Final: Thyroid/DM Flashcards

Question

range for impaired fasting glucose range for impaired oral glucose tolerance test

Answer 1

fasting: blood sugar 100-125 (if results give 1 impaired and 1 126, further testing needed to confirm diagnosis) oral: 140-199

Answer 2

* For NON pregnant, use the 2 hour 75g * \>200 is positive **AND** need symptoms of hyperglycemia (if no sx's, need another diagnostic test to confirm) * For pregnant women: * 1 hr 50g, if \>180, go to 3 hr * 3 hr 100g, if \>140 = positive

Answer 3

* Type 1 * autoimmune β-cell destruction, typically leading to absolute insulin deficiency. * Type 2 * multifactorial process, insulin insufficiency (the pancreas does release enough insulin), insulin resistance, unregulated gluconeogenesis in the liver (producing glucose in the face of hyperglycemia) * Gestational diabetes * Diabetes diagnosed during the 2nd or 3rd trimester of pregnancy that was not clearly present prior to gestation * Other: * Monogenic diabetes syndromes (neonatal diabetes and maturity-onset diabetes of the young [MODY]) * Diseases of the exocrine pancreas (cystic fibrosis) * Pancreatic insufficiency secondary to chronic/recurrent pancreatitis * Drug/chemical induced (use glucocorticoids and those treated for HIV/AIDS or after organ transplantation)

Answer 4

* The presence of any of these support dx of type 1 DM: * islet cells autoantibodies (ICAs) * insulin autoantibodies (IAAs) * autoantibodies to glutamic acid decarboxylase 65 (GAD65) * tyrosine phosphatases IA-2 transmembrane proteins * zinc transporter (ZnT8) * 70% to 80% of patients with type 1 DM have anti-GAD antibodies * Insulin Autoantibodies (IAA) in 100% of young patients but NOT in older patients. * Anti-GAD antibodies are more likely to be present in young adults with type 1 diabetes than they are in children.

Answer 5

* Thyroid disease * Celiac disease * Hashimoto thyroiditis, Graves disease, Addison disease, autoimmune hepatitis, dermatomyositis, myasthenia gravis, vitiligo, and pernicious anemia.

Answer 6

* Metformin is SAFE to use if _\>_ 30 GFR * No in: * lactic acidosis * CHF * severe renal function \< 30 GFR * live faiure * heavy alochol use * underoing major surgery * stop metformin if doing study with iodine contrast and begin again 2 days later

Answer 7

* Goal 10%, results with 5% * Start seeing effects with 5% body weight loss * Maintain at 7% * 30 mins day exercise * Unless contraindicated, children with prediabetes and diabetes should be encouraged to engage in physical activity at least an hour a day (play an hour a day)

Answer 8

if BMI \> 35 or can be \< 30 if have chronic conditions (db, HTN or cardiovac dz)

Answer 9

think "**ABC'S"**! * A1c * Every 6 months if stable * Every 3 months if not at goal * Adults: A1c goal: \< 7%. * Children/adolescents: \< 7.5% * Aspirin/antiplatelet agents * Aspirin 75 to 162 mg/day * Secondary prevention in those with diabetes and a history of CVD * Primary prevention in men and women 50 years old and older with type 1 or 2 diabetes or who have additional CV risk factors * no benefit if under 30 yrs * NO Aspirin if \< 21 years old (Reye syndrome) * Clopidogrel (75 mg/day) ok instead of aspirin * Blood pressure * Measured at every visit * Adult goal: SBP \< 140 / \< 90 * Children and adolescents: \< 130 / \< 80 OR \< 90th % for age, sex, and height * Start meds if lifestyle mods (DASH diet, weight loss, and exercise) don't lower BP * ACE inhibitors, ARBs, CCB, or diuretics are recommended. * NO ACE, ARBs, and spironolactone in pregnancy. * It is also recommended that at least one antihypertensive agent be given at night. * Cholesterol * If LDL \> 190→ start on statin * Get lipid profile at the time of diagnosis, and at least q 5 years after if \< 40 yrs old * a calculated 10-year risk of atherosclerotic cardiovascular disease (ASCVD) of \> 20% and the patient’s age is what primarily drives the decision to treat with statin therapy or not * Screening for neuropathy * Diabetic foot exam yearly for DM 2 * DM1, starting age 10 yrs with 5 yr dx duration * if have foot deformities, or ulcers = screen every visit * Inspection, foot pulses, and testing for loss of protective sensation: * light-touch perception with 10-g monofilament and at least one of the following: temperature, vibration using 128 Hz tuning fork, pinprick sensation, and ankle reflexes. * Cardiovascular neuropathy * resting tachycardia and/or orthostatic hypotension. * Screening for diabetic gastroparesis * Screening for retinopathy * Dilated retinal exam * DM 2: time of dx then q 1-2 years * DM 1: \> 10 yrs old for DM 1 for 5 yrs + * Screening for nephropathy * DM 2: Serum creatinine at least YEARLY to get GFR * DM 1: child is at least 10 yrs old with at least 5 year diagnosis, get yearly * Persistent albuminuria is a marker for CVD. * Immunizations * Pneumoccocal * Age 2 to 64 years old with diabetes = get PPSV23 vaccine. * if \< 65 yrs old when vaccine is given, repeat after age 65 (least 5 years between doses) * If \> 65, one vaccine is sufficient--unless there is also a history of nephrotic syndrome, chronic renal disease, or other immunocompromised states, such as post-transplantation. * if _\>_ 65 years or older and who have not previously received PCV13, get PCV13 first, then 6 to 12 months later PPSV23. * Flu vaccine yearly when \> 6 months with diabetes * Hepatitis B vaccine 19 yrs and older * Tobacco use assessment

