Hormonal Disorders

Erectile Dysfunction

• Counseling of both partners.
• Explain the side effects of sildenafil and other drugs. Sildenafil can cause headache, facial flushing, dyspepsia, nasal congestion and transient altered colour vision.

Erectile Dysfunction. In: Harrison’s Principles of Internal Medicine, Braunwald E. et al eds., 15th Edition, 2001. McGraw Hill Company Inc., New York, pp 291-295.

Hypoglycemia

Occurs due to increased utilization of glucose by the body (as during fasting, exercise or in alcoholics) or over dose of hypoglycemic agent(s).

Treatment

1. Oral glucose, sweats/biscuits/sweet drink etc if patient present early signs and is conscious.
2. In any diabetic patient on treatment presents with coma & glucometer is not available give Inj. Glucose (25%-50%) 50-100 ml infused rapidly. If hypoglycemia documented, immediately give Inj. Glucagon 1 mg IV. If patient receiving long acting insulin/oral hypoglycemic agents, continue IV infusion of 5% glucose with regular monitoring of blood glucose hourly.
   NOTE: In case of doubt between hypoglycaemia and diabetic ketoacidosis always choose to give 25% dextrose because hypoglycaemia can kill a patient whereas slight rise in glucose in diabetic ketoacidosis will not alter the prognosis of the patient.

• Explain about the symptoms of hypoglycemia. Stress upon regular intake of meals along with hypoglycemic agents and advise them to keep some sweet candies with them all the time. They should use these or any other sugar/glucose containing snacks/drinks at the earliest if symptoms of hypoglycemia are experienced.

1. American Diabetes Association: Clinical Practice Recommendations 2001. Diabetes Care 24 Suppl. 1, 2001.
2. Diabetes Mellitus. In: Harrison’s Principles of Internal Medicine, Braunwald E et al (eds), 15th Edition, 2001. McGraw Hill Company Inc., New York, pp 2109-2137.

Non-Ketotic Hyperosmolar Coma

It is characterized by profound dehydration due to sustained hyperglycemic dehydration & hyperosmolarity, usually seen in elderly patients with type II DM, associated with stroke or sepsis.

1. Normal saline or half normal saline (0.45%) 2-3 litres rapidly infused over 2-3 hours. Administration of 0.45% normal saline is indicated if serum sodium is > 150 mEq/L.
2. Inj. Insulin (regular) 5 units/hour as IV infusion.
3. Potassium chloride and sodium bicarbonate infusion as per requirement and administered as in ketoacidosis.

Diabetic Ketoacidosis

Ketoacidosis is acute complication of diabetes, usually occurs in IDDM but can occur in NIDDMand characterized by hyperglycemia, hyperketonemia and acidosis. Important precipitating factors include poor compliance to treatment and infections/stress.

 Treatment

Includes confirmation of diagnosis and continuous monitoring of the response to treatment as follows:

• Suspect and confirm diagnosis, assess fluid loss and degree of acidosis.
• Suspect and complete blood counts, glucose, renal functions, electrolytes and arterial blood gases.
• Evaluate for precipitating factor (s)/sepsis.

First Hour

• If blood pressure is normal, infuse 1000 ml of normal saline.
• If shock and oligemia, rapid infusion of normal saline until blood pressure rises to normal and subsequently continue with infusion, saline at the rate of 1 litre/hour.

1. Inj. Insulin (regular) 5-10 units/hour IV infusion.
Or
Inj. Insulin (regular) 20 units IM immediately followed by 5 units/hour.
2. Inj. Potassium chloride (KCl) 10-20 mmol (max 40 mmol) if serum K not more than 5 mmol/l  and urine outpur is adequate.
3. Inj. Sodium bicarbonate 50-100 mmol infused over 30-60 minutes if arterial blood pH <7.00
4. If infection/sepsis suspected Inj. Cefexime 1-2 gm IV 12 hourly to be started.

Second Hour

• Continue IV normal saline 500 ml/hour (use 0.45% saline if serum sodium > 150 mmol/l).
• Continue insulin infusion as above (if blood glucose > 250 mg/dl).
• Continue IV infusion of KCl (rate of infusion adjusted according to serum level).

Third and Fourth Hour

• Continue as for second hour.
• Observe for cognitive/neurological functions.

Fifth to Eighth Hour

• Normal saline infusion 250 ml/hour; change to dextrose saline if blood glucose < 250 mg/dl.
• Neutralizing insulin (1unit per 2 g of glucose infused) infusion to continue until ketonuria disappears.

After Eight Hours

• Continue IV fluids and insulin.
• Change to subcutaneous insulin when ketones disappear.
• Stop KCl infusion when plasma levels are normal.
• Change antibiotic if culute sensitivity report demands.

Patient Education

• Explain about the importance of regular intake of insulin and diet as per requirement.
• They should consult the physician soon if there is any symptom suggestive of infection.

