for pheochromocytoma testing? Name 6.

A

Tylenol, prochlorperazine, antipsychotics, SNRIs, TCAs, buspirone, amphetamines, cocaine, caffeine, levodopa, clonidine, ethanol, OTC decongestants

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18
Q

What medication is used as adjuvant therapy in adrenocortical carcinoma? What condition does it cause?

A
  1. Mitotane

2. Primary AI, so daily steroid is needed

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19
Q

What antibodies should be tested in suspected primary adrenal insufficiency?

A

21-hydroxylase antibodies - seen in autoimmune adrenalitis

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20
Q

When testing for pheochromocytoma what test should be performed if you have a high index of suspicion? Low index of suspicion?

A
  1. Plasma free metanephrines - has high false positive rate

2. Urine fractionated metanephrines and catecholamines

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21
Q

At what size should you biopsy a mixed cystic/solid thyroid nodule? Isoechoic/hyperechoic solid nodule? Hypoechoic solid nodule?

A

2 cm
1.5 cm
1 cm
*In general however patients w/ normal TSH and nodule >1 cm should get FNA

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22
Q

JVD, facial plethora, and flushing when patients raise their arms above the head indicate what in which patients? What is this called?

A

Thoracic outlet obstruction in patients with goiter

Pemberton sign

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23
Q

What labs can be checked to monitor for recurrent thyroid cancer?

A

Thryoglobulin and thyroglobulin antibody

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24
Q

What are the differences between type 1 & 2 amiodarone-induced thyrotoxicosis?

