INTENSIVE UPDATE AUGUST 24 - 26, 2018 & BOARD REVIEW Loews Chicago O’Hare Hotel Rosemont, IL

INNOVATIVE • COMPREHENSIVE • HANDS-ON

Evolving Issues in Endocrinology

Thomas Shima, DO, FACOFP

The American College of Osteopathic Family Physicians is accredited by the American Osteopathic Association Council to sponsor continuing medical education for osteopathic physicians.

The American College of Osteopathic Family Physicians designates the lectures and workshops for Category 1-A credits on an hour-for-hour basis, pending approval by the AOA CCME, ACOFP is not responsible for the content. ACOFP FULL DISCLOSURE FOR CME ACTIVITIES

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Name of CME Activity: ACOFP Intensive Update & Board Review in Family Medicine Dates and Location of CME Activity: August 24-26, 2018, Loews Chicago O'Hare Hotel, Rosemont, IL, United States

Name of Faculty/Moderator: Thomas Shima, DO, FACOFP

DISCLOSURE OF FINANCIAL RELATIONSHIPS WITHIN 12 MONTHS OF DATE OF THIS FORM A. Neither I nor any member of my immediate family has a financial relationship or interest with any proprietary entity producing health care goods or services.

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I have read the ACOFP policy on full disclosure. If I have indicated a financial relationship or interest, I understand that this information will be reviewed to determine whether a conflict of interest may exist, and I may be asked to provide additional information. I understand that failure or refusal to disclose, false disclosure, or inability to resolve conflicts will require the ACOFP to identify a replacement.

Thomas Shima Signature: Date: 8-15-2018 8/15/2018

ENDOCRINOLOGY FOR THE BOARDS

THOMAS SHIMA, DO, FACOFP

NAME A PLACE IN THE WORLD IS ON YOUR BUCKET LIST TO GO SEE?

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OBJECTIVES

● HYPOTHYROIDISM ● HYPERTHYROIDISM ● THYROID NODULES ● ADRENAL INSUFFICIENCY ● PITUITARY TUMORS ● DIABETES INSIPIDUS

“ HYPOTHYROIDISM

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HYPOTHYROIDISM types

● Primary Gland Failure ○ Autoimmune destruction (Hashimoto’s Disease) ○ Iodine deficiency ○ Infiltrative disease ○ Congenital abnormalities ○ Iatrogenic ○ Transient ● Central Causes ○ Pituitary dysfunction ○ Hypothalamic dysfunction ○ Medication induced

Key signs and symptoms

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Making the diagnosis of hypothyroidism

Low Primary Hypothyroidism

TSH ---> FT4 normal subclinical hypothyroidism (high) High not Primary Hypothyroidism

Treatment of thyroiditis

● Synthetic Thyrotoxine (T4) ○ Generic vs brand name ○ 1.6mcg/kg/day ○ Avoid calcium and iron supplements for 4 hrs

● Armour thyroid ○ Dessicated Pig thyroid ○ T4 and T3

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Subacute thyroiditis

● Subclinical hypothyroidism ○ Check thyroid peroxidase antibodies ○ Treat if TSH >10

Special cases of hypothyroidism

● Older patients ○ Cardiogenic effects

● Pregnancy ○ Increased requirements

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Treatment of thyroiditis

AAFP guidelines Do not screen in asymptomatic individuals

USPSTF Evidence insufficient for routine screening in asymptomatic individuals

HYPERTHYROIDISM

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TYPES OF HYPERTHYROIDISM

● Grave’s Disease--Autoimmune ● Toxic multinodular goiter ● Toxic adenoma ● Transient Thyroiditis ○ Acutely ill patients ○ Glucocorticoid use ○ Dopamine

GRAVE’S DISEASE

Thyroid stimulating antibodies Activate TSH receptors

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OTHER TYPES

Toxic multinodular goiter Iodine Deficient countries Toxic adenoma Single nodule Transient Thyroiditis Medication induced amiodarone, lithium, Interferon alpha Gestational hyperthyroidism First trimester

SIGNS AND SYMPTOMS OF HYPERTHYROIDISM

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MAKING THE DIAGNOSIS OF HYPERTHYROIDISM

● Radioactive iodine TSH -->reflex FT4 uptake test No FT3 ○ High TSH receptor antibodies ○ low (Graves Disease) ● Thyroid scan ○ Homogenous uptake ○ Single area uptake ○ Multiple area uptake

TREATMENT

● Propanolol ● Radioactive iodine ablation ○ Exacerbation of CHF (I131) ○ Most common treatment of ● Thionamides Graves Disease ○ Contraindicated in pregnancy ■ Stop 5 days before ○ No pregnancy for 6 months radioactive iodine ablation ● Thyroidectomy ○ Methimazole ■ Agranulocytosis ■ Avoid in first trimester of pregnancy ○ Propylthiouracil ■ Liver injury/failure

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TREATMENT

● Thyroid replacement medication ● Measure FT4 if using thionamides ● Every four weeks then every 3 months when stable ● TSH level not helpful early on

