Today at MEDS – August 3, 2018

Morning session
Managing Thyroid Disease: Preparing for Battle
Christine Kessler, MN, ANP-BC, CNS, BC-ADM, FAANP, Metabolic Medicine Associates, and Chris Sadler, MA, PA-C, CDE, DFAAPA, Janssen Pharmaceuticals, Inc.

What lab tests should I order when patients present with signs and symptoms suggestive of thyroid disease, and how should I interpret results? In answering these questions, Kessler and Sadler described the inverse relationship of T3 and T4 to thyroid stimulating hormone (TSH), why free T4 is superior to total T4, and how to proceed when FT4 and TSH seem discordant. They also discussed additional tests that may be needed based on initial screening results, and factors (eg, agents such as biotin) that can affect the accuracy of thyroid test results.

Case Studies in Hypo and Hyperthyroidism for Clinical Consideration
Christine Kessler, MN, ANP-BC, CNS, BC-ADM, FAANP, Metabolic Medicine Associates, and Chris Sadler, MA, PA-C, CDE, DFAAPA, Janssen Pharmaceuticals, Inc.

Hypothyroidism and hyperthyroidism can be difficult to diagnose, especially in the elderly. In addition to pointing out the aspects of the physical exam and lab studies that can aid in diagnosing both conditions, Kessler and Sadler presented strategies to safely initiate, titrate, and monitor therapies; addressed controversies surrounding the management of subclinical forms; and identified triggers and early symptoms of acute thyrotoxicosis (thyroid storm) and myxedema coma.

Thyroid Concerns in Pregnancy
Christine Kessler, MN, ANP-BC, CNS, BC-ADM, FAANP, Metabolic Medicine Associates

Kessler reviewed the physiologic changes of pregnancy that influence thyroid conditions and associated lab tests, the potential complications to mother and fetus of untreated thyroid disease, and strategies for managing hypo- and hyperthyroidism throughout pregnancy and lactation. She reminded that pregnant women with hypothyroidism generally require 30% to 50% more of their thyroid medications. And when treating hyperthyroidism, use the lowest dose of antithyroid drugs that keeps maternal free T4 and free T3 near the upper limit of the normal range.

Managing the “Hot” Mess of Thyroiditis
Christine Kessler, MN, ANP-BC, CNS, BC-ADM, FAANP, Metabolic Medicine Associates, and Chris Sadler, MA, PA-C, CDE, DFAAPA, Janssen Pharmaceuticals, Inc.

While thyroiditis is transient in most patients, it requires ongoing follow-up because of the increased risk of permanent hypothyroidism. Kessler and Sadler reviewed the work-up and differential for suspected acute and subacute thyroiditis and how to interpret laboratory and thyroid scan data. They also discussed postpartum thyroiditis (the signs of which are often misdiagnosed as anxiety and stress about motherhood) and silent thyroiditis, which is similar to postpartum thyroiditis but is unassociated with pregnancy.

Continue to: Expert Tips on Evaluating Thyroid Nodules

Expert Tips on Evaluating Thyroid Nodules
Chris Sadler, MA, PA-C, CDE, DFAAPA, Janssen Pharmaceuticals, Inc.

In the United States, up to 68% of randomly selected adults have thyroid nodules. While most are benign, the number of those that are cancerous is increasing. To assist with determining which are malignant, Sadler provided insight on the clinical and ultrasound findings that suggest increased malignant potential. He also detailed an appropriate work-up, noting that ultrasound-guided fine needle aspiration remains the best means for evaluation.

Lifestyle Interventions: A New Narrative for Diabetes Management and Metabolic Health
Ellen D. Mandel, DMH, MPA, MS, PA-C, RDN, CDE, Pace University

Mandel discussed diabetes self-management education and support. She highlighted what works and what doesn’t among various diets, that sugar isn’t the only target, that dieting is only half the equation and must be coupled with physical activity (which is not the same as exercise), and that patient involvement in self-management correlates with greater long-term success.

