Transcript Choosing wisely - Northeast Iowa Family Practice Center

Choosing wisely : Appropriate
Endocrinology testing and treatment
Tulsi Sharma, MD
WFHC, CMC, Waterloo,IA
Androgen deficiency
Lab tests
• Morning total testosterone level
• Confirmation of the diagnosis by repeating
• Evaluation of androgen deficiency should not be made
during an acute or subacute illness.
Sex Hormones and Hypogonadism
Primary hypogonadism
Congenital
Acquired
Secondary hypogonadism
Congenital
Acquired
Anorexia
• Chronic malnutrition and cachexia, regardless of the
cause, can result in secondary hypogonadism
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Crohn’s and celiac disease
Advanced cancer
Renal Failure
Liver disease
HIV
• Excessive exercise, Low BMI
Russ MJ et al. Psychosomatics. 1986 Oct;27(10):737-9.
Rigotti NA et al. JAMA. 1986 Jul 18;256(3):385-8.
Acute Illness
Gonadotroph Sick Syndrome
– Testosterone levels are invariably low
– Checking is not recommended in this setting
Woolf PD et al. J Clin Endocrinol Metab. 1985 Mar;60(3):444-50.
Symptoms of low T are vague and non-specific
Chances are, if you are overweight, physically inactive, have chronic medical
problems, or married (with children) you will fail this test
Testosterone side effects
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Polycythemia (  EPO)
HCT > 52
Sodium & water retention
Gynecomastia, early, usually resolves, esp. obese men
Testicular atrophy and infertility due to  gonadotropins
Prostate cancer, BPH
Sleep apnea
Priapism, acne, aggressive behavior, dose related
Cholestatic jaundice
 HDL-cholesterol,  TBG,  CBG (nl. Free hormone)
Premature fusion of epiphyses
S14 Classification and Diagnosis of Diabetes Diabetes Care Volume 39, Supplement 1, January 2016
Self-monitoring of Blood Glucose
• Integral component of
effective therapy
• It allows patients to
evaluate their response to
therapy
• Useful tool for guiding
medical nutrition therapy
and physical activity,
preventing hypoglycemia,
and adjusting medications
Glycemic Targets Diabetes Care 2016;39(Suppl. 1):S39–S46 | DOI: 10.2337/dc16-S008
Self-monitoring of Blood Glucose
For Patients on Intensive Insulin Regimens
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SMBG prior to meals and snacks,
At bedtime,
When they suspect low blood glucose,
After treating low blood glucose until they are
normoglycemic,
– Prior to exercise,
– Prior to critical tasks such as driving.
May require testing 6–10 (or more) times daily
Glycemic Targets Diabetes Care 2016;39(Suppl. 1):S39–S46 | DOI: 10.2337/dc16-S008
For Patients Using only Basal Insulin
• Monitor and adjust basal insulin to attain a fasting glucose
within a targeted range
• This helps in lowering of A1C
For Patients Using Oral Agents
The evidence is insufficient.
Teach them how to use SMBG data to
– adjust food intake,
– exercise,
– or pharmacological therapy
Glycemic Targets Diabetes Care 2016;39(Suppl. 1):S39–S46 | DOI: 10.2337/dc16-S008
Clinical Practice Guidelines for Hypothyroidism in Adults: AMERICAN ASSOCIATION OF
CLINICAL ENDOCRINOLOGISTS AND AMERICAN THYROID ASSOCIATION 2012
Garber JR et al. Thyroid December 2012 Endocrine Practice November-December 2012
Hypothyroidism
Overt
Subclinical
• TSH above 10
• TSH below 10
• Low Free T4
• Normal Free T4
Severity of Primary Hypothyroidism by Thyroid Levels
TSH rises first and abruptly
Decline of T4
and T3 slower
and later
TSH an excellent test except some pitfalls
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Central disease
Drugs
Heterophilic antibodies
Abnormal isoforms, TSH receptor polymorphisms
Requires steady state:
– pitfalls in an inpatient population and early phases of pregnancy
• Adrenal Insufficiency
– (may raise TSH)
Examples of Age and Ethnicity Differences in TSH
levels
– African Americans between 30-39 : upper normal
– Mexican Americans > = 80: upper normal
7.84
An Approach for Development of Age-, Gender-,and Ethnicity-Specific Thyrotropin
Reference Limits Boucai, Hollowell, Surks THYROID Volume 21, Number 1, 2011
3.24
TSH is Lower Particularly in 1st trimester
Free T4 in pregnancy unreliable
10
weeks gestation
+100
20
30
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E2
TBG
hCG
+50
TT4
%
Change
0
vs.
Non-pregnant
TSH
FT4
-50
1st. Trimester
2nd. Trimester 3rd. Trimester
Pregnancy normal-range TSH values
• First trimester
• Second trimester
• Third trimester
2.5
3.0
3.5
Other thyroid labs
• Free T4
–helps diagnose central hypothyroidism
• Total T4
– pregnancy
• Free T3
– Graves disease, thyrotoxic states
Anti-Thyroid Antibodies
• Anti-Thyroid Peroxidase Antibodies
– Correlate with the development of hypothyroidism
• Anti- Thyroglobulin Antibodies
– Does not Correlate with hypothyroidism
• TRAb , TSI – Graves disease
When Should Antithyroid Antibodies Be Measured?
• Subclinical hypothyroidism.
• Miscarriages
• Infertility
SCH – Why is it important?
• Progression to overt hypothyroidism in 5-18% per
year.
• Hyperlipidemia – Increased total cholesterol and LDL
– Colorado health fair study –Treatment decreases LDL by 8
mg/dl
• Neuropsychiatric effects
Subclinical Hypothyroidism: An Update for Primary Care Physicians Vahab
Fatourechi Mayo Clin Proc. January 2009 84(1):65-71; doi:10.4065/84.1.65
SCH – Why is it important?
Atherosclerosis , MI and congestive heart failure
Rotterdam study:
• Population based cross sectional study: 3105 M & 4878 F
• CONCLUSION: SCH is an independent risk factor for Atherosclerosis
and MI in elderly women
• MOA:
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Lipid metabolism
Collagen-induced platelet aggregation
Hypercoagulable state
Blood viscosity
Homocysteine level
Ann Intern Med. 2000 Feb 15;132(4):270-8.Subclinical hypothyroidism is an
independent risk factor for atherosclerosis and myocardial infarction in elderly women: the Rotterdam Study.
Hypothyroidism – in pregnancy
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Maternal anemia
Pre-eclampsia
Placental abnormalities,
Low birth weight infants
Postpartum hemorrhage
Increased risk of abortion and preterm delivery
Decreased IQ by 7 points in 7-9 yr olds whose
mothers had SCH in pregnancy
Decision to treat
• Overt hypothyroidism -- TSH levels > 10
– TSH target goals 0.45 to 4.12
– Pregnancy goals based on trimester
• Prospective intervention studies have determined that the
average LT4 replacement dose in adults with overt
hypothyroidism is 1.6 μg/kg per day
• Lean body mass is a better predictor of thyroid hormone
requirements than total body weight
Surks et al. 2004 JAMA 291:228-38 (EL4). Rodondi N et al. 2010 JAMA 304:1365-74 (EL2). Razvi S et al. 2010 JCEM 95:1734-40
(EL3). Gencer B et a.2012 Circulation Epub before print (EL1).
Subclinical hypothyroidism
– Pregnancy
– Infertility/Miscarriages
– Childhood and adolescence
– Bipolar disorder, depression
– Goiter
– Presence of antithyroid antibodies
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