Geriatric Endocrine Disorders

• The slides are about geriatric endocrine disorders.

Lecture Learning Objectives

• Identify common metabolic-endocrine diseases in the elderly.
• Recognize atypical presentations of metabolic disease in the elderly.
• Discuss epidemiology, pathophysiology, clinical presentation, laboratory abnormalities, and treatment of diabetes mellitus, hyperthyroidism, hypothyroidism, hyperparathyroidism, and hypoparathyroidism in the elderly.
• Discuss health promotion and disease prevention for diabetes mellitus in the elderly.

Diabetes Mellitus (DM)

• DM is a group of metabolic disorders with hyperglycemia.
• DM is classified by the pathogenic process leading to hyperglycemia.

Diabetes Mellitus in Older Adults

• DM is common in older adults and is associated with increased morbidity and mortality.
• The prevalence of DM (diagnosed and undiagnosed) in the U.S. older adult population is around 9.9 million or 25.2% of people older than 65.
• It is estimated that by 2050, 16.8 million adults older than 65 will have DM if current trends continue.
• People over 65 with DM tend to have a longer disease duration with a mean of 10 years.
• Older adults with DM tend to have higher rates of complications, comorbid diseases, and functional dependence.

Increasing Prevalence of DM in Elderly

• Aging is associated with declining pancreatic beta cell function, relative insulinopenia, and insulin resistance.
• Increased obesity is a factor.
• Lack of physical activity is a factor.
• Loss of muscle mass is a factor.

Diabetes in the Elderly

• Aging is associated with declining pancreatic beta cell function, relative insulinopenia, and insulin resistance.
• DM Type I is an autoimmune disease with absolute decrease in insulin production, early onset, insulin-dependent.
• DM Type II is a relative insulin deficiency secondary to insulin resistance.
• DM Type II involves decreased insulin effectiveness in stimulating glucose uptake by skeletal muscle and restraining hepatic glucose production.
• DM Type II is the most common form of DM in elderly.

Risk factors for Type 2 DM

• Includes family history of DM.
• Overweight or obese (BMI > 25 kg/m2) is a risk factor.
• Physical inactivity is a risk factor.
• Race/ethnicity (e.g., African Americans, Latino, Native Americans, Asian Americans, Pacific Islander) is a risk factor.
• Previous identification with IFG, IGT, or a hemoglobin A1c of 5.7-6.4% is a risk factor.
• History of gestational DM is a risk factor.
• HTN (BP > 140/90) is a risk factor.
• HDL cholesterol level< 35mg/dL and/or TG level> 250mg/dL is a risk factor.
• Polycystic ovary syndrome or acanthosis nigricans is a risk factor.
• History of CVD is a risk factor.

Heterogeneity of DM Presentation in Older Adults

• Some have had type 1 DM for decades with significant end-organ complications.
• Others develop insulin resistance and DM in their 70s or 80s without clear evidence of related complications.
• Some can effectively self-manage their disease, while others cannot due to cognitive, visual, or functional complications.
• Decision-making should be individualized based on patient factors like duration of DM, complications, comorbid conditions, life expectancy, patient goals, preferences, and functional abilities.

Criteria for Diagnosing DM in Elderly

• Hemoglobin A1c ≥ 6.5% is one criterion.
• Fasting plasma glucose ≥ 126 mg/dL (no caloric intake for ≥ 8 hours) is one criterion.
• Symptoms of hyperglycemia plus random plasma glucose ≥ 200 mg/dL is one criterion.
• Two-hour plasma glucose ≥ 200 mg/dL during a 75-g oral glucose tolerance test is a diagnostic criterion.

DM Prevention

• Numerous studies show adults with obesity and impaired glucose tolerance are at high risk for developing type 2 DM and can be helped with diabetes prevention.
• Lifestyle modification (diet, exercise, and weight loss) can delay or prevent progression to DM.
• The Diabetes Prevention Program (DPP) was a multicenter trial examining whether metformin or lifestyle modifications can decrease the progression to DM on high-risk adults.
• In adults >60 years: lifestyle modification was especially powerful, decreasing the incidence of DM by 49% compared to usual care over 10 years of follow-up.
• Metformin reduced the incidence of DM by 18% regardless of age.

