Transcript CLINICAL PHARMACY IN ENDOCRINOLOGY

CLINICAL PHARMACY IN
ENDOCRINOLOGY
COMMON ENDOCRINE
DISORDERS
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Type 1 Diabetes
Type 2 Diabetes
Osteoporosis
Thyroid Cancer
Addison's Disease
Cushing's Syndrome
Gestational Diabetes
Graves' Disease
Hashimoto's Thyroiditis
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Hyperglycemia·
Hyperparathyroidism
Hyperthyroidism
Hypoglycemia
Hypoparathyroidism
Hypothyroidism
Menopause
Obesity
Pre-diabetes
Thyroid Nodules
CLASSIFICATION OF
DIABETES
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Diabetes may be primary (idiopathic) or secondary.
Although secondary diabetes accounts for barely 1–2%
of all new cases at presentation, it should not be missed
because the cause can sometimes be treated.
The spectrum of diabetes: a comparison of type 1
and type 2 diabetes mellitus
Type 1 diabetes
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Type 1 diabetes (which
used to be called
juvenile diabetes) can
be overwhelming;
symptoms seem to
develop suddenly:
something triggers the
development of type 1
diabetes (a viral
infection)
Symptoms can rapidly develop:
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Extreme weakness and/or tiredness
Extreme thirst—dehydration
Increased urination
Abdominal pain
Nausea and/or vomiting
Blurry vision
Wounds that don’t heal well
Irritability or quick mood changes
Changes to (or loss of) menstruation
There are also signs of type 1 diabetes. Signs are different
from symptoms in that they can be measured objectively;
symptoms are experienced and reported by the
patient. Signs of type 1 diabetes include:
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Weight loss—despite eating more
Rapid heart rate
Reduced blood pressure (falling below 90/60)
Low body temperature (below 97º F)
Type 2 diabetes
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The symptoms of type 2 diabetes (type 2 diabetes
mellitus) develop gradually—so gradually, in fact,
that it’s possible to miss them or to not connect them
as related symptoms. Some people are actually
surprised when they are diagnosed with type 2
diabetes because they’ve gone to the doctor for
something else (eg, fatigue or increased urination).
The symptoms develop gradually because, if you
have the insulin resistant form of type 2, it takes time
for the effects of insulin resistance to show up.
The common symptoms of type 2
diabetes:
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Fatigue
Extreme thirst: No matter how much the patient drink, it feels
like the patient is still dehydrated. Tissues (such as muscles)
are, in fact, dehydrated when there’s too much glucose (sugar) in
blood. The body pulls fluid from the tissues to try to dilute the
blood and counteract the high glucose, so the tissues will be
dehydrated.
Frequent urination: This is related to drinking so much more in
an attempt to satisfy thirst. Since the patient is drinking more,
he’ll have to urinate more. Additionally, the body will try to get rid
of the excess glucose through urination.
Extreme hunger: Even after the person eat, he may still feel
very hungry.
The common symptoms of type 2
diabetes (cont’d):
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Weight loss.
Infections: The effects of type 2 diabetes make it harder for the body to
fight off an infection. Women may have frequent vaginal (yeast) and/or
bladder infections. That’s because bacteria can flourish when there are
high levels of glucose in the blood.
Slow wound healing: Similar to the body’s inability to fight off
infections, it might take longer for wounds (even small cuts) to heal. The
high blood glucose level affects how well the white blood cells (which
are in charge of healing wounds) work.
Blurry vision: In an attempt to get more fluid into the blood to
counteract the high blood glucose level, the body may pull fluid from the
eyes. The person may have trouble focusing then, leading to blurry
vision.
Complications as the presenting
feature
■ staphylococcal skin infections
■ retinopathy noted during a visit to the optician
■ a polyneuropathy causing tingling and
numbness in the feet
■ erectile dysfunction
■ arterial disease, resulting in myocardial
infarction or peripheral gangrene.
Gestational diabetes
This term refers to glucose intolerance that develops in the
course of pregnancy and usually remits following delivery.
The condition is typically asymptomatic. Women who have
a previous history of gestational diabetes, older or overweight
women, those with a history of large for gestational
age babies and women from certain ethnic groups are at
particular risk, but many cases occur in women who are not
in any of these categories. For this reason some advocate
screening of all pregnant women on the basis of random
plasma glucose testing in each trimester and by oral glucose
tolerance testing if the glucose concentration is, for example,
7 mmol/L or more.
