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Questions and Answers
In the context of hypopituitarism resulting from a pituitary tumor, which of the following clinical manifestations would be LEAST directly attributable to the mass effect of the tumor itself, assuming the tumor primarily affects the anterior pituitary without direct extension into surrounding brain structures?
In the context of hypopituitarism resulting from a pituitary tumor, which of the following clinical manifestations would be LEAST directly attributable to the mass effect of the tumor itself, assuming the tumor primarily affects the anterior pituitary without direct extension into surrounding brain structures?
- Endocrine dysfunction manifesting as secondary adrenal insufficiency and hypogonadism. (correct)
- Seizures arising from increased intracranial pressure and cortical irritation.
- Progressive bitemporal hemianopsia due to compression of the optic chiasm.
- Anosmia resulting from direct compression of the olfactory bulb.
A patient with long-standing hypopituitarism secondary to a non-secreting pituitary adenoma is stable on hormone replacement therapy. Which alteration in their medication regimen potentially poses the GREATEST risk for precipitating an adrenal crisis during a period of acute physiologic stress, such as a severe infection or trauma?
A patient with long-standing hypopituitarism secondary to a non-secreting pituitary adenoma is stable on hormone replacement therapy. Which alteration in their medication regimen potentially poses the GREATEST risk for precipitating an adrenal crisis during a period of acute physiologic stress, such as a severe infection or trauma?
- Abrupt cessation of low-dose hydrocortisone replacement without tapering. (correct)
- Discontinuation of growth hormone replacement to mitigate theoretical oncogenic risks.
- Switching from desmopressin to thiazide diuretics for management of concurrent nephrogenic diabetes insipidus.
- Initiation of high-dose estrogen therapy without monitoring for thromboembolic events.
A pediatric endocrinologist is evaluating a child with short stature and suspected growth hormone deficiency. After provocative testing, the child's growth hormone levels remain low. However, the IGF-1 level is normal. Which of the following explanations BEST reconciles these findings?
A pediatric endocrinologist is evaluating a child with short stature and suspected growth hormone deficiency. After provocative testing, the child's growth hormone levels remain low. However, the IGF-1 level is normal. Which of the following explanations BEST reconciles these findings?
- The somatotrophs are dysfunctional but the liver is still producing an adequate amount of IGF-1.
- The child has a biologically inactive form of growth hormone that is detected by the assay but does not stimulate IGF-1 production. (correct)
- The child has Laron syndrome, characterized by GH resistance due to a mutation in the growth hormone receptor.
- The child has a variant growth hormone receptor with increased affinity for GH but impaired signaling.
A patient with a history of acromegaly treated with transsphenoidal surgery and subsequent external beam radiation therapy presents with progressive visual field deficits and panhypopituitarism. Imaging reveals a recurrent pituitary mass. Which medical therapy would be MOST appropriate as a first-line treatment option?
A patient with a history of acromegaly treated with transsphenoidal surgery and subsequent external beam radiation therapy presents with progressive visual field deficits and panhypopituitarism. Imaging reveals a recurrent pituitary mass. Which medical therapy would be MOST appropriate as a first-line treatment option?
A 28-year-old female presents with secondary amenorrhea, galactorrhea, and a slightly elevated prolactin level. After excluding pregnancy and medication-induced hyperprolactinemia, MRI reveals a microadenoma. She desires to conceive. Which represents the MOST appropriate initial management strategy?
A 28-year-old female presents with secondary amenorrhea, galactorrhea, and a slightly elevated prolactin level. After excluding pregnancy and medication-induced hyperprolactinemia, MRI reveals a microadenoma. She desires to conceive. Which represents the MOST appropriate initial management strategy?
A patient with known central diabetes insipidus (DI) is admitted to the ICU following a traumatic brain injury. He is being treated with intravenous (IV) fluids and desmopressin (DDAVP). Which of the following electrolyte abnormalities would warrant the MOST urgent reduction or temporary discontinuation of DDAVP?
A patient with known central diabetes insipidus (DI) is admitted to the ICU following a traumatic brain injury. He is being treated with intravenous (IV) fluids and desmopressin (DDAVP). Which of the following electrolyte abnormalities would warrant the MOST urgent reduction or temporary discontinuation of DDAVP?
In a patient with nephrogenic diabetes insipidus caused by chronic lithium use, which intervention is MOST likely to improve the patient's polyuria and polydipsia, assuming lithium cannot be discontinued?
In a patient with nephrogenic diabetes insipidus caused by chronic lithium use, which intervention is MOST likely to improve the patient's polyuria and polydipsia, assuming lithium cannot be discontinued?
