Chapter 30: Endocrine and Metabolic Disorders

ADRENAL INCIDENTALOMAS

Population

• –Adults.

Recommendations

AACE 2009

• –Recommends clinical, biochemical, and radiographic evaluation for evidence of hypercortisolism, aldosteronism, the presence of pheochromocytoma, or a malignant tumor.

• –Patients who will be managed expectantly should have reevaluation at 3–6 mo and then annually for 1–2 y.

Source

• –https://www.aace.com/files/adrenal-guidelines.pdf

Comments

1. A 1-mg overnight dexamethasone suppression test can be used to screen for hypercortisolism.

2. Measure plasma-fractionated metanephrines and normetanephrines to screen for pheochromocytoma.

3. Measure plasma renin activity and aldosterone concentration to assess for primary or secondary aldosteronism.

ANDROGEN DEFICIENCY SYNDROME (ALSO SEE HYPOGONADISM, MALE)

Population

• –Adult men.

Recommendations

Endocrine Society 2018

• –Obtain an AM total testosterone level for men with symptoms and signs of androgen deficiency.^a

• –Confirm diagnosis with a second AM total testosterone level.

• –Measure a serum luteinizing hormone (LH) and follicular stimulating hormone (FSH) in all men with testosterone deficiency to distinguish between primary and secondary hypogonadism.

• –Obtain a dual-energy x-ray absorptiometry (DEXA) scan for all men with severe androgen deficiency.

• –Testosterone therapy is indicated for androgen deficiency syndromes unless contraindications exist.^b

Source

• –https://academic.oup.com/jcem/article/103/5/1715/4939465

Comment

1. Testosterone therapy options: (treatment goal is to obtain a total testosterone level in mid-normal range)

   1. Testosterone enanthate or cypionate: 150–200 mg IM every 2 wk, or 75–100 mg IM weekly.

   2. Testosterone transdermal patch: 4–6 mg daily.

   3. Testosterone 1% gel: 50–100 mg daily.

   4. Testosterone 2% gel: 10–70 mg daily.

   5. Testosterone 2% solution: 60–120 mg (2–4 pumps or twists) applied to the axillae daily.

   6. Testosterone buccal bioadhesive tablets: 30 mg to buccal mucosa q12h.

   7. Testosterone nasal gel: 11 mg (2 pump actuations, 1 actuation per nostril) TID.

CUSHING’S SYNDROME (CS)

Population

• –Pediatric and adult patients with Cushing’s syndrome.

Recommendations

Endocrine Society 2015

• –Treatment goals for Cushing’s syndrome

  • Normalize cortisol levels to eliminate the signs and symptoms of CS.

  • Monitor and treat cortisol-dependent comorbidities

• –Recommend vaccinations against:

  • Influenza, herpes zoster, pneumococcus

• –Recommend perioperative thromboprophylaxis for venous thromboembolism.

• –Recommend surgical resection of primary adrenal or ectopic focus underlying CS.

• –Assess postoperative serum cortisol levels.