N528 Endocrine, Part 1

Front 1

Hypothalamic Agents

What is Somatotropin?

Back 1

a growth hormone; stimulates the growth & metabolism of almost all cells in the body

recombinant form of human GH, restores normal growth & metabolic GH effects in GH-deficient individuals

Front 2

Hypothalamic Agents

What happens with a deficiency of somatotropin?

With an excess?

Back 2

Deficiency = Dwarfism

Excess = Acromegaly (usually caused by a pituitary tumor)

Front 3

Hypothalamic Agents

What is Octreotide?

Back 3

a synthetic growth hormone (GH) antagonist structurally related to somatostatin, inhibits acromegaly

Inhibits production of GH & to a lesser extent , of TSH, glucagon, insulin, & gastrin

Front 4

Hypothalamic Agents

What is Pegvisomant?

Back 4

newest agent that is GH antagonist, blocks GH receptors

Ameliorates effects of excess GH production, acromegaly

Front 5

Anterior Pituitary Agents

Agents (5)?

Back 5

Corticotropin (ACTH, Acthar)
Cosyntropin (Cortosyn)
Somatrem (Protropin)
Somatropin (Genotropin, Humatrope, others)
Thyrotropin [Thyrogen, Thyroid-stimulating hormone (TSH)]

Front 6

Posterior Pituitary Agents

What is Anti-Diuretic Hormone (ADH)?

Back 6

conserves H2O in the body

Secreted by the posterior pituitary when the hypothalamus senses low plasma volume or if osmolality is too high

Front 7

Posterior Pituitary Agents

Agents (2)?

Back 7

Used for SIADH

Desmopressin Acetate (DDAVP, Stimate) - most common form of ADH in use - intranasal form most common

Vasopressin (Pitressin) - drug for Diabetes Insipidus, potent vasoconstrictor

Front 8

Thyroid Drugs

What are the two types of cells in the thyroid gland & what do they secrete?

Back 8

Thyroid gland: consists of two types of cells which secrete different hormones.

Parafollicular cells: secrete calcitonin
Follicular cells: secrete thyroid hormones (T4 & T3)

Front 9

Thyroid Drugs

What role does iodine play w/Thyroid function?

Back 9

Iodine is essential for the synthesis of T4 and T3 (provided via intake)

Front 10

Thyroid Drugs

What is Hashimoto's thyroiditis?

Back 10

autoimmune thyroiditis - most common presentation of hypothyroidism

Front 11

Thyroid Drugs (Hypothyroidism)

Agents (3)?

Back 11

Levothyroxine (Levothroid, Synthroid, others)
Liothyronine (Cytomel, Triostat) - specific for T3
Thyroid (Armour Thyroid, Westhroid)

Front 12

Antithyroid Drugs

What is the most common presentation of hyperthyroidism?

How much more common in women?

In which age group is it most common?

Back 12

Grave's disease is the most common presentation

4-8xs more common in women
30-40 year olds most common

Front 13

Antithyroid Drugs (Hyperthyroidism)

Agents (4)?

Back 13

Thioamides:
Methimazole (Tapazole)
Potassium Iodide (ThyroShield, SSKI)

Propylthiouracil (PTU)
Radioactive Iodine (I131, RAI)

Front 14

Antithyroid Drugs

What are concerns about methimazole?

Back 14

Methimazole (Tapazole) is a thioamide and is pregnancy category D - crosses the placenta more readily.

Front 15

Antithyroid Drugs

What are concerns about Sodium iodine-131?

Back 15

Radioactive Iodine (I-131, RAI) destroys follicular cells with radiation (contraindicated in pregnancy)

Used to shrink thyroid prior to surgery

Front 16

Antithyroid Drugs

What is Lugol's solution?

Back 16

nonreactive iodine, inhibits organificaiont & hormone release, reduce the size & vascularity of gland

Front 17

What are the three essential classes of steroids secreted by the adrenal glands?

Back 17

Glucocorticoids
Mineralcorticoids
Gonadocorticoids

Front 18

Which two steroids are known as corticosteroids or adrenocortical hormones"?"

Back 18

Glucocorticoids & mineralocorticoids

Front 19

95% of the mineralocorticoids secreted by the adrenals are what?

Back 19

Aldosterone

Front 20

What is the primary function of Aldosterone?

Aldosterone + Androgen = ??

Back 20

The primary function of aldosterone is to promote Na reabsorption & K+ excretion by the renal tubules, thus regulating plasma volume.

