ENDOCRINE Te ENDOCRINE ESSENTIALS: Endocrine Update For General Medicine is designed to provide physicals at all stages of training and practice with a clinical vignete-based educational tol. It helps clinicians ases curent knowledge ESSENTIALS and identify those areas that need further study, so that they can stay up-to-date on important concepts in medicine. Te clinical vignette educational format is intended to replicate the clinical practice setting. Te 24 realistic clinical vignettes focus on established knowledge gaps identifed in the diagnosis and management of bone and mineral homeostasis, diabetes melitus, cardiovascular ENDOCRINE UPDATE endocrinology, men’s and women’s health, and thyroid disorder. FOR GENERAL MEDICINE Bone and Mineral Homeostasis ■ Diabetes Mellitus ■ Cardiovascular Endocrinology Te Endocrine Society 8401 Connecticut Avenue, Suite 900 Chevy Chase, MD 20815 ■ www.endo-society.org Men’s and Women’s Founded in 1916, Te Endocrine Society Health is dedicated to advancing excellence in endocrinology and promoting its essential ■ role as an integrative force in scientifc research and medical practice Tyroid ISBN 1-879225-76-X Disorders EndocrinE EssEntials EndocrinE UpdatE for GEnEral MEdicinE ENDOCRINE ESSENTIALS ENDOCRINE UPDATE FOR GENERAL MEDICINE Bradley D. Anawalt, MD Editor 8401 Connecticut Avenue, Suite 900 Chevy Chase, Maryland 20815 To receive a CME certifcate, please visit www.endo-society.org/essentials or scan this QR Code with your smart phone’s QR Reader to complete and submit your answer sheet and evaluation form online. Founded in 1916 8401 Connecticut Ave., Suite 900 Chevy Chase, MD 20815 www.endo-society.org Editor Bradley D. Anawalt, MD Endocrine Essentials: Endocrine Update for General Medicine Director, Education: Robert Bartel Product/Production Manager, Publications: Cynthia Richardson Marketing Manager: Leticia Barnes-Long Administrative Assistant, Meetings and Education: Stacey Williams Coordinator, Education: Dalia Golchan Te statements and opinions expressed in this publication are those of the individual authors and do not necessarily refect the views of Te Endocrine Society. Te Endocrine Society is not responsible or liable in any way for the currency of the information, for any errors, omissions or inaccuracies, or for any consequences arising therefrom. With respect to any drugs mentioned, the reader is advised to refer to the appropriate medical literature and the product information currently provided by the manufacturer to verify appropriate dosage, method and duration of administration, and other relevant information. In all instances, it is the responsibility of the treating physician or other health care professional, relying on independent experience and expertise, as well as knowledge of the patient, to determine the best treatment for the patient. Copyright © February 2012 by Te Endocrine Society, 8401 Connecticut Avenue, Suite 900, Chevy Chase, Maryland 20815. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, posted on the internet, or transmitted in any form, by any means, electronic, mechanical, photocopying, recording, or otherwise, without written permission of the publisher. Requests for permission for reproduction should be directed to Te Endocrine Society Publications Department: http://www.endo-society.org/journals/rights.cfm, or send an email to contributors Bradley D. Anawalt, MD Frances Hayes, MB, FRCPI University of Washington Medical Center St. Vincent’s University Hospital Hormone Foundation of Endocrine Society Department of Endocrinology Robert A. Adler, MD Irl B. Hirsch, MD McGuire Veterans Afairs Medical Center, Richmond University of Washington Virginia Commonwealth University School of Medicine Medical Center Richard Auchus, MD, PhD Mara J. Horwitz, MD University of Michigan, Department of Medicine Division of Metabolism, Endocrinology, & Diabetes University of Pittsburgh Graeme I. Bell, PhD Mary Korytkowski, MD Te University of Chicago University of Pittsburgh Departments of Medicine and Pediatrics Department of Medical-Endocrinology Section of Endocrinology, Diabetes and Metabolism Michael A. Levine, MD Daniel D Bikle, MD, PhD Te Children’s Hospital of Philadelphia Medicine and Dermatology University of Pennsylvania Veterans Afairs Medical Center and University of California, School of Medicine San Francisco Alvin M. Matsumoto, MD Glenn D. Braunstein, MD Geriatric Research, Education and Clinical Center, VA Department of Medicine Puget Sound Health Care System