Answer 10

persistent albuminuria for \>30 mg (abnormal)

Answer 11

* **celiac disease and hypothyroidism.** * don't recommend screening for these because it's ‘rare’: primary adrenal insufficiency, autoimmune hepatitis, autoimmune gastritis, dermatomyositis, and myasthenia gravis are more common in individuals with type 1 diabetes

Answer 12

* Biguanides – metformin (Glucophage and others) * Glucagon-like peptide-1 (GLP-1) receptor agonists – albiglutide (Tanzeum), dulaglutide (Trulicity), exenatide (Byetta, Bydureon), liraglutide (Victoza), lixisenatide (Lyxumia ), and semaglutide (Ozempic) * Amylin agonist - pramlintide (Symlin) * Dipeptidyl peptidase-4 (DPP-4) inhibitors – alogliptin (Nesina), linagliptin (Tradjenta), sitagliptin (Januvia), and saxagliptin (Onglyza) * Sodium/glucose cotransporter 2 (SGLT2) inhibitors (aka gliflozins) – canagliflozin (Invokana), dapagliflozin (Farxiga), empagliflozin (Jardiance), and ertugliflozin (Steglatro) * Pramlintide (Symlin)

Answer 13

mono therapy for 3 months: * **Metformin** * **GLP1-RA** * **SGLT-2** * DPP4 * thiazolidinediones TZD * alpha glucosidase inhibitors (AGIs) * sulfonylureas if pt is “high risk" for ASCVD, have stage 3 CKD, HF use: * GLP1 or SGLT-2 inhibitor if goal not at 3 months, try dual therapy

Answer 14

* Lactic acidosis * Decompensated congestive heart failure (CHF) * Severely impaired renal function (\< 30 GFR) * Liver failure, heavy alcohol use, or in patients undergoing major surgery. * Warn patients to stop drug whenever a study requiring iodinated contrast is needed and not restarted until 48 hours later if the renal function permits.

Answer 15

* 1-1.5% * most therapies for diabetes would result in a 0.5% to 1.5% reduction. * The most *effective* therapeutic classes (with an expected 1%-1.5% A1c reduction): * Biguanides (metformin) * GLP-1 receptor agonists * Does not cause hypoglycemia & weight loss. * But a/s wit vitamin B12 deficiency. * get “periodic” testing of B12 esp if pt has anemia or symptoms of peripheral neuropathy.

Answer 16

* SGLT2 inhibitors (Empagliflozin, Canagliflozin , and Dapagliflozin) * GLP-1 receptor antagonists Liraglutide * Although SGLT2 inhibitors have some proven efficacy for primary and secondary prevention of cardiovascular endpoints, their cadioprotective effects are most pronounced in patients with underlying CV disease. * Liraglutide has been show more beneficial than other GLP-1 in reducing CV endpoints (CV death, non-fatal MI, or stroke).

