Diabetes and Endocrinology

Essentials of Clinical Practice

Mushtaq Haroon, Sundus Maryium Husnain

• Publisher: Momentum Press
• Year: 2021
• Print ISBN: 9781946646729
• eBook ISBN: 9781946646736
• Topic: Medicine
• Subtopic: Diseases & Allergies

This concise book on endocrinology and diabetes deals with the core knowledge with emphasis on clinical application, bed side assessment, evaluation, and workup of such patients.

It is richly loaded with lists and tables outlining the clinical features, diagnosis, and management. Diabetes and Endocrinology serves as an invaluable supplement for the preparation of undergraduate and postgraduate viva voce and bedside short and long case examination. Facts are outlined in tabulated format for easy access and learning. Photographs and figures are added where necessary to augment understanding. The book will provide relevant knowledge and clinical skills to diagnose and assess the patient's problem and address most clinical perils in the subject at the bedside.

Associations of Hypothyroidism and Autoimmune Form of Disease

• Dyslipidemia with high cholesterol, increased free fatty acids (FFAs), low-density lipoproteins (LDL), and triglycerides (decreased metabolism/clearance). • Increased mean corpuscular volume (MCV). • Anemia (macrocytic, normochromic normocytic, iron deficiency due to menorrhagia, and occasionally pernicious anemia is associated). • Hyponatremia (due to inappropriate ADH). • High muscle enzymes (CPK, aldolase). • Mild rise in liver enzymes. • Slight reversible rise in creatinine. • Hyperprolactinemia. • Hyperhomocysteinemia. • Hypercoagulable state. Associations: • Heart disease and HTN is more common. • Leaky membranes are responsible for collection of fluid. • Sleep apnea is more common. • Carpal tunnel syndrome is more common. • Schmidt syndrome (autoimmune Addison’s disease + hypothyroidism + Type I diabetes). • Celiac disease is more common. • Cystic fibrosis. • Ovarian hyperstimulation. • Nonalcoholic fatty liver disease (NAFLD) is more common. • Down’s syndrome. • Turner’s syndrome. • POEMS syndrome (polyneuropathy, organomegaly, endocrinopathy, m-protein band (plasmacytoma), skin pigmentation or tethering.

Causes of Altered TSH Levels

Elevated levels: 1. Primary hypothyroidism. 2. Recovery from a non-thyroidal illness (repeat after 4–6 weeks). 3. Pituitary adenoma secreting TSH. 4. Addison’s disease. 5. Resistance to TSH. 6. Drugs that increase TSH include dopamine antagonists like metoclopramide, domperidone and amiodarone and dyes used for cholecystography. Reduce levels: 1. Thyrotoxicosis and subclinical hyperthyroidism. 2. Excessive intake of thyroxine. 3. Panhypopituitarism or central hypothyroidism. 4. Euthyroid sick syndrome. 5. Drugs that may decrease TSH include dopamine, high doses of steroids, and somatostatin. 6. Pregnancy and choriocarcinoma.

Treatment is with thyroxine replacement, which is usually for life. Over- and under-treatment is determined by clinical features and confirmed by TSH and free thyroid hormone levels.

Management Outline of Hypothyroidism

1. Replacement therapy with thyroxine is used, which is converted in the periphery to T3. The dose is usually 1.8 ug/kg with a little higher in children and pregnancy (2 ug/kg especially for 4–6 weeks) and lower in elderly (0.5 ug/kg). Keep TSH >0.5 mu/L. 2. In younger patients and those without coronary artery disease, the replacement dose may be started, but in elderly and patients with heart disease, it is necessary to gradually increase the dose every 2–4 weeks according to the TSH levels, as necessary. In pregnancy, one should measure the TSH almost every month. 3. In pregnancy, the dose requirement is increased, and it starts after the 1^st month and plateaus at 4–5 months. 4. In congenital hypothyroidism, the hormone levels and therapy should be started within the first 2 weeks of life to avoid mental retardation and the consequences of hypothyroidism. 5. In SCH, treatment with thyroxine depends on the symptoms and presence of antibodies. Most physicians would start treatment. 6. Patients with thyroid cancer after thyroidectomy need thyroxine not only for hypothyroidism but to prevent the cancer also. 7. In myxedema coma, treatment should not be delayed and started with thyroxine (combination of T4 and T3 formulations) or T4 200–400 mcg IV stat and then 50–100 mcg daily till patient can take orally. Lower doses are used in elderly and heart disease patients. T3 is give as 5–15 ug stat and about 2.5–10 ug IV eight hourly till the patient is clinically stable. Add hydrocortisone 100 mg IV eight hourly (till hypoadrenalism is excluded). Fluids, glucose, electrolytes, hypotension, hyponatremia, hypothermia, and so on must be managed. Mechanical ventilation may be required. 8. Patients are advised to take thyroxine while fasting for at least four hours and avoid food and other drugs for at least 20–30 minutes. It is important that the bioavailability of the drug varies with different brands and country. 9. If the patient cannot take orally (postoperative), then thyroxine may be given at 70–80 percent of the dose IV daily. 10. For poorly compliant patients, it may be necessary to give the total weekly dose once per week (do not use in patients with heart disease). 11. Some patients (less than 10 percent) may normalize their thyroid function after thyroxine replacement and may not require further therapy.

Euthyroid hyperthyroxemia is associated with elevated total T4 with variable T3 levels and without clinical evidence of disease. T4 is 99.97 percent protein-bound. There is usually a defect in the binding proteins.

Causes of Eut...

Table of contents

• Cover
• Half-Title Page
• Title Page
• Copyright
• Dedication
• Description
• Contents
• Foreword
• Preface
• Acknowledgments
• Introduction
• Adrenal gland
• Reproductive system
• List of Contributors
• About the Authors
• Index
• Backcover