Endocrine Disorders: Comprehensive Guide to Diagnosis and Management, Exams of Endocrinology

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CAM II - Endocrine

Ultrasound - ANS Diagnostic for thyroid nodules 7-10 days - ANS What is the half life of T4? Low T4 - ANS What is the trigger for the hypothalamus to secrete TRH? Depression, memory loss, slow speech - ANS What are the cognitive Sxs of hypothyroidism? Derm - ANS What affected body system could indicate mod-severe hypothyroidism? Thyroperoxidase (TPO) - ANS What enzyme do antibodies attack in Hashimoto's? Thyroglobulin (TGB) - ANS What protein do antibodies attack in Hashimoto's? True - ANS In early Hashimoto's development, labs may show hyperthyroidism or normal levels (T/F) Women - ANS Demographic most affected by Hashimoto's DM 1 - ANS What other autoimmune Dx would suggest a hypothyroid screening? Pernicious Anemia - ANS What type of anemia would suggest a hypothyroidism screening Amiodarone and Lithium - ANS What medications would suggest a hypothyroidism screening?

Infertility - ANS What concerning Sx can occur in women with hypothyroidism? 1st and 2nd trimester - ANS Which stages in pregnancy need increased thyroid med dosages to combat hypothyroidism and prevent complications? False - ANS Hypothyroidism Dx is dependent on Ultrasound imaging (T/F) Inconclusive - ANS What will the Thyroid Uptake Scan result be in hypothyroidism? 50mcg - ANS Levothyroxine starting dose for adults 25mcg - ANS Levothyroxine starting dose for elderly Pts 4mcg/kg/day - ANS What is dosage for levothyroxine for kids? Stable CAD or mild hypothyroidism in elderly - ANS What conditions would suggest starting at a low dose of levothyroxine? 4-6 weeks - ANS Follow-up frequency for starting levothyroxine New Dx - ANS Insurance will pay for T4 and T3 only for _______ to rule out rare condition of central hypothyroidism 6-12 months - ANS Follow-up frequency for levothyroxine once Pt is stable

Increase dose by 20% - ANS Pt w/ hypothyroidism on levothyroxine reports she is pregnant. What adjustment do you make? Warfarin, Antidepressants, Antidiabetics - ANS What meds can lower levothyroxine absorption? Increase to next available dose; 4 weeks - ANS Pt on levothyroxine has levels checked. Results show TSH

10mIU/L. What adjustment do you make? When is the next follow-up? Pt on levothyroxine has levels checked. Results show TSH 4.2-10mIU/L. What adjustment do you make? When is next follow-up? - ANS Recheck in 4 weeks and wait to adjust Stop taking med; A-Fib risk; 4 weeks - ANS Pt on levothyroxine has levels checked. Results show TSH <0.1. What adjustment do you make? Why? When is the next follow-up? Decrease to next available dose - ANS Pt on levothyroxine has levels checked. Results show TSH <0.4. What adjustment do you make? Myxedema Coma - ANS Hypothyroidism condition that affects multiple organs. Presentation will show AMS, elevated DBP, bradycardia, hypothermia, and swelling in face/tongue/eyes. Often fatal and common in elderly

Admit to ICU, vent, IV levothyroxine - ANS Treatment for myxedema coma Central Hypothyroidism - ANS Rare thyroid condition where hypothalamus does not secrete a sufficient amount of TSH TRH - ANS In Central hypothyroidism, the hypothalamus is not responding to _____

TS immunoglobin bind to TSH receptors - ANS What causes the overproduction of T3/T4 in Grave's disease? Radioiodine ablation - ANS 1st line treatment for Grave's Pregnancy, Grave's ophthalmopathy - ANS What are the contraindications for radioiodine ablation to treat Grave's? Methimazole and PTU - ANS What are the anti-thyroid meds to treat Grave's? Radiation contamination is active 48 hrs post-op - ANS What must you educate the Pt on I-131 therapy for Grave's? Methylprednisone tapered to prednisone - ANS Treatment for Grave's ophthalmopathy Amiodarone - ANS What med can cause hyperthyroidism? (Contraindicated DDI in Hashimoto's) A Fib and Sinus Tach - ANS EKG observations of hyperthyroidism

