ENDOCRINOLOGY: Hypothalamic-Pituitary
CLINICAL CHEMISTRY 2
Instructor: John Jeffrey Pangilinan, RMT, MSMT
Date: April 22, 2022
TOPIC OUTLINE
I. ENDOCRINE VS EXOCRINE
II. ENDOCRINE SYSTEM
Legends:
 PPT
 Side notes
 Book
ENDOCRINE VS EXOCRINE
Hypothalamic-Pituitary
 Most of the glands in the body is either categorized as
endocrine or exocrine
 Mixed gland – Organ that has both endocrine and exocrine
function
o One example is pancreas
- The pancreas is only second in size to the liver,
weighing about 70 to 105 g
- It is located behind the peritoneal cavity across the
upper abdomen at about the level of the first and second
lumbar vertebrae, about 1 to 2 in. Above the umbilicus.
- It is located in the curve made by the duodenum
- The pancreas is composed of two morphologically and
functionally different issues: endocrine tissue and
exocrine tissue.
 Acini  exocrine function (enzyme-secreting)
– Secretory product is being released in
pancreatic duct to ampulla of vater or duct of
Santorini
– Secretes about 1.5 to 2 L/d of fluid, which is
rich in digestive enzymes, into ducts that
ultimately empty into the duodenum.
– This digestive fluid is produced by pancreatic
acinar cells (grape-like clusters), which line
the pancreas and are connected by small
ducts.
– These small ducts empty into progressively
larger ducts, eventually forming one major
pancreatic duct and a smaller accessory duct.
 Islet of Langerhans  endocrine function
(hormone-releasing)
– Beta cell produces insulin that is responsible
for lowering glucose (hypoglycemic effect)
because it facilitate the increase uptake of
glucose inside the cell and it is deliver in the
mitochondria as. In the other hand, glucagon
which is diabetogenic type of hormone
responsible for increasing the glucose
concentration, opposing the effect of insulin
LEC
2021 – 2022
WEEK 11 2nd Semester
CCHEM 3
- Are well-delineated, spherical or ovoid clusters
composed of at least four different cell types.
- The islet cells secrete at least four hormones
into the blood: insulin, glucagon, gastrin, and
somatostatin.
- Glucagon is released from the islet cells of the
pancreas and inhibits insulin.
 Endocrine
– Endo means within/interior/inside
– Ductless Glands
– The secretion in endocrine is secreted in the interior or
interstitial fluid and then enter the blood circulation, the
blood circulation serves as the vehicle for the transport of
the secretion of endocrine gland
– Secretory product or secretion is known as “Hormone”
that is released in interstitial fluid
– Endocrine Gland is enveloped within a multilayer of
capillaries that is why when it is released in interstitial
fluid, it is very effective for the absorption and diffusion of
different materials so that it will then enter the circulation
via the capillaries. Therefore, once the hormone is
liberated by the secretory cell of the endocrine gland, the
blood will then serves as vehicle as route of delivery until
this hormone reaches the target cell (is a specific cell
bearing specific receptor, and a highly specific for a given
type of a hormone). Once the hormone binds to the
receptor, it will form a complex known as “hormone-
receptor complex” causes to trigger the reaction causing
to affect the cellular machinery of the cell (cellular
activities)
– Hormones is actually expressed in a very low amount
– The endocrine system relates to a group of hormones
that are typically produced and secreted by one
specialized cell type into the circulation, where the
hormonal effect is exerted in other target cells through
the binding of the hormones to specialized receptors.
– Some of these hormones are polypeptides; others are
amino acid derivatives or steroids.
 Exocrine
– Exo means outside
– Presence of Ducts (tube-like structure)
– Majority of exocrine gland is responsible for digestion that
aiding the digestion of absorption of nutrients
– Example of Exocrine Gland
o Parotid Gland is a type of salivary gland that
produces secretion in the form of saliva. The duct of
salivary gland is called the “Stensen duct”
o Sweat Gland (Sudoriferous gland)
o Oil Gland produces Sebum. It is being carried to the
exterior to the epidermal layer of the skin (Stratum
corneum). The pH of the skin is 5.0 – 5.5
ENDOCRINE SYSTEM
Hypothalamic-Pituitary
 Endocrine glands
o Known as Ductless glands
- Intersperse with many blood capillaries
o Capillaries serves as a route / channel for the transport
of our hormone a chemical mediator that travels through
our circulation to target the specific body cell having,
contain the specific receptor. Specific cell is called
Target cell
o Highly scattered because it will become the manner of
DA BARAKO’S, GFS NI TAEHYUNG (REAL!!)– TRANSCRIBERS
 distribution via general circulation
o Some organ can be endo and exo; Pancreas - produce
hormone and exo products - so this is called a Mixed
gland
o Target cell – bears and contains specific receptors for
a given type of hormone. Ones the hormone binds to the
receptors they form hormone receptor complex (like
antigen-antibody complexes)
- Hormones are highly specific for a given receptor,
combine together to form a hormone receptor
complex. This causes to trigger the reaction
afterwards.
o Endocrine or Ductless glands is to generate primary
and to clean ductless glands
- Primary endocrine or primary ductless gland
they are the primary exclusive type of an organ or
type of a gland responsible for your endocrine
function.