Aldosterone + Androgen = Mineralocorticoid

Front 21

What does the kidney due when plasma volume is low?

Back 21

The kidneys secrete renin --> production of Angiotensin II

Angiotensin II --> aldosterone secretion --> promonts Na & water retention

Front 22

What is hyperaldosteronism?

Back 22

condition from excessive aldosterone secretion usually as a result of adrenal tumors, characterized by hypertension and hypokalemia.

Front 23

How many glucocorticoids are secreted by the adrenal cortex?

Back 23

More than 30 glucocorticoids are secreted.

Front 24

What is hydrocortisone?

Back 24

The most important pharmacologically glucocorticoid. Affects the metabolism of nearly every cell & prepares the body for long term stress.

Front 25

What are five effects of glucocorticoids?

Back 25

Increases blood glucose
Increases the breakdown of proteins & lipids & their utilization as energy sources.
Suppresses the inflammatory response
Increases the sensitivity of vascular smooth muscle to norepinephrine & angiotensin II.
Influences the CNS by affecting mood & maintaing normal brain excitability.

Front 26

What is the first (of four) steps of glucocorticoid secretion?

Back 26

Secretion begins with corticotropin-releasing hormone (CRF) secreted by the hypothalamus.

Front 27

What is the second (of four) steps of glucocorticoid secretion?

Back 27

CRF travels to the pituitary, where it causes the release of ACTH.

Front 28

What is the third (of four) steps of glucocorticoid secretion?

Back 28

ACTH then travels through the blood & reaches the adrenal cortex, causing it to release glucocorticoids.

Front 29

What is the fourth (of four) steps of glucocorticoid secretion?

Back 29

When the level of cortisol in the blood increases, it provides negative feedback to the hypothalamus and the pituitary to shut off further release of glucocorticoids.

Front 30

What is adrenal insufficiency?

What is the role of glucocorticoids in relationship to adrenal insufficiency?

Back 30

Lack of corticosteroid.

Glucocorticoids are used as replacement therapy for adrenal insufficiency and to decrease inflammation and immune responses. Need to taper when d/c to prevent adrenal suppression.

Front 31

Name the main twelve uses of glucocorticoid?

Back 31

Adrenal insufficiency
Allergies (seasonal rhinitis)
Chronic inflammatory bowel disease
Asthma & COPD
Edematous states caused by hepatic, neurological & renal disorders
Neoplastic disease
Post-transplant surgery
Rheumatic diseases
Shock
Skin disorders (rash, contact dermatitis, etc.)
Others

Front 32

How might glucocorticoids interact with

anti-diabetic agents?

Back 32

Hyperglycemic effects may decrease the effectiveness of the anti-diabetic agents.

Front 33

How might glucocorticoids interact with

NSAIDs?

Back 33

Combining with NSAIDs increases the risk for PUD

Front 34

How might glucocorticoids interact with

non-potassium sparing diuretics?

Back 34

Administering with non-potassium-sparing diuretics --> hypokalemia & hypocalcemia.

Front 35

Glucocorticoid prescribing strategies:

dosing?

Back 35

Keep doses to the lowest possible amount to achieve a therapeutic effect.

Front 36

Glucocorticoid prescribing strategies:

administration?

Back 36

Administer every other day to limit adrenal atrophy.

Front 37

Glucocorticoid prescribing strategies:

for acute conditions?

Back 37

For acute conditions, prescribe large amounts for a few days, and then gradually decrease the does until discontinued.

Front 38

Glucocorticoid prescribing strategies:

to decrease systemic effects?

Back 38

To decrease the possibility of systemic effects, use inhalation, topical or intra-arterial routes.

Front 39

What does long-term administration of glucocorticoids put a person at risk for?

Back 39

Cushing's syndrome

Front 40

Name two short-acting glucocorticoids

What patient would be using this?

Back 40

Cortisone (Cortistan, Cortone)
Hydrocortisone (Cortef, Hydrocortone, others)

Usually given as a topical for skin irritation.

Front 41

Name four intermediate acting glucocorticoids

What patient would be using this?

Back 41

Methylprednisolone (Medrol, others)
Prednisolone (Delta-Cortef, others)
Prednisone (Deltasone, Meticorten, others)

Pt with hives in an urgent care receiving via IV
Prednisone is for COPD or chemo patient.

Front 42

Name two long-acting glucocorticoids

What pt would be using this?

Back 42

Betamethasone (Celestone)
Dexamethasone (Decadron, Dexasone, others)

Dexamethasone suppression test - r/o Cushing's

Front 43

What is the Somogyi Effect & what is the treatment?