and Cedars-Sinai Medical Center Department of Medicine University of Washington Gregory A. Brent, MD School of Medicine Chair, Department of Medicine, VA Greater Los Angeles Healthcare System; Medicine and Physiology, David Gefen Anthony L. McCall, MD, PhD, FACP School of Medicine at UCLA University of Virginia School of Medicine Kenneth D. Burman, MD Endocrine Section, Washington Hospital Center Alastair R. McLellan, MD, FRCP Department of Medicine, Georgetown University Gardiner Institute Western Infrmary Luiza Caramori, MD MS PhD Division of Endocrinology and Diabetes Graham T. McMahon, MD, MMSc University of Minnesota Division of Endocrinology, Diabetes & Hypertension Brigham and Women’s Hospital Alan Chait, MD Department of Medicine, Harvard Medical School Division of Metabolism, Endocrinology and Nutrition University of Washington Rochelle Naylor, MD Te University of Chicago Samuel Dagogo-Jack, MD Departments of Medicine and Pediatrics Division of Endocrinology, Diabetes & Metabolism Section of Endocrinology, Diabetes and Metabolism University of Tennessee Health Science Center Catherine B. Niewoehner, MD Anthony DeSantis, MD Virginia Medical Center University of Washington Department of Endocrinology and Metabolism School of Medicine Louis H. Philipson, MD, PhD Richard Eastell, MD, FRCP, FRCPath, FMedSci Te University of Chicago Northern General Hospital Departments of Medicine and Pediatrics Centre for Biomedical Research Section of Endocrinology, Diabetes and Metabolism Kenneth Feingold, MD Cliford J. Rosen, MD University of California, San Francisco Maine Medical Center Research Institute Department of Medicine Center for Clinical & Translational Research James Findling, MD Douglas S. Ross, MD Medical College of Wisconsin Department of Medicine, Harvard Medical School Endocrinology Center at North Hills Lisa Tannock, MD Hossein Gharib, MD, MACP, MACE University of Kentucky Mayo Clinic College of Medicine Department of Endocrinology Department of Endocrinology Tomas Weber, MD Catherine M. Gordon, MD, MSc Division of Endocrinology, Metabolism & Nutrition Children’s Hospital Boston Duke University Medical Center Division of Adolescent Medicine Bu B. Yeap, MBBS, FRACP SiriAtma Greeley, MD, PhD School of Medicine and Pharmacology Te University of Chicago University of Western Australia Departments of Medicine and Pediatrics Fremantle Hospital Section of Endocrinology, Diabetes and Metabolism contents Continuing Medical Education (CME) ......................................... vi Preface ...........................................................................................viii bone and Mineral HoMeostasis 1. Vitamin D: When and How to Use ........................................... 2 Daniel D. Bikle, MD, PhD 2. Risk Assessment for Osteoporotic Fracture .......................... 10 Richard Eastell, MD, FRCP, FRCPath, FMedSci Tomas Weber, MD 3. Drug Terapies for Osteoporosis: When, Which & How Long to Use? ........................................ 15 Anthony DeSantis, MD 4. Gauging Response to Osteoporosis Terapy ........................ 24 Cliford J. Rosen, MD Catherine B. Niewoehner, MD 5. New Options for Vertebral Fracture....................................... 31 Alastair R. McLellan, MD, FRCP 6. Investigation & Management of Hypocalcemia ................... 38 Michael A. Levine, MD 7. Normocalcemic Hyperparathyroidism ................................. 48 Robert A. Adler, MD 8. Medical Options for Primary Hyperparathyroidism ............ 54 Mara J. Horwitz, MD diabetes Mellitus 9. Monogenic Diabetes: Who Needs MODY Screening? ......... 62 Louis H. Philipson, MD, PhD Rochelle Naylor, MD; SiriAtma Greeley, MD, PhD Graeme I. Bell, PhD 10. Difcult Diabetes Cases ......................................................... 71 Graham T. McMahon MD, MMSc 11. Management of CVD Risk in Diabetes .................................. 80 Samuel Dagogo-Jack, MD 12. Prevention of Diabetic Nephropathy .................................... 88 Luiza Caramori, MD, MS, PhD 13. Insulin Management of Diabetes .......................................... 98 Mary Korytkowski, MD 14. Insulin Pumps ....................................................................... 109 Anthony L. McCall, MD, PhD, FACP 15. CGM and Its Role in Diabetes Management ...................... 120 Irl B. Hirsch, MD cardiovascular endocrinology 16. Dyslipidemia Beyond the Statin .......................................... 