Treatments only, Endo Flashcards

Question

GH deficiency in children

Answer 1

Recombinant GH restores growth velocity in GH-def children to ~10cm/yr Somatropin (Genotropin, Humatrope, Norditropin, Nutropin, Omnitrope, Saizen) In pts w/ GH insuff and growth retardation d/t mutations of GH receptors, tx w/ IGF-1 bypasses the dysfxnal GH receptor ## Footnote TROPIN grows self explanatory

Answer 2

Recombinant GH injections (rhGH, somatotrophin) CI: active neoplasm, intracranial HTN, uncontrolled DM or retinopathy Monitor: fundoscopic exam (intracranial HTN) Adults: IGF-1 every 1-2mo during titration then semiannually Children: growth curve and PE w/ skeletal assessment each visit SE: fluid retention, joint pain, carpal tunnel, myalgia, paresthesia, hyperglycemia, DM ## Footnote flooded tunnel, high sugar, aches, HTN IGF-1 every 1 to 2 months then semi annual

Answer 3

Transsphenoidal Surgery resection - pref tx (hypopituitarism dev in ~15% of pts) RT (radiation) - adjunct tx for acromegaly (req 8yrs for max GH suppression) Somatostatin analogues (adjunct) - ↓ GH Lanreotide Octreotide Pasireotide Sandostatin (LAR) Signifor Somatuline Depot GH receptor antagonists (Pegvisomant) Blocks GH-R sites; $$$ DA agonist: Bromocriptine and Cabergoline - mod suppress GH secr (high dose) **Octreotide + Cabergoline ** ## Footnote TIDE inhibits - TIDE pods challenge was killing people. TIDE pods were the ultimate inhibitor.. of life.

Answer 4

Well tolerated in most patients and adverse effects are short-lived and mostly relate to drug-induced suppression of gastrointestinal motility and secretion. Nausea, abdominal discomfort, fat malabsorption, diarrhea, and flatulence occur in one-third of patients, and these symptoms usually remit within 2 weeks. Octreotide suppresses postprandial gallbladder contractility and delays gallbladder emptying; up to 30% of patients develop long-term echogenic sludge or asymptomatic cholesterol gallstones. ## Footnote somatostatin = stop sign a stop light is short lived. (2 weeks long) GI side effects. a stop light guy who brown pants for D, with a green face and grimace light in pain. flatulence (green smoke behind him) 1/3. Jar of green stones. lots of sludge around him.

Answer 5

Cyclical replacement of estrogen and progesterone - maintain secondary sex characteristics and prevent osteoporosis Gonadotropin or LH - ovulation induction Human menopausal gonadotrophin (hMG) or recombinant FSH - Follicular growth and maturation Pulsatile GnRH tx can be used to treat hypothalamic causes of infertility ## Footnote LH/gonadotropin = ovulate, hMG/reFSH = follicular growth, GnRH for infertility est & prog for every day and to keep away spongy bone

Answer 6

Testosterone replacement (IM or patch) For infertility d/t oligospermia - human chorionic gonadotropin (hCG) - IM Alt for pts w/ intact pituitary: leuprolide (GnRH analog) Clomiphene PO - stimulates men’s own pituitary gonadotrophins → ↑ testosterone and sperm prod

Answer 7

3% hypertonic saline (monitor SerNa+ and neuro s/s) Furosemide - increases excretion of free water (adjunct) (limits tx-induced volume expansion) ## Footnote salty sally's fury crying salty sally= hypertonic saline excretion of water= crying

Answer 8

Depends on acute (<48hr) vs chronic Consult nephrology Correcting hyponatremia too quickly → central pontine myelinolysis (CPM) w/ permanent neurology s/s (paralysis, dysphagia, dysarthria) Want daily rise of Na+ (10-12mEq/d) ## Footnote 10-12 rise of salt is good 48 hour cutoff

Answer 9

Acute setting: 3% hypertonic saline Loop diuretics (furosemide) w/ saline Vasopressin-2-R antagonists (conivaptan) (prod water excretion w/o electrolyte excretion) Water restriction (500-1500mL/d) Vasopressin-R antagonist: inhib AVP V2-R and causes ↓ number of aquaporin-2 water channels in collecting duct → ↓water permeability of duct Conivaptan - parenteral V1a AND V2-R antagonist Tolvaptan - selective oral V2-R antagonist **Avoid in hypovolemic hyponatremia** | conivaptan (antagonist of vasopressin 2R) ## Footnote salty sally's fury, with Con captain V1V2 and Toll V2 captain. (a situation that everyone hates)