Hemoglobin A1C

• Obtain a baseline HbA1c.
• HbA1c should be determined every 1-3 months to determine blood glucose control.
• Poorly controlled: level 9-12%.
• Goal: level<7% is associated with significant risk reduction for neuropathy, retinopathy, renal disease, and CVD.

Common Presenting Symptoms of DM

• Polyuria, Polydipsia, Weight loss, Fatigue, Weakness, Blurred vision, Frequent superficial infections, Poor wound healing

Acute Complications of DM - Diabetic Ketoacidosis (DKA)

• DKA is characteristic of Type 1 DM, but can also occur in Type 2 DM, particularly among Hispanic and African American individuals.
• Insulin deficiency, most commonly a result of inadequate insulin therapy in type 1 DM, leads to decreased glucose metabolism, resulting in increased lipolysis, free fatty acid metabolism, and subsequent ketoacidosis.

DKA Precipitating Factors

• Common precipitating factors for DKA include pneumonia, AMI, and stroke.
• These conditions contribute to DKA by invoking a systemic stress response with increased cortisol, glucagon, and catecholamines that counteracts some of the effects of insulin.
• Patients with DKA present with symptoms of dyspnea, acidosis, dehydration, abdominal pain, nausea, and vomiting.
• Mental status alterations and coma may be present.
• Effective management involves identifying and treating the precipitating factors, as well as treating the metabolic derangements with insulin and volume repletion.

Hyperglycemic Hyperosmolar State (HHS)

• Predominantly in older patients with type 2 DM, may result in marked hyperglycemia (> 600 mg/dL) hyperosmolarity, severe volume depletion, and associated acute kidney injury.
• Patients typically have a several week history of hyperglycemia and osmotic diuresis, leading to dehydration and altered mental status.
• As with DKA, precipitating factors include serious infection, stroke, and AMI.
• Besides identifying and treating the precipitating condition, volume resuscitation with fluids can lead to rapid dramatic improvements in hyperglycemia and hyperosmolarity.
• Mental status alterations often take longer to normalize.

Acute DM Complications – Infections

• Elderly diabetics have an increased risk of infection.
• Hyperglycemia is associated with worse outcomes in common infections like pneumonia.
• DM is a potent risk factor for unusual infections like malignant otitis externa that are uncommon in patients without DM.
• Lower extremity soft-tissue and bone infections are common because of vascular insufficiency and repeated trauma unrecognized by the patient due to neuropathy.
• UTIs are relatively more common in DM patients with glucosuria and urinary retention due to autonomic neuropathy.

Chronic Complications of DM

• Macrovascular: CVA/stroke, coronary artery disease, peripheral vascular disease.
• Microvascular: Retinopathy, nephropathy, peripheral & autonomic neuropathy.
• Nephropathy: microalbuminuria may develop after years of DM.

Macrovascular Complications of DM

• CVD is the major cause of morbidity and mortality for older adults with DM.
• DM imparts a two-fold risk in CHD and stroke and increases the risk of amputation 10-fold.
• Diabetics often co-occurs with other CVD risk factors such as HTN and hyperlipidemia.
• Studies suggest a multifaceted approach addressing multiple risk factors is most effective in decreasing cardiovascular risk.
• The ADA currently recommends ASA (75-162 mg/day) for patients with DM and known CVD.
• The ADA also recommends consideration of high-intensity statin therapy for all patients with DM and CVD.
• Moderate-intensity statin therapy in older adults with DM but without CVD may also be useful.

BP Targets in Patients with DM

• Lower risk for CVD (10-year risk < 15%) target BP should be < 140/90 mm Hg.
• Higher risk for CVD (10-year risk > 15%) target BP should be < 130/80 mm Hg.
• Less aggressive goals may be more appropriate for frail older adults at a higher risk for complications of treatment such as orthostatic hypotension.