127 Kenneth Feingold, MD & Lisa Tannock, MD 17. M anagement of the Abnormal C’s: Coronary Calcium Scores, CIMT, CRP & Other Cryptic Markers of CAD ......... 137 Alan Chait, MD 18. Primary Hyperaldosteronism .............................................. 141 Richard Auchus, MD, PhD & James Findling, MD Men’s and WoMen’s HealtH 19. D iagnosis & Management of Male Hypogonadism: In the Older Man ................................................................... 150 Frances Hayes, MB, FRCPI 20. Erectile Dysfunction: Who, When and What Treatment? .. 155 Alvin M. Matsumoto, MD 21. Investigation and Management of Gynecomastia .............. 167 Bu B. Yeap, MBBS, FRACP & Glenn D. Braunstein, MD 22. Contraception in Adolescents .............................................. 178 Catherine M. Gordon, MD, MSc tHyroid disorders 23. Clinical Approach to Subclinical Hypothyroidism ............. 186 Hossein Gharib, MD, MACP, MACE Douglas S. Ross, MD 24. Management of Subclinical Hyperthyroidism ................... 193 Gregory A. Brent, MD & Kenneth D. Burman, MD Index ............................................................................................. 202 CME Post Test .............................................................................. 207 vi continuing Medical education Accreditation Statement • Recognize factors important in the Te Endocrine Society is accredited by evaluation and diagnosis of common the Accreditation Council for Continuing endocrine disorders and formulate a Medical Education to provide continuing treatment plan in a primary care setting medical education for physicians. Te Endocrine Society has achieved Target Audience Accreditation with Commendation. Tis continuing medical education Te Endocrine Society designates this activity should be of substantial interest enduring material for a maximum of 12.0 to endocrinologists, internists and family AMA PRA Category 1 Credits™. Physicians practitioners who care for patients with should claim only the credit commensurate endocrine disorders. with the extent of their participation in the activity. Disclosure Information Authors, editors, reviewers, Endocrine Statement of Independence Society staf and others involved in As a provider of continuing medical education planning this CME activity are required to (CME) accredited by the Accreditation disclose to learners any relevant fnancial Council for Continuing Medical Education, relationship(s) that have occurred within Te Endocrine Society has a policy of ensuring the last 12 months with any commercial that the content and quality of this educational interest(s) whose products or services activity are balanced, independent, objective, are discussed in the CME content. Such and scientifcally rigorous. Te scientifc relationships are defned by remuneration content of this activity was developed under in any amount from the commercial the supervision of the Editor, Bradley interest(s) in the form of grants; research Anawalt, MD. support; consulting fees; salary; ownership interest (e.g., stocks, stock options, or Disclaimer ownership interest excluding diversifed Te information presented in this activity mutual funds); honoraria or other payments represents the opinion of the authors and is for participation in speakers’ bureaus, not necessarily the ofcial position of Te advisory boards, or boards of directors; Endocrine Society. or other fnancial benefts. Te intent of this disclosure is not to prevent faculty Learning Objectives with relevant fnancial relationships from Te educational content of this volume planning or delivery of content, but rather is provided in a case-based format, with to provide learners with information that questions designed to assess competence allows them to make their own judgments. in the diagnoses and management of It remains for learners to determine endocrine disorders. While the topics vary, whether fnancial interests or relationships covering multiple aspects of endocrinology, may infuence the educational activity the learning objectives apply to problem with regard to exposition or conclusion. solving for a variety of endocrine disorders. Te Endocrine Society has reviewed all Upon completion of this enduring activity, disclosures and resolved or managed all participants should be able to: identifed conficts of interest, as applicable. • List common causes or risk factors for diabetes, endocrine, and metabolic Te editor and following authors reported no disorders and choose appropriate relevant fnancial relationships: strategies of therapy Robert A. Adler, MD, Bradley