A
  1. Typically in patients w/ pre-existing thyroid disease; treated with anti-thyroidals
  2. Typically in patients without thyroid disease; treat w/ steroids; may take years to develop
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25
What is the goal TSH in pregnant patients? By how much should synthroid be increased?
<2.5 | 30%
26
What are the criteria used in the Burch and Wartofsky score? Name at least 5.
Temperature, tachycardia, atrial fibrillation, GI symptoms, CNS symptoms, CHF, precipitating factor
27
What are the treatments for toxic adenoma or multinodular goiter?
Radioactive iodine or thyroidectomy
28
Surgery is recommended in primary hyperparathyroidism for kidney stones, bone disease, or prior hypercalcemic crises. What are the 4 indications for surgery in asymptomatic patients?
Calcium >1 upper limit of normal (~11.5); 24 hour urine calcium >400 mg; T score less than -2.5 or vertebral fracture; GFR <60 ml/min; age <50
29
What conditions are found in MEN 1? MEN2A? MEN2B?
1: Pituitary adenoma, parathyroid hyperplasia, pancreatic tumor 2A: Parathyroid hyperplasia, medullary thyroid carcinoma, pheochromocytoma 2B: Medullary thyroid carcinoma, pheochromocytoma, mucosal neuromas, marfanoid habitus
30
What cancers are associated with PTHrP?
Breast, renal cell carcinoma, squamous cell carcinoma | Others include ovarian cancer, bladder cancer, endometrial cancer, non-hodgkin lymphoma
31
What labs are seen in osteomalacia? What are some signs/symptoms? What are 2 causes?
1. Low vitamin D, calcium, and phosphorus; high PTH and alkaline phosphatase 2. Diffuse bone pain, bone tenderness to palpation, proximal muscle weakness 3. Vitamin D deficiency, aluminum hydroxide toxicity
32
What lab needs to be monitored during treatment for chronic hypoparathyroidism?
24 hour urine calcium excretion - goal is <300 mg/24 hours
33
What lab is used to determine adequacy of thyroid replacement in secondary hypothyroidism?
Free T4
34
What lab should be checked before starting bisphosphonates or denosumab, and why?
Vitamin D b/c severe hypocalcemia can occur by impairing efflux of calcium from the skeleton in patients w/ vitamin D deficiency
35
Which statins are lipophilic vs. hydrophilic? Which group is more likely to cause myopathy?
Lipophilic: atorvastatin, lovastatin, simvastatin; more likely to cause myopathy Hydrophilic: rosuvastatin, pravastatin
36
Postmenopausal women and men age >50 receiving steroids of what dose for how long should receive bisophosphonates to prevent osteoporosis?
>7.5 mg daily for >3 months
37
Which antibodies are recommended for initial screening of type 1 DM?
GAD65 and IA-2 (tyrosine phosphatases) | Other antibodies include IA-2beta, islet cell, insulin, and zinc transporter (Zn T-8)
38
What is an adjunct therapy that can be used w/ insulin in type 1 diabetes that improves glycemic control, decreases insulin doses, and promotes weight loss?
Pramlintide
39
Which DM medication increases risk of amputations or fractures? Which increases risk of bladder cancer?
1. Canagliflozin | 2. Dapagliflozin
40
What 3 drugs increase thyroxine-binding globulin therefore lead to less free T4, meaning the levothyroxine dose must be increased? What 3 drugs lead to decreased thyroxine-binding globulin -> more free T4 -> dose reduction needed of levothyroxine?
1. Estrogen, tamoxifen, methadone | 2. Androgen therapy, steroids, niacin
41
What is the most common pituitary abnormality in empty sella? What should asymptomatic patients be screened with?
1. Hyperprolactinemia | 2. 8 AM cortisol, TSH, free T4
42
What cancers are most likely to metastasize to the pituitary gland? Name 4.
Breast (most common), lung cancer, lymphoma, renal cell carcinoma
43
When should microadenomas and macroadenomas that do not require surgery be reassessed?
Repeat pituitary hormone assessment and imaging in 6 months for macroadenomas then yearly Repeat imaging in 1 year for microadenomas then every 1-2- years; repeat labs not needed if initial testing normal
44
What is used to screen for suspected growth hormone deficiency? If it is normal and pretest suspicion is high what 2 provocative tests can be used to establish the diagnosis?
1. Insulin-like growth factor 1 (IGF-1) | 2. Insulin tolerance test, GHRH-arginine test
45
What are some medications that can lead to hyperprolactinemia? Name 3 categories and 5 medications.
Antipsychotics, SSRIs, anti-hypertensives (methyldopa, verapamil) Cimetidine, estrogen, metoclopramide, opiates, domperidone
46
What is pegvisomant and when is it used?
GH receptor antagonist, can be used in combo w/ somatostatin analogue in acromegaly
