Endocrinology 4

  1. Rapid acting insulin: inject when:
    within 15 min of meal; as rescue: w/o regard to meals
  2. Glulisine (Apidra): in insulin pumps
    Available for use in insulin pumps up to 48 hours
  3. Glulisine (Apidra): Dosing:
    15 min prior to meal OR within 20 min after starting a meal
  4. Glulisine (Apidra): possibly better in what pts?
    Better in obese patients?
  5. Short acting insulin: inject when:
    within 30 min of meal; as rescue: w/o regard to meals
  6. NPH: typically inject how often:
    x2 / day (depending on meal schedule)
  7. Detemir is bound to ? and is good out of the fridge for:
    bound to albumin; good for 42 days out of refrigerator
  8. Glargine: characteristics
    peakless insulin; acidic pH; provides 24 hr coverage in most pts
  9. Change in basal insulin: BID NPH to long-acting:
    Reduce TDD by 20%; administer total dose QD
  10. Change in basal insulin: Levemir : Lantus : Levemir:
  11. NovoLog & Humalog =
    NovoLog 70/30 (30 Aspart & 70 Protamine); Humalog 75/25 (25 Lispro & 75 Protamine); Humalog 50/50 (good for pt eating 2 big CHO meals/ day)
  12. Novolin / Humulin =
    Regular insulin (30) & NPH (70)
  13. Insulin 50/50 rule
    Basal: 50% of TDD; Bolus: 50% of TDD (divided into mealtime doses)
  14. 50/50 rule with NPH as basal:
    Decrease amt used as bolus by 20%
  15. Standard insulin split mix
    2/3 of TDD in AM (1/3 short acting; 2/3 intermed); 1/3 of TDD in PM (1/2 short acting, 1/2 intermed)
  16. Adjustment algorithm: Regular T1DM pt: 1 unit of bolus changes by:
  17. Adjustment algorithm: Insulin resistant pt: 1 unit of bolus changes by:
    25-30 mg/dL
  18. Adjustment algorithm: Insulin sensitive pt: 1 unit of bolus changes by:
    as much as 70- 100mg/dL
  19. Adjustment algorithm: rule of 1800: based on:
    blood sugar level
  20. Rule of 1800 formula
    1800 / TDD = x (mg/dL changed by 1 unit insulin) = correction factor
  21. Rule of 1800 at POC
    (FSBS) – (goal) / correction factor
  22. Rule of 500: based on:
    CHO intake
  23. Rule of 500: formula
    500 / TDD = x gm CHO covered by 1 unit insulin
  24. Rule of 500: if pt has frequent decreases in blood glucose:
    decrease by 0.5 units
  25. Somogyi
    hypoglycemia triggers counter-reg hormones; causes hyperglycemia; manage insulin to prevent hypoglycemia
  26. Dawn phenomenon
    d/t waning insulin levels; causes hyperglycemia; manage with insulin, or move peak to more physiologic time
  27. Amylin =
    beta cell hormone co-secreted w/ insulin; suppresses glucagon secretion from panc; regulate gastric emptying; enhances satiety
  28. Limitations of amylin
    Sticky; adheres to surfaces; forms aggregates & insoluble particles; Half-life is minutes, must be given IV
  29. Pramlintide: mcg to units conversion
    1 unit = 6 mcg
  30. Pramlintide available in:
    5 mL vial; 60 mcg T1DM pens (15-30-45-60); 120 mcg T2DM pens (60-120)
  31. Pramlintide T1DM dosing
    15mcg (2.5 units) before meals; decrease meal-time insulin by 50%; Increase pramlintide dose by 15mcg (2.5 units) q 3-7 days as tolerated to 60 mcg (10 units)
  32. Pramlintide: AE
    Nausea & anorexia (T1 > T2); Black Box: severe insulin-induced hypoglycemia, usu within 3 hrs of dosing
