ITE Endocrinology and Metabolism 3 — Questions and Answers
Question 1: A 48-year-old woman has fatigue, weight gain, constipation, and bradycardia. TSH is 48 mIU/L and free T4 is undetectable. She takes no medications. What is the most appropriate initial treatment?
- Levothyroxine 1.6 mcg/kg/day
- Liothyronine (T3) alone
- Desiccated thyroid extract
- Levothyroxine 25 mcg/day with gradual titration (Correct answer)
Correct answer: Levothyroxine 25 mcg/day with gradual titration
In severe hypothyroidism, especially in older adults or those with cardiac risk, levothyroxine should be started at a low dose (25–50 mcg/day) and titrated slowly to avoid precipitating cardiac ischemia or arrhythmia.
Question 2: A 55-year-old man with newly diagnosed type 2 diabetes has an HbA1c of 7.8%, BMI 36 kg/m², no cardiovascular disease, and normal renal function. What is the most appropriate pharmacotherapy beyond lifestyle modification?
- Metformin alone
- Metformin + GLP-1 receptor agonist (Correct answer)
- Sulfonylurea alone
- Insulin glargine
Correct answer: Metformin + GLP-1 receptor agonist
Current ADA guidelines favor early combination therapy in patients with HbA1c >1.5–2% above goal; adding a GLP-1 agonist to metformin also promotes weight loss, which is beneficial in this obese patient.
Question 3: A 38-year-old woman presents with hypertension, hypokalemia, and metabolic alkalosis. Plasma aldosterone-to-renin ratio is markedly elevated. CT abdomen shows a 1.8 cm right adrenal adenoma. What is the definitive treatment?
- Lifelong spironolactone therapy
- Laparoscopic right adrenalectomy (Correct answer)
- Bilateral adrenalectomy
- Fludrocortisone suppression test and observation
Correct answer: Laparoscopic right adrenalectomy
A unilateral aldosterone-producing adenoma confirmed by adrenal vein sampling is best treated with laparoscopic unilateral adrenalectomy, which is curative in most cases.
Question 4: A 32-year-old pregnant woman (20 weeks) is diagnosed with Graves' disease. TSH is suppressed, free T4 is 3.4 ng/dL. Which antithyroid drug is preferred during the second trimester?
- Propylthiouracil (PTU)
- Methimazole (Correct answer)
- Radioactive iodine (RAI)
- Beta-blocker monotherapy
Correct answer: Methimazole
Methimazole is preferred after the first trimester; PTU is preferred in the first trimester due to methimazole's teratogenicity risk early in pregnancy, and RAI is absolutely contraindicated in pregnancy.
Question 5: A 62-year-old man with known acromegaly has a post-surgical IGF-1 still 2.5× the upper limit of normal. MRI shows no residual tumor. What is the most appropriate next step in management?
- Repeat surgery
- Pituitary radiation
- Somatostatin receptor ligand (octreotide LAR or lanreotide) (Correct answer)
- Pegvisomant monotherapy
Correct answer: Somatostatin receptor ligand (octreotide LAR or lanreotide)
When post-surgical IGF-1 remains elevated without visible residual tumor, somatostatin receptor ligands are first-line medical therapy; pegvisomant is reserved for those not responding to or intolerant of somatostatin analogues.
Question 6: A 44-year-old woman has a TSH of 0.02 mIU/L and free T4 of 2.8 ng/dL. She takes levothyroxine 150 mcg/day for hypothyroidism. She is asymptomatic. DEXA shows T-score −2.1 at lumbar spine. What is the most important reason to adjust her levothyroxine?
- Risk of Afib from subclinical hyperthyroidism
- Exogenous subclinical hyperthyroidism accelerates bone loss (Correct answer)
- Risk of thyroid storm
- Suppressed TSH causes pituitary enlargement
Correct answer: Exogenous subclinical hyperthyroidism accelerates bone loss
Exogenous subclinical hyperthyroidism (suppressed TSH) accelerates bone turnover and exacerbates osteoporosis, making dose reduction important in this patient with already reduced bone density.
Question 7: A 50-year-old man with type 2 diabetes and a recent MI (6 weeks ago) has HbA1c 8.5%. He is on metformin and a sulfonylurea. Which agent should be added given his cardiovascular history?
- Pioglitazone
- Empagliflozin or liraglutide (Correct answer)
- Sitagliptin
- Alogliptin
Correct answer: Empagliflozin or liraglutide
SGLT-2 inhibitors (empagliflozin, dapagliflozin) and GLP-1 agonists (liraglutide, semaglutide) have demonstrated cardiovascular mortality reduction in patients with established ASCVD and are preferred add-on agents.
ITE Endocrinology and Metabolism 3
A 48-year-old woman has fatigue, weight gain, constipation, and bradycardia.
TSH is 48 mIU/L and free T4 is undetectable.
She takes no medications.
What is the most appropriate initial treatment?