Endocrinology CT Overview

thyroid nodule tx

Nonpharm

-smoking cessation, weight management

-adequate iodine intake

-small benign nodule = observe and follow up with repeat US

Pharm

-tx of hyper or hypothyroidism

Surgery

-lobectomy or total thyroidectomy indicated for large benign nodules and malignant

-radiofrequency ablation

thyroid cancer tx

Surgery = first line

-lobectomy

-total thyroidectomy

Pharm

-if thyroid is taken out will need levothyroxine due to hypothyroidism

-radioiodine is administered after thyroidectomy in patients with differentiated thyroid cancer to able residual normal thyroid tissue

MEN syndrome tx

-regular surveillance and screening

-surgical removal of tumors where indicated

-children harboring MEN2 mutation are advised to have prophylactic total thyroidectomy by age 6

-no age with MEN2 should receive GLP1 agonist bc it may increase for medullary thyroid cancer

pheochromocytoma tx

Pharm

-alpha blockers (doxazosin), CCB are used to manage HTN

-surgical removal

parathyroid carcinoma tx

-first line = surgery

-management of hypercalcemia: IV fluids, loop diuretics, bisphosphonates, cinacalcet

adrenal adenomas tx

-observation for non functioning adenomas <4cm

Surgery

-functioning

->4cm with suspicious features

Pharm

-cortisol producing: ketoconazole

-aldosterone producing: spironolactone

paraneoplastic syndrome tx

-treat underlying malignancy

Hypercalcemia management

-normal saline, loop diuretics, calcitonin

Cushing syndrome tx

Surgery = First line

-primary Cushing disease = transsphenoidal selective resection of pituitary adenoma

-ectopic ACTH secreting tumor = resection

-adrenal cushing syndrome = adrenalectomy

Pharm

-if surgical tx is delayed or contraindicated

-ketoconazole, metyrapone

primary adrenal insufficiency tx

Non-pharm

-manage stress and emergency

-high sodium and adequate protein intake

Pharm

-hydrocortisone + fludrocortisone for life

-increase maintenance dose during stress for glucocorticoids (3x normal)

secondary adrenal insufficiency tx

-hydrocortisone ONLY

-mineralocorticoid production preserved since problem is with pituitary not adrenal gland

acute adrenal crisis tx

-begin therapy immediately

-IV fluids and IV hydrocortisone

congenital adrenal hyperplasia tx

Tx of crisis

-IV fluids, steriods, ICU

Long term

-hydrocortisone and fludrocortisone

Surgical

-genital reconstruction if severe virilized females

hyperaldosteronism tx

Surgery

-curative for adrenal adenoma

Primary

-spironolactone, eplerenone, amiloride

Secondary

-salt restriction and correction of underlying cause

-most often discontinue diuretic

type 1 DM tx

Non-pharm

-education, carbohydrate counting and insulin to carb ratio

-monitoring, sick day management, exercise

-no smoking or alcohol, regular foot care inspection

Pharm: INSULIN

Bolus: short acting

-aspart, lispro, glulisine

-at mealtime: 1 unit per 10-15g of carbs

Basal: long acting

-glargine, detemir, degludec

-0.1-.02 units/day

how to calculate short acting insulin

Carb calucation

-1-60 ratio

-23 for yogurt: 23/60= 0.38 ~0.5

Insulin calculation

Carb ratio: count carbs 45g, your ratio 1:15 = 45/15 = 3 units

Correction factor: blood sugar 200, target is 100

-200-100= 100

-correction 1:50 ratio

-100/50 = 2 units

Total insulin = 3+2= 5 units

-1 unit of insulin will drop blood glucose 30-50mg/dL

simple formula

(Total Carbs ÷ Carb Ratio) + (Current BG Target BG ÷ Correction Factor) = Total Insulin

Diabetic Ketoacidosis (DKA) tx

Non-pharm

-ICU monitoring, strict I&O, hourly glucose and ketone

-NPO, foley cath, DVT prophylaxis

-review factors, sick day management

Pharm

Fluid resuscitation: 0.9 NaCl in first hour

-0.45 NaCl 250-500 if corrected Na normal/high

-switch D5W + 0.4 NaCl when glucose <250

-replace 50% of fluid in first 12-24 hrs

Insulin: IV/IM regular 0.1 continuous infusion

-decrease glucose by 50-75

-when glucose <250 reduce insulin 0.05 until anion gap normalizes

Electrolyte replacement: potassium make sure >3 before giving insulin

Transition to sub Q insulin 1-2 hrs before stopping IV

Hyperosmolar Hyperglycemic State (HHS) tx

Non-pharm

-ICU, foley cath

-hourly vitals and neuro assessment

-electrolytes every 2-4 hours

Pharm

-Fluid resuscitation: 0.9 NaCl in first hour

-0.45 NaCl 250-500 if corrected Na normal/high

-switch D5W + 0.4 NaCl when glucose <250

-avoid rapid correction

Insulin only after adequate hydration : IV/IM regular 0.05-0.1 continuous infusion