Answer 17

* lifestyle modifications, metformin, **AND [dual therapy]**: * GLP-1 receptor agonists, SGLT2 inhibitors, DPP-4 inhibitors, TZDs, colesevelam (a bile-acid sequestrant that lowers LDL and improves glycemic control), bromocriptine-QR (Cycloset), alpha-glucosidase inhibitors, sulfonylureas, non-sulfonylurea secretagogues (aka the “glinides” or meglitinides), amylinomimetic agents (amylin agonist), and insulin are all treatment optiåons that can accompany metformin

Answer 18

GLP-1 receptor agonists, pramlintide (Similin), and most insulins

Answer 19

start with insulin (w/ or w/o other agents), esp if have sx's of diabetes if not at goal at 3 months (\< 7%), triple therapy or tx with insulin may be needed

Answer 20

* reduce 1-1.5% a1c * in pancreas, stimulates insulin secretion & prevent beta-cell apoptosis

Answer 21

* 1-1.5% * Enhance insulin secretion from the pancreas by interacting with the ATP-sensitive potassium channels in the beta cell membranes

Answer 22

1-1.5% reduced * Increases insulin sensitivity of skeletal muscle, adipose tissue, and the liver

Answer 23

Enhance insulin secretion from the pancreas by interacting with the ATP-sensitive potassium channels in the beta cell membranes (structurally different than the sulfonylureas)

Answer 24

0. 5-1% A1c reduction * Inhibits the SGLT2 membrane protein in the proximal tubule, which results in decreased renal glucose reabsorption and increased urinary glucose excretion.

Answer 25

Slows degradation of GLP-1 and glucose-dependent insulinotropic peptides (GIPs)

Answer 26

bile acid sequestrant Colesevelam (Welchol) and Bromocriptine

Answer 27

* metallic taste, nausea, diarrhea, abdominal pain, lactic acidosis (rare – but potentially fatal); B12 deficiency * Doesn’t cause hypoglycemia

Answer 28

* if a1c \< 8%, total daily dosing 0.1-0.2 units per kg of body weight * if a1 \> 8%, total daily dosing 0.2-0.3 units per kg * start with Basal (long acting) insulin * STOP/reduce sulfonurleas therapy when starting basal insulin

Answer 29

* Onset 5-15 mins * Peak 30-90 mins * Duration 4-6 hrs

Answer 30

* Onset 30-60 mins * Peak 2-3 hrs * Duration 8-10 hrs

Answer 31

* Onset 30-60 mins * Peak 2-3 hrs * Duration 8-10 hrs

Answer 32

* Onset 2-4 hrs * Peak 4-10 hrs * Duration 12-18 hrs

Answer 33

* Onset 2 to 4 hours, no peak, Duration 20 to 24 hours * Detemir (Levemir) -- Onset 2 to 4 hours, Peak 3 to 9 hours, Duration 6 to 24 hours * Degludec (Tresiba) – Onset 1 hour, Peak 9 hours, Duration greater than 42 hours *

Answer 34

* NEPHROPATHY: Yearly screening for albuminuria with a random spot urine sample for albumin/creatinine ratio after child is 10 years old or older and has had diabetes for at least 5 years. (normal spot ACR _\<_ 30 mg/dg) * RETINOPATHY: Yearly dilated eye exam after age 10 and when child has had T1DM for at least 3 to 5 years * NEUROPATHY: Yearly compressive foot exam starting at age 10 *or* after puberty has started (whichever is earlier) after diabetes duration of 5 years. * HYPERTENSION: at time of diagnosis and every office visit thereafter. Elevated blood pressure should be confirmed on **3** separate days with DM 1 * DYSLIPIDEMIA: Fasting lipid panel starting at age 10. If LDL cholesterol is less than 100 mg/dL, then repeat every 3 to 5 years. If abnormal, monitor yearly. Initial therapy should consist of optimizing glucose control and medical nutrition therapy using a Step 2 American Heart Association (AHA) diet. * Statin therapy if LDL \> 160 mg/dL, or greater than 130 mg/dL with 1 or more cardiovascular risk factors. Remember that statins are contraindicated in pregnancy, so consider birth control in adolescents who require statin therapy. * THYROID DISEASE : TSH soon after diagnosis and improvement in glucose control. * testing for antithyroid peroxidase and antithyroglobulin antibodies soon after the diagnosis. If TSH is normal, repeat every 1 to 2 years, or sooner if patient has symptoms of hypothyroidism, thyromegaly, abnormal growth rate, or unexplained glucose variation. * CELIAC DISEASE: Get tissue transglutaminase or deamidated gliadin antibodies, and serum immunoglobulin A (IgA) level, soon after diagnosis. * esp if patient has a first-degree family member with celiac disease, growth failure, weight loss or failure to gain weight, gastrointestinal (GI) symptoms (diarrhea, flatulence, abdominal pain, or other concerns for malabsorption), or recurrent unexplained hypoglycemia or worsening of glycemic control.

