1
Q
Acromegaly
Cancer
A
High risk of esophageal , gastric, colon cancer, Pt to under go colonoscopy on dx and q3-4 yrs.
2
Q
Adrenal Incidentaloma
Hormone studies
- Pheochromocytoma
- Cushings syndrome
- primary aldosteronism
- Adrenocortical carcinoma
Imaging
A
Pheochromocytoma
- HTN, palpitation, HA, Diaphoresis, Tremor
- Epinephrins / metanephrines
Cushings
- Cortisol (am / pm), Dexamethasone suppres
Primary aldosteronism
- Rrenin/Aldostrone : 20 times
Imaging ( if > 4 Cm / housefield > 10, retension of contrast > 50% after 10 mins) :
- Consider FNA / surgery follow up
3
Q
Amiodarone induced thyrotoxicosis
Type I
Type II
- discontinuing Amio wont help / stays in adipose tissue with half life of 100 days
- RAI upatake low in both
- Amiodarone has 6 mg Iodine in 200 mg tablet
A
Type I
- Increase synthesis of T4 and T3
- preexisting MNG or latent graves
- US Increased Vascularity
- Tx: Antithyroid medications (methimazole) Thryroidecdtomy for refractory cases
- Incrase MMI
Type II
- Release of preformed T4/T3
- US Decreased Vascularity
- Tx: Corticosteriods
- Decreased _C_orticosteriods _CD_
4
Q
ATP III Guidlines
- CHD or CH risk equivalent (DM / Carotid, PAD, AAA) > 20%
- > 2 risk factors (10 yr risk
- 0-1 risk factors
Total Cholestrol - HDL
A
LDL goals / Non-HDL goals
- < 100 mg/dL
- < 130 < 160
- < 160 < 190
5
Q
Causes of hyperprolactinemia
A
Physiologic
- Pregnancy / Breast feeding / Stress
Pathologic
- Pituitary adenoma / macroprolactinoma
- Hypothalamic dz with low dopamin
- Drugs: Antidepresants, antipsychotics, metoclopramid,
- Hypthyroidism
- Chest wall injury (herpes zoster)
- CKD
6
Q
Causes of Low TSH and low T4
A
Central Hypothyroidism
- LOW TSH/T4/T3
- Pituitary hormonal Deficiencies
Subclinical Thyrotoxicosis
- Low TSH / T4 and high T3 (seen in pt taking t3)
- Radioactive iodine uptake and scan helpful
Euthyroid sick syndrome
- Sick pt / Normal to low TSH/T4/T3
Medications
- Dopamin, octerotide, steriods
7
Q
Causes of secondary hTN
A
- Renal artery stenosis
- OSA
- CKD
- Pheochromocytoma
- Cushing syndrom
- Coarctation of aorta
- Primary Hyperaldosteronism
50% of patients with hyperaldosteronism have normal K levels
8
Q
- Central hypothyroidism
- Subclinical thyrotoxicosis
- Euthyroid Sick syndrome
A
- low TSH FT4 and FT3
- Low TSH and FT4 with high FT3
- Low TSH / FT4/FT3
9
Q
CKD and hyperprolactinemia
A
Usually increased by 3 folds and decreased in clearance by 30 %
10
Q
Comparative steriod potencies
- Hydrocortisone (cortisol)
- Prednisone
- Prednisolone
- Methylprednisolone
- Dexamethasone
- Betamethasone
- Triamcinolone
- Beclometasone
- Fludrocortisone
A
Glucocorticoid potency / Mineralcorticoid potency / Durations
- Hydrocortisone 1 / 1 / 8 hrs
- Prednisone 3.5-5 / 0.8 / 16-36
- Prednisolone 4 / 0.8 / 16-36
- Methylprednisolone 5-7.5 / .5 / 18-40
- Dexamethasone 25-80 / 0 / 36-54
- Betamethasone 25-30 / 0 / 36-54
- Triamcinolone 5 / 0 / 12-36
- Beclometasone 8 buffs 4 X daily same as 14 mg oral prednisone once a day
- Fludrocortisone 15 / 200 / 24
11
Q
Criteria for Parathyroidectomy in asymptomatic PHPT
Asymptomatic means
- no Fractures
- no Osteoprosis
- no kidney stones ect
A
- Serum **C**a > 1 mg/dL above normal
- Cr clearance < 60 ml/min
- Bone mineral density with T score < 2.5 at any site
- Age < 50
12
Q
Cushing’s syndrome (test to stablish)
Flow chart after stablished.