A patient with suspected primary polydipsia undergoes a water deprivation test. After several hours, the urine osmolality plateaus at a submaximal level, and the serum sodium is approaching the upper limit of normal. Administration of desmopressin results in a further increase in urine osmolality. These findings are MOST consistent with:
A patient with suspected primary polydipsia undergoes a water deprivation test. After several hours, the urine osmolality plateaus at a submaximal level, and the serum sodium is approaching the upper limit of normal. Administration of desmopressin results in a further increase in urine osmolality. These findings are MOST consistent with:
Which of the following statements BEST captures the rationale for monitoring gallbladder function in patients receiving long-term octreotide therapy for growth hormone excess?
Which of the following statements BEST captures the rationale for monitoring gallbladder function in patients receiving long-term octreotide therapy for growth hormone excess?
A clinician is initiating cosyntropin stimulation testing in a patient suspected of having secondary adrenal insufficiency due to hypopituitarism. Which factor would MOST strongly suggest the need for a prolonged (e.g., 48-72 hour) cosyntropin stimulation test rather than a standard short test?
A clinician is initiating cosyntropin stimulation testing in a patient suspected of having secondary adrenal insufficiency due to hypopituitarism. Which factor would MOST strongly suggest the need for a prolonged (e.g., 48-72 hour) cosyntropin stimulation test rather than a standard short test?
Flashcards
Pituitary Hormones
Pituitary Hormones
Hormones produced by the pituitary gland that control the function of many target glands and cells.
Hypopituitarism
Hypopituitarism
A condition resulting from the under-secretion of hormones from the anterior pituitary gland.
Endocrine Drug Therapy
Endocrine Drug Therapy
Replacement therapy used when a hormone deficiency is present, helping to produce a specific hormone response.
Somatropin & Somatrem
Somatropin & Somatrem
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Octreotide (Sandostatin)
Octreotide (Sandostatin)
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ACTH Deficiency
ACTH Deficiency
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Cosyntropin (Cortrosyn)
Cosyntropin (Cortrosyn)
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Antidiuretic hormone (ADH)
Antidiuretic hormone (ADH)
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Diabetes Insipidus
Diabetes Insipidus
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Desmopressin
Desmopressin
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Study Notes
- Endocrine disorders include hypopituitarism and diabetes insipidus
Pituitary Hormones
- Hormones from the pituitary gland control the function of many target glands and cells
- Anterior pituitary gland produces 5 types of hormones, and the posterior pituitary gland produces 2
- The anterior pituitary gland produces thyrotrophs (TSH), corticotrophs (ACTH), gonadotrophs (LH, FSH), somatotrophs (GH), and lactotrophs (Prolactin)
- The posterior pituitary gland produces oxytocin and antidiuretic hormone (ADH)
Hypopituitarism
- Hypopituitarism refers to the hyposecretion of hormones from the anterior pituitary gland leading to end organ failure.
- The most common hormones affected are growth hormone, LH and FSH.
- Lack of LH and FSH can cause lack of ovary/testes development leading to infertility.
- Lack of thyroid stimulating hormone (TSH) can cause thyroid dysfunction and metabolism problems
- Lack of adrenocorticotropic hormone (ACTH) can cause adrenal insufficiency and shock, potentially leading to death
- Hyposecretion of hormones is usually caused by pituitary tumors, autoimmune disorders, infections, or gland destruction via trauma, radiation, or surgery
Endocrine Drug Therapy
- Replacement therapy is used when a hormone deficiency is present
- Drug therapy is used to produce a specific hormone response when a hormone deficiency is present
- Diagnostic testing determines hypofunction or hyperfunction of specific hormones
- The mechanism of action differs depending on the drug, but either augments or antagonizes the natural effects of the pituitary hormones
Clinical Manifestations of Pituitary Tumors
- The effects of pituitary tumors on hypopituitarism vary based on the degree and speed of onset of pituitary dysfunction
- Resulting in headaches, visual changes, anosmia (loss of smell), and seizures
Clinical Manifestations of Growth Hormone (GH) Deficiency
- GH deficiency can cause truncal obesity
- GH deficiency can cause decreased muscle mass, strength, and energy
- GH deficiency can cause reduced exercise capacity
- GH deficiency can cause flat affect, depression, and psychologic instability
Drug Therapy for GH deficiency
- Somatropin and somatrem are used as replacement therapy for GH deficiency
- These are recombinantly made growth hormones
- They stimulate skeletal growth in patients with deficient GH
- Adverse effects include headache, hyperglycemia, hypoglycemia, hypothyroidism, and inflammation at the injection site
- Parents of children receiving growth hormones should keep a journal reflecting the child’s growth
- Theraputic effect is increased growth
Drug Therapy for GH Excess
