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11_DM/Endocrine

Terms in this set (31)

BMI
25-29.9 = overweight
30 or more = obese
Diagnose DM
FBS >125 mg/dL
75 g 2 hour OGTT >199 mg/dL
A1c>/=6.5%

Gestational
OGTT between 24-28 weeks
1 step with 75 g 2h OGTT
FBS =/> 92, 1 hr =/> 180, 2 hr =/> 153
Screening for DM
T1DM- only if symptomatic

T2DM- 45 yo or older every 3 years or earlier in obese or overweight individuals
Sulfonylureas
Lower A1c 1-2%

glyburide (avoid in renal insufficiency)

Glipide is good for renal issues

Titrate dose on weekly basis

Weight gain
Biguanide
Lower A1c 1-2%

Metformin max dose is 2550 mg/day

Worry about microcytic anemia related to B12 deficiency
Meglitinides
Stimulate meglitinide receptor, similar to sulfonylureas

Lower A1c 0.5 to 1%
Before meals

Repaglinide, Nateglinide

hypoglycemia, weight gain, dosing-adherence issues
Alpha Glucosidase inhibitors
Located on brush border of small intestine, responsible for the breakdown of carb to glucose

Lower 0.5-1%
Acarbose (maintenance is 50-100 mg, unless <60 kg then 50 mg) or Miglitol

Given with first bite of food/meal

Farting, diarrhea within first 4-8 weeks but then should get better

Do not use if CrCl<25 mL/min or SCr >2
Thiazolidinediones
Lowers 0.8- 1.5%

PPAR-y = increase in insulin-dependent glucose deposal (increase insulin sensitivity) in skeletal muscles (#1) and adipocytes and decrease in hepatic glucose production (#2)

No hypoglycemia, beta cell sparing (maintain beta cell viability)

Delayed onset

Fluid retention, weight gain, atypical hand and fee bone fractures in post meno women, potential MI with rosiglitazone (no REMS anymore)
DPP4-i
Lowers 0.6-0.8%

Worry about renal

No hypoglycemia or weight gain

Expensive agents
Bile acid sequestrate
Lowers A1c 0.4 to 0.6%
(targets FBS)

Colesevelam (WelChol)-->stops bile acid reabsorption

FXR antagonist, bile acid activate FXR +increase PEPCK (RLS for making glucose from liver)

Take with food (qD or BID)

Dyspepsia/constipation

CI with TG>500 mg/dL

High pill burden, interacts with levothyroxine, ezetimibe, and phenytoin)
SGLT-2 inhibitor
Lowers 0.8% to 1/2%
stop reabsorption of glucose from tubular lumen, increases renal excretion of glucose

Do not use canagliflozin and empagliflozin if CrCl <45 mL/min

Do not use dapagliflozin if CrCl<69 mL/min

HOTN, hyperkalemia, UTIs
Dopamine Receptor agonist
Lowers 0.4 to 0.6%

Bromocriptine (cycloset)

AM with food

N/V and lactation

CV benefit
Amylin analog
Lowers 0.5 to 0.7%

Decreases glucagon to stop it from making sugar, reduce gastric emptying, make you feel full

Use in TD1M and TD2M

N/V hypoglycemia

Weight loss

Give with meals
Incretin mimetics
Lowers 0.6 to 1.5%

Increase insulin secretion, stop glucagon from putting out glucose, reduce gastric emptying=make you full
Exenatide, liraglutide, exenatide XR, albiglutide, dulaglutide

N/V/D- exenatide (Byetta) >liraglutide (Victoza) >exanatide XR (Bydureon) or albiglutide (Tanzeum) or dulaglutide (Trulicity)

Wt loss, beta cell sparing function
Basal insulin
40% to 50% daily insulin needs

60 units NPH = 60 units of glargine = 60 detemir

30 units NPH BID = 48 units glargine = 60 units detemir

Humulin R U-500
5 times U-100 insulin
Use in patient who are insulin resistance >300 units/day
Basal insulin dose for T2DM
Add single bedtime basal insulin dose (glargine, detemir, degludec or NPH 0.1-0.2 unit/kg).

Adjust dose according to FBG concentration (treat to target) (e.g., target FBG 80-100 mg/dL).

(1)Increase the insulin dose every 3-4 days as needed.(2)Increase by 2 units if FBG average concentration is 100-140 mg/dL.
(3)Increase by 4 units if FBG average concentration is 141-180 mg/dL.
(4)Increase by 6 units if FBG average concentration is 181-220 mg/dL.
(5)Increase by 8 units if FBG average concentration is greater than 220 mg/dL.(d)Consider cutting back to previous dose if FBG concentration is below 80 mg/dL
Basal
Calculate daily dose (0.5 unit of insulin per kilogram per day).