Microvascular Complications: Retinopathy

• DM is the leading cause of blindness in the US.
• Early detection and treatment of proliferative retinopathy with laser photocoagulation have been shown to decrease the risk of visual loss.
• Visual compromise is insidious, most pts do not recognize declining visual acuity, and regular screening to detect retinopathy at an early, treatable stage is important.
• ADA currently recommends a dilated eye exam by an ophthalmologist at diagnosis, with regular follow-up exams every 1 to 2 years depending on the individual patient risk factors and initial exam results.
• In addition to retinopathy, older pts with DM also have a two-fold risk of cataracts and a three-fold risk of glaucoma compared to older pts without DM.

Microvascular Complications: Neuropathy

• The most common type of neuropathy is sensory distal symmetric polyneuropathy or "glove and stocking neuropathy”.
• Common symptoms include numbness and burning pain in the hands and feet.
• Sensory neuropathy predisposes patients to unrecognized lower extremity trauma, which can ultimately progress to infection and amputation.
• Annual screening with a 10-g monofilament at the plantar aspect of hallux and metatarsal joint is recommended.
• Autonomic diabetic neuropathy includes diabetic gastroparesis, which can cause nausea and vomiting after eating as a result of impaired gastric emptying, as well as erectile dysfunction and neurogenic bladder.
• Diabetic gastroparesis can improve quickly and dramatically with improved glycemic control compared to many other microvascular complications.

Microvascular Complications: Nephropathy

• Diabetic nephropathy is the most common cause of ESRD and is strongly associated with CVD mortality.
• Diabetic nephropathy is also more common in older diabetic patients than younger, association between severity of nephropathy and mortality appears to be weaker in older adults.
• Diabetic nephropathy leads to more albuminuria and less decline in GFR, compared to other common causes of kidney disease.
• Diagnostic criteria for diabetic nephropathy: Albuminuria > 300 g/day in a patient without other potential causes of albuminuria.
• Studies have shown that treatment with ACE inhibitors or ARBs slows the progression of diabetic nephropathy and decreases the risk if cardiovascular events.
• ADA recommends annual screening for microalbuminuria, which can be accomplished by measuring the urinary albumin-to-creatinine ratio on a spot urine.

Geriatric Syndromes

• Geriatric Syndromes are common, serious conditions in older adults that often present similarly in different patients despite disparate causes.
• DM appears to increase the risk of many geriatric syndromes, including cognitive impairment, depression, urinary incontinence, falls, and functional decline.

DM Treatment Principles

• Plasma glucose management.
• Detect & Manage DM-specific complications.
• Modify risk factors for DM-associated diseases.
• Educate patients about nutrition, exercise, care of DM during illness, and medications to lower plasma glucose.

Glycemic Treatment

• Hyperglycemia is the core pathologic finding in DM, and control of hyperglycemia is a cornerstone of DM treatment.
• Hemoglobin A1c (HbA1c) has been shown to correlate closely with average glucose levels and is strongly predictive of microvascular complications.
• A reasonable rule of thumb is that each 1% increase or decrease in HbA1c is equivalent to a corresponding approximately 30 mg/dL change in average glucose levels.

Glycemic Control Targets

• Studies suggest that tight glycemic control to HbA1c < 7% decreases the rates of microvascular complications over 8 years.
• ADA recommends HbA1c < 7% for healthy older adults with an extended life expectancy.
• For older adults who are healthy with a few chronic conditions, few functional limitations and extended life expectancy, HbA1c target of 7% to 7.5% is appropriate.
• A HbA1c target of 8%-9% may be appropriate for older adults with extensive comorbidities, functional limitations, and limited life expectancy.