 Their role is for endocrine associated for the
hormone production, unlike there is a certain
type of your organ/ tissues/cell that is only
express in the tissues of other glands that
produces the hormone but not a major role of
that particular tissue
 That means it only involves with your pituitary
 Primary endocrine gland / Primary ductless
gland: examples:
- They are only involve solely for endocrine function
- They have different origin and type of hormone
synthesize
- Responsible in maintenance of body equilibrium
(Hemostasis)
a.) Pituitary gland
b.) Pineal gland (location: brain),
c.) Thyroid Gland
d.) Parathyroid gland (2 superior pole and 2
inferior pole normally; embedded in
parenchymal tissue of thyroid gland)
e.) Adrenal gland
– Adrenal cortex and medulla.
f.) The rest are Central organs and tissues Not
exclusive which means they have endocrine
function but not solely associated for as
endocrine gland. They have either certain
portion in the tissue or they have hormone
secreting cell express in their tissue but never
the less this is not the major role of those
organ
– Not exclusive endocrine gland but has
specific cell or secretory cell that
produces hormone but still included in
Endocrine System:
a.) Thymus
– superior to the heart
– Hormone responsible for the
production of thymopoietin for
the maturation of lymphocyte to
become T lymphocytes (thymus
dependent
b.) Hypothalamus
c.) Pancreas
d.) Reproductive Organ
– Male: Testes
– Female: Ovary
e.) Kidneys
– Produce erythropoietin
– Pronormoblast to increase
maturation of our red blood cell
f.) Stomach
– gastrin
g.) Liver
h.) Small Intestine
i.) Skin
– Vitamin D, activated by the sun
exposure to be converted to
Vitamin D3
j.) Heart
– ANP
k.) Adipose tissue
– adiponectin,
l.) Placenta
– Responsible for the production
of human chorionic
gonadotropin
– There are a lot of accessory gland or tissues and
even hormone secreting cell not exclusive as
endocrine gland but they share the same function
to our primary or ductless gland. If they are taken
together those all primary endocrine glands and
the hormone secreting tissue / cell express in
different organs / tissues, they constitute to the
endocrine system
o Endocrine System: Are tissues, organs as well as
hormones associated they produce. Regulating the
metabolic processes of the cell
o Endocrinology: Studies the structure and function of
endocrine system as well as diagnosis 9Screening,
Confirmatory and treatment plan)
 Network of a ductless gland that secretes hormones directly
into the blood
 Regulated by means of control of hormone synthesis rat her
than by degradation
 Hypothalamus as a major higher brain control center, the
pituitary gland as a major secretor of hormones, and then
various end organs, which have responsive elements for the
pituitary hormone and affect many metabolic and
developmental functions.
HORMONES
OF H+BALANCE:
 Central concept / idea of endocrinology
 Chemical mediator/messenger that is release in one part of
the body but it actually regulates the activity of the cell and
the other parts of the body
 Chemical signals produced by specialized cells secreted into
the blood stream and carried to a target tissue
o It is being release distant to other parts of the cell
containing the receptor
o It release distant by a secretory cell travels via
circulation (blood is efficient vehicle to transport our
hormone) until it reaches the target cell pairing to a
receptor (specific to that given hormone), although a
given hormone travels throughout the body by means of
the blood, it affects only the specific target cell (has only
a specific receptor that recognizes that hormone)
- Thyroid stimulating hormones (TSH) produce
by anterior lobe of pituitary gland.
o Ones it is releases on it interstitial fluid and enters the
blood, delivered until it reaches the thyroid cell it binds
to the receptors on the cells of thyroid gland which
means TSH receptor can only be found in thyroid gland
and not found in the ovarian cell and any type of other
tissue
 Red blood cell has a life span around 120 days (roughly
around 4 months) because of the wear and tear. Remember
DA BARAKO’S, GFS NI TAEHYUNG (REAL!!)– TRANSCRIBERS
 RBC is bigger than vasculature of the capillaries. The
process when the red blood cell squeeze to deliver O2
effectively (very tiny capillaries) is called Diapedesis
(migration) (WBC and RBC can undergo diapedesis)
o 120 life span of RBC, because of the wear and tear and
to meet the demand of oxygenation, rbc needs to
continue deliver oxygen to the critical organs which are
oxygen dependent
o Bases of wear and tear it’s because it damages the
plasma membrane (worned out) it is susceptible for
macrophages to engulf in the form of reticuloedothelial
system that is express in spleen serves as the graveyard
site of rbc where damage rbcs are sequestered
o All living organisms (cellular proteins or cells) have
specific life span, it is actually programmed when it will
be catabolize, destroy, and regenerate/reconstruct/
resynthesize
o Receptors specific for your hormone (Intracellular
receptor: inside the cell or Extracellular receptor is
expresses or integral to the plasma membrane or the
cell membrane
o Not particular receptor like any other substance/cellular
proteins/ cells in the body. It is actually programmed by
our genes: constantly being synthesized, broken down
or catabolized every now and then
 If a hormone is expressed or present in excess there is an
over production
o Because of the specific stimulus responsible for the
overproduction
o The number of your receptor expressed in/on the skin,
highly specific for that particular excess hormones. This
receptor undergo. Decrease in concentration. There will
be reduction rate in the amount of the receptor
o In response of the excessive production or excessive
amount of your hormone
o Down-regulation
– As hormone increases, receptor decreases
– It is the mechanism of the body to make the cell or
the target of the particular hormone to make it less
sensitive to the amount of your hormone
– To prevent excessive stimulation and trigger myriad
effects of hormone
 Ex. if testes is exposed to high level of LSH
(produced by pituitary) the number of the LH
receptor express in the testicular cell
decreases (lows the target receptor) , so
excessive production of testosterone so
excess secondary characteristics, hypertrophy
of muscles, pimples, increasae libido etc so
dapat maadjust ang receptor
 In order to prevent excessive effect of LSH
there should be also reduction as a mechanism
of the body to reduce the amount of the LH
receptor to make it less sensitive to the high
levels/the highest circulating levels of your
hormone
– In contrast in Juxtaposition
 If the hormone is expressed in deficient or
reduced concentration or low concentration:
the number of the receptor may increase Up-
regulation
 To make it more sensitive (target cell) Increase
receptor in order to have intact (reduced
concentration
o 2 mechanism (by regulating the amount of the of the
receptor expressed in the target cell) to make it more
sensitive
- Up-regulation
- Down-regulation
 Chemical signals produced by specialized cells secreted into
the blood stream and carried to a target tissue
o Additional two mechanism of bodies
o Feedback Mechanism - regulates concentration of
hormone) concentration dependent of the final product
of your hormone
o Majority of the cases, most of the reactions operates on
the negative feedback aspect specially
a) Positive Feedback
 an increased in the product also increases the activity of
the system and the production rate
 leads to pathologic condition
 Increase final product, increase process
 Ex.: high Concentration. Especially if concentration is
stimulate and release of hormone; normally associated
with pathologic condition. Can happen to a certain
situations
 Ex. Low T4 (thyrosine or tetraiodothyromine), not
normal, it is a stimulus/signal to stimulate other organs
to response to a low T4 hypothalamus will response
by means of low T4 by releasing TRH (thyrotropin
releasing hormone (expect Increase TRH). TRH via
Paraphrine reaction affecting the neighboring cells of
your anterior pipuitary gland it goes down to the portal
system.