Give 50% as basal insulin. Perform dose titration to FBG values.

Give 50% as bolus insulin. Split into three mealtime doses.

Example: 80-kg patient starting multiday injection therapy:
0.5 unit/kg = 40 units of insulin/day; half as basal, half as bolus, with the following:(1)Glargine or detemir 20 units every day
(2)Aspart or glulisine, lispro 6 units prebreakfast(3)Aspart or glulisine, lispro 7 units prelunch(4)Aspart or glulisine, lispro 7 units predinner

(5)Titrate insulin doses to BG values.

(d)Correctional insulin dosing - Meant to correct for premeal glycemic excursions.

Premeal algorithm is as follows:(1)Rapid-acting insulin (the rule of 1800): 1800/current total daily insulin dose = mg/dL change/1 unit (e.g., 40 units/day: 1800/40 = 45 mg/dL [insulin sensitivity]).

Titrate according to the following algorithm:Glucose reading Change to be made to insulin dose< 80 mg/dL
Subtract 1 unit80-125 mg/dL

Usual premeal dose(fixed or based on carbohydrate intake)126-170 mg/dLAdd 1 unit171-215 mg/dLAdd 2 units216-260 mg/dLAdd 3 units

Regular insulin (the rule of 1500): 1500/current total daily insulin dose = mg/dL change/1 unit (e.g., 50 units/day: 1500/50 = 30 mg/dL [insulin sensitivity]). Titrate according to the following algorithm

Establishing an insulin/carbohydrate ratioInsulin/carbohydrate ratio (the rule of 500) - This requires extensive patient education on counting carbohydrates and may be used to estimate the early use of rapid-acting insulins at mealtime to prospectively cover what is to be ingested. 500/daily insulin dose = insulin/carbohydrate ratio. (e.g., 50 units/day: 500/50 = 10. Insulin/carbohydrate ratio = 1 unit for 10 g of carbohydrates.)
Sick Day Rules on Insulin
Don't stop basal insulin, if not eating don't take bolus insulin, check BS q4-6 hours with BS of <250 mg/dL

Hydrate-drink 8-12 oz of fluid per hour

Check ketones- check urine every 4 hours when BS is >250 mg/dL

If BS >500 mg and/or moderate to large amount of ketones is present (with BS >250 mg/dL)
ASA 81 mg po daily
ASCVD >10% or greater

men + women 50 yo old with FMH of CVD, HTN, smoking, HLD, albuminaria
Vaccines
Hep B

PPSV23 and PCV13

PPSV23 - on lifetime dose unless it was given before 65 yo

Age 65- give PCV13 an then 6 to 12 months later give PPSV23


Influenza
Hypothyroidism
High TSH >5 mIU/mL (w/ sx) >10 mIU/mL (w/o sx)

AND low Free T4 <0.7 mcg/dL

Give full synthetic T4-levothyroxine 1.6 mcg/kg/d (non elderly) or 12.5 mcg (elderly with severe hypothyroidism, or have cardiac disease) initially and then increase by 12.5 mcg q6-8 weeks to goal TSH (over treatment leads to MI, angina, and arrhythmias, osteoporosis/penia)

Check TSH q6-8 weeks unlike TSH WNL and then q3-6 months for 1 year and then annually

If you become preggers and were on levothyroxine, increase dose by 30% and monitor TSH q1-3 months. Typically most preggers require 40-50% more dose if pregnant

In babies, give 10-15 mcg/kg/d and mix into breastmilk/formula. Check Ft4 for first 6 months and then check for TSH. Subtherapeutic doses will physically and mentally handicap.

If you take Fe/Ca/Mg/Zn/Al, take 1-2 hours before levothyroxine or 4-6 hours after dose.

Conversions
Desiccated Thyroid Hormone (nonsyn T4/T3)
1 grain (65 mg) = 60-100 mg of levothyroxine = 25 mcg of T3 (cytomel, triostat)= Synthetic T4/t3 combo (liotrix) 1 grain
Hyperthyroidism
Tx w/ 131 I (radioactive iodine)/Surgery

Tx w/ thioamides before 131 I
MOA: stop conversion of T4 to T3

Thioamide:
Methimazole (less liver toxic)
PTU (preferred in pregnancy in first trimester

Tx w/ BB
propanolol or nadolol
PCOS
General Tx
1) Wt loss 5-7%
2) exercise

Tx infertility
1) Clomiphene 50-100 mg/d starting on day 5 of cycle and tx for 5 days- increase change of multiple births
2) metformin
3) Aromatase inhibitors (letrozole, anastrozole)- use in clomiphene resistant patients