  33. Pramlintide education
    Take immed prior to meal of 30 gm or more of CHO; injection technique & admin site (abdomen or thigh); do not mix with insulin
  34. Pramlintide storage
    Unopened vial/pen: refrigerated; Opened vial: refrig or rm temp; Opened pen: rm temp
  35. Pramlintide: DI
    Oral agent needing rapid onset (analgesics); meds needing threshold conc for efficacy (Abx, contraceptives); Administer oral med at least 1 hr prior
  36. Pramlintide CI
    Severe GI disease (diagnosed gastroparesis)
  37. T1DM tx algorithm
    insulin (& diet & exercise); then adjunct oral tx (biguanide / TZD); then Inj Adjunct (amylin)
  38. T2DM tx algorithm
    diet & exercise (& metformin?); oral mono or combo tx (TZD / sulf; then poss alpha-gluc inhib or meglitinide or DPP4); incretin mimetics (GLP-1); insulin; amylin [insulin may be started at any time]
  39. C-peptide test can tell:
    if pt is producing insulin
  40. Tx for impaired insulin secretion:
    Sulfonylureas; meglitinides; insulin
  41. Tx for insulin resistance:
    biguanides; TZDs
  42. Tx for decreased glucagon suppression:
    GLP-1 agonist; DPP4 inhib; amylin agonist
  43. Insulin secretagogues =
    Sulfs (Glyburide, Glipizide, Glimepiride: hugs panc all day); meglitinides (Repaglinide, Nateglinide: quick panc hug to cover meal)
  44. Sulfs: 1stG vs 2ndG:
    Replace 1stG; 2ndG do not work better but fewer DI and no sulfa allergy concerns
  45. Sulf mgmt
    initial med: start low / slow; titrate q3-4 wks as poss, adjust for hep/renal dysfn; pt ed re: hypoglycemia; consider combo tx when tx nears max dose
  46. Sulfs & renal dysfn:
    Glipizide may be used in renal impairment; glyburide may worsen renal dysfn
  47. Insulin secretagogues: CI
    Liver / renal dz; elder / debilitated; Severe trauma / infxn; PG/ BF
  48. Meglitinides: titrate:
    at 1 wk by doubling dose up to 4 mg
  49. Biguanide: MOA
    Inhibit hepatic glu O/P; Promote glu uptake by fat & mx; Decreases intestinal absorption of glucose (minor)
  50. Biguanide: CI
    Kidney / Liver dz (Scr: M 1.5, F 1.4); Elderly; Alcohol Abuse; Unstable Heart Failure; IV Contrast Media
  51. Biguanide: AE
    GI (30%); Lactic acidosis; anorexia; Vit B12 depletion
  52. Biguanide: Education:
    GI effects should resolve within 14 days; Take with meals
  53. Metformin & IV contrast
    d/c drug 24 hr before procedure, restart 48 hrs after, or labs prove kidney fn is back to nml
  54. Metformin: dose & titration
    500 – 850 QD or 500 BID; titrate 500 q7d & 850 q14d (no benefit >2000 mg / day)
  55. Metformin XR: dose & titration
    use XR if GI AE concerns; 500 QD w/ PM meal; titrate q7d
  56. TZD MOA
    Promotes glu uptake by fat & mx; Inhibits hepatic glucose output
  57. TZD CI:
    Liver dz; Heart failure (Black Box); PG & Lactation
  58. TZD AE:
    Liver tox; Fluid retention (not resolved by diuretics); Wt gain (20-30 lb?); HA, fatigue
  59. TZD pt ed
    Patience: 6-12 weeks for max efficacy; may have noticeable wt gain; Report to provider SOB with any activity
  60. TZD titration
    No sooner than 4 weeks
  61. Alpha-gluc inhibs MOA
    cause CHO to be absorbed more slowly