References

1. American Diabetes Association : Clinical Practice Recommendations 2001. Diabetes Care 24 Suppl. 1, 2001.
2. Diabetes Mellitus. In: Harrison’s Principles of Internal Medicine, Braunwald E el al (eds), 15th Edition, 2001.
McGraw Hill Company Inc., New York, pp-2109-2137.

Diabetes Mellitus

Diabetes Mellitus (DM) is a group of metabolic disorders characterized by hyperglycemia . DM is divided into 2 broad categories: Type 1 DM characterized by insulin deficiency, and type 2 DM characterized by variable degree of insulin resistance, impaired insulin secretion and increased glucose production.

1. Caloric requirement for normal weight individual: according to nature of work-
   Sedentary- 1800-2000 kcal/day
   Moderate – 2500-2800 kcal/day
   Heavy – 3200-3900 kcal/day
2. Caloric distribution
   Carbohydrate – 50-60%
   Protein – 10-20%
   Fat – 30% (10% each from poly, mono and saturated)
3. Carbohydrates quantity remains same as in normal, however no sweets and refined sugars to be given. Rice and potato can be consumed.
4. Enough amount of fibers should be consumed with every meal for better control of diabetes.
5. In overweight individual, low caloric diet to be given in consultation with dietician.
6. Pattern of distribution of calories over the day should not vary much from day to day.
7. Saccharide and aspartane (maximum 10-12 Tabs/day) can be used as sweeteners for beverages or deserts.

1. Therapy should be started with insulin (porcine/human) in a dose of 0.5 units/kg/day to 1.0 unit/kg/day.
2. Combination of regular + lente/semilente insulin should be used (now available as Premix preparation as well).
3. 1/3rd of the total insulin requirement is given as regular and 2/3rd as lente/semilente.
4. 1/3rd of the total dose is used before dinner and 2/3rd before breakfast.
5. Insulin is given SC 30-45 min before meals.
6. Medial aspect of thigh and abdominal wall are generally used for injection. The site of injection should be changed frequently. There is no need to use spirit swab if the skin is clean.
7. Dose, type and timing of insulin is adjusted according to pre-prandial blood sugar levels (80-150 mg%). Level of blood glucose estimated depends on dose of plain insulin taken 3-4 hours before or intermediate/long acting insulin taken 8-12 hours before the test.
8. Increment of dose should not be more than 10% of existing dose and dose readjustment should not be made earlier than 3 days.
9. Patients must be properly trained for administration of SC injections.
10. Meals must be ensured after injection.
11. Explain features of hypoglycemia.

• Explain the nature of the disease and potential complications arising due to poorly controlled diabetes.
• Stress the importance of adhering to regular dietary schedule.
• Patient should always carry identification card along with diagnosis and the medication.
• Explain about the warning symptoms and signs of hypoglycaemia and need to take sweets/candies/drinks in such a situation.
• Regular followup to monitor BP, eye checkup and urine checkup.
• In patients with longstanding diabetes give instructions for care of feet, choice of footwear and avoid walking barefoot.
• Mainteance of general hygiene and skin care.

Hypercalcaemia

1. Rehydration-isotonic saline 2-4 L/day increases calcium excretion.
2. After correcting dehydration administrator
   Tab. Frusemide 40-80 mg every 1-2 hours.
   Monitor electrolytes especially potassium and magnesium and replace accordingly.

1. Inj. Pamidronate 30-90 mg IV infusion in 0.9% saline over 4-24 h.
   Response lasts for weeks.
   Or
   Tab. Alendronate Sodium 10 mg orally in the morning with full glass of water at least 30 min before any food or drink; remain in upright position for at least 30 min.
2. Inj. Calcitonin 2-8 U/kg IV or SC or IM every 6-12 h; rapid but mild action.
3. Tab. Prednisolone 40-100 mg/day in 4 divided doses may be useful in osteolytic malignancies, vitamin D intoxication and sarcoidosis.
4. Tab. Phosphorus (sodium and potassium phosphate) 1-1.5 g per day in 4 divided doses for several days when hypophosphatemia is present.
5. Peritoneal dialysis with calcium-free dialysate is useful especially in cases complicated by renal failure.
   Definitive treatment, wherever possible, is parathyroidectomy in hyperparathyroidism.

• In patients with mild asymptomatic hypercalcemia due to hyperparathyroidism, advise to keep active, avoid immobilisation, drink adequate fluids and avoid thiazide diuretics, large doses of vitamin D or A and calcium supplements and calcium containing antacids.
• Check serum calcium and albumin twice a year, renal function and urine calcium once a year and bone density of distal radius once every 2 years.

1. Diseases of the Parathyroid Gland and other Hyper- and Hypocalcemic disorders. In: Harrison’s Principles of Internal Medicine, Braunwald E et al Eds., 15th Edition, 2001. McGraw Hill Company Inc., New York, pp-2205-2226.
2. Calcium. In: The Washington Manual of Medical Therapeutics, Ahya SN, Flood K, Paranjothi S Eds., 30th Edition, 2001. Philadelphia: Lippincott, Williams & Wilkins. pp-60-66.

