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COMMON INPATIENT ENDOCRINE CONSULTS

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GH (acromegaly) ACTH (Cushing's disease) Pituitary hormone deficiency ... Acromegaly: IGF-1. Cushing's disease: consider dexamethasone suppression test ... – PowerPoint PPT presentation

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Title: COMMON INPATIENT ENDOCRINE CONSULTS


1
COMMON INPATIENT ENDOCRINE CONSULTS
  • William E. Clutter, M.D.

2
Thyroid disorders
  • Effects of nonthyroidal illness (NTI, euthyroid
    sick)
  • Effects of drugs
  • Hyperthyroidism
  • Hypothyroidism
  • Post-thyroidectomy consults

3
Nonthyroidal illness (NTI)
  • Deiodinase inhibition gt decreased T3
  • TSH suppression
  • T4 FT4 suppression

4
Nonthyroidal illness
5
NTI diagnostic problems
  • Low TSH NTI vs hyperthyroidism
  • Clinical signs, including atrial fibrillation
  • FT4
  • Low-normal probably NTI, especially if TSH gt0.1
    mU/ml
  • High hyperthyroidism

6
NTI diagnostic problems
  • Low FT4 NTI vs hypothyroidism
  • Clinical signs, eg bradycardia, hypoventilation,
    hypothermia
  • TSH
  • gt20 mU/ml primary hypothyroidism
  • 5-20 primary hypothyroidism vs NTI
  • Repeat in 1-2 weeks or treat empirically and
    reassess as outpatient
  • lt5 NTI vs secondary hypothyroidism
  • History or evidence of pituitary disease?

7
Thyroid function drug effects
  • Iodine (amiodarone, X-ray contrast)
  • Hyperthyoidism
  • Hypothyroidism
  • Amiodarone inhibits deiodinase
  • Increased FT4, slightly increased TSH
  • Lithium inhibits T4 release -gt hypothyroidism
  • Heparin increases free T4 (in vitro)
  • Furosemide displaces T4 -gt increased FT4

8
Hyperthyroidism indications for emergency
management
  • Acute coronary syndrome
  • Heart failure
  • Thyroid storm
  • fever
  • agitation or stupor
  • severe concomitant illness

9
Hyperthyroidismemergency management
  • Confirm hyperthyroidism (free T4, TSH)
  • Propylthiouracil (PTU) 200-300 mg PO Q 6 hr
  • Iodine (SSKI) 2 gtt (80 mg) PO Q 12 hr
  • Beta- adrenergic antagonist if not in CHF
  • propranolol 40 mg Q 6 hr
  • adjust dose to HR lt100/min

10
Hyperthyroidismemergency management
  • Intensive therapy of concomitant disease
  • Follow free T4 Q 4-6 days
  • When free T4 normal, schedule RAI therapy
  • stop iodine 2-4 weeks before
  • stop PTU 3-5 days before

11
Hypothyroidism emergent therapy
  • Indications
  • Hypoventilation
  • Bradycardia
  • Hypotension
  • Confirm diagnosis FT4, TSH
  • T4 50-100 mg IV Q 6 hr x 24 hr, then
  • T4 75-100 mg IV Q 24 hr

12
Post-thyroidectomy consults
  • Monitor for hypocalcemia Q 12-24 hr
  • Benign disease
  • Subtotal thyroidectomy start T4 TSH in 6-8
    weeks
  • Lobectomy T4 or no therapy TSH in 6-8 weeks
  • Thyroid carcinoma
  • High risk for recurrence
  • hold T4
  • contact Radiation Oncology
  • RAI ablation or whole body RAI scan in 2 weeks,
    then
  • Start T4

13
Calcium disorders
  • Hypercalcemia
  • Hypocalcemia
  • Post-op parathyroidectomy consults

14
Severe hypercalcemia signs
  • Renal
  • polyuria, dehydration
  • renal failure
  • Gastrointestinal
  • nausea, vomiting, constipation
  • abdominal pain
  • Neurologic
  • fatigue, confusion
  • coma

15
Severe hypercalcemia causes
  • Malignancy
  • Breast carcinoma
  • Squamous lung carcinoma, head neck carcinoma
  • Myeloma
  • Renal carcinoma
  • Primary hyperparathyroidism
  • Miscellaneous
  • vitamin D intoxication
  • milk-alkali syndrome (calcium carbonate)