 Passes the blood because there is a connection
between (through paraphrine reaction) which causes to
affect thyrotrops (lobe of pituitary glands)
 In response to TRH the thyrotropes (anterior lobe of
pituitary) respond to increase theTRH by increasing
stimulating (anterlobe of pituitatry gland)
 Thyroid Stimulating
 Releasing and inhibiting hormone: Hypothalamus
 Oxytocin
– A hormone produce during delivery (normal) of the
baby
– Causes to increase magnitude of uterine
contraction to expel the baby
– If oxytocin is regulated by negative feedback it
decreases and will poorly deliver the baby.
– Final hormone produce or enhances the initial
hormone
– Increase product, increases the initial processes to
produce more products to increase uterine
contraction

b) Negative feedback
 an increased in the product decreases the activity of the
system and the production rate
 Low T4, increase TRH, Increase production of TSH
(release in the interstitial fluid absorb to our circulation.)
(Thyroid). TSH will direct the activity causing to increase
the activity of thyroid so if you increase the activity of
thyroid gland there is a correction of your T4 (increase)
and pull back to normal. TRH and TSH are inhibited
since T4 is corrected, corrected T4 causes to stop or
inhibit / terminate the activity of TRH (hypothalamous)
and TSH (pituitary gland)
 Increase production of final product causes initial
processes inhibited
 If end product is expressed in high concentration it will
inhibit
 If there is continues stimulation or production of TRH
and TSH it will over saturate the blood system that will
cause a pathological condition hypothyroidism.
 Especially if there is an excessive deionization
 Regulatory by its nature
DA BARAKO’S, GFS NI TAEHYUNG (REAL!!)– TRANSCRIBERS
  Opposes the reaction
 Terminates activity of initial processes
 Concentration dependent
 Negative feedback resembles a typical
servomechanism and forms the basis of our
understanding of hypothalamic–pituitary function. An
example of negative feedback is the relationship
between a thermostat and a home heating unit. The
thermostat is set to a given temperature. As the
temperature in the home falls below this set point, the
thermostat sends an electrical impulse to the furnace
and turns the furnace on. Heat is restored to the room
and, when the temperature in the room exceeds the
predetermined set point, the thermostat turns off the
furnace. Because the thermostat set point can be
adjusted for the comfort of the occupants, the furnace–
thermostat functional relationshipis termed an open-
loop negative feedback system.
METHODS OF HORMONE DELIVERY
There are 2 types of hormones:
A. General/ Circulating Hormone
 most of endocrine gland’s secretions are general
hormones
 produced by secretory cells, channeled into the
interstitial fluid and then entered into the circulation via
capillaries targeting the specific cells bearing the
specific receptors
 it is important to know that endocrine gland needs blood
as channels or route for delivery (PRINCIPLE OF
ENDOCRINE SIGNALLING OR ENDOCRINE
REACTION)
B. Local Hormone
 synthesized locally and acts locally without entering the
bloodstream (general circulation)
 it doesn't pass through the blood as compared to
general hormones
 it acts on two types of cells:
a. Self
- The same cells who produced the hormone are
affected or act upon, self-regulation of the cell
Principle: AUTOCRINE SIGNALLING
b. Neighboring cells
- Adjacent target cells affected by the secretion
- close in proximity
Principle: PARACRINE SIGNALLING (near or
beside)
CLASSIFICATION OF HORMONES ACCORDING TO
COMPOSITION OR STRUCTURE
1. Peptides and Protein
a) Glycoprotein
b) Polypeptides
c) Amines
d) Eicosanoids
2. Steroids
1. Peptides and Proteins
 Synthesized and stored within the cell in the form of
secretory granules and are cleaved as needed
 They cannot cross the cell membrane due to their large
molecular size and thus produce their effects on the outer
surface of the cells
 They are water soluble
 Not bound to carrier protein
 They're packed and the body cleaved it if necessary (imagine
para siyang chichirya na bubuksan mo lang if gusto mo, the
same principle with the peptides and proteins)
 After activation or cleavage of the secretory package, the
secretory contents will be released as dictated by the need
of the body to the interstitial fluid or blood
 This classification cannot diffuse to the cell membrane so it
is only capable of inducing effects outside of the cells
(extracellular receptor or cell membrane receptor)
AMINE HORMONES
 classified under protein, considered to be intermediate
between proteins and steroids
 polarity is between lipophilic (fat-loving) and hydrophilic
(water-loving)
 depending on the modification of this hormone, it can act like
protein or steroids
 Remember:
- NO MODIFICATION (NONMODIFIED FORM) = AMINE
is PROTEIN (hydrophilic nature)
- WITH MODIFICATION = AMINE leans to become
STEROIDS (lipophilic nature)
- Example: Thyroid hormones is classified under protein
derivatives but because of its intermediate polarity due
to the presence of IODINE, there' a shift characteristic
that leans toward the steroid hormone.
