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77 Cards in this Set

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What are functions of thyroid hormone?
• allows for normal growth and development • maintenance of metabolic balance • affects every organ system
What are the two hormones produced by the thyroid gland?
T4 (Thyroxine) and T3 (Triiodothyronine)
List characteristics of T4
• major circulating hormone • highly protein bound (0.03% free) • half life: 7 days
List characteristics of T3
• produced by peripheral conversion of T4 • less than 20% produced in thyroid • half life: 1.5 days
What are some thyroid function tests and what they measure?
• Total T3 & T4: measures bound and unbound T4 & T3 • Resin T3 uptake (RT3U): estimates binding capacity of TBG (thyroid binding globulin) • Free T4: measures level of unbound T4 • Radioactive Iodine Uptake (RAIU): measures iodine uptake by thyroid
What is the normal range of total T4?
4.5-12.5 mcg/dl
What is the normal range of total T3?
80 - 250 ng/dl
What is the normal range of RT3U?
What is the normal range of FT4I (free thyroxine index)?
1.0-4.3 units
What is the normal range of TSH?
0.25-6.7 mIU/L
What are causes of hyperthyroidism (thyrotoxicosis)?
• autoimmune (Grave's disease) • circulating immunoglobins with TSH-like properties (seen in Myastenia Gravis and in patients receiving IVIG) • exogenous thyroid excess • goiter due to exogenous iodine • tumors • toxic uninodular goiter
What are some clinical characteristics of hyperthyroidism?
• thyroid enlargement • exopthalmos • pretibial edema
What are symptoms of a patient with hyperthyroidism?
• fatigue • heat intolerance • loss of weight with increased appetite • nervousness
What are physical findings of hyperthyroidism?
• warm, smooth, moist skin • thinning hair • onycholysis
What drugs can be used to treat hyperthyroidism?
thioamides (Methimazole & Propylthiouracil)
What is the MOA of the Thioamides (Methimazole & PTU)?
• inhibts formation of monoiodotyrosine (MIT) and diiodotyrosine (DIT)
• inhibits coupling of MIT and DIT
• inhibits the oxidation of iodine
• PTU inhibits peripheral conversion of T4 to T3
What is the dosage for Methimazole?
• 15-40 mg daily (initial), then 5-10 mg (maintenance)
• initial dose usually last for 5-7 days
What are adverse reactions of Methimazole?
• Agranulocytosis
• Leukopenia
• LFT changes
• GI
• Rash (usually at the beginning of drug therapy)
Which drug is more potent, Methimazole or PTU?
What type of patients is Propylthiouracil (PTU) the drug of choice?
• Pregnancy
• Nursing mothers
• Thyroid storm
What is the dosage of PTU?
• Initial: 75-100 mg QID (until symptoms resolve) • Then: 100-150 mg/day in divided doses
What are adverse reactions of PTU?
• Same as Methimazole (Agranulocytosis, LFT changes, Leukopenia, GI, rash) • also hepatitis
What are the 2 types of iodine used to treat hyperthyroidism?
• iodine-based solution • radioactive iodine
When is an iodine-based solution used?
• can be used in an emergent situation (thyroid storm) • can cause rapid progression to euthyroid state
What are the 2 iodine-based solutions used?
• SSKI (40 mg of iodine per drop) • Lugol's Solution (8 mg/drop)
What is the MOA of the iodine-based solutions?
• prevents thyroid hormone release • inhibits hormone synthesis
What are adverse reactions of iodine-based solutions?
• metallic taste • rash
What is the MOA of radioactive iodine?
• destroys thyroid follicles • effects seen in 3-6 months
What type of patients would get radiactive iodine therapy?
• patient where drug therapy is ineffective • patient with cardiac disease, elderly • patients with contraindications to drug therapy
What type patients would be canidates of surgery to treat hyperthyroidism?
• patients with contraindications to drug therapy or RAI • patients with large goiters, malignancy, and obstruction
What is the presentation of a patient with acute thyrotoxicosis?
• confusion • fever • tachycardia • tremor
What is the treatment for acute thyrotoxicosis?
• Beta-blockers: to control peripheral and systemic symtoms (ie tachycardia)
• PTU or Iodines: to suppress hormone formation and secretion
• Corticosteroids: to suppress the inflammatory process
What are causes of hypothyrodism?
• Hashimoto's (autoimmune disorder) • Cretinism (in infants) • Hypothalamic disease • Iodine Deficiency • Pituitary Disease • Treatment of hyperthyroidism
How do patients with hypothyroidism present clinically?
• cold intolerance • fatigue • weakness
What are physical findings of hypothyroidism?
• coarse skin & hair • thin brittle nails
What are the goals of hypothyroidism therapy?
• restoration of thyroid hormone concentration • prevent neurologic defects in newborns
What is the gold standard of thyroid replacement therapy?
• Levothyroxine (Synthroid) • MOA: a synthetic T4
What are adverse effects of Levothyroxine (Synthroid)?
• sweating • weight loss
What are drugs that interact with thyroid replacement therapy?