Gestational diabetes
Treatment is with diet in the first instance, but
most patients require insulin cover during the
pregnancy. Insulin does not cross the
placenta. Many oral agents cross the
placenta and are usually avoided because of
the potential risk to the fetus.
THE ADRENAL MEDULLA
Phaeochromocytoma
(tumours of the sympathetic nervous
system. Ninety per cent arise in the adrenal, while
10% occur elsewhere in the sympathetic chain.)
Symptoms
 Anxiety or panic attacks
 Palpitations
 Tremor
 Sweating
 Headache
 Flushing
 Nausea and/or vomiting
 Weight loss
 Constipation or diarrhoea
 Raynaud’s phenomenon
 Chest pain
 Polyuria/nocturia
Signs
 Hypertension
 Tachycardia/arrhythmias
 Bradycardia
 Orthostatic hypotension
 Pallor or flushing
 Glycosuria
 Fever
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damage)
Phaeochromocytoma
Diagnosis
 Specific tests are:
■ Measurement of urinary catecholamines and
metabolites (metanephrines are most sensitive and
specific) is a useful screening test; normal
levels on three 24-hour collections of metanephrines
virtually exclude the diagnosis.
■ Resting plasma catecholamines are raised.
■ Plasma chromogranin A (a storage vesicle protein) is
raised.
■ Clonidine suppression test may be appropriate, but
should only be performed in specialist centres.
■ CT scans, initially of the abdomen, are helpful to
localize the tumours which are often large.
■ MRI usually shows the lesion clearly.
Treatment
Tumours should be removed if this is possible; 5-year survival
is about 95% for non-malignant tumours. Medical preoperative
and perioperative treatment is vital and includes
complete alpha- and beta-blockade with phenoxybenzamine
(20–80 mg daily initially in divided doses), then propranolol
(120–240 mg daily), plus transfusion of whole blood to reexpand
the contracted plasma volume. The alpha-blockade
must precede the beta-blockade, as worsened hypertension
may otherwise result.
ADDISON’S DISEASE
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Addison’s disease is a
rare disorder that
affects men and women
of all ages. Addison’s
disease is also referred
to as primary adrenal
insufficiency. Adrenal
insufficiency develops
when adrenal glands
do not produce enough
of the hormone cortisol.
Diseases of the Adrenal Cortex: Cushing's
Syndrome
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In 1932, a physician named
Harvey Cushing described
8 patients with central
body obesity, glucose
intolerance, hypertension,
excess hair growth,
osteoporosis, kidney
stones, menstrual
irregularity, and emotional
liability. It is now known
that these symptoms
characterize Cushing's
syndrome, which is the
result of excess production
of cortisol by the adrenal
glands.
Cushing's Syndrome
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Since cortisol production by the adrenal glands
is normally under the control of the pituitary,
overproduction can be caused by a tumor in the
pituitary or within the adrenal glands
themselves. When a pituitary tumor secretes too
much ACTH (adrenocorticotropic hormone), it
causes the otherwise normal adrenal glands to
produce too much cortisol. This type of Cushing's
syndrome is termed Cushing's disease, and it is
diagnosed like other endocrine disorders (by
measuring hormone production). In this case, serum
cortisol will be elevated, and serum ACTH will also
be elevated
Cushing's Syndrome
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When the adrenal
glands develop a
tumor, like any other
endocrine gland, they
usually produce excess
amounts of the
hormone normally
produced by these
cells. If the adrenal
tumor is composed of
cortisol-producing cells,
excess cortisol will be
produced.
Cushing's Syndrome
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This images shows several
of the characteristic findings
observed in patients with
Cushing’s syndrome:
hyperpigmented
abdominal striae, central
fat deposition, thinning of
limbs, and easy brusing.
Other common features not
shown include moon
facies, hirsutism, and a
dorsocervical fat pad.
Treatment of Cushing's Syndrome
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The treatment of this disease depends on the
cause. Pituitary tumors are usually removed
surgically and often treated with radiation therapy.
Neurosurgeons specialize in these tumors. If the
cause is determined to be within a single adrenal
gland, this is treated by surgical removal. If the
tumor has characteristics of cancer on any of the xray tests, then a larger, conventional operation is in
order. If a single adrenal gland possesses a small,
well-defined tumor, it can usually be removed with a
laparoscopic adrenalectomy.