A
Must have 2 out of 3
- 24 hr urinary cortisol
- Late night salvary cortisol
- Low dose dexamethasone suppression test
First Check ACTH
- If low Adrenal CT ( ACTH< 5)
- If high ACTH> 5 - MRI of pituitary
- **Pituitary < 6 mm **Inferior petrosal sinus sampling
- Pituitary > 6 mm Hight dose dexamethason suppression
13
Q
DDP-4 inhibitors (Gliptons)
A
Sitagliptin (januvia), Saxagliptin, Linagliptin
Decrease blood blucose by increase the endogenous incretin hormone GLP1 and GIP.
Safe with CKD
14
Q
Diabetes Neuropathy
A
- Topical capasiacin Cream
- Antidepressants (amitriptyline) (younger pt)
- Anticonvulsants(pregabalin, Valporic acid) (older)
- Alpha lipoic acid
15
Q
Diagnose postexercise hyperglycemia.
A
Hypoinsulinemia causes increased hepatic glucose output and decreased peripheral glucose uptake, which results in a higher blood glucose level and, ultimately, a higher hemoglobin A1c value; prolonged exercise, which further stimulates hepatic glucose release, exacerbates this condition.
16
Q
Diagnose thyroid lymphoma.
A
Thyroid lymphoma occurs most frequently in older patients with a history of Hashimoto thyroiditis and typically presents as an enlarging neck mass, often with local and systemic symptoms.
17
Q
Diagnose thyroid storm
A
- Thyroid storm can be differentiated from other forms of thyrotoxicosis by the presence of temperature elevation, significant tachycardia, heart failure, abdominal discomfort, diarrhea, nausea, vomiting, and (sometimes) jaundice.
- Treatment typically consists of a combination of antithyroid drugs (propylthiouracil or methimazole), iodine solution, high-dose corticosteroids, β-blockers, and (rarely) lithium. Even with aggressive therapy and supportive measures, mortality rates are as high as 15% to 20%.
18
Q
DM start with meds …
A
Metformin(M) + Lifestyle changes (LC)
LC + M + Sulfas if failed
LC + M + Lantus
Or LC + M + Pioglitazone or LC + M + Exenatide
LC + M + C + sulfas
Else
LC + M + Basal insulin
19
Q
Endocrine causes of carpal tunner syndrome:
A
Acromegaly
DM
Hypothyroidism
20
Q
ESS
Euthyroid Sick Syndrome
A
- Due to Decreased conversion of T4 to T3
- Decreased T4 production and clearance
- Altered T4 protien bining
- Suppresion of TSH
- Also meds like Steriods / dopamine will suppress TSH levels block T4 - > T3 conversion
- Long term T4 will become suppressed
21
Q
Features of anabolic steriod abuse
A
- Acne and gynecomastia
- Increased muscle mass
- Psychiatric problems
- Erythropoiesis
- Hyperlipidemia
- Normal Libido and Erectile function
- Atrophic testes w low testrone and FSH/SH levels
22
Q
Gestational DM
- fasting BG 105 compare to 75 is 4X likely to have complications
A
Need better control then avg person
NPH idealy
- Metformin / glyburide not CI but not enough studies
- Category C
23
Q
GLP 1 Receptor agonist (Exenatide)
A
- Weight loss
- Low hypoglycemia risk
24
Q
Granulomatous disorders causing hypercalcemia
A
Non infectous
- Sarcoidosis
- Berylliosis
- Crohn’s
- Lymphomas
Infectious
- TB
- Leprosy
- Coccidioidomycosis
- Histo
- PCP
25
Non PCO Disorders causing hirsutism
Ovarian tumors - **Often sever**
* Elevated Androgen
Non classic CAH - **Significant**
* increase 17 hydroxyprogesterone
Cushings syndrome - **Significant**
* Overnight dexamethasone / 24 hr urinary cortisol / late evening salivary cortisol
Hypothyriodism - **Mild**
* Elevated TSH
Hyperprolactinemia - **Mild**
* Elevated prolactin
Drugs - **Mild**
* Anabolic steriods, valproic cid, Danazol, cyclosporin
26
Hungary bone syndrome
* Patients with hyperparathyroidism have increased bone formation and resorption with increase flow of calcium out of the bone. However when PTH adenoma removed the Ca flows in the the bone formation which will cause decrese calcium and phosphorus, magnesium levels.