• Bile Acid Sequestrants: decreased thyroid absorption due to binding
• Oral contraceptives/estrogens: increase TBG, resulting in less free thyroid hormone
• Warfarin: increases metabolism of clotting factors (will cause a slight increase in INR)
• Lithium: inhibits release of thyroid hormone
How would you adjust the dosage of Levothyroxine (Synthroid) with a patient taking oral contraceptives?
increase the Levothyroxine (Synthroid) dose
What is a Myxedema Coma?
• end stage of uncorrected hypothyroidism (an acute medical emergency)
What are clinical features of a Myxedema Coma?
• Hyponatremia • Hypothermia • Progressive weakness • Stupor
What are treatment options for a Myxedema Coma?
• Levothyroxine IV • Liothyronine (synthetic T3) • Corticosteroids
What are causes of drug-induced thyroid disorders?
• Amiodarone
• Antidepressants (Valproic Acids, Atypical Psychotics)
• Iodides
• Lithium
What are the 2 parts of the adrenal gland?
• Cortex (90%) • Medulla (10%)
What are the 3 zones of the cortex and what do they secrete?
• Zona glomerulosa: aldosterone secretion
• Zona Fasiculata: androgen secretion
• Zona reticularis: cortisol secretion
What are functions of cortisol?
• helps the body respond to stress
• helps maintain blood pressure and cardiovascular function
• helps balance the effects of insulin in breaking down sugar for energy
• helps regulate the metabolism of proteins, carbohydrates, and fats
• helps slow the immune system's inflammatory response
What class of hormone is aldosterone?
What is the function of aldosterone?
helps maintain blood pressure, water, and salt balance in the body by helping the kidney retain sodium and excrete potassium
What is Cushing's syndrome?
hyperfunction of adrenal gland
What are causes of Cushing's syndrome?
• pituitary adenoma • adrenal adenoma • adrenal carcinoma
What are clinical features of Cushing syndrome?
• moon face, buffulo hump • obesity • HTN • hirsutism • myopathy • menstrual dysfunction
What are the 2 ways that Cushing's syndrome is diagnosed?
• 24 hr urine free cortisol
• Low dose dexamethasone suppression test: overnight test: 1mg @ 11pm, obtain cortisol level @ 8 am
What is the treatment for Cushing's syndrome?
surgery for adrenal adenoma, carcinoma, and pituitary dependant Cushing's
What are the 2 types of hyperaldosteronism?
• Primary • Secondary
What is the etiology of primary hyperaldosteronism?
• aldosterone producing adenoma • idiopathic adrenal hyperplasia
What is the presentation of hyperaldosteronism?
• HTN • fatigue • nocturia
What is the treatment of hyperaldosteronism?
• tumor removal • Spirinolactone 200-400 mg QD
What are causes of secondary hyperaldosteronism?
• diuretics • pregnancy • hemorrhage
Which type of diuretics can cause hyperaldosteronism the most?
What is the treatment of secondary hyperaldosteronism?
removal of the source
What hypertension drug class would you use for a patient with HTN and hyperaldosteronism?
ACE inhibitor because by blocking conversion to angiotensin II you also block aldosterone
What are the 2 types of adrenal insufficiency?
• Primary (Addison's disease) • Secondary
What are causes of primary adrenal insufficiency (Addison's disease)?
• destruction of the adrenal cortex (autoimmune, TB, AIDS, Sepsis)
What is a cause of secondary adrenal insufficiency?
excessive use of glucocorticoids
How do patients with adrenal insufficiency clinically present?
• dehydration
• decreased sodium
• hypotension
• hypoglycemic
• increased potassium
• weight loss
What is the treatment of adrenal insufficiency?
lifetime corticosteroid replacement
What does Fludrocortisone prevent in patients with Addison's disease?
What is the treatment for acute adrenal insufficiency?
• Hydrocortisone 100 mg IV Q6hrs for the first 24 hrs
• then Hydrocortisone 50 mg IM (or IV) Q 6hrs
• Hydrocortisone 40 mg PO Q AM and 20 mg PO q pm
What is the drug and dosing for chronic adrenal insufficiency?
• require hydrocortisone (Cortef) twice a day and Florinef (Fludrocortisone)
• Fludrocortisone: 0.05-0.2 mg PO Q24
Why is fludrocortisone usually given for adrenal insufficiency?
to replace aldosterone which controls sodium and potassium to keep blood pressure normal
__ mg of Cortisone = __ mg of Hydrocortisone = __ mg of Prednisone = __ mg of Methylprednisolone = __ mg of Dezamethasone
25 mg of Cortisone = 20 mg of Hydrocortisone = 5 mg of Prednisone = 4 mg of Methylprednisolone = 0.75 mg of Dezamethasone
Which corticosteroids are only available PO?
Cortisone and Prednisone
Which corticosteroids are available PO and IV?
• Hydrocortisone • Methylprednisolone • Dezamethasone
Which corticosteroid has the longest duration (is the most long-acting)?
What are uses of corticosteroids?
• replacement therapy
• anti-inflammatory and immune suppression
• arthritis, asthma, allergies, dermatologic conditions
What are adverse effects of corticosteroids?
• decreased immune system
• diabetes
• edema
• Hypocalcemia
• thinning of skin