5/7/2013. Patrick Nolan, DO, FACE

Transcription

1 Patrick Nolan, DO, FACE Patient: T.W. 83 year old male 9/18/2012 AM sudden onset of Vertigo ER visit Had MRI, some labs Home on Zofran and medicines Complete resolution of sx after 2 days MRI chronic sinus inflammation mm pituitary lesion R above sella solid mass R cavernous sinus extension, up to diaphragm on R No hemorrhage Some infundibulum deviation to L Referral made No physical signs of Cushings, Acromegaly or Hypopituitarism No sx of D.I. Poor erectile competence for years Lab ACTH 40 (0 46 pg/ml) Cortisol 10.9 ( mg/dl) Free T ( mg/dl) TSH 3.94 ( uiv/ml) Testosterone 142 ( ng/dl) Prolactin ( ng/ml) IgF 1 59 ( ng/ml) GH 0.02 ( ng/ml) VS Stable BP 138/78 both arms Pulse 80 Wt 222# Height approx 6 1 Visual Field grossly nl Testes normal 1

2 Rx Cabergoline 0.5mg po twice weekly No further C/O Felt well No new symptoms Follow up MRI Dec 17, 2012 Pituitary mass now 10 mm x 9 mm and noticeably smaller with less supra sellar extension. Patient had no symptoms. Lab Dec 13, 2012 Prolactin 14.7 Testosterone 150 Normal chemistry Normal TFT s Rx Cabergoline 0.5mg weekly Testosterone gel to be titrated F/U in 4 6 months 2

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4 44 year old male referred by Urology with low Testosterone No complaints by either him or his wife Teddy Bear syndrome Did everything his wife ever wanted of him. No libido or sexual desire whatsoever No erections in > 8 years No sexual attempts Fathered child 14 years previously 4

5 Exam Very pale ( pituitary pallor ) BP 100/64; HR 50 Regular; Wt 168#; Ht 5 11 Standing BP 90/50; HR 50 Regular No palp thyroid. Mild gynecomastia. Testes small bilat, normal genitalia otherwise Lab Panhypopituitary CMP nl CBC mild normocytic anemia LH/FSH not measurable Testosterone not measurable ACTH < 2 Cortisol < 2 mcg/dl Free T 4 < 0.2 ( ng/dl) TSH < 0.01 IgF 1 < 25 Prolactin 490 ng/ml Dilute > 40,000 ng/ml even to last dilution DX Severe panhypopituitarism Macro adenoma prolactinoma MRI Very large pituitary mass Above (surrounding) optic chiasm Invades bilateral cavernous sinuses and surrounds both carotids No field cuts! 5

6 Plans High dose Cabergoline po Counseling psychologist regarding anticipated hyper sexual response Other hormones, LT 4, Cortisone po Watched for DI on Cortisone Follow Up: 3 months MRI > 60% reduction size No need for surgery Wife is malpractice threat divorce Prolactin diluted 46 Normal spontaneous erections ( unbelievable ) Return libido and sexual function Testosterone 600 s Tapered off all med except Cabergoline Moved to Michigan with girlfriend TSH, Free T 4 nl CMP, CBC nl Testes nl Genitalia nl 6

7 38 year old male C/O fatigue, muscle weakness, sleepiness, huge appetite, lack of NRG, weight gain No definite medical history Family History Obesity, Hypertension, Type II Diabetes/Metabolic Syndrome Patient wants to take his health seriously Can t figure out what is wrong Habits 3 meals/day, no meds Probably 4 6,000 calories/day Minimal activity Minimal erections, not sustained Desires sex, but cannot function Wife unhappy, Children (x2) not happy, Dog not happy Exam Obese male wt 296#, ht 5 11 Referral by LMD low testosterone 196 AM 222 AM Normal Prolactin Normal LH/FSH Mild elevation 24 Urine Cortisol TSH, Free T 4 nl CMP, CBC nl Testes nl, Genitalia nl 7

8 Plan Counseled him and wife Weight loss support group Serious wt loss effort Intense, no tolerance diet & exercising Trial for 3 months No TOLERANCE for mistakes No Excuses Should do sleep study Follow Up: 4 months 25# wt loss, approx 87,500 calorie debt Improving clinically More NRG + function Testosterone 390 Plan Same Serious lifestyle changes 8

9 26 year old male ER Visit Shoulder injury Xray Normal 14 Y/O shoulder MD thought it strange Radiologist thought it interesting LMD referral to Endocrine for GH deficiency Ht 6 3 Wt 180# Poor muscle mass Testes tiny small penis 6cm Never had erection No libido/girlfriend Introvert personality Testosterone < 25 LH/FSH 65/80 Thyroid/Pituitary fx all nl Karyotype 47 XXY Dx Klinefelter s Syndrome 9

10 Elected to start testosterone replacement Not insured elected to self administer depo testosterone q 2 wks IM Patrick Nolan, D.O., F.A.C.E. 10

11 Review: Physiology Pathology Physical Exam Laboratory Measurements Therapeutic Options Areas of Uncertainty There is no general agreement on the acceptable normal range of testosterone John J McGill, M.D. (Review, Cleveland Clinic Journal of Medicine, November 2012) There is no well established benefit of testosterone administration in normal aging males (Committee of Institute of Medicine, 2004) 11