  62. Alpha-gluc inhibs: CI
    IBD / UC / obstruct bowel disorders; Liver / renal impairment; PG/BF
  63. Alpha-gluc inhibs: AE
    Flatulence, GI distress, diarrhea; Jaundice, elevated LFTs (acarbose)
  64. Alpha-gluc inhibs: DI
    Pancreatic enzymes
  65. Alpha-gluc inhibs: Pt Ed
    Take w/ meal; If have hypoglycemic event, must tx w/ glucose (tablet) or lactose (milk), not complex CHOs; GI AE will lessen over time
  66. Incretins =
    Peptide hormones released by the gut to normalize glucose profile; include GLP-1; GIP (no effect if given exogenously)
  67. Limitations of GLP-1
    Rapid inactivation by DPP-IV; Requires continuous SQ injection
  68. GLP-1 Bypass route:
    GLP-1 Agonist: Modify protein to prevent breakdown; DPP-4 inhib: Limit enzyme activity
  69. Januvia AE
    urticaria & angioedema; poss severe pancreatitis
  70. Januvia approved for use with:
    metformin and/or TZDs (address impaired insulin secretion, insulin resistance, and dec glucagon suppression); can give to pt w/ impaired hepatic / renal fn
  71. Saxagliptin AE
    Peripheral edema (in combo w/ TZD); HA; UTI; Hypoglycemia with sulfonylureas
  72. Only 2 oral agents can use for type 1 DM:
    metformin and Actos
  73. Time orientation: fasting blood sugars
  74. Time orientation: postprandial blood sugars
    meglitinides; alpha-gluc inhibs
  75. Acceptable T2DM meds in renal impairment
    TZDs; DPP-4 inhibs; Meglitinides; Glipizide IR; Glimepiride; Tolbutamide
  76. Most cost-effective T2DM meds:
    metformin, insulin, sulfs (TZDs effective but expensive)
  77. Incretins MOA
    inc glucose-dept insulin secretion; dec glucagon secretion; dec rate of nutrient absorption (so improved gastric emptying); inc satiety
  78. Exenatide: available as:
    5 or 10 mcg pens; SQ; thigh, abd, upper arm
  79. Exenatide dosing
    At least 6 hrs apart; Inc dose after 30d, as tolerated, prn; Decrease sulf dose by half to reduce hypoglycemia risk; Must be on 5 for 30 d, before consider inc to 10 mcg; Take before meals
  80. Exenatide benefits include:
    Sig reduction in A1c; wt loss
  81. Exenatide pt ed:
    Injxn technique (1 time prime); Take within 60 min of meal (if skip meal, skip dose); Storage: Unopened: refrigerate; Opened: refrig rm temp (to 30 days)
  82. Exenatide DI
    Oral agent needing rapid onset (analgesics); meds needing threshold conc for efficacy (Abx, contraceptives); Administer oral med at least 1 hr prior
  83. Liraglutide dosing
    0.6, 1.2 (after 1 wk), 1.8 pen; once daily, independent of meals; 0.6 mg not effective for glycemic control (only minimizes GI sx); Decrease sulf dose by half to reduce hypoglycemia risk; poss sig DI
  84. GLP-1 AE
    Inc hypoglycemia risk if combo w/ sulf; N/V; Diarrhea; Anxious / jittery; Pancreatitis; Wt loss; Thyroid C-cell tumors (liraglutide)
  85. GLP-1 Pt selection
    After oral agents have failed; HbA1c from 7-11%
  86. GLP-1 CI
    T1DM; ESRD / CrCl <30 ml/min; Pancreatitis; Severe GI dz; h/o medullary thyroid ca or Multiple Endocrine Neoplasia Syndrome (liraglutide only)
  87. Pramlintide dosing: T2DM:
    60mcg (10 units) before meals; Decrease meal-time insulin by 50%; Increase to 120mcg (20 units) in 3-7 d, as tolerated