Osteoporosis
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Osteoporosis means
"porous bone," and it's a
disorder characterized by
"holey" bones, meaning that
bones aren't as strong as
they should. Though postmenopausal women are
most commonly associated
with osteoporosis, men also
experience it, so everyone
should pay attention to their
bone health.
Osteoporosis
Osteoporosis
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Osteoporosis is a condition
characterized by a decrease
in the density of bone,
decreasing its strength and
resulting in fragile bones.
Osteoporosis literally leads
to abnormally porous bone
that is compressible, like a
sponge. This disorder of the
skeleton weakens the bone
and results in frequent
fractures (breaks) in the
bones. Osteopenia is a
condition of bone that is
slightly less dense than
normal bone but not to the
degree of bone in
osteoporosis.
Prevention of Osteoporosis
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The prevention of osteoporosis is made up of general
lifestyle preferences and other more specific treatments.
Regular and frequent activity of reasonable intensity is
recommended and very helpful at all ages. No one seems
to know just how exercise is too much or too little, but most
physicians recommend about 30 minutes of vigorous
exercise about 3 to 5 times per week. During the growing
years of adolescence and teen years, attention must be
paid to dietary calcium if peak bone mass is to be
achieved.
Prevention of Osteoporosis
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Specific attention to dietary calcium intake may also be warranted
beyond age 60 which may come in the form of increased food
calcium or from specific calcium and vitamin D supplements. For
women at menopause, the appropriate administration of estrogen
(or some of the new synthetic estrogens) is the most potent means
by which bone mass may be preserved, thereby preventing fractures
in the future. In fact, correction of low reproductive hormone levels
at any age is important if proper bone mass is to be maintained.
There is no one treatment, or combination of treatments which can
guarantee zero risk of fractures due to osteoporosis. The best
prevention, however, is a life-long commitment to physical
activity, good nutrition, and normal reproductive hormone
status.
Treatment of Osteoporosis
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patients with proven osteoporosis (by fracture
history or BMD > 2.5 SD below average)
generally need some of specific drug
therapy. All patients, osteoporosis and
osteopenia, need the lifestyle and dietary
therapies
Drugs which are used to treat
osteoporosis can be grouped into two
groups. The first category is comprised of
agents which limit the rate of bone
loss. These drugs decrease the rate at
which osteoclasts reabsorb bone and are
referred to as "anti-resorption drugs".
Anti-resorption drugs
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Calcium and Vitamin D
Estrogen
Calcitonin
Biophosphonates
Treatment of Osteoporosis
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The second group of osteoporosis drugs
promote bone formation and are referred to
as "bone forming drugs". At the present
time, only anti-resorbers are approved in the
United States by the FDA for use in treating
osteoporosis and none of the drugs in this
group have proven themselves yet.
Hyperparathyroidism
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Under normal conditions, a
normal calcium level will be
associated with a normal
parathyroid hormone level.
Also under normal
conditions, a low serum
calcium level will be
associated with a high
parathyroid hormone level; a
high calcium level will be
associated with a low
parathyroid hormone level.
These are all appropriate
ways in which a parathyroid
gland will react to calcium
that is circulating in the blood
as they attempt to regulate
calcium in the narrow normal
range.
Hyperparathyroidism
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Hyperparathyroidism is
relatively easy to detect
because the parathyroid glands
will be making an
inappropriately large amount of
parathyroid hormone in the face
of an elevated serum calcium.
This is straightforward and
simple to measure.
Another way to confirm a
hyperparathyroidism diagnosis
is by measuring the amount of
calcium in the urine over a 24hour period. If the kidneys are
functioning normally, they will
filter much of this calcium in an
attempt to rid the body of
calcium, leading to an
abnormally large amount of
calcium in the urine.
Treatment Options for Primary
Hyperparathyroidism
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The only 2 choices available for patients with primary
hyperparathyroidism are to simply do nothing or to have the
diseased parathyroid gland (or infrequently, more than one
diseased parathyroid gland) surgically removed. Some
physicians will elect to not refer their patients for an
operation if they have a mild form of primary
hyperparathyroidism.
Much of this management style stems from the fact that
standard parathyroid surgery in the past required the use of
general anesthesia and was a major operation. But it's
important to understand that parathyroid disease will get
worse. It won't go away on its own.
Hyperthyroidism
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The actual diagnosis of
hyperthyroidism is easy to
make once its possibility is
entertained. Accurate and
widely available blood tests
can confirm or rule out the
diagnosis quite easily within
a day or two. Levels of the
thyroid hormones
themselves, T4 and T3, are
measured in blood, and one
or both must be high for this
diagnosis to be made.