- octreotide (Sandostatin) is used for GH excess
- It antagonizes the effects of natural GH and inhibits GH release
- It can treat carcinoid tumors that secrete vasoactive intestinal polypeptide (VIP)
- octreotide (Sandostatin) reduces severe diarrhea, flushing, and potentially life-threatening hypotension caused by VIP
octreotide (Sandostatin)
- Adverse effects include fatigue, headache, hypo/hyperglycemia, nausea/vomiting/diarrhea, dyspnea, arthralgia, and cardiac arrhythmias; also interacts with Cyclosporine and Ciprofloxacin
- May impair gallbladder function, so instruct patient to report abdominal pain; use with caution in patients with renal impairment, so monitor glucose levels
- Can be given IV, IM, or SC
- Decreases VIP related diarrhea and the rate of growth
Clinical Manifestations of Adrenocorticotropic Hormone (ACTH) Deficiency
- Symptoms include weakness, fatigue, headache, dry pale skin, diminished axillary hair, postural hypotension, fasting hypoglycemia, diminished tolerance for stress, and poor resistance to infections
Drug Therapy for ACTH Deficiency
- Cosyntropin (Cortrosyn) is used as replacement therapy
- It can be administered IM, SQ, IV, or rectally
- Cosyntropin stimulates the release of cortisol from the adrenal cortex
- It has anti-inflammatory effects and promotes renal retention of sodium
- Side effects include edema and hypertension
- Follow directions carefully for administration, maintain adequate hydration, and decrease sodium and potassium intake
- Avoid vaccinations during drug therapy
- Therapeutic response is improved pain and comfort
Posterior Pituitary Gland
- Secretes oxytocin which stimulates uterine contractions in labor and let down of milk in breast feeding women
- Secretes antidiuretic hormone (ADH) which controls concentration of body fluids and conserves water in kidneys
Diabetes Insipidus (DI)
- Caused by central DI, nephrogenic DI, and primary DI caused by damage to thirst regulation or can be associated with Mental Illness
- Central DI is caused by decreased secretion of ADH
- Causes of decreased secretion of ADH are idiopathic, head trauma, pituitary tumor and neurosurgery
- Nephrogenic DI is caused by kidney resistance to ADH
- Causes of kidney resistance to ADH are lithium toxicity, renal disease, hypokalemia, pregnancy and medications
Diabetes Insipidus: ADH deficiency
- Deficient production of antidiuretic hormone (ADH) is the underlying cause
- ADH regulates fluid volume by stimulating reabsorption of water in the renal tubules
- When ADH is released, the renal tubules reabsorb water, creating a more concentrated urine.
- When ADH is inhibited, renal tubules do not reabsorb water, resulting in a more dilute urine.
- ADH deficiency results in fluid and electrolyte abnormalities
- Fluid and electrolyte abnormalities include increased urinary output
- Fluid and electrolyte abnormalities include increased plasma (serum) osmolality and decreased urine osmolality
Clinical Manifestations of Diabetes Insipidus
- Symptoms include polydipsia (excessive thirst), polyuria (5-20 L/Day), low specific gravity of urine, hypernatremia, nocturia, generalized weakness, weight loss, constipation, poor skin turgor, hypotension, tachycardia, irritability, mental dullness, and shock
Drug Therapy for ADH Deficiency
- Vasopressin and desmopressin are used to increase water resorption in distal tubules and collecting ducts of the nephrons
- These medications concentrate urine, reducing water excretion by up to 90%
- Vasopressin is a powerful vasoconstrictor used for hypotensive emergencies, GI bleeding, and esophageal variceal bleeding
- Desmopressin is used for dose-dependent treatment of blood disorders by increasing plasma level factors (i.e., factor VIII) and for nocturnal enuresis (bedwetting)
Desmopressin/Vasopressin
- Vasopressin can be given nasal, IV, or IM
- Use cautiously in patients with seizure disorders, asthma, cardiovascular disease, and renal disease
- Monitor IV site carefully because infiltration can cause severe tissue damage and possible necrosis
- Interacts with carbamazepine (anti-seizure medication) to enhance the antidiuretic effect and Norepinephrine (Vasopressor for blood pressure) to reduce the antidiuretic effect
- Desmopressin is given as a nasal spray, orally, IV, or IM
Adverse Effects and Therapeutic Effects of Desmopressin/Vasopressin
- Adverse effects include hypertension, fever, vertigo, headache, nausea/heartburn/abdominal cramps, uterine cramping, nasal irritation/congestion, tremors, and sweating
- The therapeutic effect is to reduce severe thirst and decrease urinary output
General Nursing Implications for all Endocrine Anitdiuretic Drugs
- Obtain thorough nursing assessment and medication history
- Assess for contraindications specific to each drug and medication history for possible interactions, rotate injection sites
- Medications should not be discontinued abruptly, do not take over-the-counter products without checking with health care provider and monitor for adverse effects
SDOH considerations for Anitdiuretic Endocrine Drugs
- Somatropin costs $800 - $3,000 per month
- Ocretotide costs $125 for 10 vials
- Cosyntropin costs $96 per dose
- Vasopressin costs $412 per 5 mL, generic version costs $88 per 5 mL
- Desmopressin costs $475 per bottle (5 mL)
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