Back 43

Nocturnal hypoglycemia develops stimulating a surge of counter regulatory hormones which raises blood sugar.

Tx: Reduce or omit h.s. dose of insulin

Front 44

What is the Dawn Phenomenon & what is the treatment?

Back 44

Results when tissue becomes desensitized to insulin nocturnally - blood glucose becomes progressively elevated throughout the night.

Tx: Add or increase the h.s. dose of insulin

Front 45

Diabetes Drugs: Biguanides

Agent (1)?

Back 45

Metformin (Glucophage)

Front 46

Diabetes Drugs: Biguanides

Indications?

Back 46

Drug of choice; first line therapy for Type 2 DM, promotes weight loss

Contraindicated in liver disease & renal dysfunction (serum creatinine ≥ 1.5 males & 1.4 females) need to monitor creatinine.

Front 47

Diabetes Drugs: Biguanides

MOA?

Back 47

Decreases hepatic gluconeogenesis, improves insulin sensitivity, increases glucose utilization by muscle.

Does not cause insulin secretion, therefore no concern for hypoglycemia.

Front 48

Diabetes Drugs: Biguanides

Adverse Effects?

Back 48

Nausea, vomiting, diarrhea, decreased appetite
Rare (but fatal): lactic acidosis (s/s muscle pain).

Stop use for 48 hrs after procedures w/contrast. Need to check creatinine before restarting metformin.

Front 49

Diabetes Drugs: Insulin Secretagogues, Nonsulfonylureas (Glinides)

Agents (2)?

Back 49

Nateglinide (Starlix)
repaglinide (Prandin) - affected by renal impairment

Front 50

Diabetes Drugs: Insulin Secretagogues, Nonsulfonylureas (Glinides)

Indications?

Back 50

Monotherapy or combination therapy for Type 2 DM

Use with caution in liver dysfunction.
Dose adjustment required for renal dysfunction

Front 51

Diabetes Drugs: Insulin Secretagogues, Nonsulfonylureas (Glinides)

MOA?

Back 51

Stimulates insulin release from pancreas

Rapid onset (give w/ meals) & short duration of action (requires TID dosing)

Front 52

Diabetes Drugs: Insulin Secretagogues, Nonsulfonylureas (Glinides)

Adverse Effects?

Back 52

Hypoglycemia, diarrhea, arthralgia, headache, sinusitis, upper respiratory infection

Several drug-drug interactions

Front 53

Diabetes Drugs: Insulin Secretagogues, Sulfonylureas

Agents (6)?

Back 53

Chlorpropamide (Diabinese) - older agents, disulfiram rxn
Tolazamide (Tolinase) - older agents
Tolbutamide (Tol-Tab) - older agents
Glyburide (Diabeta, Micronase)
Glipizide (Glucotrol)
Glimepiride (Amaryl)

Front 54

Diabetes Drugs: Insulin Secretagogues, Sulfonylureas

Indications?

Back 54

Monotherapy or combination therapy for Type 2 DM

Use with caution in liver dysfunction.
Dose adjustment required for renal dysfunction

Front 55

Diabetes Drugs: Insulin Secretagogues, Sulfonylureas

MOA?

Back 55

Stimulates insulin release from pancreas, enhances beta cell sensitivity to glucose

Over time, response to therapy may diminish. Possibly desensitizes receptors

Front 56

Diabetes Drugs: Insulin Secretagogues, Sulfonylureas

Adverse Effects?

Back 56

Hypoglycemia, nausea, bloating, weight gain, photosensitivity, disulfiram reaction (chlorpropamide)

Several drug-drug interactions
Use caution w/sulfa allergy

Front 57

Diabetes Drugs: Thiazolidinediones

Indications?

Back 57

Monotherapy or combination therapy for Type 2 DM - 3rd line agent Reserved when other agents not working

Use with caution (if at all) in liver dysfunction – baseline LFTs & periodically afterwards
Contraindicated in NYHA class III or IV

Front 58

Diabetes Drugs: Thiazolidinediones

Agents (2)?

Back 58

Pioglitazone (Actos)
Rosiglitazone (Avandia) – REMS program, no new pts

Front 59

Diabetes Drugs: Thiazolidinediones

MOA?

Back 59

Increases receptor sensitivity to insulin, decreases both insulin resistance & hepatic gluconeogenesis. No increase of insulin secretion

Front 60

Diabetes Drugs: Thiazolidinediones

Adverse Effects?

