AUGUST 25-27, 2017 UPDATE & BOARD REVIEW. acofp INTENSIVE. Evolving Issues in Endocrinology. Chris Pitsch, DO INNOVATIVE COMPREHENSIVE HANDS-ON

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1 acofp INTENSIVE UPDATE & BOARD REVIEW AUGUST 25-27, 2017 Loews Chicago O'Hare Hotel Rosemont, IL INNOVATIVE COMPREHENSIVE HANDS-ON Evolving Issues in Endocrinology Chris Pitsch, DO acofp Am eric an College of Osteopathi c Family Physicians The American College of Osteopathic Family Physicians is accredited by the American Osteopathic Association Council to sponsor continuing medical education for osteopathic physicians. The American College of Osteopathic Family Physicians designates the lectures and workshops for Category 1-A credits on an hour-for-hour basis, pending approval by the AOA CCME, ACOFP is not responsible for the content.

2 ACOFP FULL DISCLOSURE FOR CME ACTIVITIES Please check where applicable and sign below. Provide additional pages as necessary. Name of CME Activity: ACOFP Intensive Update & Board Review in Family Medicine Dates and Location of CME Activity: August 25-27, 2017, Loews Chicago O'Hare Hotel, Rosemont, IL, United States Topic(s): OMT Breakout Session #1: Thoracic and Cervical Spine Friday, 8/25/17 2:45-4:15pm 4:30-6:00pm Saturday, 8/26/17 8:30-10:00am 10:15-11:45am Evolving Issues in Endocrinology Saturday, 8/26/17 12:45-1:15pm Proctor- Test-Taking Skills Workshop: Review of Clinical Scenarios Utilizing a Hands-On Approach in Preparation for Your Board Examination Saturday, 8/26/17 6:00-9:00pm Health Issues for the Aging Adult Sunday, 8/27/17 8:30-9:00am Name of Faculty/Moderator: Chris Pitsch, DO DISCLOSURE OF FINANCIAL RELATIONSHIPS WITHIN 12 MONTHS OF DATE OF THIS FORM A. Neither I nor any member of my immediate family has a financial relationship or interest with any proprietary entity producing health care goods or services. B. I have, or an immediate family member has, a financial relationship or interest with a proprietary entity producing health care goods or services. Please check the relationship(s) that applies. Research Grants Stock/Bond Holdings (excluding mutual funds) Speakers Bureaus* Employment Ownership Partnership Consultant for Fee Others, please list: Please indicate the name(s) of the organization(s) with which you have a financial relationship or interest, and the specific clinical area(s) that correspond to the relationship(s). If more than four relationships, please list on separate piece of paper: Organization With Which Relationship Exists Clinical Area Involved *If you checked Speakers Bureaus in item B, please continue: Did you participate in company-provided speaker training related to your proposed topic? Yes: No: Did you travel to participate in this training? Yes: No: Did the company provide you with slides of the presentation in which you were trained as a speaker? Yes: No: Did the company pay the travel/lodging/other expenses? Yes: No: Did you receive an honorarium or consulting fee for participating in this training? Yes: No: Have you received any other type of compensation from the company? Please specify: Yes: No: When serving as faculty for ACOFP, will you use slides provided by a proprietary entity for your presentation and/or lecture handout materials? Yes: No: Will your topic involve information or data obtained from commercial speaker training? Yes: No: DISCLOSURE OF UNLABELED/INVESTIGATIONAL USES OF PRODUCTS A. The content of my material(s)/presentation(s) in this CME activity will not include discussion of unapproved or investigational uses of products or devices. B. The content of my material(s)/presentation in this CME activity will include discussion of unapproved or investigational uses of products or devices as indicated below: I have read the ACOFP policy on full disclosure. If I have indicated a financial relationship or interest, I understand that this information will be reviewed to determine whether a conflict of interest may exist, and I may be asked to provide additional information. I understand that failure or refusal to disclose, false disclosure, or inability to resolve conflicts will require the ACOFP to identify a replacement. Signature: Chris Pitsch, DO Date: Please fax this form to ACOFP at or to joank@acofp.org as soon as possible. Deadline: July 21, 2017

3 Evolving Issues in Endocrinology Chris Pitsch, DO, HMDC Objectives Identify Hypothyroidism and its common causes Identify Hyperthyroidism and its common causes Understand the evaluation of a thyroid nodule Recognize Adrenal Insufficiency Review Pituitary Tumors Hypothyroidism Overt Hypothyroidism: High TSH in the presence of low free T4. Most of these patients are symptomatic or show some sign of disease Subclinical Hypothyroidism: High TSH in the presence of normal free T4 and T3. Most of these patients are asymptomatic or only minimally symptomatic 1