 Mechanism of Action:
– Hormones interact with a cell membrane receptor. This
activates a second messenger system to affect the
cellular function.
MECHANISM OF ACTION:
– Once the hormone binds to specific target cells bearing
the specific receptors, it's referred to as:
a. HORMONE-RECEPTOR COMPLEX (HR COMPLEX)
– the first messenger is hormone
– once the hormone binds with the cells, there will be
an activation of adenylyl cyclase (responsible for
the generation or production of the second
messenger)
b. cAMP or CYCLIC ADENOSINE MONOPHOSPHATE
– the second messenger (most common)
– produced upon activation of adenylyl cyclase
– it serves as the source of phosphate for the protein
phosphorylation
– what happen is that the hormone kinases remove
the phosphate group from the cAMP which cause
phosphorylation of proteins leading to change of the
physiologic nature of the cell machinery inducing
the effect
– upon activation, some proteins become active and
some become inactive. Just like switching it on and
off
DA BARAKO’S, GFS NI TAEHYUNG (REAL!!)– TRANSCRIBERS
Note:
 PROTEINS, NONMODIFIED AMINES and
EICOSANOIDS cannot diffuse to the lipid bilayer of the
cell membrane and therefore binds with the extracellular
receptors.
 Negative regulator that inactivates the cAMP (second
messenger) is PHOSPHODIESTERASE.
a) Glycoproteins
– proteins complexed with carbohydrates, complexed
means “combined with.”
 LH (Luteinizing Hormone)
– directs testosterone production from Leydig
cells in men and ovulation in women
 FSH (Follicle Stimulating Hormone)
– Responsible for ovarian recruitment and early
folliculogenesis in women and
spermatogenesis in men
 HCG (Human Chorionic Gonadotropin)
– It is dimeric hormone normally secreted by
trophoblasts to promote implantation of the
blastocyst and the placenta to maintain the
corpus luteum through the first trimester of
pregnancy.
– It is a prognostic indicator for ovarian cancer, a
diagnostic marker for classification of testicular
cancer, and the most useful marker for detection
of gestational trophoblastic diseases (gtds).
 TSH (Thyroid Stimulating Hormone)
– Directs thyroid hormone production from the
thyroid
 Erythropoietin
– Acts on the erythroid progenitor cells in the bone
marrow, increasing the number of red blood
cells (rbcs).
– Is a single-chain polypeptide produced by cells
close to the proximal tubules, and its production
is regulated by blood oxygen levels.
b) Polypeptides
 ACTH
– produced by the anterior pituitary gland
– regulates the adrenal steroidogenesis
 ADH
– produced by the hypothalamus but stored in
neurohypophysis (posterior lobe of pituitary
gland)
– major action is to regulate renal free water
excretion and, therefore, has a central role in
water balance
 GH/ Growth Hormone (Somatotropin)
– produced by the anterior lobe of pituitary gland
– direct effector hormone
– has direct effects on substrate metabolism in
numerous tissues and also stimulates the liver
to produce growth factors that are critical in
enhancing linear growth.
 Angiotensin
– produced by the liver
– associated with RAAS for maintaining the blood
pressure and ensure good perfusion of to all
tissues and organs
 Calcitonin
– produced by the thyroid gland
– originates in the medullary cells of the thyroid
gland, is secreted when the concentration of
Ca2+ in blood increases.
– exerts its Ca2+- lowering effect by inhibiting the
actions of both PTH and vitamin D.
 Cholecystokinin
– affects the gall bladder in terms of bile ejection
– is produced by the cells of the intestinal mucosa
and is responsible for release of enzymes from
the acinar cells by the pancreas into the
pancreatic fluid.
 Gastrin
– stomach
– the most potent stimulus to gastric secretion
– it is secreted by specialized G cells in the gastric
mucosa and the duodenum in response to vagal
stimulation and contact with secretagogues.
 Glucagon
– the primary hormone responsible for increasing
glucose levels
– it is synthesized by the a-cells of islets of
Langerhans in the pancreas and released
during stress and fasting states
– it acts by increasing plasma glucose levels by
glycogenolysis in the liver and an increase in
gluconeogenesis.
– it can be referred to as a hyperglycemic agent
 Insulin
– the primary hormone responsible for the entry of
glucose into the cell
– it is synthesized by the b-cells of islets of
Langerhans in the pancreas.
– regulates glucose by increasing glycogenesis,
lipogenesis, and glycolysis and inhibiting
glycogenolysis
– it is the only hormone that decreases glucose
levels and can be referred to as a
hypoglycemic agent
 MSH (Melanocyte Stimulating Hormone)
– plays a key role in producing colored
pigmentation found in the skin, hair and eyes in
response to ultraviolet radiation.
 Oxytocin
– produced by the hypothalamus but stored in
neurohypophysis (posterior lobe of pituitary
gland)
– it is a cyclic nonapeptide, with a disulfide bridge
connecting amino acid residues 1 and 6. As a
posttranslational modification, the C-terminus is
amidated.
– it has a critical role in lactation and likely plays a
major role in labor and parturition.