Answer 10

Chronic setting: Fluid restriction and V2-R antagonist Referral to nephrologist for chronic vaptan use ## Footnote tell them to stop drinking water and put them on toll captain refer if they want the con captain V1V2

Answer 11

Conivaptan - parenteral V1a AND V2-R antagonist Tolvaptan - selective oral V2-R antagonist **Avoid in hypovolemic hyponatremia** ## Footnote con captain and toll captian find reason for con captain having both V1 and V2 while TOLL just has V2

Answer 12

Mild: supportive tx (fluids) Central and Vasopressinase-induced DI: Desmopressin acetate (incr water permeability in renal tubular cells → decr urine volume and incr Uosm) - concentrates urine! SE: agitation, emotional changes, SI ## Footnote Desmopressin (desmond miles the time traveler) Desmond miles is moody because his family got murdered

Answer 13

****Transsphenoidal surgery - most effective SE: transient DI and hypopituitarism, CN damage, visual disturbance, CSF leak ------------------------------- Radiation- primary tx or adjunct to surgery Slow onset of action → good for post-op mgmt Meds: Prolactinomas - DA agonists (DOC) Acromegaly - somatostatin analogs and GH-R antagonists TSH-secreting tumors - somatostatin analogs **ACTH-secreting tumors and non-fxnal tumors are gen not responsive to meds** and req surgery or radiation

Answer 14

Severe (symptomatic or Ca > 14mg/dL) Rehydration - IV NS 500-1000mL/h x 2-4hrs +/- **loop diuretics** - IV furosemide (Lasix) → ↑ calcuria and diuresis SE: hypoK or hypoMg +/- corticosteroids (prednisone, hydrocortisone) - ↓ **conversion of inactive to active vit/ D** (esp w/ excess calcitriol is present) **** +/- Bisphosphonates, Calcitonin: ↓ release of Ca from bone, esp in chronic cases

Answer 15

Replacement of lost Ca (PO +/- Vit D); Severe hypocalcemia: (Ca >14) IV Calcium: 10% Ca gluconate 10-30 mL IV over 10-20min (can cause VD or ischemia) +/- IV magnesium +/- Vit. D ## Footnote replace lost Calcium! can use vit D too. easy. severe: IV Ca, Mg, D (Ivy green CAMD')

Answer 16

Adequate hydration: 6-8 glasses of water/d (↓ effects of hypercalcemia, ↓ nephrolithiasis) Physical activity - avoid bed rest (↓ osteoporosis risk ) Avoid meds like thiazides, lithium, high dose of Vit A Mod intake of calcium or vit. D supplement ## Footnote flush out the stones, run your bones Avoid slides, batteries, Retinol Add Ca + D to neg. feedback on the PTH

Answer 17

Parathyroidectomy rec for pts w/: Symptomatic hyperparathyroidism Kidney stones, bone dz Persistence urinary Ca >400mg/dL SerCa > 1mg/dL above ULN < 50 y/o ## Footnote surgery for bones and stones dz or 400 Ca in urine. Ca in blood above 1 ULN or less than 50y/o

Answer 18

Annual labs (SerCa, Vit D, PTH, renal fxn, 24hr urine for Ca) DEXA scan every 2yrs Spinal X-ray or CT, abd US or CT Definitive tx is Surgery ## Footnote once a year -3 C's: (SerCa, Uri24h Ca, Cr/BUN) + D (e) PTH, Deep 3 C's 1/yr Dexa/2 Spine Xray/CT, abd CT/US

Answer 19

**Cinacalcet** (Sensipar): pref esp if bone density is WNL Does NOT improve bone density or reduce calciuria Recheck SerCa 1 wk after initiating **Bisphosphonates** - pref w/ osteoporosis PO Bisphosphonates - alendronate (Fosamax), ibandronate (Boniva) Can improve bone density Do NOT sig impact hypercalcemia or hypercalciuria IV Bisphosphonates - pamidronate (Aredia), zoledronic acid (Reclast) Temporarily treats hypercalcemia Good for sx prep w/** severe hyperCa** other - estrogen replacement, decreased bone loss. Risk of CA, TE Raloxifene- decr. reabs in bone. decrease CA risk in uterus and breast | WNL = within normal limits ## Footnote Sinna is normal, Alen's got holes, IVY pam&zols got ever bigger holes Raloxifene