  88. Which insulins are cloudy?
    NPH; mixes
  89. Which insulin may be given IV?
  90. Non-prescription insulins
    Regular; NPH; Novolin 70/30; Humulin 70/30
  91. Hypothalamus hormones
  92. Pituitary hormones
    Prolactin; GH; ACTH; ADH; TSH; LH/FSH
  93. Adrenal hormones
    Epinephrine; Cortisol; Aldosterone
  94. Control of prolactin
    produced by pit; neg inhib by DA (so the more DA, less prolactin)
  95. Regulation of Hypothalamus
    Upper cortical inputs (CNS); Autonomic NS; environmental cues (light & temp); Peripheral endocrine FB
  96. FSH: fx
    Estrogen (F); Spermatogenesis (M) [if no estrogen prod: FSH increases]
  97. LH: fx
    regulates ovulation; stimulates testosterone in men [if no testosterone prod: LH increases]
  98. TSH: fx
    increases thyroid hormone production [if no TH prod: TSH increases]
  99. Prolactin: fx
    induces lactation
  100. GH: fx
    controls acral growth
  101. ACTH: fx
    stimulates cortisol production
  102. Primary hypothyroidism
    Thyroid gland fails to make T4; TSH is HIGH; FREE T4 is LOW
  103. Secondary hypothyroidism:
    Pituitary gland fails to make TSH; TSH is inappropriately LOW; FREE T4 is LOW; Other Pit Hormone Deficiencies; cannot follow TSH (must also follow Free T4)
  104. Hypothyroid S/S
    Cold intolerance; Fatigue; Heavy Menstrual Bleeding; Wt Gain; Myxedema Coma
  105. Secondary hypothyroidism: incidence
    Much rarer than primary
  106. Secondary hypothyroidism: you cannot:
    Follow TSH to adjust thyroid hormone replacement
  107. Secondary hypothyroidism: poss sequela of:
  108. Secondary hypothyroidism: consider in pt with S/S of:
    hypothyroidism & low normal TSH, low normal t4
  109. Secondary hypothyroidism: Do not:
    replete thyroid hormone before repleting cortisol; if pt adrenal/ cortisol deficient, & replete TH first, revs up metab, can lead to adrenal crisis (wont have enough cortisol to support metabm)
  110. Secondary hypothyroidism: Dx
    Sx of Hypothyroidism; Low TSH; Low T4; Other Sx to suggest Pan-Hypopituitarism
  111. Adrenal Insufficiency (AI) is:
    Cortisol Deficiency
  112. Primary Adrenal Insuff =
    Addison Dz; adrenal gland does not respond to ACTH & not make adrenal hormones
  113. Secondary Adrenal Insuff =
    Pit does not make ACTH; adrenal is not stimulated to make cortisol
  114. Tertiary Adrenal Insuff =
    Suppression of CRH & ACTH by exogenous cortisol use
  115. Primary Adrenal Insuff: Sx
    Sx based on hypocortisolism & hypoaldosteronism: Fatigue & Hyponatremia (most important); Hypotension; Hyperkalemia; Hyperpigmentation (from ACTH); Death
  116. Gold standard to dx primary Addison dz
    Low morning cortisol <5
  117. Secondary Adrenal Insuff: due to:
    Failure of pit to secrete ACTH; caused by the same causes of Pan-Hypopituitarism
  118. Secondary AI & RAAS
    b/c secondary & tertiary adrenal insuff only involve low ACTH levels, the RAAS is still intact; Only cortisol is deficient.