It is also useful to measure
the level of thyroidstimulating hormone (TSH).
This hormone is secreted
from the pituitary gland
(shown in orange) with the
purpose of stimulating the
thyroid to produce thyroid
hormone.
Graves' disease
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Graves' disease is an autoimmune disease
characterized by a metabolic imbalance resulting
from overproduction of thyroid hormones
(thyrotoxicosis). It is characterized by goiter (a
diffusely enlarged and hyperactive thyroid gland)
exophthalmos (abnormal protrusion of the eyeball),
"orange-peel" skin, and hyperthyroidism. It is the
most common cause of hyperthyroidism in the
world, and the most common cause of general
thyroid enlargement in developed countries.
Although Graves' disease is known to be caused by
an antibody-mediated autoimmune reaction, the
trigger for this reaction is still unknown.
Graves' disease has a multitude of
other symptoms, including:
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Hypertension
Shortness of breath
Muscle weakness (especially in
the large muscles of the arms and
legs) and degeneration
Insomnia
Increased energy
Fatigue
Mental impairment, memory
lapses, diminished attention span
Decreased concentration
Restlessness, erratic behavior,
emotional lability
Brittle nails
Double vision, eye pain, irritation
or the feeling of grit or sand in the
eyes
Swelling or redness of eyes or
eyelids/eyelid retraction
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Sensitivity to light
Abnormal breast enlargement (men)
Diminished/changed sex drive
Decrease in menstrual periods
(oligomenorrhea),
Irregular and scant menstrual flow
(amenorrhea)
Difficulty
conceiving/infertility/recurrent
miscarriage
Hair loss
Itchy skin, hives
Chronic sinus infections
Hypothyroidism
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Hypothyroidism is a condition in which the body
lacks sufficient thyroid hormone. Since the main
purpose of thyroid hormone is to "run the body's
metabolism," it is understandable that people with
this condition will have symptoms associated with a
slow metabolism. The estimates vary, but
approximately 10 million Americans have this
common medical condition. In fact, as many as 10%
of women may have some degree of thyroid
hormone deficiency. Hypothyroidism is more
common than you would believe, and millions of
people are currently hypothyroid and don't know it.
Causes of Hypothyroidism
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There are two fairly common causes of
hypothyroidism. The first is a result of previous (or
currently ongoing) inflammation of the thyroid gland,
which leaves a large percentage of the cells of the
thyroid damaged (or dead) and incapable of
producing sufficient hormone. The most common
cause of thyroid gland failure is called autoimmune
thyroiditis (also called Hashimoto's thyroiditis), a
form of thyroid inflammation caused by the patient's
own immune system.
Hypothyroidism
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The second major cause is the broad category of "medical
treatments." The treatment of many thyroid conditions
warrants surgical removal of a portion or all of the thyroid
gland. If the total mass of thyroid producing cells left within
the body are not enough to meet the needs of the body, the
patient will develop hypothyroidism. Remember, this is often
the goal of the surgery for thyroid cancer.
But at other times, the surgery will be to remove a
worrisome nodule, leaving half of the thyroid in the neck
undisturbed. Sometimes, this remaining thyroid lobe and
isthmus will produce enough hormone to meet the demands
of the body. For other patients, however, it may become
apparent years later that the remaining thyroid just can't
quite keep up with demand.
Symptoms of Hypothyroidism
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Fatigue
Weakness
Weight gain or increased difficulty losing weight
Coarse, dry hair
Dry, rough pale skin
Hair loss
Cold intolerance (can't tolerate cold temperatures like those
around)
Muscle cramps and frequent muscle aches
Constipation
Depression
Irritability
Memory loss
Abnormal menstrual cycles
Decreased libido
Hypothyroidism
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Most people will have a combination of these
symptoms. Occasionally, some patients with
hypothyroidism have no symptoms at all, or
they are just so subtle that they go unnoticed.
Recommended Treatment - Synthetic
preparation of thyroid hormone
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Recommended Vitamin, Minerals and Supplements :
Multi-minerals - needed for proper composition and function of
the body.
Royal Jelly - contains B complex, energizer, helps to prevent
nervousness.
Ginseng and sage - potent energizer
Bee pollen -has all the essential vitamins and minerals.
Vitamins / Minerals
Vitamin B Complex, B2, B12
Vitamin A, C, E
Iodine - 500 mcg.
L-Tyrosine - 800 mg.