Change in Average Glucose Level by HBA1C

• HbA1c of 5 corresponds to average glucose of 97 mg/dL.
• HbA1c of 6 corresponds to average glucose of 126 mg/dL.
• HbA1c of 7 corresponds to average glucose of 154 mg/dL.
• HbA1c of 8 corresponds to average glucose of 183 mg/dL.
• HbA1c of 9 corresponds to average glucose of 212 mg/dL.
• HbA1c of 10 corresponds to average glucose of 240 mg/dL.
• HbA1c of 11 corresponds to average glucose of 269 mg/dL.
• HbA1c of 12 corresponds to average glucose of 298 mg/dL.

Non-Pharmacologic Treatments for DM

• Dietary intervention is an integral component of DM treatment.
• Caloric restriction with a goal of at least a 7% loss of body weight is a recommended lifestyle intervention for appropriate patients with DM.
• Limit saturated fat to 7% of total calories.
• Minimize consumption of trans fats.
• Limit cholesterol intake to less than 200 mg/dL
• Regular exercise has been shown to improve glycemic control, BP, and lipids, and contribute to weight loss.
• The ADA recommends that older adults with DM should strive to achieve 150 minutes per week of moderate-intensity exercise, including both aerobic activity and resistance training.
• ADA recommends maximizing physical activity to reap some of the benefits of exercise for patients with functional impairments who are unable to accomplish the listed requirements.
• The exercise regimen should start with low-intensity physical activity and gradually increase in intensity and duration because older patients with DM are at high risk for CVD.

Agents Used for DM Treatment: Biguanides

• Metformin, reduces hepatic glucose production with dosage 1-2%
• Weight neutral, no hypoglycemia, inexpensive, reduced CV events are all positive agent specific outcomes.
• Negative agent specific outcomes: Diarrhea, nausea, lactic acidosis, Vit B12 deficiency
• Contraindicated with: Renal Insufficiency, CHF, Radiographic contrast studies, Acidosis.

Agents Used for DM Treatment: Alpha-Glucosidase Inhibitors

• Acarbose, miglitol, voglibose, reduces glucose production with dosage 0.5-0.8%
• Acarbose, miglitol, voglibose results in reduced postprandial glycemia.
• Positive agent specific outcomes: Reduce postprandial glycemia
• GI flatulence, liver function tests are negative agent specific outcomes.
• Contraindicated with Renal/Liver Disease.

Agents Used for DM Treatment: Insulin secretagogues

• Glyburide (Micronase), glipizide (Glucotrol), glimepiride increases Insulin secretion.
• Dosage 1-2%.
• Short onset of action, lower postprandial glucose, inexpensive are all positive agent specific outcomes.
• Hypoglycemia, weight gain are negative agent specific outcomes.
• Contraindicated with Renal/Liver disease.

Agents Used for DM Treatment: SGLT2 inhibitor

• Canagliflozin, dapagliflozin, empagliflozin increases renal glucose with dosage 0.5-1.0%
• Positive agent specific outcomes: Do not cause hypoglycemia, reduce weight, BP
• Negative agent specific outcomes: Urinary and genital infections, polyuria, dehydration, hyperkalemia , DKA
• Contraindicated with: Moderate renal insufficiency, insulin deficient DM.

Agents Used for DM Treatment: Thiazolidinediones

• Pioglitazone, rosiglitazone, decreases Insulin resistance, increases glucose with dosage 0.5-1.4%
• Positive agent specific outcomes: Lower insulin requirements
• Negative agent specific outcomes: Peripheral edema, CHF, weight gain, fractures, macular.
• Contraindicated with: CHF/Liver disease.

Agents Used for DM Treatment: All Insulins

• NPH, regular, lispro, detemir, inhaled insulin, glargine increases glucose utilization, decrease hepatic glucose production, not limited in dosage.
• Known safety profile.
• Positive agent specific outcomes: known safety profile
• Negative agent specific outcomes: Injection, weight gain, hypoglycemia .