  119. Secondary AI: Sx
    Hyperkalemia & Hypotension are rarely seen; hyperpigmentation is not seen
  120. Secondary AI: Dx
    Low morning cortisol <5; Low ACTH in setting of low cortisol; No Response to synthetic ACTH (cortrosyn) stim test; Insulin Tolerance Test; Metyrapone Test
  121. Secondary AI: synthetic ACTH (cortrosyn) stim test
    baseline cortisol, then: 250 mcg IM Cortrosyn; cortisol s/b over 18 (if adrenal gland is working)
  122. ACTH & 11-deoxycortisol
    ACTH stims adrenal to make 11-deoxycortisol (which makes cortisol); Nml pit will drive up 11-d, if 11-d goes up & ACTH goes up, then pt has nml pit-adrenal axis;
  123. Metyrapone Test:
    Give metyrapone: blocks cortisol prodn, cortisol goes down, FB to hypo-pit, if pit working, more ACTH to inc cortisol
  124. Hypogonadotropic Hypogonadism =
    F: Amenorrhea/Infertility; M: Erectile Dysfunction/ Infertility; Inappropriately Low FSH/LH for low estrogen or testosterone
  125. Hypogonadotropic Hypogonadism: Eval
    Hx (congenital or acquired); MRI Pituitary to assess for cause; Labs (prolactin; Iron/TIBC (Hemachromotosis); other Hormonal Work-Up; if estrogen level low, do Provera challenge); Give Hormone Replacement
  126. Diab Insipidus =
    No ADH; unable to conc urine; Polyuria; Polydipsia (esp night); UOP: 5-20 L / d; U spec grav < 1.0006; Hypernatremia; Normal Glucose
  127. DI: Water Deprivation Test
    Follow every 1-2 hrs: Na; UOP, Urine Osmo; Wt; BP & HR (Lying / Standing); Once serum osm >300 & urine osm has not increased, give 10 ug of vasopressin and follow urine osm
  128. Water Deprivation Test: purpose
    distinguish btw central and (nephrogenic) DI; Nephrogenic: give AVP, kidney wont respond, urine remains dilute; Central: give AVP, later serum osm changes?
  129. DI: Ddx
    DM; Primary Polydipsia; CHF; Prostate Hypertrophy; Cushing syn (Excess Glucocorticoids); Other Osmotic Load (Calcium); Lithium; Parkinson Dz
  130. Causes of DI
    Panhypopituitarism (often have intact ADH secretion with deficient ant pit hormones); Sarcoidosis/ Infiltrative Dz; Tumor; Trauma; Image Pituitary to Dx
  131. Sx of Hypopituitarism
    Secondary Hypothyroidism; Hypocortisolism (secondary adrenal insuff); Amenorrhea, Menopause, Erectile Dysfunction, Infertility; Polyuria/Polydipsia
  132. Management of Panhypopituitarism
    Investigate / Tx Underlying Cause (MRI pit); Replace Hormones (unless CI); Cortisol First; Thyroid Hormone; Sex Steroids: Estrogen (unless postmenopause); Testosterone
  133. Hyperprolactinemia: Sx (Women)
    Galactorrhea; Amenorrhea; Infertility
  134. Hyperprolactinemia: Sx (Men)
    ED; Infertility; HA; Mass Effect (eg, from tumor in head); Galactorrhea
  135. Pathognomonic for hyperprolactinemia in men:
  136. Prolactin >200: due to:
    Hyperprolactinemia; Pit Adenoma; Renal Fail; PG
  137. Prolactin = 20-100: poss due to:
    Hyperprolactinemia; Pit Adenoma; Renal Fail; PG; Drugs; Other Pit Tumors; Hypothal Tumors; Chest Wall Stimulation
  138. Drugs that cause Hyperprolactinemia
    Anti-DA (Anti-psychotics; Reglan); TCAs; SSRI; Verapamil; Alcohol, esp Beer; Heroin; Cocaine
  139. Prolactinoma: Mgmt
    medical mgmt first (before surg); tumor size (< 1 cm: microadenoma; >1 cm: macroadenoma & must tx); mass effect or visual field disturbance? Is estrogen / testost prodn disrupted? Is fertility desired?
