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Opioid-Induced Adrenal Insufficiency

Author/s: 
Douglas Rice, Hirofumi Yoshida

A woman in her 40s with opioid use disorder receiving methadone (70 mg daily) was admitted for extended antibiotic treatment for methicillin-resistant Staphylococcus aureus bacteremia. She had been taking methadone at varying doses (ranging from 15 to 70 mg daily) for 15 years.

Following the resolution of bacteremia, she experienced unexplained persistent hyponatremia (129 mEq/L) and dizziness, with her urine sodium levels exceeding 40 mEq/L. A high dose, 250-μg cosyntropin stimulation test was performed, which revealed her cortisol levels were 6.6, 17.2, and 19.2 μg/mL (to convert to nmol/L, multiply by 27.6) at baseline, 30 minutes, and 60 minutes, respectively. A serum adrenocorticotropic hormone (ACTH) level was not measured.

Keywords 
Opioid-Related Disorders Opioid Use Hyponatremia Methicillin-Resistant Staphylococcus aureus methadone opioids Endocrinology Diabetes and Endocrinology

Management of Outpatients With Diabetes at High Risk of Hypoglycemia

Author/s: 
Celeste C Thomas, Karishma Chopra, Andrew M Davis

More than 30 million people in the US have diabetes, approximately 5% with type 1 and approximately 95% with type 2. About 5 million individuals in the US with type 2 diabetes use insulin and 7 million take sulfonylureas; both of these medications have a greater association with hypoglycemia than metformin, glucagon-like peptide 1 receptor agonists, dipeptidyl peptidase 4 inhibitors, or sodium-glucose cotransporter 2 inhibitors. Each month, 70% of people with type 1 diabetes experience some degree of hypoglycemia.1 Level 1 hypoglycemia is defined as blood glucose of 54 to 70 mg/dL; level 2 is less than 54 mg/dL; and severe hypoglycemia (level 3) occurs when low blood glucose levels cause neurologic or physical symptoms that require help from others. Furthermore, recurrent severe hypoglycemia increases risk of future dementia.2 Hypoglycemia occurs more often in people with lower education, lower income, and food insecurity.3 This synopsis focuses on outpatient management of diabetes with high risk of hypoglycemia; the guideline also addresses prevention of hypoglycemia in hospitalized patients.4

Keywords 
diabetes Diabetes and Endocrinology Endocrinology insulin

Thyroid Cancer: A Review

Author/s: 
Laura Boucai, Mark Zafereo, Maria E Cabanillas

Importance: Approximately 43 720 new cases of thyroid carcinoma are expected to be diagnosed in 2023 in the US. Five-year relative survival is approximately 98.5%. This review summarizes current evidence regarding pathophysiology, diagnosis, and management of early-stage and advanced thyroid cancer.

Observations: Papillary thyroid cancer accounts for approximately 84% of all thyroid cancers. Papillary, follicular (≈4%), and oncocytic (≈2%) forms arise from thyroid follicular cells and are termed well-differentiated thyroid cancer. Aggressive forms of follicular cell-derived thyroid cancer are poorly differentiated thyroid cancer (≈5%) and anaplastic thyroid cancer (≈1%). Medullary thyroid cancer (≈4%) arises from parafollicular C cells. Most cases of well-differentiated thyroid cancer are asymptomatic and detected during physical examination or incidentally found on diagnostic imaging studies. For microcarcinomas (≤1 cm), observation without surgical resection can be considered. For tumors larger than 1 cm with or without lymph node metastases, surgery with or without radioactive iodine is curative in most cases. Surgical resection is the preferred approach for patients with recurrent locoregional disease. For metastatic disease, surgical resection or stereotactic body irradiation is favored over systemic therapy (eg, lenvatinib, dabrafenib). Antiangiogenic multikinase inhibitors (eg, sorafenib, lenvatinib, cabozantinib) are approved for thyroid cancer that does not respond to radioactive iodine, with response rates 12% to 65%. Targeted therapies such as dabrafenib and selpercatinib are directed to genetic mutations (BRAF, RET, NTRK, MEK) that give rise to thyroid cancer and are used in patients with advanced thyroid carcinoma.

Conclusions: Approximately 44 000 new cases of thyroid cancer are diagnosed each year in the US, with a 5-year relative survival of 98.5%. Surgery is curative in most cases of well-differentiated thyroid cancer. Radioactive iodine treatment after surgery improves overall survival in patients at high risk of recurrence. Antiangiogenic multikinase inhibitors and targeted therapies to genetic mutations that give rise to thyroid cancer are increasingly used in the treatment of metastatic disease.

Keywords 
Endocrinology oncology Otolaryngology surgery Surgical Oncology Thyroid Disorders diabetes Endocrine Cancer Targeted and Immune Therapy
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