4 Question # 1 What is the most common cause of hypothyroidism in the US? a) Iodine Deficiency b) Chronic Autoimmune (Hashimoto s) Thyroiditis c) Hypothalamic Dysfunction d) Iatrogenic e) Medication Effect Hypothyroidism Hashimoto s (Chronic Autoimmune) Thyroiditis The most common cause of hypothyroidism in the US and other iodinesufficient areas of the world It is caused by cell and antibody mediated destruction of thyroid tissue Subacute Thyroiditis Relatively Uncommon Usually Transient Typically presents as hyperthyroidism, followed by euthyroidism then hypothyroidism and subsequent restoration of normal function Hypothyroidism Medication Induced Methimazole, PTU, Amiodarone, Lithium Iodine Deficiency The most common cause of hypothyroidism worldwide Rare in Developed Countries Iatrogenic Neck Irradiation Thyroidectomy 2

5 Hypothyroidism Central Hypothyroidism Thyroid hormone deficiency due to a disorder of the pituitary, hypothalamus, or hypothalamic-pituitary portal circulation A rare cause of hypothyroidism, estimated to occur in 1:20,000 to 1:80,000 in the general population* *Ross, Douglas S. Central Hypothyroidism. Uptodate.com Hypothyroidism Symptoms: Fatigue, cold intolerance, weight gain, dry skin, menstrual irregularities, depression Diagnosis: Primarily lab based Check TSH, Free T4 and TPO antibodies Imaging not required Treatment: Thyroid hormone replacement Question # 2 A 32 year old female presents to your office complaining of a 2 month history of anxiety, palpitations, weight loss, and amenorrhea. On exam she has obvious exophthalmos, her hair appears questionably thin, her thyroid feels large but not nodular, and she is tachycardic. The rest of the physical exam is normal. Her labs reveal a low TSH <0.05 mu/l and elevated T3 and free T4 (with T3 > T4). A radioactive iodine uptake and scan revealed increased uptake. What is the most likely diagnosis? a) Grave s Disease b) Subacute Thyroiditis c) Iodine Deficiency d) Exogenous Hyperthyroidism e) Autoimmune hypothyroidism 3

6 Hyperthyroidism Graves Disease An autoimmune disorder in which thyroid-stimulating immunoglobulin (TSI) causes an excess production of thyroid hormone The most common cause of hyperthyroidism The female to male ratio is 5:1 Approximately 30% of patients with Graves show some sign of Graves Opthalmopathy* Diffusely increased radioactive iodine uptake *Diseases and Conditions: Graves' Disease. Mayoclinic.org Hyperthyroidism Exogenous Hyperthyroidism Clinical findings are generally normal Diffusely decreased radioactive iodine uptake Solitary Toxic Hyperactive Nodule A single palpable nodule on exam A single focus of increased radioactive iodine uptake Hyperthyroidism Toxic Multinodular Goiter Enlarged thyroid Lumpy and Bumpy Multiple foci of increased and/or decreased radioactive iodine uptake Subacute Thyroiditis On exam possibly tender enlarged thyroid but can be painless Usually transient And remember it typically presents as hyperthyroidism, followed by euthyroidism then hypothyroidism and subsequent restoration of normal function 4

7 Hyperthyroidism Symptoms: anxiety, weakness, weight loss, ophthalmopathy, palpitations, heat intolerance, diaphoresis Diagnosis: Labs: TSH, Free T4, T3, TPO, thyroglobulin, TSH receptor antibodies Hyperthyroidism Treatment: Medications: PTU-first choice during pregnancy. Methimazole-has a longer half life allowing once a day dosing. Meds alone can induce remission in 50% of patients with Graves. Remember to not only periodically check TFT s but also a CBC because these meds can rarely cause agranulocytosis Radioactive Iodine Ablation: Highly effective in toxic nodules and multinodular goiter. Approximately 90% effective in Grave s. However, it may result in hypothyroidism requiring medication Surgery: Used much less frequently then other treatment options. Can result in surgical complications including recurrent laryngeal nerve damage Question # 3 A 54 year old female presents to your office and you palpate a single nodule on exam. You subsequently check her TSH which is normal and then you perform a fine needle aspiration the results of which are suspicious but not definitive. The following week you obtain a radioactive iodine uptake and scan which reveals a hot nodule. What is your next step? a) Surgical Referral b) Repeat FNA Biopsy c) Check T3, free T4, and TSH receptor antibodies d) Observation e) Begin levothyroxine and recheck TSH in 6 weeks 5