1cm - ANS Thyroid nodule size required for fine needle biopsy Radioactive Iodine - ANS Preferred Grave's Disease Tx in US Thionamide - ANS Med class option for hyperthyroidism Thionamide - ANS Methimazole, carbimazole, and propylthiouracil (PTU) are in the ________ med class that treat hyperthyroidism

Reduce dose by 50% and maintain for 12-18 months - ANS Once euthyroidism is achieved with methimazole, what adjustment should be made? 5-10/30mg PO QD - ANS Low/High dosage for methimazole Propylthiouracil (PTU) - ANS Of the thionamide med class, which has the highest risk for liver damage PTU - ANS Which thionamide is preferred in pregnancy? 100-150mg PO q 6 hrs until Sxs resolve then taper to maintnenance - ANS Dosage pattern for PTU to treat hypothyroidism BB - ANS What med can lower risk for cardiac complications caused by hyperthyroidism? Atenolol or Propanolol - ANS Which BBs can be given for hyperthyroidism cardiac protection? 50% chance of hyperthyroidism reoccurrence - ANS What risk do anti-thyroid meds carry? Agranulocytosis - ANS A life-threatening drop in white blood cells. This condition is sometimes produced by prolonged anti-thyroid med usage >1 yr Pancytopenia - ANS What other condition besides agranulocytosis can occur with prolonged anti-thyroid med usage? 6 weeks - ANS Follow-up frequency for anti-thyroid meds to check TSH

Methimazole - ANS What med is given pre-op for thyroidectomy? 4-6 weeks - ANS Follow-up frequency post- partial thyroidectomy 4-5 months - ANS How long does it take radioactive iodine ablation to take full effect? 4-6 weeks - ANS Follow-up frequency during radioactive iodine treatment Grave's exophthalmos gets worse for 3-6 months before it gets better; Prednisone - ANS What complication must the Pt be aware of before starting hyperthyroid treatment? What is the treatment for this? Thyroid Storm - ANS A fatal condition when excessive thyroid hormone is released HTN, Hypotension, then shock - ANS What BP pattern is seen with thyroid storm? Admit to ICU, IVF, propranolol, dextrose, electrolyte correction, hyperthyroid correction - ANS Treatment for thyroid storm DeQuervain's Thyroiditis - ANS What thyroid condition can be caused by viral illness or post-partum? Goiter - ANS Clinical presentation of DeQuervain's thyroiditis in 50% of cases ESR (mildly elevated T4/T3) - ANS What lab value is elevated with DeQuervain's thyroiditis? Aspirin - ANS 1st line treatment for DeQuervain/Subacute Thyroiditis

Anti-TPO and Anti-TGB - ANS What antibodies are + in Hashimoto's thyroiditis? Thyrotoxicosis - ANS Amiodarone and levothyroxine DDI will cause ___ from excess iodine load Supportive Care - ANS Treatment for silent thyroiditis Congenital remnant of piriform sinus - ANS What is an anatomical reason for developing suppurative thyroiditis?

• ANS 80% of all thyroid cancers will presents as will present ____-type carcinoma Neck swelling and hoarseness - ANS What physical exam findings will present with thyroid cancer?

1.5cm - ANS What size thyroid nodule would indicate a total thyroidectomy is recommended? True - ANS All thyroid cancers have an excellent prognosis....except anaplastic (T/F) Bone, Lung, CNS - ANS Where can follicular thyroid cancers mets? Calcitonin - ANS What hormone is produced in excess and indicative of medullary thyroid cancer? Total Thyroidectomy - ANS Treatment for medullary thyroid cancer Anaplastic - ANS Most aggressive form of thyroid cancer that has a fatality rate