* IV Calcium given when patient has Ca \< 7.5 mg/dl or Tetany, respiratory distress
* **Do not administer phosphorus** unless levels \< 1 mg/dl as it may worsen the hypocalcemia
27
Hypercalcemia with Eelvated to normal PTH
Which lab to order next
Urinary Calcium 24 hr collection
* \> 100
* Primary and tertiary hyperparathyroidism
* \< 100
* **Familial hypercalcemic hypocalciuria**
28
Hypercalcemia with Suppressed PTH
* Elevated PTHrP
* Elevated D3
* Elevated D2
* Normal labs
* Elevated PTHrP - Tumor has no feed back
* Elevated D3 - Sarcoid, lymphoma (CXR)
* Elevated D2 - Vit D toxicity
* Normal labs - Hyperthyroid / MM / Adrenal tumor / acromegaly / Immobilization
29
Hypercalcemia
Tx: IVF +
* Calcitonin
* Cinacalcet
* Prednisone
* Zoledronate
* **_Calcitonin_** for Ca \> 14 in cancer patients
* **_Cinacalcet_**: Calcium mimetic drug - works on _ca sensors on PTH cells to lower PTH_ (used in CKD and primary PTH)
* **_Prednisone_**: Sarcoidosis and lymphoma as they produce 1-hydroxylase with excess conversion of active Vit D
* **_Zolendronate_** is good in dz that cause excess bone resorption
30
Hyperglycemia and TAGs how to treat it
## Footnote
150-199
200-499
\>500
150-199:
* Weight reduction / activity
200-499
* _Primary _target **LDL **(statin)
* _Secondary _target: **non HDL **(increase _statin dose and add fibrates_)
\>500
* _Primary goal _is to **prevent pancreatitis** with _fibrates/niacin_
31
Hyperthyroidism
* B-Blocker
* Steriods
* Methamezole
* Radioactive iodine ablation
B-Blockers
* Symptom control / painless thyroiditis / preformed hormones
Steriods
* Type II amiodarone thryroiditis-CD **Corticosteriors** for **Decreased** vaslcular
Methimezole
* Graves
Radioactive iodine abliation
* Graves / toxi nodular goiter
32
Subclinical hypothyroidism / females
If TSH \< 10
* and Anti TPO if so then must treat with levothroxine
* Else if patient is pregnent has a goiter, is symptomatic, ovulatory dysfunction, hypercholesterolemia must be treated.
33
**_Hypothyroidism and elevated transaminases_**
Muscle injury could increase transaminases - watup
34
Indications for MRI in patinets with central hypogonadism
* **Testostrone levels**
* \< 150 \> 65 yrs old
* \< 200 Age \< 65
* Mass effect / HA or visual field defects
* Multiple pituitary hormone def
* Hyperprolactinemia
35
Indications for treating prolactinoma
**Females**
* Presence of classic symptoms / **amenorrhea and glactorrhea**
* **Infertility** without classic symptoms
* **Osteoprosis** and risk of bone loss
* **Acne and hirsutism**
**Males**
* **Hypogonadism** and **gynecomastia**
* **Osteoprossis**
Both sexes
* Enlarged adenoma
36
Interpret thyroid function studies in an older patient.
* Older patients generally should not be given levothyroxine solely for an elevated thyroid-stimulating hormone level.
