Endocrinology
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| Dawn Phenomenon | hyperglycemia that happens in the morning
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| Somogyi's | Rebound hyperglycemia, can happen at any time during the day
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| Insulin and TZD onboard together increases risk for | Edema
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| Amylin secretion | Amylin is co-secreted with insulin. If no insulin is secreted, amylin is not secreted.
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| Pramlintide has a black box warning for | Type 1: insulin-induced severe hypoglycemia, typically occurs within 3 hours of dosing
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| T4 half life | 7 days, still dose daily
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| T3 half life | 1-3 days; more potent, so more CV AEs
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| Drug of Choice in Hypothyroidism | Levothyroxine (T4); 6-8 weeks to reach steady state. T4 levels will normalize much quicker than TSH b/c feedback loop takes time. Monitor 3-6 months for one year after reaching euthyroid, then yearly
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| T3 | Tri-iodothyronine (another tx for hypothyroidism). Cytomel. Increased risk for cardiotoxicity. Only use this if they fail on the t4. Cytomel is more expensive and requires more monitoring.
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| Switching brands of levothyroxine | Stay consistent with brand b/c levels are different, provider and patient must give authorization
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| Liotrix (Thyrolar, Euthyroid) | Synthetic T3 and T4 in a fixed ratio. Expensive and lacks therapeutic rationale. 3rd line.
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| Thyroid USP (Armour Thyroid) | Dessicated beef or pork thyroid gland. Red flag: allergies. Variable ratio of T3 to T4. Leave this alone or to endocrinologists
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| Thyroglobulin | Fixed 2.5:1 ratio of T4 to T3, expensive, no clinical advantage
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| General guidelines for thyroid replacement dosages are determined by | age, duration, severity of hypothyroidism, and cardiac risk factors
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| TSH long standing or severe | If greater than 15
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| If a patient has cardiac risk (at any age) or is older than 65 | Then reduce thyroid replacement to only 25% of full dose. Watch for angina exacerbation
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| Monitoring T4 replacement therapy | monitor TSH and T4 every 4-6 weeks. T4 normalizes within a few weeks, TSH normalizes after a minimum of 6-8 weeks. Symptoms may not resolve for 3-6 months.
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| Patient education | may take without regard to food, don't double up on doses, may not see improvement for 2-3 weeks. Signs of excess dose (sx of hyperthyroidism) or lack of efficacy, anticipate life-long therapy, OTC drugs
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| Myxedema Coma in Hypothyroidism | Rare syndrome, most prevalent in the elderly in the winter. Cardinal features: hypothermia, respiratory depression, unconsciousness. Treat immediately, but not at full replacement doses.
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| Causes and tx of Hyperthyroidism | Autoimmune Graves disease, Autonomous hyperfunction, thyroiditis. Tx: Thioamides (MMI, PUT), Surgery, Radioactive Iodine
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| Propylthioracil (PTU) in hyperthyroidism | Acutely, PTU works faster than methimazole b/c it works at the conversion of T4 to T3. But in general, it takes 17 weeks to work. Compliance is an issue b/c it 3-4x/day dosing
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| PTU | It is the preferred agent in pregnancy and lactation
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| Methimazole (MMI) for hyperthyroidism | works within 6 weeks, fewer AEs. Higher compliance b/c dosage is QD or BID. Need to take for 6mos-2years
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| When is surgery indicated for hyperthyroidism treatment? | Indicated in patients wtih obstructions, malignancy, presgnancy in 2nd trimester, or those with contraindiations to RAI or thiomides
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| Radioactive Iodine | Indicated in elderly patients who are poor candidates for surgery or have cardiac disease
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| TT3 measures | total T3; useful for early detection of hyperthyroidism
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| TSH | most sensitive for detecting hypothyroid state
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| Elevations in TSH | hypothyroidism
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| Depression in TSH | hyperthyroidism
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| If a patient is less than 45 years old with no cardiac risk and mild hypothyroidism that is short in duration, what kind of thyroid replacement should they receive? | 100% full replacement. 100-125mcg/day of Levothyroxine
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| If a patient is less than 45 years old with no cardiac disease with longstanding or severe hypothyroidism, what kind of thyroid replacement should they receive? | 50% full replacement dose. Monitor/adjust every 2-3 weeks
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| If a patient is older than 45 with short or mild hypothyroidism, what kind of thyroid replacement should they receive? | 50% full replacement dose. Monitor/adjust every 2-3 weeks
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| At any age if a patient has cardiac risk factors or if they are over 65, how much thyroid replacement should they receive? | 25% full replacement dose. Monitor/adjust every 4-6 weeks. Watch for angina exacerbation
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| What is the effect of estrogen on thyroid hormone therapy in patients with nonfunctioning thyroid gland? | Decreases the response to thyroid hormone therapy
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| What is the effect of thyroid replacement hormones on anticoagulants? | Increases action of anticoagulants, may need to decrease anticoagulant dose.
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| What is the effect of thyroid replacement hormones of Beta blockers and Digitalis glycosides | Decreases the action of BB and Digitali glycosides
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| Hyperthyroidism Treatment Adjuncts | BB - decrease action of thyroid hormoneCorticosteroids - Decrease action of thyroid hormone and decreases immune response in Graves diseaseIodine - blocks release of thyroid hormones from the gland
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| Monitoring Hyperthyroidism | TT4 and FT4I: after 4-6 weeks of therapy, after a dose change, every 6-12 months thereafterRAI: monthly TSH and Ft4 to detect iatrogenic hypothyroidism
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| Common AE of Thiomides | Skin rash or itching
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| If you miss a dose of thioamides... | take it as soon as you remember, double up if necessary
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| How should a patient take Iodides? | mix with milk of juice to prevent GI distress, and administer through a straw to prevent tooth discoloration
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| Thyroid Storm Cause | Abrupt precipitation by physiologic or emotional stress.
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| Thyroid storm symptoms | Cardiovascular collapse; high fever, tachypnea, tachycardia, confusion, restless, hepatomegaly with mild jaundice, muscle wasting and weakness
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| Treatment of Thyroid storm | Propylthiourcil, propanolol, corticosteroid, iodide, supportive measures
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