47
What cancers are most commonly associated with ACTH production? Name 3.
Lung (small cell), pancreas, thymus carcinoma | Others include bronchial carcinoid, pheochromocytoma, and medullary thyroid cancer
48
What urine osmolality is a normal response to water deprivation? What urine osmolality/plasma osmolality ratio is diagnostic of diabetes inspidus?
1. Urine osm >750-800 mOsm/kg | 2. Urine osm/plasma osm <2
49
What urine osmolality is consistent w/ complete nephrogenic DI, partial DI, and complete central DI after desmopressin challenge?
Complete nephrogenic: <300 mOsm/kg Partial DI: 300-800 mOsm/kg Central: >800 mOsm/kg
50
What are some medications that can be used for treatment of cushing syndrome? Name 5.
Ketoconazole, Metyrapone, Mitotane, Etomidate, Cabergoline, Mifepristone, Pasireotide
51
Pheochromocytomas occur in which familial syndromes?
MEN2, von hippel-lindau syndrome, neurofibromatosis type 1
52
What is iodine 123 metaiodobenzylguanidine (MIBG) scanning used for?
To confirm catecholamine-secreting neuroendocrine tumor presence if CT is negative Can also be used in patients w/ >10 cm pheochromocytomas to detect metastatic disease
53
What is the management of an incidental adrenal mass?
Test for pheochromocytoma even in absence of sx Test for subclinical cushing syndrome w/ 1 mg overnight dexamethasone suppression test; if positive test for cushing disease, and measure ACTH & DHEAS Test for primary aldosteronism if HTN or hypokalemia present
54
What are the next steps in working up Cushing syndrome in a patient that had abnormal diagnostic tests?
Measure ATCH - if elevated, do pituitary MRI; if no pituitary tumor or tumor <6 mm is visualized, perform 8 mg dexamethasone suppression test A pituitary source will respond to negative feedback, suppressing the AM cortisol by >50% but ectopic source of ACTH will have high cortisol Before exploratory pituitary surgery will need inferior petrosal sinus sampling (gold standard) since high dose suppression test has low sensitivity and specificity
55
What medications can be used to induce ovulation in patients w/ PCOS or hyperprolactinemia?
Clomiphene citrate, Letrozole
56
What are the c-peptide and insulin levels in surreptitious oral hypoglycemic use? Surreptitious insulin use? Insulinoma?
1. Both inappropriately elevated 2. Low serum C-peptide, elevated insulin levels 3. Both elevated, glucose <45
57
What drugs can increase statin levels? Name 5.
Fibrates, calcium channel blockers, amiodarone, macrolide, antifungals, cyclosporine
58
What is the workup for a thyroid nodule in the setting of normal or elevated TSH? Low TSH?
1. Ultrasound -> if >1 cm obtain fine needle aspiration | 2. Radioactive thyroid scan, free T4, total T3; get fine needle aspiration if "cold"
59
What are the 4 types of thyroid cancer in order of most common to least? Which has a low risk of distant mestastasis? Which has a high risk of metastases to lung and bone?
Papillary -> follicular -> medullary -> anaplastic Papillary spreads to cervical lymph nodes but not distally Follicular can spread to lung and bones
60
How does biotin interfere with thyroid testing?
Causes falsely elevated free T3 & free T4, and falsely low TSH
61
What are some medications that increase metabolism of levothyroxine, so a higher dose may be needed? Name 4.
Phenytoin, carbamazepine, phenobarbital, rifampin, sertraline
62
When should subclinical hyperthyroidism be treated?
TSH <0.1 and symptoms, cardiac risk factors, heart disease, osteoporosis, or postmenopausal women not taking estrogen or bisphosphonates
63
What presents w/ pronounced virilization (frontal balding, voice deepening, clitoromegaly) and androgen excess (premature pubarche, acne, accelerated bone age, hirsutism, menstrual irregularities) in late childhood or early adulthood? How do you diagnose this?
1. Non-classic congenital adrenal hyperplasia | 2. Elevated 17-hydroxyprogesterone levels (>200); confirmed by significant increase (>1000) after high dose ACTH
64
What presents with amenorrhea, vasomotor sx, sleep disturbance, and dyspareunia in setting of two elevated FSH levels in women under 40? What are possible causes?
1. Spontaneous primary ovarian insufficiency 2. May have a familial etiology; may suggest autoimmune polyglandular syndrome in a patient w/ personal hx of autoimmune disease
65
Above what levels of testosterone and DHEAS should imaging be obtained to assess for adrenal tumor or ovarian tumor?
Testosterone >200 ng/dL | DHEAS >700 mcg/mL
66
What are the glucose targets in gestational diabetes? What is the goal A1c in pregnant women?
