What is the recommended daily intake of calcium for adults 19-50 years old?
1000 mg/day or more. 1200 mg/day if >age 50.
What disorders are associated with deficits in Vitamin D?
Rickets and osteomalacia.
How many mg of calcium are in an 8-ounce glass of milk?
What are the two major causes of hypercalcemia?
Malignancy and hyperparathyroidism
Name two medications that can increase calcium levels
Lithium and thiazide diuretics
What is a normal 25 OH vitamin D level?
> 30 ng/mL “sufficient"
What is the recommended daily amount of vitamin D?
Name drugs that can cause osteoporosis
iii. Levothyroxine (overreplacement)
iv. Cytotoxic drugs
vi. Long term use of heparin
Why is dental disease a contraindication for bisphosphate treatment?
Osteonecrosis of the jaw may occur
When should patients be screened for osteoporosis?
There is no consensus from the major organizations.
American Thyroid Association-screen women and men > 35 years every 5 years
American Association of Clinical Endocrinologists-screen older patients periodically
American college of Physicians-women > 50 with s/s of thyroid disease
The following instructions apply to____________? Take in the morning before breakfast on an empty stomach, no food including orange juice or coffee for at least 30 minutes after administration. Take with a full glass of water. Remain upright (sitting or standing) for at least 30 minutes
Bisphosphonates such as alendronate (Fosamax)
What is the adverse effect of greatest concern when using bisphosphonates for the treatment of osteoporosis?
Esophagitis is the greatest concern
When would bisphosphonates be contraindicated?
In individuals that can not sit up for 30 minutes or have esophogeal disorders
What are the uses for selective estrogen receptor modulators (SERMs) such as raloxifene (Evista)?
Postmenopausal osteoporosis, and breast CA
What are the adverse effects of SERMs?
Venous embolism, fetal harm, and hot flashes
At what age do women experience accelerated bone loss?
After menopause with continued loss for several years (2%-3% per year).
Name lifestyle measures aimed to promote bone health
Avoid smoking and ETOH. Regular weight-bearing exercise prevents bone loss
How is ostroporosis defined?
Bone marrow density (BMD) value 2.5 SD below the mean
What does Trousseau’s sign assess for?
What is the cut-off point of daily albumin excretion above which a diabetic patient without HTN should be given and ACEI?
Greater than 30
How does diabetes cause atherosclerosis?
Endothelial dysfunction, abnormalities in coagulation, increase in plaque formation, and platelet aggregation
What drugs are used for diabetic peripheral neuropathy?
Pregabalin, duloxetine, gabapentin
Why is DKA more common in type 1 diabetics?
Type 2 patients have insulin production
What kind of activity should be avoided in patients with diabetic retinopathy
Why do diabetics with elevated AM glucose levels need to check their BS at 3 AM?
Need to rule out Dawn phenomenon and Somogi
What type of ear infection can be problematic in patients with DM?
Malignant otitis media caused by Pseudomonas aeruginosa
How many oz of orange juice should be taken in the event of hypoglycemia?
Where do the majority of diabetic foot ulcers begin?
At the site of a callus
Sustained hyperglycemia, polyuria, polydipsia, ketonuria, and weight loss are clinical signs of____________?
Diabetes mellitus (DM).
How is DM diagnosed?
Fasting blood sugar > or equal to 126 mg/dl or
random check > 200 mg/dl.
Glucose interacts spontaneously with Hgb in RBCs to form glycated derivatives that can be measured in the blood. What is the name of this test that serves as an index of average glucose levels over the prior 2-3 months?
Glycosylated hemoglobin (HbgA1C).
What is the target value HgbA1C for diabetic patients?
Less than 7%. Ideal is 6.5.
What is the purpose of measuring C-peptide levels in diabetic patients?
Normal C-peptide levels indicate that the pancreas is producing insulin.
If a patient injects regular insulin and then eats breakfast, when would you be worried about hypoglycemia.
Before lunch when the insulin is at its peak.
Which types of insulin are always cloudy?
NPH and any type of pre-mix (70/30 or 75/25) that contains NPH.
Why is it important to gently agitate NPH insulin prior to administration?
To disperse the particles in suspension.
Why is it important to draw regular insulin up first when combinations of insulin are used?
The NPH will inactivate or contaminate the rapid acting insulin.
How many units of insulin are in one ml of U100 insulin?
Each ml contains 100 units of insulin.
Name the new rapid acting insulins that have an earlier onset of action than regular insulin and need to be injected 10-15 minutes prior to eating.
What are the major adverse effects from the oral hypoglycemics for Type 2 diabetics called sulfonylureas?
What is the mechanism of action of sulfonylureas?
They stimulate release of insulin from the pancreas
Are oral hypoglycemics used during pregnancy?
Glyburide has safety studies, however, insulin is still preferred
Which class of anti diabetic drugs stimulate the release of insulin from the pancreas, can led to hypoglycemia, and must be given before meals?
Meglitinides such as repaglinide (Prandin) and nateglinide (Starlix).
Which anti diabetic drug suppresses gluconeogenesis, enhances glucose uptake and utilization by muscle and does not promote insulin secretion or cause hypoglycemia?