Answer 20

Cinacalcet (Sensipar): pref esp if bone density is WNL MOA: binds to CaSRs in PT and ↓ PTH secr SE: N/D, arthralgia, myalgia, paresthesia Does NOT improve bone density or reduce calciuria Recheck SerCa 1 wk after initiating ## Footnote Sinna 's normal. just decreases PTH by binding to Ca receptor in PT (sinna flirts with pink ice cream receptionist in panem) he has joint pain, muscle pain from years of haircutting in Panem doesn't change the fact that katniss still has to battle (no effect to bone density). After the hunger games are over, Ca is rechecked (hunger games over after 1 week)

Answer 21

Bisphosphonates - pref w/ osteoporosis MOA: bind to hydroxyapatite and imp ability of osteoclasts to reabs bone (↓ number of active osteoclasts by inhibiting osteoclast progenitor dev and promote apoptosis) ## Footnote inhibit the people with the axe

Answer 22

PO Bisphosphonates - alendronate (Fosamax), ibandronate (Boniva) Can improve bone density Do NOT sig impact hypercalcemia or hypercalciuria ## Footnote alen the drone stops axe people, they use robot legs to jump in big hole can't do much to remove pink ice cream

Answer 23

IV Bisphosphonates - pamidronate (Aredia), zoledronic acid (Reclast) Temporarily treats hypercalcemia Good for sx prep w/ severe hyperCa ## Footnote Pam drone and Zole drone can jump down big holes too, but they also have the robot arms to deal with too much pink ice cream show a surgeon on the scene

Answer 24

Raloxifene (Evista) - SERM Estrogen agonist in bone to ↓ reabs Estrogen antagonist in uterus and breast to ↓ CA risk ## Footnote Raloxifene is both an agonist and antagonist. Relax and fiend Estrogen stop osteoporosis. Raloxifene - tells axe guys to relax. its also an estrogen antagonist in uterus and breast - a "fiend", antagonist to cancer in uterus and breast. can draw on body where its a fiend and where its not.

Answer 25

Weakened bones → osteopenia, osteoporosis, pathologic factors Eval w/ DEXA scan every 2yrs Vertebrae at high risk Tx: bisphosphonates or denosumab (Prolia) Vit. D def: Eval w/ serum 25-OH Vit. D Tx: vit D replacement therapy Renal effects → nephrolithiasis, nephrocalcinosis, CKD Refer to nephrology or urology

Answer 26

Refer to nephrology if CKD present Medical management - mainstay Vit. D supplement Dietary restriction of phosphate (if CKD)

Answer 27

Acute management: Maintain airway - risk of laryngospasm or bronchospasm IV Ca Gluconate 10% Ind: low SerCa, tetany, seizures, bronchospasms, prolonged QT, HF PO - Calcitrol and Calcium to wean offf from IV Ca Vit D therapy (started w/ Ca tx) Calcitriol (1,25 Vit. D) - faster onset Magnesium (if low) Magnesium sulfate IV → Mg oxide PO Monitor - SerCa, P, Mg, UCa | start IV then PO ## Footnote IV Ca Gluconate 10% indication is any of the symptoms from the green shelf in the pictures PO- Calcitrol and Calcium to wean off from IV Vit D therapy started at same time Magnesium if low is given IV and then transitioned to Mg oxide PO Monitor all of these + P

Answer 28

Chronic management/maintenance: PO Calcium Supplement: Ind: **sympt pts ** Monitor SerCa every 3-6mo (“normal” Ca leads to hypercalciuria and renal stones) Vit. D and Mg supplements: as needed PTH replacement tx: Recombinant human PTH, Synthetic PTH, palopegteriparatide (prodrug of PTH) Ind: pts intolerant of Ca/Vit. D Long-term lab monitoring: Urine and SerCa, SerCr, P, 25-OH Vit. D every 3-6mo then 6-12mo Periodic renal imagine (US) if persistent | supplements only if symptomatic. Recomb human PTH, synth PTH,.. ## Footnote Recomb human PTH, synth PTH, palopegteriparatide if they can tolerate the supplements. Labs: Ca Cr D 3, 6, 12 if it keeps going US