Back 60

Hepatotoxicity, weight gain, peripheral edema, rash, macular edema, heart failure exacerbation, increase risk of MI (rosiglitazone)

Several drug-drug interactions, metabolized by liver
May increase risk of osteoporosis
May increase risk of bladder cancer (pioglitazone)

Front 61

Diabetes Drugs: Alpha-glucosidase Inhibitors

Indications?

Back 61

Adjunct therapy only for Type 2 DM, esp if post-prandial BS elevated.

Do not use in renal dysfunction (creatinine > 2.0)
Contraindicated in malabsorption, IBD, or intestinal obstruction.

Front 62

Diabetes Drugs: Alpha-glucosidase Inhibitors

Agents (2)?

Back 62

Acarbose (Precose) – baseline LFTs then periodically afterwards
Miglitol (Glyset)

Front 63

Diabetes Drugs: Alpha-glucosidase Inhibitors

MOA?

Back 63

Reduces rate & extent of CHO digestion & absorption

Front 64

Diabetes Drugs: Alpha-glucosidase Inhibitors

Adverse Effects?

Back 64

Flatulence, diarrhea, abdominal pain, decreased absorption of iron (anemia)

May influence absorption of other drugs.
Glucose (dextrose) is recommended for treating hypoglycemia as sucrose metabolism is inhibited.

Front 65

Diabetes Drugs: Glucagon-like Peptide-1 Agonists

Indications?

Back 65

Monotherapy (exenatide) or combination therapy for Type 2 DM; generally considered as adjunct – does not replace insulin. For pts who fail metformin alone, or with glinides or sulfonylureas

Contraindicated in severe renal dysfunction (both), h/o pancreatitis (both), & h/o thyroid CA (liraglutide)

Front 66

Diabetes Drugs: Glucagon-like Peptide-1 Agonists

Agents (2)?

Back 66

Exenatide (Byetta)
Liraglutide (Victoza)

REMS program - d/t risk for pancreatitis & thyroid tumors

Front 67

Diabetes Drugs: Glucagon-like Peptide-1 Agonists

MOA?

Back 67

Increase insulin release in the presence of elevated glucose concentrations, decrease glucagon secretion in a glucose-dependent manner & delay gastric emptying.

Front 68

Diabetes Drugs: Glucagon-like Peptide-1 Agonists

Adverse Effects

Back 68

Nausea, vomiting, diarrhea, headache hypoglycemia, pancreatitis, teratogenic, injection site reactions, renal failure, thyroid tumors

Several drug-drug interactions

Front 69

Diabetes Drugs: Dipeptidyl Peptidase-4 Inhibitors

Indications?

Back 69

Monotherapy or combination therapy for Type 2 DM; generally considered as adjunct therapy

Contraindicated in ESRD & dose adjustment in renal impairment (sitagliptin, saxagliptin)

Front 70

Diabetes Drugs: Dipeptidyl Peptidase-4 Inhibitors

Agents (3)?

Back 70

Sitagliptin (Januvia)
Saxagliptin (Onglyza)
Linagliptin (Tradjenta)

Front 71

Diabetes Drugs: Dipeptidyl Peptidase-4 Inhibitors

MOA?

Back 71

Inhibit the degradation of GiP and GLP-1

Front 72

Diabetes Drugs: Dipeptidyl Peptidase-4 Inhibitors

Adverse Effects?

Back 72

Increased risk of infection (URI --> sepsis), headache, hypoglycemia, pancreatitis, hypersensitivity reactions, peripheral edema (saxagliptin)

Several drug-drug interactions (saxagliptin)

Front 73

Diabetes Drugs: Amylin Receptor Agonists

Indications?

Back 73

Adjunct therapy for Type 1 & Type 2 DM

Contraindicated in pts with hypoglycemic unawareness or gastroparesis
Black Box warning for individuals while driving

Front 74

Diabetes Drugs: Amylin Receptor Agonists

Agents?

Back 74

Pramlintide (Symlin)

When initiating, reduce dose of any secretagogues, reduce insulin dose by at least 50%

Front 75

Diabetes Drugs: Amylin Receptor Agonists

MOA?

Back 75

Inhibit the degradation of GiP & GLP-1

Front 76

Diabetes Drugs: Amylin Receptor Agonists

Adverse Effects?