What is the most important rare side effect associated with the use of metformin?
Metformin inhibits lactic acid oxidation leading to lactic acidosis.
What conditions may make a person on metformin more prone to lactic acidosis?
Renal insufficiency, liver disease, severe infection, and hypoxemia,
What are the clinical signs of lactic acidosis?
Hyperventilation, myalgia, malaise and unusual somnolence
Why is it necessary to hold metformin prior to diagnostic tests using dyes and prior to surgery?
To decrease the risk of lactic acidosis
Why is metformin contraindicated in patients with renal impairment?
The risk of lactic acidosis is incresed when the serum creatinine is elevated.
Name the two drugs that lower blood sugar by inhibiting digestion and absorption of dietary carbohydrates thereby reducing the rise in blood sugar that occurs after meals.
Acarbose (Precose) and Miglitol (Glyset)-alpha-glucosidase inhibitors
What is the MOA of thiazolidinediones (TZDs) such as rosiglitazone (Advandia)?
TZDs reduce blood sugar by increasing insulin sensitivity
TZDs can cause weight (loss or gain)?
TZDs can cause major weight gain
TZDs are contraindicated in patients with_____________?
Why was a Black Box Warning recently issued for rosiglitazone (Avandia)?
Increased cardiovascular events were found in patients taking Avandia.
Actos (pioglitazone) has been associated with:
Possible increaseD risk of bladder cancer
What is the treatment of diabetic ketoacidosis?
Fluid and electrolyte replacement and regular insulin given IV.
What is the treatment for insulin overdose?
IV dextrose or glucagon
Why is it important to place an individual on their side after the administration of glucagon for hypoglycemia?
Nausea and vomiting can occur after receiving glucagon
Incretins are hormones that are released from the GI tract after a meal. They slow gastric emptying, stimulate insulin release for the pancreas, inhibit postprandial release of glucagon, and suppress appetite. An injectable drug that mimics this effect is called__________?
A drug that slows the breakdown of naturally occuring incretins to improve glucose control is called______________?
Abdominal obesity, low HDL, high triglycerides, HTN, obesity, insulin resistance, and impaired fasting glucose are some of the characteristics of ______________?
The metabolic syndrome
HbA1c of____________is now diagnostic of diabetes?
What level of HbA1c is now considered prediabetes?
A HbA1c of 7.0% reflects an average glucose of___________?
A HbA1c of 8% reflects an average glucose of____________?
A HbA1c of 9% reflects an average glucose of____________?
Metformin is contraindicated when the creatinine is greater than _________?
1.3 in women, and 1.4 in men of eGFR < 50
How is hypoglycemia treated in a patient with diabetes?
4 oz of orange juice, 5 gram glucose tablet, 8oz of milk, glucagon
Patients with diabetes sometime save slowing of the GI tract (gastroparesis). Which antidiabetic agents would not be appropriate with this condition?
DPP4 inhibitors-sitagliptin (Januvia) and incretin mimetics-exenatide (Byetta)
Pancreatitis has been associated with exenatide (Byetta). Have the oral DPP4 inhibitors such as sitagliptan (Januvia) been associated with pancreatitis?
What is the Somogyi phenonom
First described by Dr. Michael Somogyi in the 1930’s. Hyperglycemia following an episode of nocturnal hypoglycemia. Hypoglycemia episode leads to release of counter-regulatory hormones (epinephrine, cortisol, & growth hormone) and release of liver stored glucose. Signs and Symptoms include morning headaches, nightmares, restless sleep, normal BG at bedtime, BG less than 60 mg/dl at 3:00 am and fasting hyperglycemia.
What is the treatment for rebound hyperglycemia (Somogyi)?
Goal is to prevent nocturnal hypoglycemia, changes in insulin regimen, bedtime snack and essential 3:00 am BG monitoring
What is the Dawn phenonom?
Diurnal increase in the need for insulin that occurs in the late hours of sleep. Increase in counter-regulatory hormones leads to: An increase in glucose production, a decrease in glucose utilization, and an increase in morning blood glucose levels (fasting hyperglycemia).
What is the treatment for the Dawn Phenomenon?
Monitor BG at bedtime and serially during hours of sleep especially at 3:00 AM. Increase insulin dosage and changes in timing of insulin.
Define “basal” insulin.
The insulin that is normally secreted continuously to keep the bloodsugar around 100 gm/dL during times of fasting
How would you calcualte basal insulin?
It is normally 50% of the total daily dose of insulin
How is the total daily dose of insulin calculated?
Which of the insulin preparations are considered “basal” insulins?
Insuline glargine (Lantus) and possibly detemir (Levemir)
Liraglutide (Victoza) given once a day is associated with:
Medullary thyroid cancer
Flat affect, puffy pale face, dry skin, brittle hair and hair loss, decreased heart rate and temperature, lethargy, fatigue, intolerance to cold, elevated TSH and depressed T4 are clinical signs of (hypothyroidism or hyperthyroidism)?
TSH levels in a patient with hypothyroidism are (elevated or depressed)?
Name a condition associated with hypothyroidism.
Excessive levels of thyroid hormone, depressed TSH and elevated T4 are associated with_____________?
