fasting glucose

(to diagnose, fasting glucose must be > or = to 126 mg/dL on more than one occasion at least two weeks apart)

0.5 - 1.0 U/kg/day of insulin

with ~50% of the inslin given as basal insulin

before therapy need to clinically assess for adrenal insufficiency and angina, if those require treatment as well

levothyroxin (synthroid): 25 - 75 mcg qp

efore therapy need to clinically assess for adrenal insufficiency and angina, if those require treatment as well

levothyroxin (synthroid):

start with 100 - 150/day

efore therapy need to clinically assess for adrenal insufficiency and angina, if those require treatment as well

levothyroxin (synthroid):

start with 25 - 50 qd

repeat TSH in 6 weeks

adjust dosage by 25 mcg every 6-8 weeks based on TSH in otherwise healthy pt

adjust every 1-3 weeks in cardiac pts

what is the average daily replacement dose for primary hypothyroidism treatment (after the initial treatment and now just doing maintenance)

and once controlled (during maintenance phase) how often must you go to follow up visits

average daily replacement dose is usually 1.7 mcg/kg of synthroid (usually 100 - 150 mcg)

once full replacement is achieved and TSH levels are stable, you can extend f/u visits to 6 months and then yearly (instead of every 6 - 8 weeks in the initial treatment phase)

*severe hypothyroidism*

levothyroxine 400 mcg IV bolus

continue IV at 50 - 100 mcg/day

hydrocortisone - if adrenal insufficiency is suspected

*autoimmune hyperthyroidism*

methimazole - oral (preferred to PTU)

OR

radioiodine treatment (RAI) to reduce amount of thyroid tissue

OR

thyroidectomy - if not responding to tx

if symptomatic - propranolol

*autoimmune hyperthyroidism*

propranolol for symptoms during early treatment with anti-thyroid drugs and radioiodine tx

*autoimmune hyperthyroidism*

thyroidectomy to reduce the amount of thyroid tissue

(also possible tx if the goiter is enlarged in Grave's)

*severe hyperthyroidism*

aggressive large dose PTU

THEN

1 hour later, oral/IV ipodate sodium

THEN

1 hour later, iodine

propranolol

glucocorticoids -> hydrocortisone

*subclinical hyperthyroidism/mild thyrotoxicosis*

surgery = definitive treatment

anti-thyroid drug (methimazole) + propranolol (but can stimulate goiter growth)

RAI to treat areas of autonomy

hypothyroid: thyroxine hormone replacement

euthyroid + goiter: thyroxine hormone replacement

*viral URTI, w/ diff thyroid phases: hyper -> hypo -> eu*

ASA/NSAIDs sufficient to control symptoms, and propranolol for thyrotoxicosis symptoms

*viral URTI, w/ diff thyroid phases: hyper -> hypo -> eu*

ASA/NSAIS for symptoms

propranolol for the thyrotox symptoms

RAI to cause fall in T3

monitor thyroid function every 2 - 3 weeks using TSH and FT4

*viral URTI, w/ diff thyroid phases: hyper -> hypo -> eu*

ASA/NSAIDs for symptoms

thyroid hormone during hypothyroid stage may be needed

monitor thyroid function every 2 - 4 weeks using TSH and FT4

*sporadic or postpartum, nontender goiter*

hyperthyroid phase (1st stage) - propranolol for symptoms, but initial stage usually mild

hypothyroidism (2nd stage) - thyroxine replacement for only 6 - 9 months as recovery is the rule

*multifocal systemic fibrosis syndrome*

tamoxifen provides remission in 3 - 6 months

short term corticosteroids (help with compression symptoms)

surgical decompression may be needed

surgical excision with near-total thyroidectomy with post-surgical ablation of the remnant thyroid tissue

except: papillary <1cm, < 45 yrs, no local mets

ensure adequate airway

calcium gluconate in IV solution, slowly, until tetany ceases

calcium gluconate in 1L D5W or NS, slow IV drip

aim: calium to = 8- 9 mg/dL

oral calcium (1 - 2g/day) as soon as pt is able

Vit D derivative

hypoMg2+: magnesium sulfate, q 6hr, immediately

F/U with PCP - NEXT DAY

oral calcium (1 - 2 g/day)

calcitriol (rocaltrol), start 0.25 PO q AM and titrate to 0.50 - 2.0 PO q AM

(may need to correct constipation caused by the Ca)

phenothiazines (compazine and thorazine) - may precipitate extrapyramidal symptoms

furosemide (lasix) - can worsen hypocalcemia

serum Ca - every 3 months

spot urine - want < 30 mg/dL

bisphosphanates - to inhibit bone resorption

calcimimetics - increase PTH gland affinity for Ca (lowering PTH)