Treatment of subacute thyroiditis

● Observation ● Beta blockers for symptomatic therapy ● NSAIDs for pain

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THYROID NODULES

THYROID NODULES

EPIDEMIOLOGY RISK FACTORS

● Can be palpated in apx 4-7% ● Radiation to the head or neck of patients with nodules ● Nodules in patients <20 or >70 ● Many are incidental and found ● ?? Men>Women on US or on autopsy ● ? Graves Disease ● Those that are cancerous ● Family History (MEN) represent approximately 1% of all malignancies

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DIAGNOSIS & treatment

Special patient populations

● Pregnancy ○ Wait till after delivery ○ Treat hyperfunctioning nodules with antithyroid medication

● Children ○ Thyroid nodules is rare ○ Incidence of cancer is high

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ADRENAL INSUFFICIENCY

Primary versus Secondary Adrenal Insufficiency

Primary Adrenal Insufficiency ● The adrenal gland is the problem

Secondary Adrenal Insufficiency ● The Pituitary or Hypothalamus are the problems

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COMMON CAUSES

● Autoimmune adrenalitis (Addison’s Disease) ● Infection ● Hemorrhage ● Metastatic cancer ● Medication use ● Adrenoleukodystrophy

SIGNS AND SYMPTOMS

● Anorexia ● Weakness/fatigue ● Hyperpigmentation ● nausea/vomiting ● Abdominal pain ● Constipation or diarrhea ● Hypotension ● Vertigo ● Muscle or joint pain

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MAKING THE DIAGNOSIS

● Low a.m. serum cortisol level ● Hyperkalemia ● Hyponatremia

Cosyntropin stimulation test ● Low cortisol level ● High ACTH level→ Primary A.I. ● Low ACTH level→ Secondary A.I. ● Normal ACTH→ Not A.I.

TREATMENT

Glucocorticoids ● Prednisone ● hydrocortisone

Mineralocorticoids ● Fludrocortisone

Testosterone (females only)

Dehydroepiandrosterone (DHEA)

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Pituitary tumors

● Pituitary adenomas ● most common type of pituitary disorder ● benign neoplasms

Prolactinomas comprise 40-57% nonfunctioning adenomas 28-37% GH–secreting adenomas 11-13% ACTH–secreting adenomas 1-2%

Signs and symptoms

● syndromes of hormone hypersecretion or deficiency ● neurologic manifestations ● incidental finding on imaging ● Hypogonadism ● Fatigue ● Loss of libido ● Erectile dysfunction (men) ● Oligomenorrhea or amenorrhea(women)

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Making the diagnosis

● CT

● MRI

TREATMENT

NONFUNCTIONING ● Referral to Neurosurgery (GH or ACTH) ● Repeat MRI in 2-3 years

FUNCTIONING ● Dopamine (Prolactinoma) ● Referral to Neurosurgery ● Referral to Endocrinology (GH or ACTH)

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Diabetes insipidus (DI)

TYPES CENTRAL DI ● Pituitary damaged and doesn’t produced Anti-diuretic hormone (ADH) (vasopressin)

NEPHROGENIC DI ● Kidneys non responsive to vasopressin

Signs and symptoms

● Excessive urine (all day/night) ● Extreme thirst ● Increased fluid intake ● Dehydration ● Weight loss ● Decreased appetite ● Fever ● Vomiting ● diarrhea

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CAUSES

Central ● Idiopathic ● Malignant or benign tumors ● Cranial surgery ● Head trauma

Nephrogenic

● Medication induced

Making the diagnosis

● Hypernatremia ● UA ○ Dilute ○ Low specific gravity ○ Osmolality low

● FLUID DEPRIVATION TEST

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treatment

CENTRAL

● DESMOPRESSIN (INTRANASAL OR ORAL) ● CARBAMAZEPINE

NEPHROGENIC ● CORRECT UNDERLYING CAUSE ● HCTZ ● INDOMETHACIN ● AMILORIDE

references

1. Hypothyroidism: An Update David Y Gaitonde MD, Kevin Rowley DO, and Lori B Sweeney MD. Am Fam Physician. 2012; 86(3): 244-251. 2. Hyperthyroidism: Diagnosis and Treatment Igor Kravets MD, Am Fam Physician; 2016; 93(5): 363-370 3. Thyroid Nodules Mark A Knox, MD. Am Fam Physician. 2013;88(3):193-196. 4. Addison Disease: Early Detection and Treatment Principles Aaron Michels MD, Nicole Michels PhD. Am Fam Physician. 2014;89(7):563-568. 5. Pituitary Adenomas: An Overview Marcy G. Lake DO, Linda S. Krook MD, Samaya V. Cruz MD. Am Fam Physician. 2013;88(5):319-327. 6. Diabetes Insipidus U.S. Department of Health and Human Services; National Institutes of Health NIH Publication No. 08–4620 September 2008 7. Subclinical Hyperthyroidism: When to consider Treatment Ines Donangelo MD, Se Young Suh MD, Am Fam Physician. 2017; 95 (11): 710-716.

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questions?

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