Agents Used for DM Treatment: Medical nutrition therapy and physical activity

• Low-calorie, low-fat diet, exercise reduces insulin resistance, increases insulin secretion with dosage 1-3%
• Known to be CHF/Liver disease
• positive agent specific outcomes: other health benefits
• Negative agent specific outcomes: Compliance difficult, long-term success low.

Guidelines for Ongoing Medical Care for DM Patients

• Individualized glycemia goal and therapeutic plan.
• Self-monitoring of blood glucose (individualized frequency).
• HbA1c testing (2-4 times/year).
• Diabetes self-management education and support and Nutrition Therapy
• Lifestyle management in care of diabetes, including Physical Activity
• Psychosocial care, including evaluation for depression, anxiety.
• Diabetes related eye examination (annual or biannual)
• Diabetes related foot examination (1-2 times/year by physician; daily by patient)
• Diabetes-related neuropathy examination(annual)
• Diabetes related kidney disease testing(annual)
• Manage or treat diabetes-related conditions, including blood pressure (assess quarterly).
• Manage or treat diabetes-related conditions, including lipids (annual).
• Manage or treat diabetes-related conditions, including consider antiplatelet therapy.
• Manage or treat diabetes-related conditions, including influenza/pneumococcal/hepatitis immunizations.

Hypothyroidism

• Common disease of older adults, especially of older women, with a reported prevalence of 15% to 20% in women over the age of 75 and 4% -7% of men.
• Prevalence rises with age, and is more prominent in women than in men.
• It is a masquerader; elderly have fewer symptoms than younger patients
• May present with nonspecific geriatric age group symptoms such as confusion, anorexia, weight loss, falling, incontinence.
• The American Thyroid Association recommends screening for hypothyroidism in persons > 65 years.

Causes of Hypothyroidism in Elderly

• Autoimmune thyroiditis, increased serum levels of antithyroid peroxidase and antimicrosomal antibodies.
• Prior radioiodine treatment (RAI) for hyperthyroidism.
• Risk of hypothyroidism is > 50% after the first year of RAI, with an additional incidence of 2%-4% each year thereafter.
• S/P subtotal thyroidectomy.
• Medications (iodine-containing contrast agents, lithium, amiodarone, and iodine-containing cough meds).
• Medications including may also lead to hypothyroidism particularly in persons with autoimmune thyroiditis.
• Pituitary or hypothalamic abnormality in the production or release of TSH (AKA Secondary Hypothyroidism).

Clinical Features of Hypothyroidism

• Symptoms: weakness, fatigue, lethargy, dry hair, cold intolerance, poor memory/depression, constipation, mild weight gain, dyspnea, hoarse voice, muscle cramping, paresthesias
• Exam findings: bradycardia, mild diastolic HTN, Prolongation of the relaxation phase of DTR's, cool peripheral extremities, goiter or thyroid atrophy, pale cool doughy skin, enlarged cardiac silhouette 2nd to pericardial effusion, dull, expressionless face, large tongue, sparse hair, periorbital puffiness
• In mild hypothyroidism, the classic findings of overt hypothyroidism may not be present, and the clinical

Lab Abnormalities in Hypothyroidism

• Elevated TSH, it is sensitive marker of primary hypothyroidism but not found in secondary hypothyroidism.
• Decreased serum-free T4 is common to all varieties of hypothyroidism.
• Radioactive iodine uptake usually low.
• Thyroid peroxidase (TPO) antibodies are increased in > 90% of patients with autoimmune-mediated hypothyroidism.
• Elevated cholesterol, increased CPK, and anemia may be present.
• Bradycardia, low amplitude QRS complexes, and flattened or inverted T waves may be present on ECG.
• Start low and go slow.

Hypothyroidism Treatment

• In elderly or in patients with known CAD, starting dose of levothyroxine (Synthroid) is 12.5-25 ug/d.
• Dose should be adjusted in 12.5-25-ug increments every 6-8 weeks on the basis of TSH levels, until a normal TSH level is achieved.
• The average daily replacement dose is 1.6 ug/kg per day, but dosing should be individualized and guided by TSH measurement.
• TSH levels cannot be used in secondary hypothyroidism, and therapy needs to be guided by free T4 measurement.
• Patients generally will require replacement therapy for life.