Gut Grief: The Enteroendocrine Connection in Autoimmune Diseases
Christine Kessler, MN, ANP-BC, CNS, BC-ADM, FAANP, Metabolic Medicine Associates

“We need to look to the gut as the biggest player in chronic health and autoimmune disease,” said Kessler. Kessler went on to explain how altered gut flora impacts immune, endocrine, cardiovascular, neuropsychologic, reproductive, and metabolic health. She identified 12 endocrine-disrupting chemicals associated with autoimmunity. And she reviewed the causes of microbiome dysbiosis, the bidirectional nature of the gut-microbiome-brain axis, and strategies for promoting microbiome health.

Mind and Body: The Vicious Cycle of Depression in Diabetes and Chronic Illness
Ellen D. Mandel, DMH, MPA, MS, PA-C, RDN, CDE, Pace University

One in 4 American adults experiences mental illness in a year, and having a serious mental illness increases the risk of having a chronic medical condition. Because emotional well‐being is associated with positive diabetes outcomes, it’s imperative that diabetes self‐management education and support address psychosocial issues. It’s also important to screen for depression. To that end, Mandel shared a time-saving 2-question screening tool. 

Cold Case Studies in Renal Medication Dosing: The Good, the Bad, and the Iatrogenic
Kim Zuber, PA-C, MS, American Academy of Nephrology PAs

Using actual cases of incorrect management, Zuber pointed out the most common medications taken by patients with chronic kidney disease (CKD) by disease stage and the most common errors made with those medications. She also reviewed the over-the-counter medications that can be dangerous for patients with CKD. When prescribing for patients with CKD, Zuber reminded, go low, go slow, and rerun lab tests often.

Morning session
Managing Thyroid Disease: Preparing for Battle
Christine Kessler, MN, ANP-BC, CNS, BC-ADM, FAANP, Metabolic Medicine Associates, and Chris Sadler, MA, PA-C, CDE, DFAAPA, Janssen Pharmaceuticals, Inc.

What lab tests should I order when patients present with signs and symptoms suggestive of thyroid disease, and how should I interpret results? In answering these questions, Kessler and Sadler described the inverse relationship of T3 and T4 to thyroid stimulating hormone (TSH), why free T4 is superior to total T4, and how to proceed when FT4 and TSH seem discordant. They also discussed additional tests that may be needed based on initial screening results, and factors (eg, agents such as biotin) that can affect the accuracy of thyroid test results.

Case Studies in Hypo and Hyperthyroidism for Clinical Consideration
Christine Kessler, MN, ANP-BC, CNS, BC-ADM, FAANP, Metabolic Medicine Associates, and Chris Sadler, MA, PA-C, CDE, DFAAPA, Janssen Pharmaceuticals, Inc.

Hypothyroidism and hyperthyroidism can be difficult to diagnose, especially in the elderly. In addition to pointing out the aspects of the physical exam and lab studies that can aid in diagnosing both conditions, Kessler and Sadler presented strategies to safely initiate, titrate, and monitor therapies; addressed controversies surrounding the management of subclinical forms; and identified triggers and early symptoms of acute thyrotoxicosis (thyroid storm) and myxedema coma.

Thyroid Concerns in Pregnancy
Christine Kessler, MN, ANP-BC, CNS, BC-ADM, FAANP, Metabolic Medicine Associates

Kessler reviewed the physiologic changes of pregnancy that influence thyroid conditions and associated lab tests, the potential complications to mother and fetus of untreated thyroid disease, and strategies for managing hypo- and hyperthyroidism throughout pregnancy and lactation. She reminded that pregnant women with hypothyroidism generally require 30% to 50% more of their thyroid medications. And when treating hyperthyroidism, use the lowest dose of antithyroid drugs that keeps maternal free T4 and free T3 near the upper limit of the normal range.

Managing the “Hot” Mess of Thyroiditis
Christine Kessler, MN, ANP-BC, CNS, BC-ADM, FAANP, Metabolic Medicine Associates, and Chris Sadler, MA, PA-C, CDE, DFAAPA, Janssen Pharmaceuticals, Inc.

While thyroiditis is transient in most patients, it requires ongoing follow-up because of the increased risk of permanent hypothyroidism. Kessler and Sadler reviewed the work-up and differential for suspected acute and subacute thyroiditis and how to interpret laboratory and thyroid scan data. They also discussed postpartum thyroiditis (the signs of which are often misdiagnosed as anxiety and stress about motherhood) and silent thyroiditis, which is similar to postpartum thyroiditis but is unassociated with pregnancy.