– Synthetic form: Picin
 PTH (Parathyroid Hormone)
– primary target of PTH is bone and kidneys
– Bone: mobilizes calcium from bone by
increasing bone resorption
– Kidney: increase the reabsorption of renal
tubular calcium, increase phosphate excretion,
enhance1α-hydroxylation of 25-hydroxy
vitamin D
 Prolactin
– produced by the anterior pituitary gland
– STRESS HORMONE
– it is structurally related to GH and human
placental lactogen
– it is classified as a direct effector hormone (as
opposed to a tropic hormone) because it has
diffused target tissue and lacks a single
endocrine end organ.
– it has vital functions in relationship to
reproduction
 Somatostatin
– produced by the hypothalamus, some are
produced in the pancreas
– inhibits GH and TSH release from the pituitary
gland
DA BARAKO’S, GFS NI TAEHYUNG (REAL!!)– TRANSCRIBERS
 – increases plasma glucose levels by the
inhibition of insulin, glucagon, growth hormone,
and other endocrine hormones.
c) Amines
 Epinephrine
– produced by the adrenal medulla, increases
plasma glucose by inhibiting insulin secretion,
increasing glycogenolysis, and promoting
lipolysis
– released during times of stress
 Norepinephrine
– neurotransmitter that transmits signals between
nerve cells
 Triiodothyronine
 Thyroxine
 Melatonin
– it regulates night and day cycles or sleep-wake
cycles
 Mechanism of Action:
– Epinephrine and norepinephrine do not bind to
carrier proteins and interact with the receptor site
on the cell membrane.
– Thyroxine and triiodothyronine circulate bound to
carrier proteins, with the free hormone being
transported across the cell membrane to interact
with the intracellular receptor.
a. Associated with CATECHOLAMINES
– collective term that applies to both epinephrine and
norepinephrine
– it does not require carrier proteins thus when released in
the secretory package, the effect is rapid and
uncontrollable
– the concentration of catecholamine is not regulated by
the carrier proteins (i.e., the primary role of carrier protein
is to regulate the amount of hormone released)
– the receptor is extracellular receptor
Examples:
Epinephrine (adrenaline) and Norepinephrine (noradrenaline)
– released during emergency state or "adrenaline rush"
– these hormones activate the sympathetic nervous
system - "fight, flight, fright reaction" - or the
thoracolumbar (thoracic and lumbar) aspect of the
nervous system
– epinephrine is used to trigger cardiac contractility
(administer to revive the dead or single-lined patients)
b. THYROID HORMONES: T3 (Triiodothyronine) and T4
(Thyroxine)
– Thyroid hormone is made primarily of the trace element
iodine, making iodine metabolism a key determinant in
thyroid function.
– the concentration of thyroid hormone is regulated by
carrier proteins
– the receptor is intracellular receptor
– the exception to the rule among protein derivatives that is
capable of passing through the lipid bilayer
– T3 is the physiologically active form of thyroid hormones
c. MELATONIN
– also associated with the amine group
2. Steroids
 Lipid molecules that have cholesterol as their common
precursor
 Produced by the adrenal glands, ovaries, testes and
placenta
 Water insoluble (hydrophobic)
 Examples:
– Aldosterone, cortisol, estradiol progesterone,
testosterone and vitamin D
 water insoluble or hydrophobic in nature derived mainly from
cholesterol
 Cholesterol is the precursor for the production of steroid
hormones
 it requires the presence of carrier proteins in order to induce
its physiologic effect, it has to be free in order to be in active
form
 the receptor is intracellular receptor
 it is transported across the cell membrane in order to interact
with the extracellular receptor
 as it interacts with the receptor, it will form hormone-receptor
complex. The complexed substance will bind with the
chromatin in order to produce mRNA [the transcript (coding
sequence or codon) for translation]
INTRONS = NONCODING SEQUENCE (removed)
EXONS = CODING SEQUENCE, ligated exons that form
mRNA
 liberated mRNA will then be utilized for protein synthesis that
will carry out the function of the cell.
STEROIDOGENESIS
 production of steroid type hormones
 happens in the adrenal cortex or adrenal glands
 also happens in the reproductive glands such as ovaries,
testes, and accessory gland placenta
PINEAL GLAND
 Attach to the midbrain
- A small endocrine gland that is attached to the roof of the
third ventricle of the brain (midbrain). It is a portion of
epithalamus that is positioned between two superior
caliculi covered by the capsule of pia mater.
- It is also known as epiphysis cerebri.
- Consist of many masses of neuroglia and even
neurosecretory cells known as pinealocytes responsible
for producing melatonin.
 Once dubbed the “third eye”
 Produces MELATONIN
- Melatonin is an amine hormone that is derived from the
precursor serotonin.
- This is why patients with difficulty in sleeping are
recommended to eat foods rich in serotonin just like
bananas, etc.
- It appears to contribute to setting our biological clock,
sleep, and wake cycle. The suprachiasmatic nucleus of
the hypothalamus regulates our circadian rhythm.
– Decreases the pigmentation of the skin
– A "natural" sleep aid
– Also regulates circadian rhythm
 Secretions are controlled by the nerve stimuli
- More melatonin is produced during darkness. It is
inhibited by the presence of light.
- Melatonin depresses pigmentation. It is also a potent
antioxidant.
HYPOTHALAMUS
 Portion of the brain located in the walls and floor of the third
ventricle
- A small part of the diencephalon. Forms the floor and the
wall of the third ventricle that is somewhat a neighbor of
the pineal gland.
- Without the hypothalamus, life will never exist.
