Macular edema treatment
Anti VEGF intravitreal injections
Monthly for 12 months then followed by intermittent injections to prevent recurrence
Asymptomatic patients with primary hyperparathyroid are surgical candidates if they have any of the following:
- serum calcium level >1 mg/dL (0.25 mmol/L) above the upper limit of normal
- creatinine clearance <60 mL/min
- T-score <−2.5 or vertebral fracture
- age <50 years
The diagnosis of Familial hypocalciuric hypercalcemia, if ca / creat ratio
< 0.01
IF > 0.02, FHH is excluded
Sclerosis inhibitors Romosozumab ( evenity) contraindication
It increases risk of CVA, MI, CV death
It’s should be followed by bisphosphonate or denosumab
Bisphosphante contraindicated in
GFR < 35
Vit D or Hypocalcemia until corrected
Denosumab side effects
Cellulitis
Bronchitis
Osteonecrosis of the jew and femur
Paget disease assessment
- Serum ca
- Vit D
- Whole body radionuclide bone scan
Treatment of Paget disease
Single dose of 5 mg iv zoledronic acid
Morning cortisol level suggests AI
< 82.8
Morning cortisol level unlikely to be AI
> 414
Synacthen test
=< 496.8 ; AI
> 496.8 ; unlikely
Adrenal insufficiency diagnosis steps
- Morning cortisol
- If in green zone ; Synacthen
- If confirmed AI ; do ACTH to see if it’s 1ry or 2 ry
- If 1 ry AI ; do 21 hydroxylase antibody
- If antibody-ve ; do CT adrenal
To diagnose primary aldosteronism
PAC/PRA should be……?
A PAC/PRA > 20 with a PAC of at least 15 ng/dL (414 pmol/L) is considered a positive result
How to diagnose primary aldosteronism In patients taking an ACEi or or ARBs?
renin should be elevated and testing may start with PRA measurement.
If the PRA is suppressed, the likelihood of primary aldosteronism is high
How to diagnose primary aldosteronism in patients taking Mineralocorticoid receptor antagonists (spironolactone and eplerenone) and high doses of amiloride ?
These medications can significantly interfere with interpretation of PAC/PRA and
should be discontinued 4 to 6 weeks before evaluation if possible.
However, if testing while a patient is taking a mineralocorticoid receptor antagonist reveals suppressed PRA, further testing can be done without stopping the medication.
The localization study of choice for primary aldosteronism
-CT adrenal
- Most patients with primary aldosteronism should undergo adrenal vein sampling to confirm the source.
Treatment of primary aldosteronism
- adrenalectomy ( Serum potassium levels should be monitored weekly for the first month postoperatively)
- Spironolactone if not candidates or refuse surgery
Initial tests in pheochromocytoma
Initial tests include measurement of
- plasma free metanephrine collected in a supine position or
- 24-hour urine fractionated metanephrine and catecholamine levels.
*medications should be discontinued at least 2 weeks before testing if possible.
mild elevations may require repeat testing.
Levels >4 times the upper limit of normal, in the absence of acute stress or illness, are consistent with a catecholamine-secreting tumor.
Plasma free-metanephrine is a more convenient test and is often chosen if the index of suspicion is high.
If suspicion is low, urine fractionated metanephrine and catecholamines may be a better option.
tumor localization in pheochromocytoma ?
tumor localization should only occur after establishing the biochemical diagnosis of catecholamine excess to avoid misdiagnosing an incidental nonfunctioning adrenal mass as a pheochromocytoma.
-abdominal and pelvic contrast-enhanced CT
If the CT scan is negative, and suspicion of a catecholamine-secreting tumor is high,
-the next step is advanced
imaging, including the iodine 123-metaiodobenzylguanidine, octreotide, or gallium-68 DOTATATE scans.
Advanced imaging may also be indicated in patients with very large pheochromocytomas (>10 cm) to detect
metastatic disease or paragangliomas to detect several tumors.
The definitive treatment for pheochromocytoma/paraganglioma ?
- surgical resection.
- Preoperative α-receptor blockade with phenoxybenzamine for 10 to 14 days before surgery is essential to prevent hypertensive crises during surgery.
The dose is progressively increased to achieve
1. BP 130/80 mm Hg or less and pulse of 60 to 70/min seated,
- and SBP >/= 90 with pulse of 70 - 80/min standing.
α-blockade & β-blocker in pheochromocytoma?
A β-blocker is added after α-blockade is achieved to manage reflex tachycardia, but it should never be started before adequate α-blockade, because unopposed α-adrenergic vasoconstriction can result in a hypertensive crisis.
Pheochromocytomas may occur in familial syndromes including …?
- MEN type 2,
- von Hippel-Lindau syndrome, and
- neurofibromatosis type 1.
Therefore, all patients with catecholamine-secreting tumors should be offered genetic counseling.
All patients with an adrenal incidentaloma should undergo testing for
Cushing syndrome and pheochromocytoma if the unenhanced CT attenuation is > 10 HU
In selected patient:
- HTN + Hyper K ; PAC/PRC ration
- androgens , who suspected; DHEA, testosterone and androstenedione
Target TSH in papillary thyroid cancer
To reduce cancer recurrence, a sufficient dose of levothyroxine is administered to suppress the serum TSH below normal