-decrease glucose by 50-75

Electrolyte replacement: potassium make sure >3 before giving insulin

hypoglycemia tx

-15-15 rule: give 15g fast acting carbs wait 15 min and recheck

-repeat if glucose <70

Conscious mild-mod hypoglycemia

-oral glucose 15-20g

Severe hypoglycemia

-glucagon 1mg IM/SC (adults), 0,5mg (kids)

-hospital: D10W infusion to maintain glucose 100-150

-glucagon ineffective in alcohol induced

dawn phenomenon tx

increase morning intermediate or long acting insulin

-consider insulin pump

-adjust timing of insulin

Somogyi effect tx

-reduce evening insulin

-change timing of evening snack

-adjust bedtime snack

-consider switching insulin types

latent autoimmune diabetes in adults (LADA) tx

Non-pharm

-education, nutritional therapy, weight management, exercise

-self monitoring

Pharm

-first line: insulin

-metformin

-insulin typically increase over 2-4 years

-regular C peptide to asses beta cell function

metabolic syndrome tx

Non-pharm

-weight loss 5-10%, exercise, diet, smoking cessation, stress management

Pharm

-HTN: ACE/ARB

-dyslipidemia: statins

-insulin resistance: metformin

-obesity: weight loss meds (orlistat)

obesity management

Recommended for BMI >27 if lifestyle therapy fails

-orlistat: lipase inhibitor

-phentermine + topiramate: sympathomimetic + AED

-naltrexone + bupropion: opioid antagonist + antidepressant

-liraglutide, semaglutide: GLP1

gestational diabetes tx

-nutrition counseling + meds

-insulin = gold standard

Complication

-excessive fetal growth can cause maternal and perinatal morbidity

-increased risk in future pregnancy

-increase risk of T2DM in future

prediabetes tx

Non-pharm

-behavior mods + dietary therapy + 5-7% weight loss

-smoking cessation

Pharm

-first line = metformin

type 2 DM tx

Goal = A1c: <7

-checked every 3-4 months until target then 2x per year

Step 1

-first line = metformin + comprehensive lifestyle

-engage in 150 min or more of exercise that breaks a sweat per week spread over 3 days with no more than 2 consecutive days without activity

Step 2/3: T2DM + artherosclerotic or CV risk, CKD, HR

-SGLT2i or GLP1

-pick whichever one you didn't before

Step 4: Insulin initiation

-A1c uncontrolled >3 mon

-Alc >10%

-blood glucose >300

-symptomatic for hyperglycemia

1. long acting insulin: glargine

-10 units or 0.1-0.2 units/kg

-target fasting plasma of 80-130

2. short or rapid acting: lispro

-added if not enough glycemic control with basal insulin alone

-10% of basal dose or 5 units before largest meal

-or basal +1, +2, +3 respectively

diabetic retinopathy tx

Tx

-glycemic and BP control

-regular screening

-lazer photocoagulation or anti-VEGF

diabetic nephropathy tx

Tx

-ACE/Arb

-SLGLTi = preferred initial therapy for T2D< with CKD

diabetic neuropathy tx

Tx

-pain management: gabapentin and pregabalin

cardiovascular complication tx

Tx

-ACE/ARB

-statin for all >40

-consider 81mg of ASA in high ASCVD score

-hypertriglyceridemia: icosapent ethyl

-GLP1 for pts for T2DM with high ASCVD

-SGLT2 for CV and T2DM

peripheral artery disease tx

Tx

-smoking cessation, exercise therapy, antiplatelet therapy, revascularization

diabetic foot ulcer tx

Tx

-wound care, offloading, infection

-revascularization

infections with diabetes

-increased susceptibility to infection

Common

-UTI, skin infection, periodontal disease

Tx

-glycemic control

-tx of infection

Prevention

-appropriate vaccination

hyperparathyroidism tx

-manage acute hypercalcemia: normal saline + free water

-prevention of complication

-specific management of underlying

Primary hyperparathyroidism tx

Active surveillance

-monitor serum calcium, renal function

-osteoporosis, nephrolithiasis

Pharm

-adequate calcium intake

-Bisphosphonates: maintain bone density

-cinacalcet: help decreased PTH and calcium levels

Surgery

-parathyroidectomy = definitive

-indications: symptomatic, calcium >1 above normal, <60 creatinine, nephrolithiasis, osteoporosis

secondary and tertiary hyperparathyroidism tx

Secondary

-referral

-phosphate binder, calcium, vti D analogs

-control of PTH, calcium, phosphate

Tertiary

-parathyroidectomy

hypoparathyroidism tx

Non-pharm

-high calcium, low phosphorus diet

-monitor and maintain serum calcium levels every 3 months

Pharm

-acute/severe hypocalcemia: IV calcium gluconate

-chronic: calcium carbonate QD, calcitriol BID

-thiazide diuretics, magnesium

-recombinant PTH

Surgery

-transplantation of preserved parathyroid tissue

DiGeorge Syndrome

-22q11.2 deletion syndrome

-parathyroid glands fail to develop properly or absent

Sx

-cardiac anomalies, abnormal facies, thymic hypoplasia, cleft palate, hypocalcemia