- There are many biological rules provided by the
hypothalamus. It regulates thirst, hunger, satisfaction, and
temperature, sexual behavior regulation, circadian rhythm
regulation.
- Hypothalamus serves as the body’s thermostat.
- There is an increase in hyperactivity of the hypothalamus
DA BARAKO’S, GFS NI TAEHYUNG (REAL!!)– TRANSCRIBERS
 during stimulation of Interleukin-1 which elicits the
hypothalamus to release prostaglandin to reset the
hypothalamic activity as well as the temperature.
 Link between the nervous system and the endocrine system
 Supraoptic and paraventricular nuclei (magnocellular
neurosecretory cells of the hypothalamus) produce
vasopressin and oxytocin
- Aside from oxytocin, it also produces ADH, arginine
vasopressin, and also hypophysiotropic hormone
(inhibiting, releasing hormones) which is produced by
the hypothalamus and is dim to regulate the anterior lobe
of the pituitary gland.
 Above the pituitary gland and is connected to the posterior
pituitary by the infundibulum (pituitary stalk).
- Hypothalamic pituitary axis, there is a regulatory nature
made by the hypothalamus to the pituitary gland in
response to a specific stimulus.
Hypothalamic Hormones
1. Corticotropin-releasing hormone (CRH)
- Releases cortisol
- is secreted from the hypothalamus in response to
circadian signals, serum cortisol, and stress, causing
release of stored ACTH, which stimulates transport of
free cholesterol into adrenal mitochondria, initiating
steroiproduction.
2. Gonadotropin-releasing hormone (GnRH)
- GnRH → FSH and LH to target reproductive hormones.
- GnRH is synthesized in neurons situated in the arcuate
nucleus and other nuclei of the hypothalamus and is
released into the portal hypophyseal system that, in
turn, determines the production of LH and FSH from the
pituitary gland
3. Growth hormone-releasing hormone (GHRH) / Somatocrinin
- Growth hormone: Somatotropin
- Release of somatotropin from the pituitary is stimulated
by the hypothalamic peptide growth hormone–releasing
hormone (GHRH); somatotropin’s secretion is inhibited
by SS
4. Thyrotropin-releasing hormone (TRH)
- Stimulates the release of TSH and prolactin
- TRH is synthesized by neurons in the supraoptic and
supraventricular nuclei of the hypothalamus and stored
in the median eminence of the hypothalamus. When
secreted, this hormone stimulates cells in the anterior
pituitary gland to manufacture and release thyrotropin
(TSH).
5. Dopamine/ Prolactin-inhibiting hormone
- Is the only neuroendocrine signal that inhibits
prolactin and is now considered to be the elusive
Prolactin inhibitory factor (PIF)
- Any compound that affects dopaminergic activity
in the median eminence of the hypothalamus will
also alter prolactin secretion.
6. Somatostatin (SS)/ Growth hormone-inhibiting hormone/
Thyroid Stimulating Hormone-inhibiting hormone
- Hypophysiotropic hormones are synthesized by
parvocellular neurosecretory cells of the hypothalamus.
- ADH and oxytocin are produced by magnocellular
neurosecretory cells of the hypothalamus.
- POSA:
o Paraventricular nuclei for Oxytocin
o Supraoptic nuclei for ADH/ Arginine
vasopressin
- The hypothalamus secretes two regulatory hormones
that effect growth.
- GH-releasing hormone is a 40–amino acid polypeptide
that stimulates release of GH from the anterior pituitary.
- GH-inhibiting factor, also known as somatostatin,
inhibits GH secretion.
- Additional factors from higher cerebral centers (cerebral
cortex), including catecholamines, serotonin, ghrelin
and endorphins, have a positive effect on GH secretion.
- Inhibition of GH secretion also occurs when infants are
socially deprived.
- The mechanism for this reversible inhibition is not
known, but neglect and potential child abuse are major
differentials in infants with retarded growth.
PITUITARY GLAND (HYPOPHYSIS/ Hypophysis cerebri)
- Anterior lobe is larger than the posterior lobe. The
hypothalamus shows that it has a regulatory nature on the
pituitary activity which in turn depicts the role of the
pituitary gland on other endocrine glands.
- Nervous system and endocrine system work hand-in-hand
for the maintenance of the body’s equilibrium
- Nervous system is much faster than the endocrine.
- Any stimulus that disrupts the equilibrium will be perceived
by the brain that will automatically be processed by the
hypothalamus. Controlling, regulating, and even targeting
the different endocrine glands in the body in order to
modify the biological processes taken in the cell.
 Derived from Latin and Greek word pitui “spit mucus”
 Was recognized as the “master gland”
 Also known as “Hypophysis” (Greek word–undergrowth)
under the hypothalamus
 Also recognized as a Transponder
- The pituitary gland has its own master which is the
hypothalamus.
- Functions as a transponder that can translate or convert
the neural input to become an endocrinology product in the
form of the hormone.
- Pituitary gland provides an indirect language in the
regulation of the growth and development of the body.
Example: Growth hormone for bone elongation. LSH for
the release of estrogen and testosterone for the sexual
characteristic of femaleness and maleness.
 Located in the small cavity in the sphenoid bone of the skull
called the Sella Turcica or Turkish Saddle
- T- shaped gland/structure that lies in the hypophyseal
fossa of the Sella turcica of the sphenoid bone
- Sphenoid bone, a bone that is located at the floor of the
skull. It is similar with the out stretched wings/ butterfly. Sa
gitna may tinatawag na concavity or tinatawag na
hypophyseal fossa of Sella turcica.