Anawalt, • Identify and diferentiate endocrine MD, Richard Auchus, MD, PhD, Daniel D. cases that can be treated in a primary Bikle, MD, PhD, Glenn D. Braunstein, MD, care setting and those that are in need of Gregory Brent, MD, Luiza Caramori, MD, referral to an endocrinologist for treatment MS, PhD, Anthony DeSantis, MD, Richard vii Eastell, MD, FRCP, FCRPath, FMedSci, labeling approved by the Food and Drug Kenneth Feingold, MD, James Findling, Administration (FDA). Te Endocrine MD, Hossein Gharib, MD, MACP, MACE, Society requires that any discussions of SiriAtma Greeley, MD, PhD, Francis such “of-label” use be based on scientifc Hayes, MB, FRCPI, Mara J. Horwitz, research that conforms to generally MD, Mary Korytkowski, MD, Michael A. accepted standards of experimental Levine, MD, Alvin M. Matsumoto, MD, design, data collection, and data analysis. Anthony L. McCall, MD, PhD, FACP, Before recommending or prescribing Alastair R. McLellan, MD, FRCP, Graham any therapeutic agent or device, learners T. McMahon, MD, MMSc, Rochelle Naylor, should review the complete prescribing MD, Catherine B. Niewoehner, MD, Louis information, including indications, H. Philipson, MD, PhD, Cliford Rosen, contraindications, warnings, precautions, MD, Lisa Tannock, MD, Bu B. Yeap, MBBS, and adverse events. FRACP, Tomas Weber, MD Privacy and Confdentiality Statement Endocrine Society staf associated with Te Endocrine Society will record learner's the development of content for this personal information as provided on activity reported no relevant fnancial CME evaluations to allow for issuance relationships. and tracking of CME certifcates. Te Endocrine Society may also track aggregate Te following authors/faculty reported responses to questions in activities and relevant fnancial relationships: evaluations and use these data to inform Graeme I. Bell, PhD, Employee, KAI the ongoing evaluation and improvement Pharmaceuticals of its CME program. No individual Kenneth Burman, MD, Consultant, Up To performance data or any other personal Date; Investigator, Exelixis, Inc., Amgen, information collected from evaluations Pfzer, Inc. will be shared with third parties. 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Hirsch, MD, Consultant, Johnson & as Internet Explorer 7+, Firefox 2+, Safari, Johnson, Roche Diagnostics Opera, or Google Chrome; in addition, Douglas S. Ross, MD, Researcher, Celera cookies and Javascript must be enabled in the browser's options. Policy on Unlabeled/Of-Label Use Te Endocrine Society has determined Te estimated time to complete this activity, that disclosure of unlabeled/of-label including review of material, is 12 hours. or investigational use of commercial product(s) is informative for audiences Last Review Date: March 2012 and therefore requires this information to Activity release date: March 15, 2012 be disclosed to the learners. Activity expiration date: March 17, 2015 Uses of specifc therapeutic agents, devices, and other products discussed For questions about content or CME credit, in this educational activity may not be please contact Te Endocrine Society at the same as those indicated in product viii preface I am pleased to present this second volume of Endocrine Essentials, a work that reviews the recent clinical research on some of the most common clinical endocrinology topics that primary care clinicians, endocrinologists and other clinicians grapple with in the clinic. Tese topics include osteoporosis, calcium disorders, diabetes management, subclinical thyroid dysfunction, lipid disorders and selected areas in men’s and women’s health. Each chapter is based on a talk given at the Endocrine Society’s Annual Scientifc Meeting in 2010 or 2011. Te chapter synthesizes the most recent clinical research into practical approaches to the management of common endocrinology disorders. Te chapters contain a succinct review of a topic and case-based questions and answers. Each chapter also includes a multiple choice question written in the format of questions used in the American Board of Internal Medicine exam. Te content of each chapter will be useful for busy clinicians who want a rational, evidence-based approach to the clinical dilemmas that they face in the clinic and for those clinicians preparing for board examinations in internal medicine or endocrinology. I hope that you enjoy reading this book and applying the principles in it to the care of your patients! Bradley D. Anawalt, MD Clinical Science Chair, ENDO 2011 Bone and Mineral HoMeostasis