Surgical resection; Can spread it further - ANS What Tx is contraindicated with Thyroid Gland Lymphoma? Why? Ultrasound, Serum TGB, PET (if met suspected) - ANS Required diagnostics for thyroid cancer treatment tracking TSH - ANS What hormone should be suppressed post-surgical resection of thyroid cancer to prevent tumors from regrowing? I-131 Ablation - ANS Treatment if thyroid tissue still remains after total-thyroidectomy TGB - ANS Evidence of _____ post-thyroid cancer treatment means reoccurrence will occur until proven otherwise Toxic Nodular Goiter - ANS Somatic mutation of thyrotropin receptors that causes glands to swell Iodine Uptake Scan - ANS What diagnostic should always be ordered when suspecting hyperthyroidism? Toxic Nodular Goiter - ANS If left untreated, what thyroid condition can lead to osteoporosis, arrythmias, HF, coma, and death TSH and US - ANS Diagnostics for goiters Increase GI calcium absorption - ANS PTH enhances the synthesis of 1,25(OH)D. What is this hormone's purpose? Calcitonin - ANS Hormone that prevents osteoclast activity and to remove calcium from blood to store in bone

Cancer - ANS When hypercalcemia is seen on labs, what should also be on your differential every time besides hyperparathyroidism? Adenoma - ANS 80% of hyperparathyroidism cases are caused by what? Hypercalcemia - ANS Pt comes in with muscle fatigue, depression, and constant kidney stones. Probable Dx? Salt and Pepper Skull Distal clavicle resorption - ANS What are the 2 x-ray skeletal findings of untreated hyperparathyroidism? Sestamibi Technetium Scan - ANS Diagnostic for hyperparathyroidism that has 95% sensitivity to identifying adenomas Osteitis fibrosa cystica - ANS Seen in primary hyperparathyroidism. Presents with bone pain, subperiosteal erosions affecting the phalanges of the hand, and brown tumor bone cysts. Serum ionized calcium - ANS Step 2 in hyperparathyroidism work up after obtaining CMP with total calcium. (Most accurate measurement)

2.5 - ANS What will the serum calcium/phosphate ratio be in hyperparathyroidism? Monitor and recheck at follow-up - ANS Treatment of aSx Pt with suspect hyperparathyroidism that has

serum calcium level of 6 mg/dL Surgery (Threshold >11) - ANS Treatment of aSx Pt with suspect hyperparathyroidism that has serum calcium level of 12mg/dL

Decrease of 50% within 10 mins after removal - ANS What indicates surgical success of removing hyperparathyroid glands? Lip numbness and facial twitch - ANS What signs indicate hypocalcemia post-op of parathyroidectomy? Secondary Hyperparathyroidism - ANS Kidneys no longer make Vitamin D and filter phosphorus from blood due to chronic disease. Retained phosphorus binds calcium and causes hypocalcemia. Parathyroid attempts to compensate Vit-D injections + calcimimetics - ANS How is hypocalcemia corrected in secondary hyperparathyroidism? (once phosphate is balanced) Lower phosphorus in diet + phosphorus binder meds - ANS How is hyperphosphatemia corrected in secondary hyperparathyroidism? DiGeorge Syndrome - ANS Lifelong risk of symptomatic tetany caused by hypoparathyroidism Trousseau's Sign - ANS Carpopedal spasm caused by hypoparathyroidism Unexplained dementia and psychosis - ANS What mental health Sxs could indicate hypoparathyroidism? Admit to ICU and increase calcium levels - ANS Treatment for hypoparathyroidism Pituitary adenoma - ANS Most common cause of hyper/hypopituitary (overall) TSH, ACTH, FSH/LH, Prolactin, ADH, GH, Oxytocin - ANS What are the hormones the pituitary secrete? (7)

Breast cancer - ANS What cancer most commonly metastasizes to pituitary? Infertility - ANS Effect: Pituitary does not secrete enough FSH/LH in women Slowed Labor - ANS Effect: Pituitary does not secrete enough oxytocin Low Testosterone - ANS Effect: Pituitary does not secrete enough FSH/LH in males Diabetes insipidus - ANS Effect: Pituitary does not secrete enough ADH Kallman Syndrome - ANS Isolated gonadotropin deficiency associated with anosmia (lack of smell) Prader-Wili syndrome - ANS Isolated gonadotropin deficiency that will present with mental retardation and hyperphagia Sheehan's Syndrome - ANS Pituitary infarction post-partum Depression - ANS What mental health Sx will present with ACTH deficiency? Recurrent hypoglycemic seizures - ANS What complication will occur with Laron Syndrome? Stroke and TBI - ANS What is the most common cause of hypopituitarism in adults?