* elevated serum TSH level in older patients is not associated with detrimental medical outcomes (such as depressive symptoms and impaired cognitive function) but, in fact, is associated with a lower mortality rate
37
LADA - Latent autoimmune diabetes of adulthood
* Age of onset \> 35 \< 50
* Acute onset of symptoms
* BMI \< 25 kg/m2
* Personal or family history of autoimmune dz
* Check GAD
38
Levothyroxine drug intractions
Lower Levothyroxin absorption **_(increase dose)_**
* Bile acid binding agents / Iron / ca / PPI
Increase TBG concentration **_(increase dose)_**
* Estrogen, tamoxifen raloxifene / heroin, methadone
Decrease TBG concentration **_(decrease dose)_**
* Androgens, steriods, anabolic steriods
Increase Thryoid Hormone **_(decrease dose)_**
* Rifampicin, Phenytoin, Carbamazepine
39
Manage an asymptomatic incidental adrenal mass.
ncidentally discovered adrenal masses that are small, are associated with no clinical or biochemical features suggestive of excess hormonal secretion, and have no imaging features suggestive of possible malignancy should be followed with observation and repeat testing in 6 to 12 months.
Neither the size (
40
Manage hirsutism in polycystic ovary syndrome.
Initial treatment for hirsutism in women with polycystic ovary syndrome is an oral contraceptive.
Spironolactone can be very useful for the treatment of hyperandrogenism in PCOS but is added only if an oral contraceptive does not adequately improve symptoms.
Although early observational trials suggested that metformin may be effective in treating hirsutism in patients with PCOS, subsequent randomized clinical control trials have had mixed results
Dexamethasone For Tx congenital adrenal hyperplasia. This patient's 17-hydroxyprogesterone must be measured
41
MEN
MEN 2A
MEN2B
MEN 1
* Pancreatic / Pitiutary /
* _Parathyroid _
MEN IIa
* **_Parathyroid_, **
* **Medullary Thyroid CA, pheo, **
MEN IIb
* **Medullary Thyroid CA, peho**,
* marfanoid body hapitus
NOTE
**_MEN II - Medullary Thyroid and PHEO_**
42
Methimazole is associated with an increased risk of fetal abnormalities
* Aplasia cutis and choanal atresia, when used in the first trimester. After fetal organogenesis is complete, methimazole should be used. Methimazole is the antithyroid agent of choice except in the first trimester of pregnancy
* Propylthiouracil is associated with a higher risk of severe hepatotoxicity than methimazole. Close monitoring of pregnant women treated with antithyroid agents is required, as is periodic fetal thyroid
43
PCOD
Improving hirsutism
* **_OC_**s to manage oligomenorrhea and hirsutism ( *it _increases sex hormone_ binding protien and results in decrease androgen levels also Lower LH so ovaries dont produce as much androgens)*
* if hirsutism not decrease in 6 months will need to **_start spironolactone_**
* **_Metformin not approved_** for PCOD unless paitent has glucose intolerance
44
Pertusis Criteria (actually ID)
* cough \> 2 weeks with one or more of following
* Paroxysms of cough, inpiratory whoop, posttussive vomiting
45
Pioglitazone (TZDs)
1-1.5%
* If **_can not tolerate Metformin**_ / _**sulfas_**
* **_Weight gain, edema, CHF, bone fracture, Bladder cancer_**
* Low risk of hypoglycemia
* Can be used with **_renal insufficiency_**
46
Pituitary apoplexy
Endocrine emergency:
Treatment
1. _High dose Steriods_
2. _CT of the Head / NSGY consultation_
47
PTH / Vit D / Ca
axis
* **_PTH_** release from parthyroid glands
* (**inhibited by _1,25 OH-D and Ca_**)
* **_PTH**_ increase _**Ca_** reabsorption from _kidney_ and _bone resorption_ - also helps increase **_1,25 OH D_** _conversion_
* **_1,25 Vit D_** increase _GI_ **_ca**_ and _**po4_** absorption
48
Raloxifene vs tamoxifen
* Raloxifene is specifically approved for the treatment of osteoporosis
* Treat a patient with ductal carcinoma in situ with tamoxifen.