8 Thyroid Nodules and Cancers Primary Cancers: Papillary Considered a differentiated cancer The most common type of thyroid cancer Variants of papillary cancer include follicular, tall cell, insular, and hobnail variants Some variant forms can be more aggressive than the common type Excellent overall prognosis with 98% survival in stage 1 and 2 patients Thyroid Nodules and Cancers Follicular Considered a differentiated cancer The second most common type of thyroid cancer More common in iodine deficient regions Generally occurs in an older population than papillary cancer More Aggressive Associated with metastasis to bones, lungs, and brain Sometimes referred to as functioning thyroid cancer secondary to the fact that it often secretes thyroglobulin and sometimes thyroid hormone Thyroid Nodules and Cancers Medullary Can be associated with MEN 2A and 2B Anaplastic Undifferentiated Type Very Aggressive Metastasis from other primary Benign Nodules Ultrasound Monitoring Consider thyroid hormone treatment if childhood history of neck irradiation 6

9 Thyroid Nodules and Cancers Diagnosis If TSH low follow hyperthyroidism diagnosis pathway If TSH is high or normal the next step is Fine Needle Aspiration (FNA) Biopsy If the biopsy shows malignancy surgical referral is warranted If the biopsy is benign continued observation is warranted If the biopsy is suspicious or detects follicular neoplasm the next best step is a radioactive iodine scan If the scan shows a hot nodule observation is warranted If the scan shows a cold nodule surgical referral is warranted Question #4 A 52 yo female presents to your office complaining of multiple gradually developing symptoms. She notes that she feels like her skin is becoming progressively darker (hyperpigmented) even the creases of her palms. She reports frequent fatigue, muscle weakness, light headedness when standing up, and weight loss. Her lab work reveals hyponatremia, hyperkalemia, and elevated ACTH levels. What is your diagnosis? a) Adrenal Crisis b) Pheochromocytoma c) Primary Adrenal Insufficiency d) Secondary Adrenal Insufficiency e) Tertiary Adrenal Insufficiency Adrenal Insufficiency Primary Adrenal Insufficiency Causes: Autoimmune destruction of the adrenal gland: Most Common Infectious: TB, HIV, CMV Metastatic Tumor Adrenal gland hemorrhage Congenital adrenal hyperplasia Drugs: Ketoconazole, Etomidate, Mitotane 7

10 Adrenal Insufficiency Secondary Adrenal Insufficiency Causes: Iatrogenic: From glucocorticoid and/or anabolic steroid administration Pituitary or Hypothalamic tumors Tertiary Adrenal Insufficiency Causes: Hypothalamic disease leading to a decreased release of corticotropin releasing hormone Adrenal Insufficiency Symptoms fatigue, weakness, nausea, vomiting, diarrhea, abdominal pain, anorexia, weight loss, and orthostatic hypotension Hyperpigmentation in Primary Disease Diagnosis ACTH Level (Elevated in primary disease, Low in secondary disease) Random Cortisol Level Metabolic Panel: Hyponatremia and Hyperkalemia in primary Disease Cosyntropin Stimulation Test Question # 5 The most common Pituitary microadenoma is? a) Nonfunctioning b) TSH Secreting c) GH-secreting d) Prolactinoma e) ACTH secreting 8

11 Pituitary Tumors Microadenomas are < 1 cm and Macroadenomas are > 1 cm Prolactinoma: Most common microadenoma. Usually associated with prolactin levels > 200 ng/dl Nonfunctioning: Most common macroadenoma GH-secreting ACTH-secreting TSH-secreting Carcinomas Pituitary Tumors Symptoms Frequently Asymptomatic Varying symptoms from hormonal excess or deficiency; Galactorrhea, Hypogonadism, Hyperthyroidism, Cushing syndrome, Gigantism, Acromegaly, Adrenal Insufficiency, Hypothyroidism, Inability to lactate Headaches, Visual field deficits Pituitary Tumors Diagnosis Imaging: MRI of the pituitary/sella (Incidental discovery on routine imaging for other reasons very common) Labs: prolactin, IGF-1, 24-hour urine for cortisol, ACTH, TSH, LH, FSH, and testosterone levels 9

12 Answer Key 1. B 2. A 3. D 4. C 5. D References Ross, Douglas S. Central Hypothyroidism. Dec. 3, Uptodate.com Le, Tao; Mendoza, Michael; Coffa, Diana ( ). First Aid for the Family Medicine Boards, Second Edition (FIRST AID Specialty Boards) McGraw-Hill. Kindle Edition. Diseases and Conditions: Graves Disease. Mayoclinic.org Nieman, Lynette K. Clinical manifestations of Adrenal Inufficiency in Adults. Feb. 1, Uptodate.com. Wilbur, Jason K.; Mark Graber ( ). Family Practice Examination & Board Review, Second Edition (McGraw-Hill Specialty Board Review). McGraw-Hill. Kindle Edition. 10