Answer 35

* Insulin injection * Insulin pump * Wireless insulin pump ("Pod" style) * Continuous glucose monitor (CGM) * "Artificial pancreas"

Answer 36

* \>95% of NB's have no or little clinical manifestations at birth * if present, lethargy, hypotonia, hoarse cry, feeding problems, constipation, macroglossia, open posterior fontanelle, umbilical hernia, dry skin, hypothermia, and prolonged jaundice. * Goiter is uncommon * only in infants with genetic defects in thyroid hormone synthesis

Answer 37

* TH essential for growth and neurological development in childhood. * Longer the condition goes undetected, the lower the IQ. * NB Screening: TSH testing, if high, get (T4) testing * repeat at 2 weeks (for delayed onset) * TSH screening alone will **not** identify infants with central hypothyroidism, while infants with subclinical hypothyroidism can only be detected by TSH testing. * don't exclude hypothyroidism in Newborn screening if have high suspicion

Answer 38

* start Synthroid (levo) asap 10-15 mcg/kg/day * tablets -\> crush into breast milk, formula, water * do not give with Ca, soy, iron supp

Answer 39

* **Hashimoto thyroiditis (aka chronic lymphocytic thyroiditis)** * early to mid-puberty * can be a/s with type 1 diabetes mellitus, Addison disease, juvenile idiopathic arthritis, or lupus * higher in Down syndrome and Turner syndrome

Answer 40

* decline in linear growth, weight gain (usually minimal), fatigue, constipation, cold intolerance, poor school performance, bradycardia, dry skin, proximal muscle weakness, delayed relaxation phase of deep tendon reflexes, irregular menstrual periods, and delayed puberty. * thyroid gland is usually enlarged and **firm with pebbly texture, or goiter.** * atrophic thyroid glands (rather than a goiter) → final stage of thyroid failure in Hashimoto thyroiditis.

Answer 41

* Thyroid function tests (TSH and free T4) and thyroid antibodies (thyroid peroxidase antibody and thyroglobulin antibody) [will be high] * Initial findings of hypothyroidism may be elevated serum TSH concentrations and normal free T4 concentrations (subclinical hypothyroidism). As thyroid failure progresses, serum free T4 concentrations fall (overt hypothyroidism).

Answer 42

Levothyroxine goal: normalization of serum TSH values (no need to monitor thyroid antibodies)

Answer 43

Most children with congenital hypothyroidism do not have clinical manifestations of hypothyroidism due to the presence of maternal thyroid hormones or a small amount of thyroid tissue in the infant. If present, signs and symptoms of congenital hypothyroidism may include lethargy, hypotonia, hoarse cry, feeding problems, constipation, macroglossia, open posterior fontanelle, umbilical hernia, dry skin, hypothermia, and prolonged jaundice

Answer 44

Approximately 85% of cases of congenital hypothyroidism are due to thyroid dysgenesis, which includes agenesis, hypoplasia, and ectopy. Approximately 10% to 15% of cases of congenital hypothyroidism are due to inborn errors of thyroxine synthesis which are inherited in autosomal recessive pattern. Hashimoto thyroiditis is the most common cause of acquired hypothyroidism. Central hypothyroidism is due to disruption in the hypothalamus or pituitary leading to decreased TSH levels, and is a rare cause of congenital hypothyroidism.

Answer 45

C Elevated TSH and normal free T₄ Subclinical hypothyroidism is characterized by elevated TSH and normal free T₄. Overt hypothyroidism is characterized by elevated TSH and low free T₄. Low TSH and normal free T₄ is characteristic of subclinical hyperthyroidism. Low TSH and high free T₄ is characteristic of overt hyperthyroidism.

Answer 46

* Graves disease is the most common cause of hyperthyroidism in children and adults. * autoimmune condition in which antibodies bind and activate the thyrotropin (aka TSH) receptor. Graves disease accounts for more than 95% of childhood and adolescent cases of hyperthyroidism, with a peak incidence of 11 to 15 years of age (female predominance). * In adults, Graves disease accounts for 50% to 80% of cases of hyperthyroidism, with a peak incidence between 40 and 60 years of age (again female predominance), although it can occur at any age. * may occur in conjunction with other autoimmune diseases, including type 1 diabetes mellitus, hypoparathyroidism, Addison disease, myasthenia gravis, vitiligo, and pernicious anemia.