* For premenopausal women with hormone receptor-positive ductal carcinoma in situ or invasive breast cancer, the standard of care is tamoxifen for 5 years to reduce both the risk of recurrence and the development of a new primary tumor in the ipsilateral or contralateral breast.
49
PHPT
Bsiphosphonates vs Surgery ..
non surgical patients
Bisphosphonates
* _Increases bone mineral density in pt with PHPT_ without decrease ca serum levels
* For pt who do not meet surgery criteria or wish not to have surgery
Primary Hyperparathyroidism without surgical indication
* Can be monitored with annual serum ca and cr with **_DEXA Q2Y (every 2 yrs because the in order to notice difference in scan need \> 5% change in bone)_**
50
OSA and bicaronate levels
**Hypercarbia** will cause increase in **Bicarb**
51
Insulin
1.5-3.5%
* A1C \> 8.5 Start basal
* IF A1C \> 10 Start basal and prandial
* Weight gain and hypglycemia
52
Risk factors for Thyroid cancer:
* Hx of **_radiation exposure_** \< 15 (Rx)
* **_Family history_** of thyroid cancer
* Other
* Elevated TSH
* Exterme ages \< 20 or \> 70
* Male sex
* Rapid growth
* Hard and fix nodules
* Elarged neck lymph node
53
Insulin
**Short acting - onset of action / duration**
* Regular
* Analogs (aspart/lispro)
* Long Acting
* NPH
* Glargine
* Detemir
* Regular / 2-3 / 8-10
* Analogs (aspart/lispro) 0.5-1 / 4-6
* Long Acting
* NPH 4-8 / 12-18
* Glargine None / 20-14
* Detemir None / 16-20
54
Risk of hypothalmic pituitary adrenal suppresion after steriod use
## Footnote
**High risk :** \> 20 mg prednisone or equivalent for \> 3 weeks / stigmata of Cushing's syndrome
**Intermediate risk** : Prednisone 5-20 mg for \> 3 weeks / smaller dose \< 5 mg prednisone at QHS for a few weeks
**Low risk**: Prednisone any dose for \< 3 weeks / \< 5mg dialy
**High risk**
Stress dose likely to be needed during surgery / ACTH stimulation test to assess steriod requirement maybe needed
**Intermediate**
ACTH stimulation test to determine whether or not stress dose steriods are needed
**Low risk**
No testing or stress dose coverage required
55
**_Secondary amenorrhea evaluation (b hCG -ve)_**
* BMI
* Elevated TSH
* Elevated prolactin
* FSH
* Testostrone
BMI
* Low - Eating Disorder
* High - PCOS
Elevated TSH
* Treat hyperthyroidism
Elevated prolactin
* R/O drugs / hypothyroid / CKD
* MRI brain
FSH
* Low with low estrogen Hypothalmic Disorder
* High with low estrogen ovarian fialure
Testostrone
* Elevated \> 200 Ovarian hyperandrogenism
* Elevated \< 200 Adrenal or ovarian tumor(CT abd)
56
Sulfonylureas
1-2 %
Metformin failure
weight gain / hypoglycemia
57
Synthroid dosing based on situation
* Elderly
* Pregnancy
* Estrogen therapy / Oral contraceptives:
* CAD
* Coffee intake:
Elderly :
* Start at 50 increase by 25 every 3-6 weeks
Pregnancy:
* Increase by 30% check **_TSH Q4weeks_**
Estrogen therapy / Oral contraceptives:
* **_TSH Q12Weeks,_** may need to increase
CAD:
* Start 25 increase 25 q3-6weeks
Coffee intake:
* May lower absorption by 35%
58
Testostrone Def
How to dx.