10mm - ANS Size classification for pituitary macroadenoma

Visual defects, HA, Amenorrhea - ANS Top 3 Sxs of pituitary neoplasms MRI w/wo gadolinium - ANS Diagnostic imaging for pituitary neoplasm Trans sphenoidal surgery - ANS Treatment for pituitary neoplasms Macroadenoma - ANS Which class of pituitary neoplasms has the lowest remission rate? Prolactin and GH-secreting - ANS Which type pituitary neoplasms respond to medication? DI, cranial nerve damage, visual defects, hypopituitarism, hormone deficiencies - ANS Pt is considering surgery to remove pituitary neoplasms. As the PA, you need to make them aware of the risks that come with surgery. What complications can arise form the surgery? Pituitary infarction - ANS Pt being treated for pituitary neoplasm has acute onset AMS and visual defects. What could be occurring? Pituitary Ring Sign - ANS Enlarged pituitary bulging under optic chiasm seen on MRI that is indicative of pituitary infarction High dose corticosteroid and trans sphenoidal surgery - ANS Immediate treatment for pituitary infarction Cushing's Disease - ANS Effect: Pituitary secretes too much ACTH Prolactinoma - ANS Most common type of pituitary adenoma

Pregnancy - ANS Female Pt comes in for galactorrhea. What should be considered before pituitary abnormality?

100ug/L - ANS What lab value of prolactin is indicative of prolactinoma? (ug/L) Dopaminergic agonists - ANS What med class do prolactinomas respond to? Cabergoline - ANS What is the preferred dopaminergic agonist for treating prolactinomas? Bromocriptine - ANS 2nd line med for prolactinoma True - ANS All pituitary macroadenomas must be surgically excised (T/F) IGF-1 - ANS Once GH is in circulation, it stimulates the production of ______ which is the primary mediator of GH effects on body Slow, unnoticed progression - ANS What is the growth pattern of an adult with acromegaly? IGF-1 - ANS What lab is targeted first when suspecting acromegaly? Prolactin - ANS What other homrone <0.4 - ANS What is the goal GH level after treating acromegaly with trans sphenoidal surgery? Somatostatin - ANS What hormone in the secreted in the body tissues suppresses GnRH?

Somatostatin analogue (octreotide) - ANS Last line treatment if cabergoline and surgery fails to treat acromegaly Colon Cancer - ANS What other cancer are Pts with acromegaly more at risk for? DM II - ANS What metabolic disorder are Pts with acromegaly at risk for? CAD - ANS What cardiac condition are Pts with acromegaly at risk for? Posterior Pituitary - ANS If Pt has Diabetes insipidus, where is the damage/cancer located? Arginine vasopressin - ANS What is the other name for ADH? Absence of bright spot - ANS What MRI pattern would indicate diabetes insipidus with pituitary imaging? Desmopressin - ANS Med used to counteract diabetes insipidus Nephrogenic DI - ANS Kidneys do not respond to ADH HTCZ - ANS Treatment for nephrogenic diabetes insipidus Concentrated urine and hyponatremia - ANS What will SIADH cause? Water restriction - ANS Treatment for SIADH