Continue to: Expert Tips on Evaluating Thyroid Nodules

Expert Tips on Evaluating Thyroid Nodules
Chris Sadler, MA, PA-C, CDE, DFAAPA, Janssen Pharmaceuticals, Inc.

In the United States, up to 68% of randomly selected adults have thyroid nodules. While most are benign, the number of those that are cancerous is increasing. To assist with determining which are malignant, Sadler provided insight on the clinical and ultrasound findings that suggest increased malignant potential. He also detailed an appropriate work-up, noting that ultrasound-guided fine needle aspiration remains the best means for evaluation.

Lifestyle Interventions: A New Narrative for Diabetes Management and Metabolic Health
Ellen D. Mandel, DMH, MPA, MS, PA-C, RDN, CDE, Pace University

Mandel discussed diabetes self-management education and support. She highlighted what works and what doesn’t among various diets, that sugar isn’t the only target, that dieting is only half the equation and must be coupled with physical activity (which is not the same as exercise), and that patient involvement in self-management correlates with greater long-term success.

Gut Grief: The Enteroendocrine Connection in Autoimmune Diseases
Christine Kessler, MN, ANP-BC, CNS, BC-ADM, FAANP, Metabolic Medicine Associates

“We need to look to the gut as the biggest player in chronic health and autoimmune disease,” said Kessler. Kessler went on to explain how altered gut flora impacts immune, endocrine, cardiovascular, neuropsychologic, reproductive, and metabolic health. She identified 12 endocrine-disrupting chemicals associated with autoimmunity. And she reviewed the causes of microbiome dysbiosis, the bidirectional nature of the gut-microbiome-brain axis, and strategies for promoting microbiome health.

Mind and Body: The Vicious Cycle of Depression in Diabetes and Chronic Illness
Ellen D. Mandel, DMH, MPA, MS, PA-C, RDN, CDE, Pace University

One in 4 American adults experiences mental illness in a year, and having a serious mental illness increases the risk of having a chronic medical condition. Because emotional well‐being is associated with positive diabetes outcomes, it’s imperative that diabetes self‐management education and support address psychosocial issues. It’s also important to screen for depression. To that end, Mandel shared a time-saving 2-question screening tool. 

Cold Case Studies in Renal Medication Dosing: The Good, the Bad, and the Iatrogenic
Kim Zuber, PA-C, MS, American Academy of Nephrology PAs

Using actual cases of incorrect management, Zuber pointed out the most common medications taken by patients with chronic kidney disease (CKD) by disease stage and the most common errors made with those medications. She also reviewed the over-the-counter medications that can be dangerous for patients with CKD. When prescribing for patients with CKD, Zuber reminded, go low, go slow, and rerun lab tests often.

Morning session
Managing Thyroid Disease: Preparing for Battle
Christine Kessler, MN, ANP-BC, CNS, BC-ADM, FAANP, Metabolic Medicine Associates, and Chris Sadler, MA, PA-C, CDE, DFAAPA, Janssen Pharmaceuticals, Inc.

What lab tests should I order when patients present with signs and symptoms suggestive of thyroid disease, and how should I interpret results? In answering these questions, Kessler and Sadler described the inverse relationship of T3 and T4 to thyroid stimulating hormone (TSH), why free T4 is superior to total T4, and how to proceed when FT4 and TSH seem discordant. They also discussed additional tests that may be needed based on initial screening results, and factors (eg, agents such as biotin) that can affect the accuracy of thyroid test results.

Case Studies in Hypo and Hyperthyroidism for Clinical Consideration
Christine Kessler, MN, ANP-BC, CNS, BC-ADM, FAANP, Metabolic Medicine Associates, and Chris Sadler, MA, PA-C, CDE, DFAAPA, Janssen Pharmaceuticals, Inc.

Hypothyroidism and hyperthyroidism can be difficult to diagnose, especially in the elderly. In addition to pointing out the aspects of the physical exam and lab studies that can aid in diagnosing both conditions, Kessler and Sadler presented strategies to safely initiate, titrate, and monitor therapies; addressed controversies surrounding the management of subclinical forms; and identified triggers and early symptoms of acute thyrotoxicosis (thyroid storm) and myxedema coma.