16
Severe hypercalcemia evaluation
  • Evidence of cancer
  • Breast mass h/o breast cancer
  • h/o smoking, cough, hemoptysis, mass on CXR
  • Weight loss, anemia, etc
  • Evidence of primary hyperparathyroidism
  • Hypercalcemia for gt6 months
  • h/o renal stones
  • Plasma PTH, 25-OH vitamin D
  • (SPEP, PTH-rP, 1,25-OH D, bone scan)

17
Severe hypercalcemia indications for emergency
Rx
  • Severe symptoms of hypercalcemia
  • Plasma Ca gt12 mg/dl

18
Severe hypercalcemia therapy
  • Restore ECF volume
  • Normal saline rapidly
  • Positive fluid balance gt2 liters in first 24 hr
  • Saline diuresis
  • Normal saline 100-200 ml/hr
  • Replace potassium
  • Zoledronic acid 4 mg IV over 15 min
  • if plasma Ca gt14 mg/dl or gt12 mg/dl after
    rehydration
  • Monitor plasma calcium QD
  • Myeloma or vitamin D toxicity
  • prednisone 30 mg BID

19
Hypocalcemia clinical signs
  • Paresthesiae
  • Tetany
  • Trousseaus, Chvosteks signs
  • Seizures
  • Chronic cataracts, basal ganglia Ca

20
Hypocalcemia causes
  • Hypoparathyroidism
  • Surgical
  • Autoimmune
  • Magnesium deficiency
  • PTH resistance
  • Vitamin D deficiency
  • Vitamin D resistance
  • Other renal failure, pancreatitis, tumor lysis

21
Hypocalcemia evaluation
  • Confirm low ionized calcium
  • History
  • Neck surgery
  • Other autoimmune endocrine disorders
  • Causes of Mg deficiency
  • GI disorders (malabsorption)
  • Family history

22
Hypocalcemia evaluation
  • Physical exam
  • Signs of tetany
  • Signs of pseudohypoparathyroidism
  • Lab
  • PTH, total ionized calcium
  • Creatinine, Mg, P
  • (25-OH vitamin D)

23
Hypoparathyroidism therapy
  • IV calcium infusion
  • 2 gm Ca gluconate (20 ml) IV over 10 min
  • 6 gm Ca gluconate/500 cc D5W over 6 hr
  • Follow plasma Ca P Q 4-6 hr adjust rate
  • Oral calcium 1-2 gm BID - TID
  • Oral calcitriol 0.25-2 mcg/day

24
Post-op parathyroidectomy
  • Monitor for hypocalcemia
  • Limited surgery plasma calcium at discharge
    followup
  • 4-gland exploration plasma calcium Q 6-12 hr
  • If hypocalcemia develops, consider
  • Hypoparathyroidism
  • Hungry bone syndrome (elevated alkaline
    phosphatase)
  • Vitamin D deficiency
  • Treat if
  • Symptomatic or Trousseasus positive
  • Plasma calcium lt8 mg/dl

25
Adrenal disorders
  • Adrenal failure
  • Post-op adrenalectomy consults
  • Steroid coverage for illness, surgery
  • Severe hypertension, R/O adrenal cause

26
Adrenal failure signs
  • Weakness fatigue
  • Anorexia weight loss
  • Nausea vomiting
  • Lethargy, stupor
  • Hyponatremia
  • Hypotension
  • Shock death
  • Hyperkalemia
  • Hyperpigmentation

Only in primary adrenal failure
27
Adrenal failure causes
  • Primary (cortisol aldosterone deficient)
  • AUTOIMMUNE
  • tuberculosis, fungal infections
  • Hemorrhage, sepsis, etc
  • Secondary (ACTH cortisol deficient)
  • GLUCOCORTICOID THERAPY
  • hypothalamic or pituitary lesions

28
Adrenal failure evaluation
  • Dexamethasone 10 mg IV if hypotensive
  • Cortrosyn stimulation test
  • Cortrosyn 250 mcg IV
  • Plasma cortisol _at_ 30 min
  • Normal gt20 mcg/dl
  • Not sensitive for new onset secondary adrenal
    failure
  • Eg, after pituitary surgery, pituitary apoplexy
  • Treat empirically with prednisone for 4 weeks
  • Hold prednisone AM of test