Myxedema Coma

• May progress into a hypothermic, stuporous state (myxedema coma) with respiratory depression.
• Factors that predispose to myxedema coma include cold exposure, trauma, infection, and the administration of narcotics.
• Treatment, Levothyroxine (200-400ug) as a single IV bolus followed by a daily oral dose of 1.6 ug/kg per day reduced by 25% if administered along with hydrocortisone (50 mg every 6 h) for impaired adrenal reserve,
• Additional treatment includes ventilatory support and treatment of precipitating factors.

Hyperthyroidism

• Hyperthyroidism is the result of an excessive amount of circulating thyroid hormone either from endogenous production or iatrogenic sources.
• This disorder is accompanied by a broad-spectrum of signs and symptoms that vary among individuals and can differ markedly between young and old persons.
• A greater percentage of affected individuals are > 60 y/o.
• Several studies of prevalence indicate the presence of hyperthyroidism in 1% to 3% of community-residing older persons.
• More common in woman than in men, with estimates ranging from 4:1 to 10:1.
• Hyperthyroidism in elderly is even more of a masquerader than hypothyroidism.
• Presenting feature may be decline in functional capacity.
• Eye findings are less common in the elderly.
• Symptoms of heart failure & angina may dominate clinical picture.
• Thyroid gland normal in size in 40%.
• Classic triad in the elderly: tachycardia, weight loss, and fatigue.
• Decreased appetite common; sweating less common.
• Patients are often incorrectly diagnosed as having a malignancy or severe depression.
• Although Grave's disease occurs, the most common cause is toxic multinodular goiter and uninodular toxic goiter.

Causes of Hyperthyroidism in Elderly

• Multinodular toxic goiter- In older persons, multinodular goiter is commonly found but not usually associated with clinical disease.
• Graves disease is most common cause in young population and may still be present in older patients.
• Toxic adenoma (solitary), Ingestion of iodide or iodine-containing substances.
• Excessive L-thyroxine dosage especially important if dosage is > 0.15 mg.
• Amiodarone in approximately 40% of its users, serum T4 levels will be found to be above normal range; but only rarely (in less than 5%), clinically apparent thyrotoxicosis will develop.
• TSH-producing pituitary tumor, has been described, and these are extremely rare; TSH remains nonsuppressed in the presence of increased circulating thyroid hormone.
• Silent/or subacute thyroiditis Increase release of thyroid hormone during inflammatory

Symptoms and Frequency of Signs and Symptoms of Hyperthyroidism

• Symptoms: Nervousness, Weight loss, Emotional liability, Heat intolerance, Tachycardia, Tremors, Increased sweating

HYPERTHYROIDISM LABS AND DIAGNOSIS

• Lab evaluation:
• Serum free T4 and a measurement of TSH are the test for diagnosing thyroid dysfunction
• Fining of a normal or low serum free T4 with a suppressed serum TSH raises the possibility of T3 toxicosis and warrants a measurement of serum T3 by immunoassay.
• Although the finding of anti-TSH receptor antibodies confirms the diagnosis of Graves disease, it is rarely necessary to obtain this test

Hyperthyroidism Differential Diagnosis

• Pts with hyperthyroidism in later life commonly have coexisting illness and it is important not to attribute all presenting signs and symptoms to the hyperthyroid state itself.
• The most common DDX to consider include: Anxiety, Malignancy, Depression, DM, Menopause, Pheochromocytoma

HYPERTHYROIDISM TREATMENT

Therapy should be directed at the specific cause of the hyperthyroid state. Transient forms of hyperthyroidism may not require treatment

• Treat with, Excessive hormone ingestion, lodine exposure, Subacute thyroiditis
• Majority of older pts with either Graves disease or multinodular toxic goiter can be treated with antithyroid meds, or surgery.
• Preferred treatment however is RAI in order to avoid hospitalization and associated anesthesia and surgery risks.