Tx Hairiness/too much androgen
1) Oral contraceptives (OC) with E + P
2) spironolactone 100-200 mg/d (synergistic effect if used in combo with OC
3) Eflornithine (Vaniqa)- stops ornithine decarboxylase (stop hair growth)

Tx insulin resistance
1) metformin
2) pioglitazone (increase HDL)

Tx menstrual irregularities and endometrial hyperplasia
1) OC
Prolactinormas/Hyperprolactinemia
Prolactinormas is a pituitary tumor (adenoma) that excretes lg amt of PRL

Tx
1) remove offending agent or have surgery performed on tumor
2) Bromocriptine (Parlodel)
-MOA-D2 receptor agonist=dec. PRL (antagonism D2 = more PRL)
-causes N/V

3) Cabergoline (Dostinex)
-Use if resistant to bromocriptine

Tx w #2 and #3 are CI with ischemic heart disease, PVD, and uncontrolled HTN. Worry about 3A4 inhibitors
GH Excess- Acromegaly
When pituitary tumor (adenoma) that excretes lg amt of GH

Tx
1) surgery
2) surgery fails then use drugs
-dopamine agonists (see PRL section)
-Octreotide (long acting or normal)- drug of choice**
N/V/D, MOA= bind to SS receptor = direct inhibition of GH
-lanreotide (syn. octapeptide analog of SS)
-pasireotide (MOA = as octreotide), inc. LFT/N/V
-pegvisomant (1st line with IGF-1 values after surgery), blocks GH receptor binding = dec IGF-1

Monitoring
IGF-1 q6-12 months
GH Deficiency
Tx. give GH
1) recombinant GH (somatropin) in the evening, may lead to fluid retention
Obesity
BMI >30

Tx.
1) Diethylpropion give with meals x 12 weeks, inc. NE/DA to decrease appetite

2) Phentermine ODT, suppress appetite

3) Orlistat dec. aborp. of fat, give w/ MTV daily (w/ fat soluable vitamin A,D, E, K)

4) Lorcaserin activates 2C receptor in hypothalamus = increase fullness = dec. food intake, ADR-HA, N

5) Phentermine/topiramate
-suppress appetite (REMS program), high abuse potential

6) Naltrexone/buproprion

7) Liraglutide
CI Medullary Thyroid Cancer
Addison's disease (Adrenal insufficiency)
Hallmark=Low plasma cortisol (GC) /low K, Low Na, Low glucose

Tx with (replace GC)
Cortisone 25 mg = hydrocortisone 20 mg = prednisone 5 mg = methylprednisolone 4 mg = 0.75 mg of dexamethasone

Tx Adrenal crisis= hydrocortisone IV + NS/D5W

Maintenance Therapy
Hydrocortisone BID
Fludrocortisone qAM (tx primary disease, not secondary)

Sick days- Inc dose by 2-3 times

Monitor BP, Wt, K and Na
Cushing's disease (Adrenal excess)
Excess GC caused by tumor (usually?)

Tx, remove tumor via surgery or radiation

Tx with steroidogenic inhibtors, if you are not a surgery/radiation candidate
1) Ketoconazole-titrate dose to reduce cortisol to WNL, 400 to 1200 mg/d, needs acid (do give to pt on PPI)

2) Metyrapone- must give with GC replacement, choice for pregnant women, worry about hypokalemia, acne, and hairiness

3) Aminogluethimide- must give GC replacement, N,V (big deal and ppl stop it)

Tx with adrenolytic
1) Mitotane- requires GC replacement for life, compassionate use only

Other Tx
1) spironolactone- HTN + hypokalemia

2) pasireotide (bind to SS) -worry about hyperglycemia

3) Mifepristone (block GC receptor)- used for hyperglycemia + Cushing's
Hyperaldosteronism
Tx
1) Spironolactone- worry about big boobs
2) Eplerenone-better tolerated than spironolactone, less boobs
Male Hypogonadism
Low free Testosterone / total testosterone


Tx with testosterone (CIII substance-high abuse/dependence potential)

BBW- Inc DVT and PE

Worry about MI/Strokes

1) T gels (Androgel-underarm,sholder,abdomen) Testim-underarm and shoulder, Fortesta-front and inner thighs)- apply 2-5 hours before showering, worry about spreading it to others

2) implantable T pellets + aromatase inhibitors

3) T solutions (Axiron- underarm, use deodorant and then apply solution)

4) LAI of T (T underdeconante, Aveed)- BBW of pulmonary oil micro embolism/anaphylaxis

5) Intranasal (Natesto)- inc PSA, HA, nose bleed

ADR
edema, moobs

CI
Breast or Prostate Cancer
PSA >3
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