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Endocrine Tx


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 (won’t have enough cortisol to support metabm)
Hypogonadotropic Hypogonadism tx Give Hormone Replacement
Management of Panhypopituitarism Investigate / Tx Underlying Cause (MRI pit); Replace Hormones (unless CI); Cortisol First; Thyroid Hormone; Sex Steroids: Estrogen (unless postmenopause); Testosterone
Acromegaly Tx Surgical; Somatostatin Analogs: Sandostatin; poss dopamine agonists; XRT
Hypercalcemia: nonpharm tx Tx underlying cause; enhance calciuresis: Fluids (2-3 L / day po for mild; IV saline for severe / Ca > 13); loop diuretics (only after volume repletion); furosemide
Hypercalcemia: Pharm tx: Inhibit osteoclastic resorption: bisphosphonates; calcitonin; cinacalcet
Hypercalcemia: Pharm tx: Inhibit osteoclast resorption/ reduce GI absorption: Glucocorticoids (prednisone; solumedrol)
Hypocalcemia Tx Vit D (25 OH D deficiency): Calcium (2000-4000 mg/day); ergocalciferol / cholecalciferol if 25 OH D deficient; Calcitriol if 25 OH D sufficient
Osteomalacia: Tx Ergocalciferol (D2-Drisdol) 50K U BID x 6-12 mos; Vitamin D (25 OH D def): Ca (1500-2000 mg/day); cholecalciferol (D3); Calcitriol (for hypophosphatemic osteomalacia)
Pagets Dz: Tx Inhibit osteoclast resorption/ bone formation: bisphosphonates; calcitonin
Skeletal response to continuously delivered PTH inc osteoclasts, inc resorption, inc serum Ca
Skeletal response to once-daily delivered PTH inc osteoblasts, inc bone formation, inc bone mass/ strength
Adrenal crisis tx Tx HYPOTENSION w/ volume (2 to 3 L of NS or D5NS); Give IV DEXAMETHASONE 4mg or IV HYDROCORTISONE 100mg (Dex preferred bc it won’t interfere w/ further dx testing & is long acting)
Chronic adrenal insuff: maint tx Hydrocortisone 20mg AM / 10mg PM; Dex; prednisone
Tx chronic primary adrenal insuff: besides cortisol, must also tx insuff of: aldosterone: Fludrocortisone; check for postural HypoTN, orthostasis, serum K, renin; poss inc dose summer (inc persp Na loss) & dec dose in HTN (do not d/c altogether); NO K sparing diuretics for anti-HTN Rx
adrenal insuff Prophylaxis: Steroids in Surgery Give pre-op hydrocortisone / continue 24 hrs; cut dose by 50% after first 24 h; cut dose by 50% each day until return to maint level (small procedures: give single dose of HC IV beforeprocedure)
Cushing syn: tx Surg Resection; Transphenoidal microsurgical removal (if sure Cushing dz); Bilateral Adrenalectomy (uncommon); Pharmacologic adrenal blockade
Hirsutism / virilization: Tx Stop any offending meds; Postmeno F can undergo lap bilat oophorectomy, if scans are nml; small hilar cell tumors of ovary may not be visible on scans
Primary hyperaldosteronism: Tx: Aldosterone Producing Adenoma: surgical (effective only in patients with unilateral disease)
Primary hyperaldosteronism: Tx: IHA or poor surgical candidate: med tx: Mineralocorticoid receptor antagonists: Spironolactone (DOC) or Eplerenone; CCB; ACEI
Pheochromocytoma: Tx : First: Alpha Adrenergic-Blockade first; Beta-blockade next if nec; NEVER start before alpha-blockade (can lead to worsened hypertensive crises); CCB (may be better tolerated than alpha-blockade)
Pheochromocytoma: Tx: Surgical resection is tx of choice (May req open lap); Need adequate a-blockade pre-op; Watch for post-op comps(Labile BP; Post-resection hypoTN/ shock; Hypoglycemia)
toxic multinodular goiter Tx Rx RAI
subacute thyroiditis: Tx ASA/ NSAIDs; prednisone
Multinodular goiters: tx thyroxine suppression of TSH; surg if obstruction
Tx for Graves dz PTU (esp for PG/BF)(TID); Tapazole (qd)
PTU works within: 17 weeks
Surgery for hyperthyroid: subtotal or total thyroidectomy: indicated in: pts with obstructions (lg goiters), malignancy, pregnancy in 2nd trimester, or those with contraindications to RAI or thioamides
Tx of choice for hyperthyroid in US: radioactive I ablation (CI in PG)
Hyperthyroid tx adjuncts: beta-blockers (propranolol); c'steroids (dec action of thy hormone & imm response in Graves); Iodine (blocks thy hor release)
Tx for thyroid storm First: Propranolol, hydrocortisone; PTU/methimazole, Iodide; Supportive measures; mortality 20%
Myxedema Coma: tx stat IV levothyroxine; then check labs
thyroid replacement tx dosing <45 yo 100%; > 45 or LT/severe dz 50%; CVD or >65 25%; PG: inc dose by 50%
hyperthyroid ophthalmopathy tx: IV methylprednisolone
hyperthyroid drug of choice for PG & breastfeeding pts = PTU
hypoPTH tx: airway, IV Ca gluconate; maintenance oral Ca, vit D, calcitriol, Mg; poss PTH tissue txp
diabetes insipidus tx Central: desmopressin acetate (DDAVP). Nephrogenic: Na restriction, HCTZ w/K, +/- indocin
SIADH mgmt H2O restriction (500-1000mL/day) and Na supplementation. If cannot fluid restrict (chronic dz/age): tx with demeclocycline. Consider Lasix + IVNS (for inc free water excretion). Hypertonic saline only if life-threatening dz
Created by: Adam Barnard Adam Barnard