TREATMENT HYPERTHYROIDISM Medications

• A useful initial step in treating hyperthyroidism is to administer a Beta-adrenergic blocking agent such as metoprolol nadolol,or atenolol.
• An agent will quickly control palpitations, angina, tachycardia, and agitation. Caution should be used in patient with HF, COPD, or DM being treated with insulin
• Beta Blockers Once a Graves disease or toxic nodular goiter is confirmed, treatment should be initiated with one of the antithyroid drugs propylthiouracil (PTU) or methimazole

Other HYPERTHYROIDISM information: Medications

• A decline in serum T4 is usually seen within 2 to 4 weeks after initiation of antithyroid drug therapy and dose should be tapered once thyroid hormone levels reach the normal range to avoid hypothyroidism.
• More definitive therapy is needed once the patient returns to a euthyroid state on medication.
• The recommended treatment in most older persons with hyperthyroidism is thyroid gland ablation with I 131. and followed for 3-5 day
• Once the pt. achieves a euthyroid status on antithyroid meds these agents are stopped 3-5 days, after which, RAI is given orally
• Therapy with beta blockers can be maintained and antithyroid agents restarted 5 days after RAI and should be continued for 1 to 3 months until the major effect of RAI is achieved.
• Most clinicians advocate treating the older person with hyperthyroidism with a relatively large dose of RAI to ensure ablation of thyroid tissue and avoid the possibility of hyperthyroidism recurrence
• After treatment, the pt is closely monitored to start replacement doses of thyroid hormone, because hypothyroidism may develop in as few as 4 weeks after treatment.
• Regardless of RAI dosing regimen used 40% to 50% of pts will be hypothyroid within 12 months of RAI administration within 2%-3% developing hypothyroidism each year thereafter
• The use of Surgery is not recommended as a primary treatment for hyperthyroidism in older patients.
  • Prior treatment with antithyroid medications prevents the possibility of radiation induced thyroiditis after RAI therapy
• Coexisting illness, particularly cardiac increase operative risk.
• In addition, postoperative complications of hypothyroidism and recurrent laryngeal nerve damage are significant risks

Other HYPERTHYROIDISM information

• Antithyroid drugs (PTU, Methimazole), Inhibit thyroid hormone synthesis
• Side effects includes, Agranulocytosis (rare), Hepatitis also rare and check if fever or sore throat occur

Hyperparathyroidism

• Has a common disorder that affects predominantly postmenopausal women with an incidence of 2 per 1000 women and may have Primary hyperparathyroidism (PHPT), Secondary hyperparathyroidism (SHPT), or Tertiary hyperparathyroidism (THPT)

• 50% or more patients have no or minimal nonspecific symptoms or signs

• (PHPT)Caused by inappropriate secretion of PTH, which results in hypercalcemia- frequent single benign parathyroid adenoma and multiple adenoma/four-gland hyperplasia Levels almost always elevated above norm/high for level hypercalcemia

• (SHPT)Result of the parathyroid glands response to hypocalcemia in a attempt to maintain calcium homeostasis causes vitamin D insufficiency with CRF

• (SHPT) Result of the parathyroid glands response to hypocalcemia in attempt to maintain calcium homeostasis causes vitamin D insufficiency with CRF and Malabsorption syndromes - use of calcium homeostasis with use of Drugs(bisphosphonates, furosemide, anticonvulsants, phosphorus and Hypercalciuria caused by renal calcium leak

• (THPT) Occurs because of prolonged hypocalcemia leading to parathyroid gland hyperplasia and autonomous overexcretion of PTH resulting in hypercalcemia and no longer responsive to medical therapy