Vit D analogs - lowers PTH levels

calcitriol (for 2ndary/tertiary) - lowers PTH levels

(others: estrogen replacement, raloxifene, propranolol, phosphate binding meds for renal osteodystrophy)

serum Ca 1 mg/dL above normal w/ urine Ca excretion > 50 mg/24hr

urine Ca > 400 mg/24hr

cortical bone density > 2 SD BELOW normal

< 50 - 60 years of age

difficulty ensuring medical f/u

2nd trimester pregnancy

parathyroidectomy

minially invase PTHectomy surgery usually sufficient if adenoma identified preoperatively by sestamibi and US

keep active

drink plenty of fluids

avoid immobilization

avoid thiazides, large doses of Vits D and A, Ca-containing antacids or supplements, and digitalis

serum Ca and albumin - twice a year

renal function and urine Ca - yearly

bone density (hip, spine, distal radius) - every 2 yeras

sun exposure - 15 minutes, 2X week W/O sunscreen

vit D replacement (prevention), if sundeprived pt - 1000 - 2000 IU/day

frank Vit D deficiency - vit D2 (ergocaliferol) 50,000 units oreally 1x or 2x weekly for 6 - 12 months, then 1000 - 2000 IU per day long term

calcium replacement - not needed if malabsorption or poor nutrition is NOT susprected - Ca citrate or carbonate with  meals

calcium replacement:

Ca citrate - 0.4 - 0.6 g/day

OR

Ca carbonate (tums) 1 - 1.5 g/day

with meals

*primary hyperaldosteronism (adenoma)*

initial treatment: low sodium diet and potassium supplement; refer to endocrinologist for initial work up

*primary hyperaldosteronism*

surgical removal

spironolactone while awaiting surgery

*primary hyperaldolsteronism*

spironolactone - blocks the effect of aldosterone on the renal tubules (life long treatment)

*adrenal insufficiency*

hydrocortisone = drug of choice; 2/3 in AM, 1/3 in PM (mimicing cortisol levels throughout a day)

prednisone = alternative to hydrocortizone

these are increased in case of: infection, trauna, surgery, diagnostic procedures

can add fludrocortisone to hydrocortizone (or prednisone) - if symptom resolution isn't complete via monotherapy

when would you need to incraese the levels of fludrocortisone during the treatment of addison's disease

when is it decreased

*adrenal insufficiency*

increased for:

postural hypotension

hypoNA+

hyperK+

fatigue

elevated plasma renin activity

decreased for:

edema

hypoK+

HTN

*emergent insufficient cortisol levels*

immediate IV hydrocortizone 100 - 300 mg in NS

for rest of day, continue hydrocortisone 50 - 100 mg IV q 6hrs; next day q 8 hrs; then taper and change to oral

empiric antibiotics

D5W to treat hypoglycemia

selective transsphenoidal resection of pituitary adenoma = surgery of choice

hydrocortisone needed temporarily after resection of pit adenoma or adrenal adenoma

ketoconazole, 200 mg PO q 6hrs (to suppress the high cortisol levels)

monitor liver enzymes

adrenal neoplasm: laparoscopic resection of adrenal neoplasm

ectopic: surgical rections

dopamine agonist - if no remission or normalization of GH

somatostatin analogs if acromegaly presists despite pituitary surgery

GH receptor antagonist

support

GH injections

desmopressin

intranasal - most common administration

start 0.05 - 0.1 ml (100 mcg/mL sol) every 12 - 24 hrs

oral

start 0.05 mg BID, increased to max of 0.4 mg q 8 hrs if needed

goal: normalize pituitary hormones and shrink or ablate larger tumor masses

transshenoidal surgical resection of tumor

gamma knife radiation

to slow progression: good glycemic control

strict control of BP

Start ACEI or ARB

restrict protein intake to 0.8g/kg/day

consultation when GFR < 60 ml/min

pt should be checking feet daily and taking precautions (diabetic footwear)

prescribe: TCAs, anticonvulsants, duloxetine (cymbalta), pregabalin (lyrica), gabapentin (neurontin)