- Fossa = shallow depression that is actually expressed
DA BARAKO’S, GFS NI TAEHYUNG (REAL!!)– TRANSCRIBERS
 in the sphenoid bone = like a butterfly
-
In this concavity it actually lodge the Pituitary Gland =
exact location of PG = hypophyseal fossa of Sella
turcica. It is actually attached to the hypothalamus by
means of infundibulum (pituitary stalk)
 All pituitary hormones have circadian rhythms
 Essentially the PG has two anatomically and functionally
divided/separated lobes or portion.
 Divided into three groups:
1. Anterior lobe (adenohypophysis)
o originates from Rathke’s pouch
o It accounts the 75% of the total weight of the PG
o Pars distalis = larger portion
o Pars tuberalis = covering/sheath that wraps the
infundibulum
2. Intermediate lobe (pars intermedialis/intermedia)
o Undergoes physiologic atrophy or involution or
decrease in size or shrinkage during human fetal
development. Exist in separate lobe in human adult.
Remnant in the adult. Some cells of the intermediate
lobe migrate in the certain portion of anterior lobes
where MSH (melanocyte stimulating hormone) are
actually produced.
3. Posterior lobe (neurohypophysis)
o It accounts the 25% of the remainder of the total weight
of the PG
o Never produces hormones, it only serves as the storage
depot for the oxytocin and antidiuretic hormone released
by the Magnocellular Neurosecretory cells of the
hypothalamus derived from the diencephalon
o arises from the diencephalon
o Pars nervosa = large bulbar portion
o Infundibulum = constitute the neurohypophysis
5 TYPES OF CELLS BY IMMUNOCHEMICAL TEST:
 We are talking about here the anterior lobe base on the
immunochemical staining of the particular type of the cell.
 Traditionally speaking, the parenchymal or tissue cells of the
AL of PG has been classified in to two general types:
– Chromophobes = predominant, 65%, without affinity to
dye. Color resisting cell.
– Chromophils = 35%, with affinity to the dye. Color
loving.
o Acidophils = affinity with eosin (acidic dye) = red
o Basophils = take up basic dye like methylene blue,
methylene violet = purple or blue
Red = acidophils Blue = basophils
1. Somatotrophs 3. Thyrotrophs
– Secrete growth – Secretes TSH
hormone 4. Gonadotrophs
2. Lactotrophs or – Secrete LH and FSH
Mammotropes 5. Corticotrophs
– Secrete prolactin (milk – Secrete ACTH
production)
ENDOCRINE FEEDBACK LOOP
 Feedback loop – regulated based on the negative feedback
mechanism by means of the concentration of the final
product regulating the activity both hypothalamic pituitary
axis.
 Ex: Low T4 (thyroxine)- in response there would be an
increased TRH by the hypothalamus in return there would be
increased in the TSH by AL of PG to correct the activity of
the thyroid to correct the imbalance.
1. Low T4
2. Increase TRH
3. Increase TSH
4. Increase the activity of thyroid
 Short Feedback Loop
– Refers to pituitary hormone providing negative feedback to
the hypothalamus, inhibiting the secretion of the releasing
hormone.
– Take note: The communication/relationship of the thyroid
gland to the level of the pituitary gland.
– The feedback of thyroxine at the level of the pituitary
 Long Feedback Loop
– Refers to the hormone that was released from the
peripheral endocrine gland inhibiting pituitary or
hypothalamic secretion of releasing hormone.
– Take note: The communication/relationship of the thyroid
gland to the level of the hypothalamus.
– The feedback at the level of the hypothalamus
 Ultrashort Feedback Loop
– Hormone inhibits its own secretion in a paracrine manner
– Take note: The communication/relationship between the
hypothalamic - pituitary.
– The feedback between the pituitary and hypothalamus
(when present)
PITUITARY HORMONES
1. Tropic Hormones
- Class of hormones from the AL of PG that affect the
secretions of another endocrine gland
 actions are specific for another endocrine gland
– TSH = thyroid gland = release hormones (T4 or T3)
– LH & FSH = ovary or gonads = if it stimulate the
testis or ovary these gonads will produce other
hormones such as testosterone, estrogen and
progesterone
– ACTH (adrenocorticotropic hormone)
 The loss of a tropic hormone (ACTH, TSH, LH, and
FSH) is reflected in function cessation of the affected
endocrine gland.
2. Direct Effectors
- Hormone that directly affects the peripheral tissue and
DA BARAKO’S, GFS NI TAEHYUNG (REAL!!)– TRANSCRIBERS
 does not require signal from the PG.
 act directly on peripheral tissue
– GH = target is bone
– Prolactin = mammary gland or breast = milk
production
 Loss of the direct effectors (GH and prolactin) may not
be readily apparent.
POSTERIOR PITUITARY (NEUROHYPOPHYSIS)
 The hormones released by neurohypophysis are
synthesized in the supraoptic nuclei (ADH) and
paraventricular nuclei (oxytocin) of the hypothalamus
 Release of the hormones occurs in response to serum
osmolality or by suckling
 Hormones produced are controlled by CNS
 There is a physical connection of the hypothalamus with the
posterior lobe of PG via infundibulum
 Axon = extends up to the PL of PG in effect the hormone
reaches the PL of PG for the storage and eventually release
if needed by the body to modify the biological processes
depending on the body needs.