DHEA - ANS What male sex hormone is secreted by adrenals? Aldosterone - ANS What hormone accounts 90% of mineralcorticoud activity? Elevate - ANS Hyperaldosteronism will ____ BP Addison's Disease - ANS Autoimmune disorder where the adrenal glands do not produce enough of the hormones cortisol or aldosterone Pt must be tapered off - ANS If Pt is on long term oral steroid, how is adrenal insufficiency prevented? Zona glomerulosa - ANS What section of the adrenal gland is affected if there is low aldosterone in Addison's? Zona fasciculata - ANS What section of the adrenal gland is affected if there is low cortisol in Addison's? Zona reticularis - ANS What section of the adrenal gland is affected if there is low DHEA in Addison's? Addison's - ANS Pt comes in with massive salt craving and hypotension. Labs show hyponatremia and hyperkalemia. What do they have? Glucocorticoid Deficiency - ANS Condition that can lead to fatigue, weight loss, myalgia, postural hypotension, and hyponatremia Adrenal Crisis - ANS Pt comes for lightheadedness. Exam shows orthostatic hypotension, tachycardia, hyperpigmentation on neck, and general weakness. What is probably Dx?

ACTH Stim Test - ANS What is the 1st line diagnostic for adrenal insufficiency? Hydrocortisone and Fluticasone - ANS What are the glucocorticoid replacement therapies for adrenal insufficiency? Double the dose - ANS Pt is on glucocorticoid therapy for adrenal insufficiency. They develop an infection and are running a fever. How should therapy be adjusted? Dexamethasone 4mg IV - ANS Initial treatment for adrenal crisis Measure baseline cortisol and ACTH - ANS What labs must be taken before administering initial adrenal crisis treatment? Admit to ICU and start coma protocol - ANS What actions should be taken once adrenal crisis is confirmed? Ketoconazole - ANS What medication can induce primary adrenal insufficiency? Androgen - ANS What adrenal hormone is low if Pt is experiencing, dry skin, decreased libido, loss of pubic hair, and fatigue? Pituitary adenoma - ANS Most common cause of Cushing's Adrenocortical carcinoma (<30% 5 yr survival) - ANS What ACTH independent Cushing's cause has the worst prognosis? Moon Facies - ANS A rounded, puffy face caused by high doses of corticosteroids

Moon face, buffalo hump, trunchal obesity, supraclavicular fat pads, purple striae on abdomen - ANS What is the physical appearance of a Pt with Cushing's? Dexamethasone - ANS What medication is given for an overnight adrenal suppression test to look for Cushing's? High cortisol in the morning - ANS What would the red flag for Cushing's in an overnight suppression test? Sprionolactone - ANS What HTN med can also be used to treat Cushing's if surgical resection is unsuccessful? Adrenal neoplasm or Primary hyperaldosteronism - ANS What adrenal disorders can cause secondary HTN? Hyperladosteronism - ANS Pt still has uncontrolled HTN even with 3+ med combos. What differential Dx could be causing this? Metabolic alkalosis - ANS What metabolic disorder can hyperaldosteronism present with? Laying down vs. upright postures - ANS What can Pt actions can affect diagnostics when measuring baseline renin/aldosterone? CMP, serum renin, serum aldosterone - ANS What labs are you ordering to look for hyperaldosteronism? Aldosterone antagonist MOA - ANS Why does spironolactone work for hyperaldosteronism?

1cm - ANS What size of adrenal macroadenoma is the threshold for adrenalectomy?

Malignant or hormone active - ANS What type of adrenal masses require action? Lung, Kidney, Skin - ANS If adrenal gland has cancer, what locations could the cancer have originated from? Pheochromocytoma - ANS a benign tumor of the adrenal medulla that causes the gland to produce excess epinephrine HTN crisis - ANS What serious condition can pheochromocytoma cause? Lungs, bone, liver - ANS Where can malignant pheochromocytoma mets.? ≥ 2 - ANS Autosomal dominant inheritance of MEN will have tumors in ≥____ different endocrine glands True - ANS Almost all Pts with MEN-1 gene have an affected parent as well (T/F) 14-18 - ANS How early can hypercalcemia from parathyroid disease present? Every 3 years - ANS If Pt has MEN-1 how often do they receive a pituitary MRI? Medullary thyroid carcinoma - ANS Most common presentation of MEN-2 (95%) Hyperparathyroidism and pheochromocytoma - ANS What are the 2nd most common presentations of MEN-2? Calcitonin - ANS What lab order has a strong link to medullary thyroid cancer?