Answer 47

* Hyperfunctioning thyroid nodules, thyrotoxic phase of autoimmune Hashimoto thyroiditis (so-called Hashitoxicosis, caused by release of preformed thyroid hormone from the inflamed thyroid gland), and factitious hyperthyroidism from exogenous thyroid hormone.

Answer 48

* Weight loss, heat intolerance, difficulty sleeping, tremor, increased frequency of defecation, irritability, and menstrual irregularity. * Tachycardia, palpitations, and widened pulse pressure. * Atrial fibrillation common if \> 50 yrs * Children * behavioral disturbances, decreased attention span, difficulty concentrating, emotional lability, and hyperactivity. * upper percentiles for height. Rare findings include localized dermopathy (pretibial myxedema) and thyroid acropachy (clubbing). * tremors, a shortened relaxation phase in deep tendon reflexes, fatigue, and proximal muscle weakness. * Graves ophthalmopathy * Proptosis, periorbital edema, & inflammation * Gynecomastia, reduced libido, and erectile dysfunction.

Answer 49

* low/undetectable TSH, elevated T₄ * T3 may also be elevated, and some individuals may have low TSH, normal free T₄, and elevated T₃. Thyrotropin receptor antibodies **(TRAbs) are present in 95% of affected patients.** * Thyroid peroxidase and antithyroglobulin antibodies may be positive * Thyroid stimulating immunoglobulins (TSI) may also be positive but this test has less sensitivity and a negative result does **not** exclude Graves disease.

Answer 50

* 24-hour radioiodine uptake: * measure uptake at 4 and 24 hours * high: graves, toxic nodular goiter * low: inflamed/destructed gland (thyroiditis), iodine exposure * 24-hour radioiodine scan: * do same time uptake * differentiates from Graves disease, toxic adenoma, and toxic multinodular goiter. * Graves disease, * generally diffuse and homogenous * focal in a toxic adenoma and heterogeneous with multiple areas of focal increased and suppressed uptake in toxic multinodular goiter. * Pertechnetate thyroid scan: * Provides an image of the thyroid and can distinguish between Graves disease, toxic adenoma, and toxic multinodular goiter. * only 20 minutes to perform; but no numerical measurement of uptake and cannot be used to dose radioiodine therapy.

Answer 51

ECG to determine atrial fibrillation is present

Answer 52

get a bone-density test should be obtained.

Answer 53

* CT or MRI of the neck should be obtained

Answer 54

* **antithyroid medication** * reduce thyroid hormone production and block its effect peripherally. * methimazole (for 2nd/3rd trimester) and propylthiouracil( for 1st trimester): inhibit thyroid hormone production. * methamizole SE pruritic papular or urticarial rash, granulocytopenia or agranulocytosis (which typically is accompanied by fever, sore throat, mouth sores, and other systemic symptoms consistent with infection) and hepatitis. * BB for cardiovascular findings. * **radioiodine ablation of the thyroid gland** * orally administered iodine-131 concentrates in the thyroid gland and induces cell death. * **surgical thyroidectomy** * surgery if fail initial medical therapy, relapse after cessation of antithyroid drugs, have significant drug reactions, have large goiters, or severe ophthalmopathy. * complications: hypoparathyroidism and recurrent laryngeal nerve damage. As with RAI, permanent hypothyroidism is the goal of therapy. *

Answer 55

**Increased uptake with diffuse homogenous appearance on scan**

Answer 56

* the causes of hyp**ER**thyroidism (Graves, toxic nodules, thyroiditis) or functional of a nodule (NOT thyroid function) * iodine isotope scans * U/S = anatomy of gland and differentials solid from cystic nodules and for fine needle easpiration

Answer 57

Fasting blood/**plasma** glucose _\>_ 126 or oral glucose tolerance test (75g) with plasma glucoes _\>_ 200 mg 2 hrs after getting glucose or A1C _\>_ 6.5 or 2 hour 75g oral glucose tolerance test \> 200 at 2 hours \*\*need to do 2 tests on 2 different days to be diagnostic

Answer 58

metformin reduces A1c 1-1.5% (most are 0.5-1.5%) doesn't cause hypoglycemia monitor vitamin B12 (causes deficiency)

Final: Thyroid/DM Flashcards

(82 cards)