29
Adrenal failureemergency therapy
  • Indications
  • Hypotension
  • Stupor
  • Severe hyperkalemia or hyponatremia
  • Hydrocortisone 100 mg IV Q 8 hr
  • or dexamethasone 4 mg Q 12 hr
  • D5/normal saline

30
Post-op adrenalectomy
  • Cushings syndrome due to adrenal adenoma
  • Perioperative hydrocortisone 50 mg IV Q 8 hr
  • Rapid taper to prednisone 10 mg QAM 5 mg QPM
  • Incidentaloma
  • ? Subclinical Cushings syndrome
  • Dexamethasone Cortrosyn stimulation test
  • Aldosteronoma
  • Stop spironolactone monitor BP, plasma K
  • Pheochromocytoma
  • Stop phenoxybenzamine monitor BP
  • IV NS for hypotension

31
Steroid coverage
  • Indications
  • Known adrenal failure
  • Chronic steroid treatment
  • Recent (1 year) chronic steroid treatment
  • For severe illness, major surgery
  • Hydrocortisone 50 mg IV Q 8 hr
  • For moderate illness, minor surgery
  • Hydrocortisone 25 mg IV Q 8 hr
  • Post-op, taper to chronic replacement over 2-3
    days

32
Severe hypertension
  • Pheochromocytoma
  • Primary hyperaldosteronism
  • Cushings syndrome
  • Evaluation
  • Plasma K if low, plasma aldosterone/PRA
  • Plasma catecholamines metanephrines
  • Overnight dexamethasone suppression if clinical
    signs of Cushings syndrome (may be falsely
    positive)

33
Pituitary disorders
  • Sella turcica mass
  • Post-op pituitary surgery

34
Sellar or suprasellar mass
  • Pituitary hormone excess
  • Prolactin
  • GH (acromegaly)
  • ACTH (Cushings disease)
  • Pituitary hormone deficiency
  • Hypothyroidism, adrenal failure, hypogonadism
  • Diabetes insipidus
  • Mass effects
  • Headache
  • Visual field loss
  • Pituitary apoplexy
  • Incidental finding (10 have microadenomas)

35
Pituitary disease evaluation
  • Signs of hormone excess or deficiency
  • Informal visual fields
  • Labs
  • Prolactin
  • Free T4
  • Cortrosyn stimulation test
  • Women menstrual history men plasma
    testosterone
  • MRI pituitary protocol
  • Formal visual fields if mass contacts chiasm

36
Post-op pituitary surgery
  • Perioperative steroid coverage
  • Treat pre-operative hypothyroidism, hypogonadism
  • Taper steroids discharge on prednisone 5 mg QAM
  • If polyuria develops
  • monitor urine output plasma Na Q 6-12 hr
  • Limit fluids to 75-100 cc/hr
  • If hypernatremic DDAVP 1-2 mg SC or IV x 1, then
    follow urine output

37
Post-op pituitary surgery
  • Outpatient followup 4 weeks after discharge
  • Free T4
  • Cortrosyn stimulation test
  • Plasma testosterone in men
  • Acromegaly IGF-1
  • Cushings disease consider dexamethasone
    suppression test

38
Unexpected hypoglycemia
  • Severe illness
  • Hepatic failure
  • Renal failure
  • Sepsis
  • Sulfonylurea or insulin administration
  • Insulinoma

39
Unexpected hypoglycemia
  • BEFORE TREATMENT WITH GLUCOSE
  • BMP lab glucose to confirm Accuchek
  • Plasma insulin
  • Plasma C-peptide
  • Plasma proinsulin
  • ANY TIME CLOSE TO HYPOGLYCEMIA
  • Plasma sulfonylurea assay
  • Call chemistry lab medicine resident to confirm
    samples received

40
Helpful phone numbers names
  • Chemistry lab medicine resident 424-1153
  • Nuclear medicine (docs) 362-2802
  • Barnes Drug Information 454-8399
  • Endocrine surgeons
  • Jeffrey Moley
  • Michael Brunt
  • Bruce Hall
  • Will Gillanders
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