Back 76

Abdominal pain, loss of appetite, nausea, vomiting, hypoglycemia, dizziness, headache, cough, fatigue

Severe hypoglycemia with concurrent insulin or oral hypoglycemic agent

Front 77

Diabetes Drugs: Combination Drugs & Others

Agents

Back 77

Glipizide/Metformin (Metaglip)
Glyburide/Metformin (Glucovance)
Rosiglitazone/Glimepride (Avandaryl)
Pioglitazone/Metformin (ACTOplusmet)
Rosiglitazone/Metformin (Avandamet)

Front 78

Insulin Preparations: Rapid Acting

Agents (3)?

Back 78

Insulin Lispro (Humalog)
Insulin Aspart (NovoLog)
Insulin Glulisine (Apidra)

SQ only

Front 79

Insulin Preparations: Rapid Acting

Onset of Action?

Back 79

5-15 minutes

mimics body kinetics the best

Front 80

Insulin Preparations: Rapid Acting

Peak Action?

Back 80

30-90 minutes

Front 81

Insulin Preparations: Rapid Acting

Duration of Action?

Back 81

< 5 hours

Front 82

Insulin Preparations: Short Acting

Agents (1)?

Back 82

Regular insulin (Humulin R)

Can be given SQ or IV

Front 83

Insulin Preparations: Short Acting

Onset of Action?

Back 83

0.5-1 hour

Front 84

Insulin Preparations: Short Acting

Peak Action?

Back 84

2-4 hours

Front 85

Insulin Preparations: Short Acting

Duration of Action?

Back 85

5-7 hours

Front 86

Insulin Preparations: Intermediate Acting

Agent (1)?

Back 86

NPH

Front 87

Insulin Preparations: Intermediate Acting

Onset of Action?

Back 87

2-4 hours

Front 88

Insulin Preparations: Intermediate Acting

Peak Action?

Back 88

4-12 hours

Front 89

Insulin Preparations: Intermediate Acting

Duration of Action?

Back 89

12-18 hours

Front 90

Insulin Preparations: Long Acting

Agents (2)?

Back 90

Insulin glargine (Lantus)
Insulin detemir (Levemir)

Less peaks & valleys

Front 91

Insulin Preparations: Long Acting (glargine)

Onset of Action?

Back 91

1.5 hours

Front 92

Insulin Preparations: Long Acting (glargine)

Peak Action?

Back 92

No pronounced peak

Front 93

Insulin Preparations: Long Acting (glargine)

Duration of Action?

Back 93

20-24 hours

Front 94

Insulin Preparations: Long Acting (detemir)

Onset of Action?

Back 94

0.8-2 hours

Front 95

Insulin Preparations: Long Acting (detemir)

Peak Action?

Back 95

Relatively flat

Front 96

Insulin Preparations: Long Acting (detemir)

Duration of Action?

Back 96

5.7-23.2 hours

Front 97

Insulin Preparations

NPH/regular (70/30)

Back 97

Humulin 70/30
Novolin 70/30

Front 98

Insulin Preparations

Insulin aspart protamine suspension / insulin aspart (70/30)

Back 98

NovoLog Mix 70/30

Front 99

Insulin Preparations

Insulin lispro protamine suspension / insulin lispro (70/25)

Back 99

Humalog Mix 75/25

Front 100

Insulin Preparations

Insulin lispro protamine suspension / insulin lispro (50/50)

Back 100

Humalog Mix 50/50

Front 101

Endocrine Physiology Review

What is the role of the hypothalamus in the endocrine system?

Back 101

Hypothalamus secretes releasing hormones to the pituitary gland. These trigger the pituitary to know what hormones are to be released.

Hypothalamus secretes thyrotropin-releasing hormone (TRH) --> pituitary --> secretes TSH --> thyroid hormones

Front 102

Endocrine Physiology Review

What are the two parts of the pituitary gland?

Back 102

Anterior (adenohypophysis)
Posterior (neurohypophysis)

Front 103

Endocrine Physiology Review

What is the adenohypophysis?

Back 103

The anterior pituitary lobe that consists of glandular tissue & secretes ACTH, TSH, growth hormone, prolactin, FSH & LH

Front 104

Endocrine Physiology Review

What is the neurohypophysis?

Back 104

The posterior pituitary lobe that contains nervous tissue rather than glandular. Neurons in the posterior pituitary store ADH & oxytocin (released in response from nerve stimulation in the hypothalamus).

Front 105

Target tissues for drug therapy for diabetes?

Back 105

Front 106

What is the ADA recommendations for glycemic control for most nonpregnant adults with diabetes?

Back 106

A1C: 7% (5.5-7%/6)
Before meals: 70-130
After meals: < 180