**How to dx:**
* Two low Total testostrone / Usually measure 7-10 am
* Free levels only in Obese or advanced age
Once dx can do LH/FSH levels
* If low means **_secondary hypogonadism_**
* if High LH/FSH **_primary hypogonadism_**
59
**_Threshold size for FNA_**
* High risk hx and/or U/S features
* Solid hypoechoic nodule
* Solid isoechoic or hyperechoic nodule
* Mixed solid / cystic nodule
* Spongiform nodule
* Purely Cystic nodules
* High risk hx and/or U/S features **_\> 0.5 cm_**
* Solid hypoechoic nodule \>1.0 cm
* Solid isoechoic or hyperechoic nodule \> 1-1.5 cm
* Mixed solid / cystic nodule \> 1.5-2 cm
* Spongiform nodule \> 2 cm
* Purely Cystic nodules not indicated
60
Thyroid nodule
* If high cancer risk factor or suspicious ultrasound finding -\> FNA
* No Cancer risk factor then Measure TSH
* if TSH high or normal -\> FNA
* Else I-123 scintigraphy
* if hyperfunctional treat hyperthyroidism
* **_Cold nodule needs FNA_**
61
Thyroiditis Common forms - **_RAIU Low_**
Cause / mechanism / pain / Tx / test
* **Hashimotos** -
* **Subacute Lymphocytic** -
* **Subacute Granulomatous** -
* **Hashimotos **- Autoimmune / **goiter + hypothyroid** / minimal pain / + AntiTPO / Normal ESR / **Tx Levothyroxine**
* **Subacute Lymphocytic **- Autoimmune / thyrotoxicosis with hypothyroidism / minimal pain / + AntiTPO / Normal ESR / **Tx Bblker**
* **Subacute Granulomatous** - Viral / thyroitosicosis with hypothyroidism / **tender **/** - AntiTPO** / **Elevated ESR / Tx: BBLK + NSAIDs + Steriod**
62
Thyrotoxicosis
RAIU uptake
* If **_no uptake_** means there is destruction of tissue and thyroid gets released
* If patient pregnent can use U/S or Thryotropin receptor antibodies
**High uptake**
* Graves
* Toxic multinodular goiter (TMNG)
* Toxic nodule
**Low uptake**
* Painless or subacute thyroiditis
* Amiodarone induced thyroiditis
* Surreptitious thyroid hormmone
* Iatrogenic
* Struma ovarii
* Iodine induced
63
Treat a macroprolactinoma.
## Footnote
•In a patient with a macroprolactinoma, administration of a dopamine agonist, such as cabergoline, is indicated as the initial treatment.
64
Treatment of Osteoprosis
1. Postmenopausal women
2. Not to use with Patient Creatnine clearance \< 35
3. Hypocalcemia in CKD pateints
4. Failed Bisphosphonates
5. Modestly reduces risk of Fx / not first line
6. Post menopausal women intolerant to bisphosphonates and at Increase risk of Breast cancer
1. 1200 mg Ca and 800 IU Vit D
2. Oral or IV bisphosphonates (alendronate, risedronate and zoledronic acid)
3. Dnosumab (risk of skin infection)
4. Teriparatide (Recombinant human parathyroid hormone) Have had Fx or reduced BMD (do not give with renal insufficiency / monitor Ca, uric acid and RFP)
5. Nasal Calcitonin
6. Selective estrogen receptor modulators (Raloxifen)
65
TSH Low / FT4 high
What is next
Primary hperthyroidism
RAIU scan
High
* **Diffused** pattern Graves
* **Nodular uptake**
* Toxic adenoma
* Mutinodular goiter
Low
* Measure Tg: **Decreased** :
* Exogenour hormone
* Measure **TG:Elevated**:
* Thyroiditis
* Iiodinde esposure
* extraglanular production
66
TSH Low / FT4 Normal
What is next:
measure FT3
Low :
* Subclinical hyperthyroidism
* Early pregnency
* Nonthyroid illness
High
T3 Toxicosis (R/O graves RAIU scan)
67
TSH Normal / High FT4 High
What is next
MRI pituitary (2nd hyperthyroidism)
68
Turner's syndrome
Two elevated FSH valuses
* In a woman with primary ovarian insufficiency, Turner syndrome must be excluded as the cause by obtaining the patient's karyotype.