Answer 29

Transplant of cryopreserved PT tissue Ind: pts undergoing parathyroidectomy Transplanted in **brachioradialis (MC), pectoralis, SCM**

Answer 30

Cheaper and plant-based Ind: vit. D def, osteoporosis, hypoparathyroidism, FHH MOA: stimulates Ca and P abs in SI; Ca reabs in renal tubule; secretion of Ca from bones to blood AE: C, AMS, fatigue, arrhythmias CI: allergy, hypercalcemia, Hypervitaminosis D

Answer 31

Animal sources Ind: vit. D def, osteoporosis, hypoparathyroidism MOA: stimulates Ca and P abs in SI; Ca reabs in renal tubule; secretion of Ca from bones to blood AE: C, AMS, fatigue, arrhythmias CI: allergy, hypercalcemia, Hypervitaminosis D

Answer 32

Ind: hypoCa in hypoparathyroidism/pseudohypoparathyroidism, secondary hyperparathyroidism (CKD) MOA: binds and activates Vit.D-R in kidney, PT, intestine, bone (↓ PTH, stimulates Ca abs, promotes bone formation) AE: related to hypercalcemia - abd pain, N/C, HA, AMS, arrhythmias, **polydipsia** CI: allergy, hypercalcemia, hypervitaminosis D

Answer 33

Ind: hypoCa prevention/tx, primary osteoporosis prevention MOA: prevents or treats negative Ca balance AE: HA, abd pain, C, acid rebound, flatulence, N/V CI: hyperCa, hypercalciuria, hypophosphatemia, renal calculi, hx of V-fib

Answer 34

MOA: prevents or treats negative Ca balance AE: bradycardia, arrhythmias, VD, cutaneous calcification, hyperCa, hypoP CI: hyperCa, hypercalciuria, hypophosphatemia, renal calculi, hx of V-fib

Answer 35

MOA: prevents or treats negative Mg balance AE: D, GI irritation CI: HyperMg, allergy

Answer 36

First-line - levothyroxine Combination T3/T4 therapies - dessicated thyroid; liotrix Synthetic T3 - liothyronine evaluate clinically for adrenal insufficiency/angina before start Take on an **empty stomach**, w/ water Peak response usually seen in ~4 weeks BBW - use of TH replacement as obesity tx

Answer 37

Adjustment of medication based on TSH level Elevated TSH - inadequate thyroid hormone replacement therapy Verify how patient is taking medication! Normal TSH - adequate thyroid hormone replacement therapy May need high-normal TSH if pt has hx of CAD or a-fib If still symptomatic → free T3/T4 levels to evaluate adequacy of tx May consider T3 supplement or changing to combination T3/T4 (controversial) Low/Suppressed TSH - excess thyroid hormone replacement therapy Consider severe systemic illness or hypopituitarism Meds - NSAIDs, opioids, CCBs, steroids Suppressed TSH (0.03 mIU/L or less) - risk of a-fib, osteoporosis

Answer 38

Increased thyroid hormone requirements Meds - anticonvulsants, sertraline, bile acid-binding resins, PPIs Increased estrogen - pregnancy, estrogen-containing medications GI Disorders - celiac disease, IBD, lactose intolerance, gastritis; wt gain - over 10% body wt

Answer 39

Decreased thyroid hormone requirements Decreased estrogen - cessation of estrogenic meds, postpartum, post-oophorectomy Increased androgen - testosterone therapy wt loss - over 10% body weight

Answer 40

synthroid, Levoxyl, Levothroid Ind: hypothyroidism, TSH suppression (CA/goiter) Titrate up every 4-6wks; 30-60min before food SE: similar to effects of hyperthyroidism Angina, palpitations, tachy, arrhythmia, CHF, flushing, anxiety, fatigue, insomnia, irritability, pseudotumor cerebri Menstrual irreg, wt loss, abd cramps, D/V, ↑ appetite CI: hypersensitivity, thyrotoxicosis, acute MI, uncorrected adrenal insuff Monitor: TSH Q4-6wks then Q6-12mo

