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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 – – – – – 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 • • • • • • • • • • 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 – – – – 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 • • • • • 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 40 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: – – – – – 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 • • • • • • • 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 THANK YOU