12 Somatic: gynecomastia, decreased body hair, anemia, muscle loss, fatigue, bone loss, hot flashes. Psychological: depressed mood, impaired cognition/memory/energy, irritability. Sexual: decreased libido, ED Changes in normal aging men are similar to hypogonadism Peter Snyder, MD (Up To Date 2013) Testes Size (4 7cm normal) Are testes descended? Gynecomastia Body hair Loss of body hair Muscle mass Scalp hair recession Arm span greater than height Anosmia Signs of chronic illness (poor nutrition, alcoholism, liver disease, chronic renal failure, RA) 12

13 Primary Hypogonadism Karyotype abnormality (e.g. Klinefelter syndrome) Toxin exposure (chemotherapy) Congenital defect Orchitis Testicular trauma or infarction Hemochromatosis Medications (e.g. ketoconazole) Increased temperature of testicular environment Secondary Hypogonadism Kallmann syndrome Gonadotropin releasing hormone (GnRH) receptor mutation or deficiency Genetic mutation associated with pituitary hormone deficiency Obesity, insulin resistance Type 2 Diabetes Obstructive sleep apnea Aging Hemochromatosis Secondary Hypogonadism Estrogen excess Anabolic steroid abuse Anorexia nervosa Acute illness Human immunodeficiency virus infection Chronic medical conditions Alcohol abuse Severe primary hypothyroidism 13

14 Secondary Hypogonadism Sellar mass of infiltrative lesion Metastatic lesion Trauma (head injury) Radiation exposure Surgery Stalk severance Pituitary apoplexy Semen Analysis 15 million/cc (40 million total) 40% motile is normal. Consider repeating 2 4 times for full assessment. Testosterone: June December orders (Providence Lab) June December orders (Providence Lab) Providence Lab Total Testosterone: $140 LH: $108 FSH: $86 Mayo Clinic Bioavailable Testosterone: $177 Free Testosterone: $135 Prolactin: $99 Jil Jefson, Providence Lab 14

15 Physicians in the U.S. = 700,000 Accidental deaths caused by physicians per year = 120,000 Accidental deaths per physician is Statistics courtesy of U.S. Dept of Health & Human Services Gun owners in the U.S. = 80,000,000 (Yes, that s 80 million!) Accidental gun deaths per year (all age groups) =1,500 Accidental deaths per gun owner is Statistics courtesy of FBI Statistically, doctors are approximately 9,000 times more dangerous than gun owners. Remember, Guns don t kill people, doctors do. Not everyone has a gun, but almost everyone has at least one doctor. This means you are over 9,000 times more likely to be killed by a doctor than a gun owner. 15

16 Please alert your friends to this alarming threat. We must ban doctors before this gets completely out of hand! Out of concern for the public at large, we withheld the statistics on lawyers for fear the shock would cause people to panic and seek medical attention! 50 66% drop in testosterone with age (20 y.o. 80 y.o.) 30% drop during day (8am 8pm) Do not measure during hospitalization or acute illness (low T may be a marker of poor health?) UpToDate

17 Statistics remember regression toward the mean. Testosterone repeat twice if low at 8am Free testosterone (calculated from T, SHBG, albumin formula varies) Bioavailable testosterone(not precipitated by ammomium sulfate) Gold Standard equilibrium dialysis Bioavailable or free testosterone if suspect low SHBG: obesity, cirrhosis, advanced age, nephrosis, endocrinopathy (diabetes, hypothyroidism, corticosteroid use, acromegaly) Or if suspect elevated SHBG: weight loss, hyperthyroidism, estrogen LH, FSH T 4, TSH Prolactin Fe/TIBC 17

18 Low or normal LH with Testosterone below 150 Increased prolactin Headache, visual loss Low T 4 with low/normal TSH Do not measure testosterone: Acute illness/hospitalization Severe obesity with fatigue Evaluate and treat sleep apnea first If Exclude treatable condition (disorder of thyroid, prolactin, corticosteroid, iron, pituitary lesion, sleep apnea) If Symptoms are present If (2) 8am tests are less than ng/dl (consider age: or 15 20% below cut point) Do CBC at baseline (rule out erythrocytosis) Discuss prostate, cardiovascular, sleep apnea risks, and transmission risks of topical preps. Oral preparations are not used because of liver toxicity, tumors. Parenteral (IM $24/month for 100mg/week) (50 100mg IM q week (300mg q 3 weeks) Transdermal ($ /month, average dose) Common usage liquid (Axiron) 2 4 actuations per day in axilla 18

19 Gel (Androgel) 1% 2.5 5g packets one per day (4 pumps/day) Other: Androderm, testoderm, testopatch patches, testim, fortesta gels Also available: Subcutaneous pellets (testopel) pellets per 3 6 months (requires surgery, up to 12% extrusion) Buccal (gum, STRIANT) bid; 16% gum irritation At initiation Acne, gynecomastia, aggressiveness, closure of epiphyses Increased BPH symptoms Increased sleep apnea Erythrocytosis (measure CBC at baseline and after 3 6 months of therapy, especially with IM forms) Skin rashes (patches) Transmission (gels, rare), cardiovascular events higher in some studies meta analysis of 51 randomized trials: No increase prostate cancer, need for prostate biopsy, urinary symptoms compared to placebo. No benefit when testosterone added to PDE5 inhibitors in patients with low testosterone levels Long term effects not yet evaluated (WHI like study has not yet been performed Weight lifting as effective testosterone in HIV population in increasing muscle strength 19

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