• If SHPT or THPT patients may have symptoms from the primary disease process

• The most common clinical circumstance involves routine blood check showing high hypercalcemia Mild nonspecifics may include fatigue-CNS symptoms of depression/mild cognitive impairment; increased thirst and polyuria is present Hx of renal calculi, fracture, loss of height, and/or disproportionately low-for age BMD on DXA scan-Even if asymptomatic, PHTH patients with calcium stones and/or nephrocalconosis are categorized as having symptomatic disease. With all this Commonest cause of hypercalcemia occurring in OP setting. Generalized disorder of bone metabolism Inappropriately elevated PTH for given Ca level Etiology

• Renal imaging by US may reveal nephrolithiasis if kidney stone suspected-Serum BUN and creatinine should be measured in SHPT as renal insufficiency is often present- Hypercalcemia,Hypercalciuria

• Hypophosphatemia-Hyperphosphaturia and Normal anion gap acidosis Other things include

• Levels of PTH are almost always elevated above the upper limits of normal or WNL but inappropriately high for the level of hypercalcemia.With PTH levels there must be a DDX for HPTH including (malignancy with/without bone metastasis in squamous cell carcinoma of lung (breast cancer, renal cell carcinoma, MM, lymphoma) and hypercalcemia in these malignancies may be mediated by tumor-secreted PTH related protein. Other things includine, Thiazide diuretics-Vit D toxicity,Sarcoidosis orHyperthyroidism, familial hypocalciuric hypercalcemia(FHH). With all this Etiology

• Commonest cause of hypercalcemia occurring in Out Patient Setting-Generalized disorder of bone metabolism and Inappropriately elevated PTH for given Calcium if checked(Etiloogy will show one with PTH adenoma parathyroid 81 with % hyperplasic 15% and with carcinoma 4%) and Sex predilection: Females > males Age predilection: Age 40 to 70 years PTH affects many systems that show-Renal stones(calcium oxalate): Most common symptomatic presentation

• For PTH PUD we must test (Calcium stimulates gastrin release) or do the acute pancreatitis Calcium activates phospholipases. Also check for symptoms of Constipation Most common Gl and metallic calcification of renal tubules and band keratopathy for metastatic calcification-nephrocalcinosis may induce polyuria-loss. We may see other issues- Pruritis: Metastatic calcification skin.

• Short QT interval: Brady-HTN is a result of calcium increases muscular contraction in resistance vessels and pseudo gout Calcium pyrophosphate (positively birefringent). Can include Mental changes as personality changes, psychosis, depression

• PTH may cause Skeletal Lesions: -Osteopenia-Osteitis fibrosa cystica (increase ostrobic bone resorption and increase bone formation associated w BM microfracuture

• resorption on bone that involves cortical r

• Diagnosis made on clinical grounds Confirmed by demonstration of inappropriately high PTH level for degree of hypercalcemia.

• Hypercalcemia may be intermittent or sustained. -Serum phosphate is usually low but may be normal

• Hypercalciuria helps in hypercalemia with normal EKG of arrhythmias

• We may offer offer surgery or Parathyroidectomy offered to pts who meet the criteria for surgery established by the 2008 NID consensus panel or who are symptomatic.

• Increased risk of fx is in older women with a significant osteoporosis reduced by correction of the hyperparathyroidism

• If parathyroid hyperplasia is found, 3.5 of 4 identified glands must be remm

Hypoparathyroidism cause and treatment

• Classically, a low ionized serum calcium and an elevated serum phosphorus level is is identified in association a (PTH)is one with low levels-Hypoparathyroidism is a Differential Diagnosis, of a common occurrence with older patients being measured with low albumin but not the low Calcium binding Measurement of ionizedCalcium is only way to to assess true serum calcium values (Vitamin D deficiency, Hyperphosphatemia, Hungry bone syndrome successful parathyroidectomy Blood transfusions or Magnesium metabolism disorders
• Any causative med should be discontinued, and treatment initiated with symptoms and acuity of hypocalcemia
• Main treatment of Calcium salts and Vitamin D
• Goals to to maintains serum calcium levels withing normal range