Chapter 30: Endocrine and Metabolic Disorders

ADRENAL INCIDENTALOMAS

Population

• – Adults.

Recommendations

AACE 2009

• – Evaluate clinically, biochemically, and radiographically for evidence of hypercortisolism, aldosteronism, the presence of pheochromocytoma or a malignant tumor.

• – Reevaluate patients who will be managed expectantly 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.

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.

Source

• – www.endocrine.org/guidelines-and-clinical-practice/clinical-practice-guidelines/treatment-of-cushing-syndrome

DIABETES MELLITUS (DM), TYPE 1

Population

• – Children and adults with Type I DM.

Recommendations

ADA 2020

• – A1c goal <7% appropriate for most, <6.5% if obtainable without hypoglycemia, or 7–8% if hypoglycemia unawareness.

• – Use intensive insulin therapy with >3 injections daily using either basal and prandial insulin or an insulin pump.

• – Patients using multiple insulin injections should self-monitor blood glucose at least 4 times daily.

• – Consider continuous glucose monitoring in both children and adults, as it results in lower HbA1c levels.

• – Assess psychological and social situation.

• – Advise all patients not to smoke.

• – Begin screening at age 10, at onset of puberty, or after 5 y with type 1 DM, whichever is earlier:

  • Urine albumin-to-creatinine ratio annually.

  • Dilated fundoscopic exam q 2 y after initial assessment.

  • Monofilament screening for diabetic neuropathy annually.

  • Comprehensive foot examination at least annually.

• – Screen for other autoimmune conditions at time of diagnosis of type 1 DM:

  • Celiac disease: IgA tissue transglutaminase antibodies. If negative, rescreen 2 and 5 y after DM diagnosis.

  • Thyroid dysfunction: Check TSH, thyroid peroxidase and thyroglobulin antibodies initially; routine screening thereafter.

  • Pernicious anemia: Check B12 level if anemia or peripheral neuropathy is present.

• – Fasting lipid panel at age 10 or at onset of puberty, whichever is earlier (consider as early as age 2 y for a strong family history of hyperlipidemia).

  • Repeat annually if results are abnormal or every 5 y if results ...