* Turner syndrome is associated with several cardiovascular malformations, including aortic valve disease, aortic dilation, and aortic coarctation; renal malformations, most commonly horseshoe kidney; and autoimmune disorders, such as thyroid disease.
69
What to do after Medullary thyroid dx
* Evaluate for Metastic Dz
* **_Calcitonin levels_** corolate with extend of Dz and local lymph nodes / if **Calcitonin \> 400 need CT of abd/pelv**
* Coexisting tumors
* RET mutation identification
70
71
81
Diagnosis of Diabetes
• **_A1c\>6.5%_**
or
• **_FPG\>126_**
or
• **_2-hr glucose \> 200 on 75 gm OGTT_**
or
• **_Random glucose \> 200**_ and _**symptoms_**
101
Hypoglycemia
A. Insulinoma
B. Surreptitious use of insulin
C. Surreptitious use of Oral meds
**_Tests_**
* Drug levels
* if sugar is low and insulin is low its most likely normal
* C-peptide levels / insulin levels after fasting 72 hrs once drops \> 50 need to do levels
102
Hyperosmolar Nonketotic State
* Glucose \> 600
* pH\>7.3, CO2\>15
* Minimal ketonemia/ketonuria
* **_Correct Na for hyperglycemia_** (for each 100 mg/dL glucose \> 100 add 1.6 mg to serum sodium)
* If K is \< 3.3, hold insulin and give K
103
DKA
IVF
K Keep \> 3.3
IV insulin once K \> 3.3
Once glucose 200 can reduce IV insulin 50% and change to d5W1/2
Adjunct KCL / Vasopressors / Bicarb / phosphate (no definite benefit found)
124
Laboratory Diagnosis of Hypocalcemia
• **_Hypoparathyroidism_** (autoimmune)
low Ca, high PO4, low PTH
• **_Hypomagnesemia_** (alcohol)
low Ca, high P04, low PTH
128
Paget Disease
* Usually asymptomatic
* high Bone turnover -\> structurally weak bone
* very high Alkaline phosphatase 100's
* Treat if pain is severe, pagetic lesions in**_ weight-bearing**_ areas, or _**lytic lesions_**
So do not treat if not symptomatic / first step to go to NSAIDs then Bisphosphonates/Calcitonin
129
Familial Hypocalciuric Hypercalcemia
* Rare
* Lower Sensitivity of Ca-sensing receptor and higher Ca levels are needed to suppress PTH
* Familial /Autosomal Dominnant
* 24-hr urine calcium \< 100
Will have a very low urine calcium | Ca / ratio \< 0.01
Treatment not recommended
135
tuberculosis-induced hypercalcemia.
excessive production of _1,25-dihydroxyvitamin D_ by the _tuberculous granulomas_. The ***granulomas*** of tuberculosis (and other granulomatous diseases, such as **_sarcoidosis, Crohn disease, and leprosy_**) are composed of macrophages that possess the 1α-hydroxylase enzyme needed to convert 25-hydroxyvitamin D to its active form, 1,25-dihydroxyvitamin D.
Low PTH, PO4 high
with Malignancy Hypercalcemia High PTH /prPTH and low PO4
137
Woman with low bone mass. How to treat?
The NOF recommends antiosteoporotic therapy for persons whose risk of major osteoporotic fracture over the next 10 years is 20% or greater or whose risk of hip fracture over the next 10 years is 3% or greater.
**_Denosumab_**, osteoclast formation, reserved for patients with a high risk of fracture, including those with multiple risk factors for fracture or a history of previous fractures.
**_Estrogen_** is contradicted in this patients with dx of breast cancer.
**_Raloxifene_**, a selective estrogen receptor modulator, approved for osteoporosis prevention by the FDA. However, significant hot flushes.
**_Teriparatide_** (recombinant human parathyroid hormone) is also contraindicated in persons with malignancy involving bone, Paget disease, or existing hyperparathyroidism or hypercalcemia.
**_Bispho alendronate_** is the most appropriate drug to use for osteoporosis prevention in patients with osteopenia and a history of radiation therapy
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