  140. Prolactinoma: Mgmt
    Dopaminergic Drugs if: Macroadenoma; Mass Effect; Visual Field Deficit; Fertilty Desired
  141. Prolactinoma: Mgmt: Hormone Replacement if:
    No Fertility Desired; Microadenoma; Visual Field Full; No Mass Effect; Estrogen or Testosterone is low
  142. Prolactinoma: Medical Management
    Tx w/ Dopaminergic Drugs; DA inhib fx on prolactin; shrink tumor; Cabergoline / Bromocriptine; AE: nausea, hypotension
  143. Acromegaly vs Gigantism
    Acromeg: pit tumor secreting GH in adulthood; Gigantism: pit tumor secreting GH during puberty before epiphyseal plate fusion; rapid linear growth, heights up to 8ft 11
  144. Risks of LT exposure to GH include:
    Arthropathy, neuropathy, CVD; HTN; resp dz; malig; CHO intol/DM
  145. When to Suspect Acromegaly
    MEN-1 / other FH; Prominent Brow; Enlarged soft tissue of hands / ft; Teeth Splaying; DM; HTN/ LVH; Can be Subtle
  146. Acromegaly Dx
    Elevated IGF-1; GH Fails to Suppress <2 ng/mL after 75 g CHO load
  147. Acromegaly Tx
    Surgical; Somatostatin Analogs: Sandostatin; XRT
  148. Cushing syndrome
    Too much Cortisol Prodn; Exogenous (Use of synthetic Glucocorticoids); Endogenous = Cushing Dz
  149. Cushing syndrome: Sx
    DM; HTN; Osteoporosis; Psychosis; Easy Bruising; Truncal Obesity; Hyponatremia; Moon Facies; Buffalo Hump; Mx Wasting; Hirsutism; Purple Striae; Supraclavicular Fat; Infections
  150. Cushing Dz =
    Pit ACTH overprodn; Ectopic ACTH Prodn; or Pit/Adrenal Adenoma producing cortisol; 75-80 % of cases with endogenous cortisol excess; elevated cortisol levels do not suppress hypothalamic & ant pit secretion of CRH & ACTH
  151. Ectopic ACTH production =
    Nonpituitary Tumors secrete ACTH and do not respond to negative inhibition of high cortisol levels
  152. Ectopic ACTH production poss d/t:
    Small Cell Lung Ca; Carcinoid Tumors; Pheochromocytoma; Thymoma; Pancreatic Cell tumors; Medullary Ca of the Thyroid
  153. Adrenal Hypercortisolism
    ACTH & CRH are suppressed; Caused by: Adrenal Adenomas; Adrenal Ca; Micronodular or Macronodular Hyperplasia
  154. Hypercortisolism: Dx
    24 hr urine for free cortisol (if >100, prob Cushing, if >300, def Cushing; Check Cortisol at night; Suppressing Cortisol with oral dex; checking ACTH levels
  155. Hypercortisolism: Dx: why suppress cortisol w/Dex
    if suppress to <2, then do not have Cushing (dex provided enough glucocorticoid to pit, signals need not prod cortisol); if ACTH >2, prob has tumor that does not respond to dex
  156. Hypercortisolism: Dx: radiography
    Do not do radiographic studies prior to lab studies (poss Incidental Tumors, False Negative Scans)
  157. Hypofunction of endocrine gland d/t:
    destn of primary gland: auto-immune (addison, thyroiditis) or surgical removal
  158. Lack of stimulating hormone: causes
    Pituitary (PanHypopituitarism); Hypothalamus (Stress, Tumor)
  159. Hyperfunctioning of Endocrine Gland
    Autonomous Fn of Primary Gland (Thyroid Toxic Adenoma); Autonomous Fn of Gland making Stim Hormone (Cushing Dz: ACTH); Ab’s that Stim Hor Receptor (Graves / TSI); Ectopic Prod Stim Hormone (Ectopic ACTH)
Card Set
Endocrinology 4
Endocrinology flashcards made by previous students