Thyroid Concerns in Pregnancy
Christine Kessler, MN, ANP-BC, CNS, BC-ADM, FAANP, Metabolic Medicine Associates

Kessler reviewed the physiologic changes of pregnancy that influence thyroid conditions and associated lab tests, the potential complications to mother and fetus of untreated thyroid disease, and strategies for managing hypo- and hyperthyroidism throughout pregnancy and lactation. She reminded that pregnant women with hypothyroidism generally require 30% to 50% more of their thyroid medications. And when treating hyperthyroidism, use the lowest dose of antithyroid drugs that keeps maternal free T4 and free T3 near the upper limit of the normal range.

Managing the “Hot” Mess of Thyroiditis
Christine Kessler, MN, ANP-BC, CNS, BC-ADM, FAANP, Metabolic Medicine Associates, and Chris Sadler, MA, PA-C, CDE, DFAAPA, Janssen Pharmaceuticals, Inc.

While thyroiditis is transient in most patients, it requires ongoing follow-up because of the increased risk of permanent hypothyroidism. Kessler and Sadler reviewed the work-up and differential for suspected acute and subacute thyroiditis and how to interpret laboratory and thyroid scan data. They also discussed postpartum thyroiditis (the signs of which are often misdiagnosed as anxiety and stress about motherhood) and silent thyroiditis, which is similar to postpartum thyroiditis but is unassociated with pregnancy.

Continue to: Expert Tips on Evaluating Thyroid Nodules

Expert Tips on Evaluating Thyroid Nodules
Chris Sadler, MA, PA-C, CDE, DFAAPA, Janssen Pharmaceuticals, Inc.

In the United States, up to 68% of randomly selected adults have thyroid nodules. While most are benign, the number of those that are cancerous is increasing. To assist with determining which are malignant, Sadler provided insight on the clinical and ultrasound findings that suggest increased malignant potential. He also detailed an appropriate work-up, noting that ultrasound-guided fine needle aspiration remains the best means for evaluation.

Lifestyle Interventions: A New Narrative for Diabetes Management and Metabolic Health
Ellen D. Mandel, DMH, MPA, MS, PA-C, RDN, CDE, Pace University

Mandel discussed diabetes self-management education and support. She highlighted what works and what doesn’t among various diets, that sugar isn’t the only target, that dieting is only half the equation and must be coupled with physical activity (which is not the same as exercise), and that patient involvement in self-management correlates with greater long-term success.

Gut Grief: The Enteroendocrine Connection in Autoimmune Diseases
Christine Kessler, MN, ANP-BC, CNS, BC-ADM, FAANP, Metabolic Medicine Associates

“We need to look to the gut as the biggest player in chronic health and autoimmune disease,” said Kessler. Kessler went on to explain how altered gut flora impacts immune, endocrine, cardiovascular, neuropsychologic, reproductive, and metabolic health. She identified 12 endocrine-disrupting chemicals associated with autoimmunity. And she reviewed the causes of microbiome dysbiosis, the bidirectional nature of the gut-microbiome-brain axis, and strategies for promoting microbiome health.

Mind and Body: The Vicious Cycle of Depression in Diabetes and Chronic Illness
Ellen D. Mandel, DMH, MPA, MS, PA-C, RDN, CDE, Pace University

One in 4 American adults experiences mental illness in a year, and having a serious mental illness increases the risk of having a chronic medical condition. Because emotional well‐being is associated with positive diabetes outcomes, it’s imperative that diabetes self‐management education and support address psychosocial issues. It’s also important to screen for depression. To that end, Mandel shared a time-saving 2-question screening tool. 

Cold Case Studies in Renal Medication Dosing: The Good, the Bad, and the Iatrogenic
Kim Zuber, PA-C, MS, American Academy of Nephrology PAs

Using actual cases of incorrect management, Zuber pointed out the most common medications taken by patients with chronic kidney disease (CKD) by disease stage and the most common errors made with those medications. She also reviewed the over-the-counter medications that can be dangerous for patients with CKD. When prescribing for patients with CKD, Zuber reminded, go low, go slow, and rerun lab tests often.