U/S and fine needle biopsy - ANS Pt has MEN-2 and thyroid nodule >1cm. What do you do next? CT or MRI - ANS What imaging is used to check for pheochromocytoma? Total thyroidectomy - ANS What prophylactic treatment is used for children by age 6 Dx'd with MEN- 2/3? Ganglioneuromas of lips, tongue, and colon - ANS Most common presentation of MEN- Medullary thyroid carcinoma - ANS 2nd most common presentation of MEN- GLP-1 meds - ANS What meds should Pts with MEN-2/3 avoid? Pheochromocytoma - ANS If Pt has MEN what should always be screened prior to surgery? Hyperparathyroidism - ANS Most common presentation of MEN- Low glucose with elevated insulin - ANS What lab diagnostic pattern is indicative of insulinomas? Diazoxide - ANS Med used to prevent hypoglycemia with insulinomas Surgery - ANS Treatment for insulinomas MEN-1 - ANS Gastrinomas are MEN-__ in 20% of cases

Zollinger-Ellison Syndrome - ANS hypersecretion of gastric acid that produces peptic ulcers as a result of a non-beta-cell tumor of the pancreatic islets Inactive adrenocortical adenoma - ANS Most common cause of unilateral adrenal mass Liver - ANS Where can gastrinomas mets.? Whipple Procedure + PPI - ANS Treatment for gastrinomas Liver - ANS Where can glucagonomas mets.? (60%) Chemo - ANS Treatment for glucagonomas if widespread metastases Octreotide Scan - ANS Somatostatin receptor scintigraphy non-invasive test used to evaluate the body for the presence of neuroendocrine tumor cells McCune-Albright Syndrome - ANS Early puberty caused by MEN hypogonadal secretion Carney complex - ANS Cancer that affects pituitary, adrenal cortex, thyroid, and gonads. Can cause cardiac myxomas and hyperpigmentation Paraneoplastic Syndrome - ANS Medical condition caused by tumor secretions (hormones, cytokines, TNF, Interleukin-1), may cause hypercalcermia, hypoglycemia, SIADH Paget Disease - ANS Chronic inflammation of bones, resulting in thickening and softening of bones, that can occur in any bone but most commonly affects the long bones of the legs, the lower spine, the pelvis, and the skull

FRAX Score - ANS Risk assessment tool developed by WHO which calculates a patients 10-year risk of developing an osteoporosis related fracture (intended for postmenopausal women and men > 50 years) DEXA Scan - ANS procedure that measures bone mineral density (BMD) to examine for osteoporosis Metformin 850mg BID - ANS Treatment and dosage for pre-diabetes Beta Cell - ANS What pancreatic cell type synthesizes insulin? Acanthosis nigricans - ANS Clinical sign of DMII with skin

200 after 2 hrs - ANS What pattern is indicative of DMII with glucose tolerance test? 6.5% - ANS A1C threshold for DMII MI - ANS In DMII, lowering A1C to goal is a direct correlation to reducing risk for _____ by 15% Distal and symmetric - ANS What is the neuropathy pattern of DM? Lowering A1C - ANS What is the only way to reverse the loss of sensation? Duloxetine, gabapentin, pregabalin - ANS What meds can treat diabetic painful neuropathy?

Charcot Foot - ANS Neuropathic fracture/dislocation found in patients with diabetes, most commonly resulting in a "rocker-bottom" foot deformity

Osteomyelitis - ANS DM Pts with foot wounds open for more than 10 days have a higher risk for ____

30mg/dL - ANS Spot urine microalbumin/creatinine ratio indicative of DM (mg/dL) Proliferative Diabetic Retinopathy - ANS Eye exam observes neovascularization and macular edema in diabetic Pt. What's the Dx? VEGF - ANS What is the target of reducing diabetes-related macular edema? Glucose - ANS Which lab result will indicate a med adjustment? A1C or glucose? Hitting goal A1C within 3 months of Dx - ANS What is massive positive predictor of mortality for Pt with new DM Dx? Gastric Bypass or 10% Wt loss - ANS What are the diet-related options for aggressive lifestyle changes to hit A1C goal? Biguanides - ANS Diabetic med that increases hepatic adenosine monophosphate-activate protein kinase activity. Improves fasting and post-prandial glucose 500-1000mg - ANS Standard Metformin dosages 500mg - ANS Metformin ER dosage 45 - ANS What GFR value is needed to start metformin?