-CATCH-22

Tx

-lifelong calcium and Vit D

-regular monitoring of calcium

-thymic transplant

hypothyroidism tx

First line:

-levothyroxine 1.6 mcg/kg/day PO

-recheck TSH 6-8 weeks

Other:

-liothyronine if levo isn't working or as add on for sx relief

-armour thyroid

-follow up annually TSH level

Pregnant

-monitor TSH every 4 weeks in first half of pregnancy

-immediately after pregnancy

congenital hypothyroidism tx

-levothyroxine

autoimmune Hashimoto thyroiditis

-cell mediated and antibody mediated destruction of thyroid gland

-autoantibodies against thyroid peroxidase, thyroglobulin, TSH receptor

Subclinical hypothyroidism

-compensation phase: normal thyroid hormones are maintained to rise TSH

-later unbound T4 levels fall and TSH level rise further > sx become apparent

hyperthyroidism tx

First line

-methimazole

-propylthiouracil: used in first trimester for pregnancy then switch

-symptomatic relief: propranolol

Other

-Radioactive Iodine: releases iodine that is absorbed by thyroid gland which destroys thyroid cells

-surgery: results in permanent hypoparathyroidism

Both require lifelong thyroid hormone replacement

thyroiditis

-most common: chronic Hashimoto thyroiditis

-postpartum thyroiditis and subacute lymphocytic thyroiditis > transient hyperthyroidism

-TPO antibodies or Tg antibodies = high

painful subacute thyroiditis tx

Tx

-conservative

- NSAIDs

infectious suppurative thyroiditis tx

Tx

-abx

I&D

IgA related thyroiditis

-replacement of thyroid tissue with fibrosis tissue > thyroid gland become form and fixed

Sx

-hypothyroidism

-difficulty swallowing

-hard woody thyroid gland

Tx

-thyroid hormone replacement

-surgery for severe cases

acromegaly tx

Non-pharm

-education

-sleep study and CPAP

-colonoscopy screening, cardiac eval, DM management, PT, weight management

Pharm

-first line: somatostatin receptor ligands (octreotide, lanreotide)

-GH receptor antagonist

-dopamine agonist (cabergoline)

Surgery

-transsphenoidal adenomectomy = preferred initial

gigantism tx

Non-pharm

-genetic counseling, monitoring of growth

-psychological support

-management of complication, nutrition

Pharm

-octreotide, pegvisomant, cabergoline

Surgery

-first line: transsphenoidal adenomectomy

dwarfism tx

Non-pharm

-nutrition, counseling, PT, support groups

-monitoring of growth

Pharm

-GH therapy: somatropin

-treat endocrine disorder

pituitary adenoma tx

Non-pharm

-observation for small nonfunctioning

-regular monitoring with MRI and hormone levels

Pharm

-first line for prolactinomas: cabergoline

Surgery

-transsphenoidal resection if visual defects, hormone hypersecretion, pituitary apoplexy

Radiation

-reserved for recurrent disease after surgery

-stereotactic radiosurgery for small residual tumor

hypopituitarism tx

Non-pharm

-education, medical alert bracelet

-stress dose steroids

Pharm

-ACTH deficiency (most urgent): hydrocortisone

-TSH deficiency: levothyroxine

-gonadotropin deficiency: testosterone, estrogen/progesterone

-GH deficiency: somatropin

-ADH deficiency: desmopressin

hyperpituitarism tx

Non-pharm

-monitor is small

-manage complication, education

Pharm

-prolactinomas = cabergoline

-GH = somatostatin

-ACTH = surgical resection, ketoconazole

-TSH = somatostatin, surgical resection

-non prolactin adenomas = transsphenoidal adenomectomy

prolactinomas tx

Non-pharm

-observation for small

-calcium and vit D supplement

-bone density monitoring

Pharm

-first line: cabergoline, bromocriptine

Surgery

-reserved for drug intolerance, large adenomas, patient preference

diabetes insipidus tx

Non-pharm

-ensure enough water, monitor fluids

-dietary mods

-check medications

Pharm

-Central = desmopressin

-nephrogenic = thiazide diuretics, amiloride, NSAIDs, low sodium diet

SIADH tx

Non-pharm

-education, fluid restriction, dietary mods

Pharm

-acute severe hyponatremia <125 = 3% hypertonic saline

-chronic asymptomatic = demeclocycline

-alternative: tolvaptan, conivaptan

male primary hypogonadism tx

Testosterone replacement therapy

-boys who have no yet entered puberty by age 14

-men with primary testicular failure

male secondary hypogonadism tx

-significant weight loss

Testosterone replacement therapy

-mainstay

-indications: serum testosterone <150

-men without elevated LH and average of 2 morning serum total testosterone <275

-applied to upper arms, shoulders, abdomen

females hypogonadism tx

Hormone replacement therapy with estrogen

-oral estrogen, transdermal estrogen, vaginal estrogen, injectable estrogen

-progesterone and estrogen combined for postmenopausal women to mimic natural menstrual cycle

-risk: breast cancer, CV risk, VTE. endometrial cancer, gallbladder disease, bone health