Hypocalcaemia

• Side effects of oral calcium carbonate are dyspepsia and constipation.
• Absorption requires gastric acid and is impaired in achlorhydria or when acid suppressive therapy is being given.
• Serum calcium should be monitored frequently (daily in severe hypocalcemia, weekly with moderate hypocalcemia for first month) and maintained at 8.0-8.6 mg/dl, and PTH and 24 h urinary calcium within 2-4 weeks of starting treatment.
• Once serum and urinary calcium is normal and PTH falls, maintenance treatment as described with reassessment at 3 monthly intervals.

1. Diseases of the Parathyroid Gland and other Hyper-and Hypocalcemic disorders. In: Harrison’s Principles of Internal Medicine, Braunwald E et al eds., 15th Edition, 2001, McGraw Hill Company Inc., New York, pp-2205-2226.
2. Calcium. In: The Washington Manual of Medical Therapeutics, Ahya SN, Flood K, Paranjothi S eds., 30th Edition, 2001. Philadelphia : Lippincott, Williams & Wilkins, pp-60-66.

Hyperthyroidism

Classically occurs in Graves’ disease, which is characterized by diffuse goiter, ophthalmopathy and dermopathy in varying combinations. Other important causes are toxic multinodular goiter (TMN) and toxic adenomas.

1. Adjunctive treatment- for adrenergic symptoms like sweating, tremor and tachycardia.
   Tab. Propranolol 40-120 mg a day.
   Or
   Tab. Atenolol 50-200 mg a day to be continued until patient becomes euthyroid.
2. Tab. Propylthiouracil 100-150 mg every 6-8 hours.
   OrTab. Carbimazole 10-20 mg every 8-12 hours after euthyroid state achieved in 6-8 weeks once daily dosing possible.

1. Tab. Propylthiouracil 600 mg loading dose, then 200-300 mg every 6 hours orally or through Ryle’s tube.
   Or
   Tab. Carbimazole 15-25 mg 6 hourly.
2. 1 hour after 1st dose of antithyroid drug, saturated solution of Potassium iodide (SSKI) 5 drops every 6 hours.
   Or
   Lugol’s iodine 10 drops 3 times a day.
   Or
   Sodium iodide 1 g IV slowly.
3. Tab. Propranolol 40-60 mg 4 hourly or 0.5-2 mg IV every 4 hr.
4. Inj. Dexamethasone 2 mg IV 6 hourly.
   Continue iodides and dexamethasone until normal metabolic stage achieved and supportive treatment like cooling, antipyretics, antibiotics for infection, IV fluids, etc.
   Once euthyroid status is achieved, manage as already outlined.

• If fever or sore throat develops on antithyroid drugs complete blood count should be done; discontinue if PMN count £ 1500/mm3.
• If allergic rash or drug sensitivity develops, give antihistamines and preferably change to another drug. If agranulocytosis, hepatitis, drug fever, arthralgias develop, preferably stop antithyroid treatment.
• Iodide- useful in impending thyrotoxic crisis and patients with severe cardiac disease; must be used only following antithyroid drugs.

1. An Update on the management of hyperthyroidism and hypothyroidism. Arch Intern Med 2000; 160: 1067-1071.
2. Disorders of the Thyroid Gland. In: Harrison’s Principles of Internal Medicine, Braunwald E et al (eds), 15th Edition, 2001, McGraw Hill Company Inc., New York, pp-2060-2084.

Hypothyroidism

1. Warm blankets, mechanical ventilation for respiratory failure.
2. Correction of electrolyte disturbances.
3. L-thyroxine 500 mcg IV bolus, then 50-100 mcg IV daily; if IV preparation not available same dose via Ryle’s tube. Once acute phase is over, maintain L-thyroxine as above.
4. Inj. Hydrocortisone 100 mg IV stat, 25-50 mg 8 hourly.
   (CAUTION- Avoid sedatives)

• L-thyroxine to be taken as single daily dose, ideally on awakening, at least 30 minutes before eating.
• Fiber and bran products (e.g. Isapaghula husk) may impair absorption, as also cholestyramine, colestipol, iron sulphate, sucralfate, aluminium hydroxide. Metabolism of L-thyroxine is increased by phenytoin, rifampicin, carbamezapine.
• Explain to the patient that the treatment is lifelong. Do not modify dose or stop treatment without consultation.
• Over treatment may lead to decreased bone mineral density and adverse cardiac consequences.

References

1. An update on the management of hyperthyroidism and hypothyroidism. Arch Intern Med 2000; 160: 1067-1071.
2. Disorders of the Thyroid Gland. In: Harrison’s Principles of Internal Medicine, Braunwald E et al (eds.), 15th Edition, 2001, McGraw Hill Company Inc., New York, pp-2060-2084.