<30 - ANS What GFR value will indicate d/c metformin? m Lactic acidosis development in CKD - ANS GFR is monitored while on metformin but it does not cause renal failure or damage. What is the reason GFR is monitored? Extended Release - ANS What type Metformin has less GI side effects? B12 - ANS What vitamin/mineral deficiency can develop with metformin? Pioglitazone (Actos) - ANS DM med that improves glucose absorption in periphery, decreases hepatic gluconeogenesis. Mod/Severe CHF, risk of peripheral and macular edema, bladder cancer association - ANS What are the contraindications of pioglitazone (actos)? Titrate up slowly - ANS What is the dosage pattern when starting metformin? SGLT2is - ANS DM med that has CV benefits by dumping excess glucose and Na+ in urine Canagliflozin (Invokana) Empagliflozin (Jardiance) Dapagliflozin (Farxiga) - ANS What are the SGLT2i options? Lowers A1C 0.9% reduction and 5lbs loss - ANS What are the end results of SGLT2is?

GLP-1 Receptor Agonist - ANS A receptor analogue that increases insulin secretion in the presence of elevated blood glucose; delays gastric emptying to decrease postprandial glucose and glucagon secretion Lowers A1C 1.5% and 10-20lbs loss - ANS What are the end results of GLP-1 Agonists? GIP/GLP-1 agonist - ANS What med class is mounjaro? Sulfonylureas - ANS Very cheap and effective DM med class that stimulates insulin release from pancreatic B cells and insulin sensitivity, but has a higher risk of hypoglycemia Glipizide - ANS Most common sulfonylurea option

65 - ANS Contraindicated demographic for glyburide and glimepiride (sulfylnureas) A1C >1% and 7lbs loss - ANS What are the end results of using sulfonylureas? DPP4is - ANS Increases and prolongs incretin hormone activity, by inactivating the targeted enzyme. Incretins increase insulin release and synthesis from pancreatic beta cells and reduce glucagon secretion from pancreatic alpha cells Pancreatitis - ANS Major contraindication for DDP4i's and GLP-1 agonists GLP-1 agonists - ANS What DM med is contraindicated if there is family hx of medullary thyroid cancer? Titrate Metformin XR up to 2g/day + postprandial coverage med - ANS What is the treatment plan if Pt has an initial A1C >8%?

Biguanides, GLP-1 Agonists, Sulfonylureas, DPP4i's - ANS What are the 4 post-prandial DM meds? GLP-1 Agonist to reach A1C goal - ANS A Type 2 diabetic patient has been on Metformin 2000mg daily and following a no-added sugar, low-carb diet for the past five years is found to have an A1c of 8.5%. Glucose is ranging 140-240. What should you do? DPP4i's - ANS What med class are sitagliptin, saxagliptin, and linagliptin? Lactic acidosis - ANS A condition that causes tissue hypoxia, severe asthma with excess beta-adrenergic agonist use, cardiogenic or hemorrhagic shock Hyerventilation - ANS 1st clinical sign of lactic acidosis High anion gap without elevated ketones - ANS What lab result patterns are indicative of lactic acidosis? Insulin Therapy - ANS What treatment is started when Pt has an initial A1C >10%? Liraglutide and degludec basal insulin - ANS What composes xultophy combo med?

2.5% - ANS How much does xultophy reduce A1C? Fast-acting - ANS If post-prandial glucose is high which insulin type dosage will be titrated up? Fast- acting or basal Basal - ANS If fasting glucose is still elevated with med combo, which insulin type dosage will be titrated up? Fast-acting or basal