Hyperthyroidism or Grave's disease
Rapid bounding pulse, dysrthythmias, angina,, nervousness, insomnia, rapid thought flow and speech, increased metabolism, increased temperature, skeletal muscle atrophy, intolerance to heat, warm moist skin, weight loss despite appetite and exophthalmus are clinical signs of_____________?
Graves' disease or hyperthyroidism.
TSH level in a patient with Graves' disease are (elevated or depressed)?
How is hypothyroidism treatment?
With thyroid hormone replacement.
How is oral levothyroxine administered?
On an empty stomach to enhance absorption.
Why should you avoid taking levothyroxine with calcium, iron, or antacids?
Absorption of the levothyroxine will be diminished
Why is it important to start with low doses of thyroid replacement in the elderly?
Excess doses can cause tachycardia, angina and dysrhythmias
How long does it take for levothyroxine to reach plateau?
How is Grave's disease treated?
With antithyroid drugs until radioactive iodine can be given
Propylthiouracil (PTU), methimazole (Tapazole) and radioactive iodine-131 are used to treat_________________________?
Which antithyroid drug is preferred in pregnancy because it does not cross the placental barrier?
What drug is commonly used to suppress tachycardia in patients with hyperthyroidism?
Very young children, pregnant or nursing mothers are candidates for radioactive treatment. True or False.
What are the risk factors for thyroid disease?
a. Diabetes mellitus
b. Pernicious anemia
c. Primary adrenal insufficiency
e. Leukotrichia (premature graying)
What is the purpose of drawing thyroid autoantibodies?
To rule out Hashimoto’s thyroiditis
Name drugs that alter iodine uptake and interfere with thyroid function
c. Estrogen (HRT or OC)
Why is it necessary to order free levels of T3 and T4?
Thyroid hormones are highly protein bound and measurement of total is inaccurate
Which test is the most accurate indicator of thyroid function?
When would a FT4 or FT3 level be needed?
TSH may not be accurate if there is pituitary failure
Acute illness where TSH may be transiently elevated or suppressed without true thyroid pathology
Recovery from hyperthyroidism where the TSH will often remain suppresses as thyroid hormone levels return to normal
What does the radionuclide uptake measurement provide?
Activity of the gland and nodules
What test would need to be done in a female prior to RAI?
What type of nodules seen on uptake are consistent with cancer (hot or cold)?
What is the ocular disorder associated with Grave’s disease?
Ophthalmopathy is present in 25% of patients with Graves’ disease and results from inflammation of the eye and the orbit
What is the treatment for ophthalmopathy?
Diuretics and ophthalmic prednisone
Does RAI improve ophthalmopathy?
It can make it worse
Normal thyroid function
How is the levothyroxine dose altered in pregnancy?
Increase by about 30%
Why is it important to listen for a bruit in patients with thyroid disease?
Hyperthyroidism may elicit a bruit
What is the greatest risk factor for the development of thyroid cancer?
Until 1950 radiation treatments were given to children for enlarged thymus, tonsils and acne
What is subclinical hypothyroidism?
TSH is elevated, T4 is normal
Is it necessary to treat subclinical hypothyroidism?
If TSH is > 10 or the patient is symptomatic
What is the dosage for thyroid replacement in an adult?
1.6 micrograms/kg in adults
How should treatment for hypothyroidism in the elderly be initiated?
25 micrograms or start low and go slow
What findings are consistent with thyroid cancer?
Fixation to adjacent structures
Persistent hoarseness, pressure, dysphonia, dysphagia, or dyspnea (include this in you HPI because these are pertinent “positive or negative” findings)
What characteristics about the nodules seen on thyroid ultrasound are ar high risk for malignancy?
Microcalcifications, hypoechogenicity, a solid nodule, irregular nodule margins, chaotic intranodular vasculature, and a nodule that is more tall that wide. Any two of these characteristics in a nonpalpable nodule warrants FNA
What is the definitive test for suspected thyroid cancer?
Fine needle aspiration (FNA) is the most sensitive and specific
Why is it important to do a TSH on a patient with atrialfibrillation?
Hyperthyroidism may be the cause
What does TSH measure?
The pituitary’s response to peripheral levels of thyroid hormone
What is apathetic hyperthyroidism of the elderly?
Older adults often present with atypical symptoms of depression, and atrial fibrillation rather than tachycardia
What is the most common autoimmune disease in the US?
Why is it important that patients with Grave’s disease refrain from smoking?
Smoking worsens the ocular manifestations of Grave’s disease
A patient with Grave’s disease is prescribed a beta adrenergic antagonist. What comorbid conditions will be exacerbated with the initiation of the propranolol
A patient presents with a suppressed TSH and an increased free T4. The next step is to order:
Thyrotropin receptor antibodies (TSII or TSI)
The most reliable laboratory test for distinguishing active Grave’s disease from other causes of thyrotoxicosis is:
Measurement of thyroid stimulating immunoglobulins (TSI)
When can a female patient treated with radioactive iodine-131 start trying to conceive?
Four months is recommended
What lab tests should be evaluated prior to initiation of antithyroid drugs?