Endocrine

Endocrine #

Hypogonadism (low testosterone) in Males #

Diagnosis #

Symptoms #

  • Low libido
  • Decreased morning erections
  • Loss of body hair
  • Low bone mineral density
    • low impact fracture
  • Gynecomastia
  • Small testes
    • infertility
  • Less specific:
    • Fatigue
    • depression
    • anemia
    • reduced muscle strength/increased fat

Labs #

  • ≥2 low AM (0800-1000hrs) total testosterone levels (must be with with symptoms as above)
    • free testosterone only needed if you think sex-hormone binding globulin (SHBG) deficiency (older men)
    • Elevated FSH and LH → primary hypogonadism
    • Normal/low FSH and LH → secondary hypogonadism
      • Consider
        • prolactin → hyperprolactinemia
        • Fe sat → hemochromatosis
        • pituitary function test (likely referral to endo)
        • MRI sella turcica

Endocrine society strongly recommends against treatment unless diagnosis established as above, very hard to stop because of hypogonadism during recovery of pituitary-testicular axis

  • Testosterone therapy eventually causes
    • Small testicles
    • Spermatogenesis supression
    • Will contribute to BPH
    • Increased CV risk
      • Higher with injections, lower with gels/transdermals

Contraindications #

  • Prostate cancer
  • Erythrocytosis (Hct > 50)
  • Severe OSA
  • CHF (testosterone retains some sodium)

Monitoring #

  • Initially every 2-3 months, when stable every 6-12 months
  • Measure in between dosing days (i.e. if dosed on Mon, measure on Thurs or Fri)
    • Gel has variable absorption, need two measurements to
  • Hct < 50% (or above Hgb above upper limit)
    • above normal should stop/lower therapy until normalizes
    • If can’t keep Hct normal and total testosterone normal
      • Eval for OSA/hypoxia
      • If no treatable cause → phlebotomy
  • Total testosterone 500-600 ng/dL
    • Reduce if higher
  • LH should normalize if adequately treated (will be high in hypogonadism)
  • If fx at time of diagnosis or density in osetoporotic range
    • DXA every 2 years until normalizes

DM1 #

Inpatient #

Common Scenarios #

  • On basal-bolus
    • If eating: continue home dosing (consider 20% reduction to be safe)
    • If NPO: continue basal only
  • On pump
    • Verify settings
    • Make sure pt has enough supplies while admitted
    • Continue pump
      • If no, convert to basal/bolus

DKA #

Converting insulin drip to basal rate #

Once gap closed and bicarb normalized:

  • Add up total insulin in last 6 hours (must be stable), x4 (24hr needs) = TDD
  • 60-80% TDD as basal
    • Give first dose of basal 2 hrs before stopping drip

DM2 (Diabetes Type 2) #

A1c >7% or random glucose >200mg/dL diagnostic.

Outpatient #

Goal: 80-130mg/dL fasting/pre-prandial; <180mg/dL PP with <50mg/dL pre-prandial to post-prandial rise

Treatment #

  1. Metformin
    • Best data on outcomes
    • Mechanism: ↓ hepatic production, ↑ insulin sensitivity
    • AEs: diarrhea (pt will get this, but will go away), GI upset
    • A1c Reduction: >2% (high)
    • Ramp on start:
      • 500mg qhs x 1 week
      • 500mg BID x 1 week
      • 1g qAM + 500mg qhs x 1 week
      • 1g BID indefinitely
        • If not tolerated go to previous step and extend to 2 weeks before up-titration
        • Can try ER formulation to minimize GI side effects, still is BID though
    • Always take with food (to help with GI upset)
    • Long term metformin can cause B12 deficiency, check if neuropathy in any pt on metformin more than 5yrs
  2. GLP-1 RA, DPP-4, SGLT-2, TZD, vs SU
    • GLP-1 RAs ("-tides")
      • Mechanism: slows gastric emptying, increased satiety, predictable weight loss (graphic)
      • Injections
        • daily
          • Exenatide (Byetta) (BID)
          • liraglutide (Victoza)
        • or weekly
          • dulaglutide (Trulicity)
          • semaglutide
      • AEs: very low risk of hypoglycemia (“smart” secretors), ?pancreatitis, risk of thyroid cancer in pts with strong FMHx (otherwise ok), GI (will get better with use)
      • A1c Reduction: >2% (high)
    • Sulfonylureas (“g-ides”)
      • Glipizide
      • “Dumb” insulin secretors (increase secretion regardless of glucose level)
      • Think of the using the extended release forms as you would basal insulin
      • Always take with meals!
        • If you skip a meal, skip a dose
      • AEs: hypoglycemia
      • A1c Reduction: >2% (high)
    • Thiazolidinediones (TZDs)
      • Pioglitazone (Actos)
      • Increases insulin sensitivity
      • potential CV benefits (pioglitazone)
      • AEs: edema, caution in HF as edema can mimic HF sx, bladder cancer => caution in pt with strong FMHx (otherwise ok)
      • A1c Reduction: >2% (high)
    • DPP-4 inhibitors ("-gliptins")
      • Linagliptin (Tradjenta)
      • Increased insulin secretion (inhibits degradation of GLP-1s)
      • AEs: essentially zero risk hypoglycemia, ?thyroid cancer (only seen in mice), ?pancreatitis (never been shown)
      • A1c Reduction: 1-2% (intermediate)
      • Generally really well tolerated
    • SGLT2 inhibotors ("-flozins")
      • ertugliflozin (Steglatro), dapagliflozin (Farxiga), canagliflozin (Invokana)
      • Mechanism: increased urinary glucose excretion
      • AEs: moderate risk of hypoglycemia, UTI, euglycemic DKA (very low risk, but be aware), avoid canagliflozin in pts with foot ulcers
      • A1c Reduction: 1-2% (intermediate)
      • Take in morning so active during day
  3. Insulin
    • Basal
      • Normal starting dose 0.1-0.2U/kg/day
        • 0.15U/kg/day good fist bet or just start with 10U
    • Mealtime
      • Looking for PP BG to be <180 and total change from pre-prandial to post to be <50 (this is what normal looks like)
      • Don’t treat PPs if high but ΔBG < 50; look for highs earlier in the day to treat (i.e. came into that meal high)
      • Start with 4U or 10% of basal dose
        • Titrate by 1-2U, twice weekly