Premeal plasma glucose <95 1 hour postprandial glucose <140 2 hour postprandial goucose <120 6-6.5%
67
How does PTH increase calcium? How does vitamin D increase calcium?
1. Decreases renal calcium excretion, increases calcium resorption from bones, increases renal conversion of 25-OH vitamin D to 1,25-OH vitamin D which improves efficiency of intestinal calcium absorption 2. Increases calcium absorption in intestines
68
What is the management for parathyroid carcinoma?
Surgical resection; cinacalcet if not a candidate | *Imaging is NOT useful and FNA is NOT recommended due to possible tumor seeding
69
What is the pathophysiology behind secondary hyperparathyroidism?
Failing kidneys do not convert enough vitamin D to its active form, so less calcium is absorbed in the intestines -> more PTH produced Failing kidneys do not adequately excrete phosphate, so insoluble calcium phosphate forms in the body and removes calcium from circulation -> more PTH produced *Also can occur in malabsorption b/c fat-soluble vitamin D is not reabsorbed
70
What are some clinical findings of severe hypocalcemia? Name 5.
Laryngospasm, seizure, myocardial dysfunction, QTc prolongation Trousseau sign, Chvostek sign
71
What electrolyte disorder causes function, reversible parathyroid hypofunction?
Hypomagnesemia
72
What is the diagnosis of osteoporosis in premenopausal women and men under age 50?
Fragility fracture OR low bone mass on DEXA w/ Z score less than -2
73
Which bisphosphonates can be used for prevention of glucocorticoid-induced osteoporosis? Which bisphosphonate can be used to prevent fractures in patients w/ osteopenia?
1. Risedronate and zoledronic acid (IV) | 2. Zoledronic acid
74
What are the indications for treatment of Paget disease? What is the treatment?
1. Bone pain, radiculopathy, involvement of weight bearing bones, elevated ALP (2-4 x upper limit of normal) 2. Bisphosphonates (zoledronic acid preferred)
75
What can you use in acute adrenal insufficiency to treat empirically before awaiting lab results, b/c this does not interfere w/ the serum cortisol assay?
4 mg dexamethasone
76
What type of vitamin D supplementation is preferred in underlying liver, kidney disease, and hypoparathyroidism?
Liver: 25-hydroxycholecalciferol (calcidiol) Kidney: 1,25-dihydroxyvitamin D (calcitriol) Hypoparathyroidism: 25-hydroxycholecalciferol (calcidiol) *Any other should get cholecalciferol (D3) or ergocalciferol (D2)
77
What can be used to treat bone pain from osteoporotic fractures?
Calcitonin
78
What can be used for intra-operative HTN in pheochromocytoma surgery?
Nitroprusside or phentolamine
79
What is the management for moderate-severe TG-induced pancreatitis (TG >1000, lipase >3x ULN, AKI, lactic acidosis, hypocalcemia)?
If glucose >500 use insulin drip | If glucose <500 perform plasma exchange
80
What presents w/ severe HA, bitemporal visual deficits, and CN III paresis in a patient w/ central hypogonadism? What is the treatment?
1. Pituitary apoplexy (hemorrhage) | 2. Steroids, surgical decompression
81
Eruptive xanthomas are small yellow papules w/ surrounding erythema that present where on the body and is associated with what?
1. Extensor surfaces of the extremities, and the buttocks | 2. Familial hypertriglyceridemia
82
What presents in a diabetic with acute or subacute pain and paresthesia in a dermatomal pattern in the thoracic or abdominal region, +/- associated weakness of abdominal wall muscles with apparent abdominal swelling?
Truncal diabetic mononeuropathy
83
What are some indications for pituitary imaging in hypogonadotropic hypogonadism in diabetes?
Testosterone <200 at age <65, <150 at age >65 Mass effect symptoms Multiple pituitary hormone deficiencies (TSH, GH) Hyperprolactinemia
84
There can be discordant bone density results. What are some causes of a focal increase in bone density? Name 3. Focal decrease in bone density? Name 2. Does steroid-induced osteoporosis cause more bone loss in the spine or hip? Does hyperparathyroidism cause more bone loss in the spine or hip?
1. Osteophytes (OA) and syndesmophytes (spondyloarthritis); osteoblastic metastasis, compression fracture, paget disease 2. Osteolytic lesions, fibrous dysplasia 3. Bone loss in spine > hip 4. Bone loss in hip > spine
85
What type of insulin-mediated hypoglycemia presents in patients w/ weight loss after gastric bypass?
Islet cell hyperplasia
86
At what FRAX score is a postmenopausal woman <65 y.o. at high risk and should be screened for osteoporosis?
10 year fracture risk >8.4%

Endocrine (1 decks)

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