Answer 41

Cytomel, Triostat Ind: Hypothyroidism, myxedema, goiter suppression 30-60 min before food or other medications SE: Similar to effects of hyperthyroidism Arrhythmia, tachycardia, hypotension or HTN, MI, CHF Twitching, irritability, nervousness Menstrual irreg, wt loss, abd cramps, D/V, ↑ appetite CI: hypersensitivity; thyrotoxicosis; acute MI; uncorrected adrenal insuff Monitoring: TSH Q4-6wks then Q6-12mo

Answer 42

Armour Thyroid, Nature-Thyroid, Westhroid Ind: Hypothyroidism (not rec) titrate every 6 weeks to euthyroid status 30-60 min before food or other meds SE: Similar to effects of hyperthyroidism Angina, palpitations, tachy, arrhythmia, CHF, flushing, anxiety, fatigue, insomnia, irritability Menstrual irreg, wt loss, abd cramps, D/V, increased appetite CI: hypersensitivity, beef, or pork; thyrotoxicosis; acute MI; uncorrected adrenal insuff Monitor: TSH Q4-6wks then Q6-12mo

Answer 43

Definitive tx: RAI - NOT safe in pregnancy Methimazole can decrease efficacy; may worsen ophthalmopathy → give w/ steroids Surgery - safe in pregnancy; thionamide drugs pre-op SE: damage to recurrent laryngeal nerve, hypoparathyroidism ----------------------------- Thionamide (thiourea) Drugs - inhib prod of thyroid hormone Ind: mild, elderly, young adults, pts who cannot have more definitive tx, prepare for RAI or sx No permanent damage to thyroid SE: agranulocytosis, aplastic anemia, hepatotoxicity Methimazole - pref in most pts PTU (Propylthiouracil) - pref if 1st trimester or breastfeeding

Answer 44

Grave’s Disease tx: Beta blockers (propranolol, atenolol) Iodine contrast agents (iopanoic acid, ipodate sodium) Blocks T3→T4 conversion; ind: severe s/s - NOT in US

Answer 45

Tx - observation if no s/s Evaluate and Tx if s/s

Answer 46

Toxic solitary nodule - eval w/ FNA to r/o CA s/s - BB + methimazole or PTU (suppress TSH) Sx - if pt <40y/o or healthy older pt Alt: RAI if not sx candidate

Answer 47

Amiodarone-induced: s/s - BB + methimazole (adjunct iodinated contrast agent) Refractory - sx

Answer 48

Toxic multinodular goiter: s/s - BB + methimazole or PTU Sx - definitive tx; thyroidectomy Alt: RAI

Answer 49

Thyroiditis: Thinamides - ineffective; TH prod is low s/s - BB; severe - iodinated contrast agents NSAIDs or opioids for pain mgmt

Answer 50

May observe if asympt and minimally enlarged or normal size thyroid Hypothyroidism - levothyroxine Large gland/goiter - levothyroxine suppressive tx

Answer 51

High dose ASA/NSAIDs +/- corticosteroids (severe/refractory) BB for acute s/s Severe thyrotoxicosis - iodinated contrast agents

Answer 52

Antibiotics Surgical drainage of abscess

Answer 53

Tamoxifen +/- steroid therapy Sx for decompression if needed

Answer 54

Observe w/o adm of thyroid hormone unless pt has hx of pre-existing hypothyroidism or clinical s/s Correcting underlying dz → returns labs to normal

Answer 55

General follow up Regular palpation and US Q6 mo initially, then yearly AVOID excess iodine intake LT4 suppression Indicated for nodules > 2cm + normal or high TSH Reduces emergence of new nodules Risk: heart dz exacerbation, osteoporosis, hyperthyroidism Thionamide drugs +/- BB: if s/s of thyrotoxicosis Surgery – CA, hyperfxning nodules, toxic MNG Ethanol injection – shrink benign tumor RAI therapy –toxic thyroid adenomas, toxic MNG, Graves Risks: hypothyroidism

Answer 56

Pituitary ACTH tumor: pasireotide (Signifor) - inhib ACTH sec ## Footnote parasite or passthetime inhibit ACTH like a brain parasite that sucks out the ACTH or inhibit or, could inhibit ACTH by meditating, passing the time peacefull and controlling the mind's stress

Treatments only, Endo Flashcards

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