DM2 Meds Alogorithm

Med Hepatic Production Insuin Secretion Insulin Sensitivity Intertinal Absorption Other
Metformin
Sulfonylureas
TZDs
Acarbose
GLP-1 RAs ↓ gastric emptying, ↑ satiety, ↑ weight loss
DPP-4 inhibs
SGLT-2 inhibs ↑ urinary excretion

Follow up/Surveillance #

  • A1c 2x/yr (or every 3 months if not well controlled)
  • Annually
    • Lipids
    • Creatine
    • Foot exam
    • Retinal exam

Inpatient #

  • Goal: 140-180mg/dL
    • Can be higher in older/terminally ill
    • Can target lower (<140mg/dL) in right patient if needed
  • Do not use just SSI (poor form), need basal too

Treatment #

  • Orals
    • Stop all orals, control with only insulin.
    • Resume 1-2 days prior to d/c
  • Insulin
    • Total needs usually 0.3-0.5U/kg/day
    • Usually split about 50-50 between basal and short acting
    • Basal
      • 0.15U/kg/day (actual weight) is good starting spot
      • Uptitrate if fastings are high
    • Correctional
      • SSI for 24hrs, then can do scheduled or ↑ basal
Common Scenarios #
  • Not on insulin
    • Hold orals
    • If BG <180mg/dL on admit → start just LDSSI
      • If needs more than two doses in 24hrs → start basal
      • If not, d/c SSI, change to qday BG checks
    • If BG >180mg/dL on admit → start basal (0.15U/kg/day) + LDSSI
      • Decrease if CrCl <30 (reduced elimination)
  • On home basal only
    • Continue home dose (can reduce by 20-40% to be safe)
    • Add correctional
  • On home basal-bolus
    • If eating → continue both (can reduce by 20% to be safe)
    • If NPO → continue just basal
  • On Pre-Mixed
    • Add up total daily dose (TDD) of insulin
      • if eating → 50% TDD as basal, 50% TDD as scheduled short acting
      • if NPO → 50% TDD as basal only
  • On pump
    • Verify settings
    • Make sure pt has enough supplies while admitted
    • Continue pump
      • If no, convert to basal/bolus
  • Surgery
    • Basal/pump: reduce 20-40% for day of surgery
    • NPH: reduce 50% morning of
    • Orals/mealtime insulin: hold day of

Insulin #

Basal Titration #

  • Gut feel => 10-20% changes
  • 2x3 Method: ↑2U every 3 days
  • Treat to Target (TTT)
    • Average fasting BGs over a week, changes every 7 days. If:
    • >180: ↑8U
    • >160: ↑6U
    • >140: ↑4U
    • >120: ↑2U
  • 303 method: every 3 days if
    • >130 (110 if aggressive) increase by 3U
    • <80 (70 if aggressive) decrease by 3U

Steroid Induced Hyperglycemia #

Tends to have bigger effect on postprandial glucose.

  • If fasting BG > 180mg/dL → consider basal 0.15U/kg/day
  • If fasting BG < 180mg/dL and postprandials → consider 0.1U/kg NPH qAM (only)
    • NPH has more of a “peak effect”, can target for during day when eating

Thyroid Storm/Severe Thyrotoxicosis #

  • Grey line inbetween the two

Treatment #

  • PTU 200mg q4h (if thyroid storm) or Methimazole 20mg q4-6h (if severe)
  • Propranolol 60-80mg q4-6h
  • Hydocortisone 100mg q8h
  • Iodine
  • Follow fT4

Pearls #

  • Correction factor = Change in BG / insulin dosed
    • Gives you an idea of how much to use
      • Lower numbers → more insulin resistant
    • DM2’s usually around 20-30
    • DM1’s usually closer to 50
  • Carb factor = correction factor / 3
    • Can pre-dose or know how much to give after meal
  • Maximize basal before postprandials
    • If BG high, add half of daily SSI dose to basal
  • Be sure to order pen needles if rx’ing an insulin pen
  • Normal post-prandial glucose rise should be <50 and absolute number should be <180mg/dL