 Never produce hormones
 Magnocellular Neurosecretory cells
- supraoptic nuclei
- paraventricular nuclei
 Oxytocin and ADH = nonapeptide = 9AA = homologous
- Only differ in the 3rd (isoleucine of oxytocin,
phenylalanine for ADH) and 8th position (leucine for
oxytocin, arginine for ADH)
OXYTOCIN
 Stimulus: suckling infants on the mammary gland or uterine
contraction
 Effects: during the onset of delivery and after the onset of
delivery
 Target: uterus and mammary gland (breast)
 Take note: during the onset of delivery the oxytocin
enhances the contraction of the smooth muscle of uterus
known as Fergusson reflex = responsible for expelling the
baby outside or parturition or child birth
 Function in non-pregnant/ males: not elucidated
 Role in sexual: pleasure or desire during and after sex
 Stimulates contraction of the gravid uterus at term-
(Fergusson reflex)
 Released in response to neural stimulation of receptors in
the birth canal, uterus and of touch receptors in the breast
 Stimulates muscle contraction (during delivery and
lactation)
 Synthetic preparation of oxytocin are used to increase weak
uterine contractions during labor and to aid in lactation
(Pitocin) = synthetic form of oxytocin.
 Oxytocin is a cyclic nonapeptide, with a disulfide bridge
connecting amino acid residues 1 and 6
 As a posttranslational modification, the C-terminus is
amidated.
 Oxytocin has a critical role in lactation and likely plays a
major role in labor and parturition
ANTI-DIURETIC HORMONE (ADH) /ARGININE
VASOPRESSIN (AVP)
 Decreases urine output or production
 Stimulus: increase plasma osmolality as detected by the
osmo receptor of the brain
 Effect: More water reabsorption = increase blood volume,
pressure and lower osmolality
 Vasopressin: means generalized vasoconstriction to
elevate BP during traumatic injury
 Target: Kidney = Distal convoluted tubule and collecting duct
= V2 receptor
 Target: Vascular endothelium (blood vessel) = V1a (V1
receptor) and V1b (V3 receptor)
 Non-apeptide that acts on the DCT and CD of the kidney
 It increases blood pressure where a decreased in blood
volume or blood pressure will likewise stimulate ADH release
 It’s a potent pressor agent and affects blood clotting by
promoting factor VII release
 Physical and Emotional Stress (surgery) increase ADH
output
 Inhibitors of ADH release: ethanol (active component of
alcoholic beverages), cortisol (anti-inflammatory), lithium
(treating bipolar disorder)
- It causes polyuria opposite to emotional stress and
emesis.
 Potent Physiologic Stimuli to ADH release: emetic stimuli
(vomiting)
 Diagnostic test: Overnight Water Deprivation
- Concentration test that does not require consumption of
water or fasting with fluids for 8-12 hours
CLINICAL DISORDERS (ADH)
1. Diabetes Insipidus (DI)
 Deficient ADH = induce polyuria = increase more than
tenfold urine output
 Neurogenic type = hypothalamic, cranial, central, true
diabetes insipidus, normal structure of the V2 receptor
 Nephrogenic type = normal amount of hormone but there
is abnormality in the receptor
 Results in severe polyuria (≥ 3 L of urine / day)
 Low specific gravity = (<1.005) almost similar to water
(1.00)
 Urine osmolality = (<400 mOsm per kg)
 Clinical Pictures include:
– Normoglycemia = no problem in glucose
– Polyuria with low specific gravity
– Polydypsia
– Polyphagia (occasional)
 DI is a consequence of vasopressin deficiency.
However, total vasopressin deficiency is unusual, and
the typical patient presents with a partial deficiency.
SIADH
 Opposite to DI, there is an overproduction, excessive or
insuppressible production of ADH from the hypothalamus
and released by PL of PG.
 Hallmark: Increase release ADH = increase water
reabsorption = less urine output = Hyponatremia,
hypoosmolality, high urine osmolality with low volume.
 Syndrome of Inappropriate Antidiuretic Hormone
Secretion
 Refers to the sustained production of ADH in the absence of
a known stimuli
 Characterized by
– Decreased urine volume
– Low plasma osmolality
– Normal or elevated urine na levels
– Low serum electrolytes
DA BARAKO’S, GFS NI TAEHYUNG (REAL!!)– TRANSCRIBERS
 output
 Inhibitors of ADH release: ethanol, cortisol, lithium
 Potent Physiologic Stimuli to ADH release: emetic stimuli
 Diagnostic test: Overnight Water Deprivation
 SIADH causes an increase in water retention because of
increased AVP (ADH) production.

References:
Sir Jeff’s Notes
Bishop 7th Edition

DA BARAKO’S, GFS NI TAEHYUNG (REAL!!)– TRANSCRIBERS

 Endocrinology (Parathyroid Gland)
CLINICAL CHEMISTRY 2
Instructor: John Jeffrey Pangilinan, RMT, MSMT
Date: April 28, 2022
TOPIC OUTLINE
I. Parathyroid Gland
II. Hyperparathyroidism
a. Primary Hyperparathyroidism
b. Secondary Hyperparathyroidism
c. Tertiary Hyperparathyroidism
III. Hypoparathyroidism
PARATHYROID GLAND
• It is located on or near the thyroid capsule (region of the
thyroid gland); sometimes within the thyroid gland.
• Most people have 4 parathyroid glands but some have 8 or
as few as two.
o 4 parathyroid glands are usually situated at the back
position or at the posterior aspect of thyroid gland
parenchyma.
• Smallest endocrine gland.
o Parathyroid gland is considered to be the smallest
endocrine gland expressed in human body.
o Produces parathyroid hormone, also known as
parathormone.
• Secretes parathyroid hormone (PTH).
o Parathyroid hormone: is the primary hormone that
maintains the calcium homeostasis or balance by
means of different mechanism.
o Both calcium and phosphorus are maintained by the
PTH within the prescribed limits.
o Calcium and Phosphorus are the major mineral ions
/ mineral constituents of the bone responsible for the
formation of HYDROXYAPATITE CRYSTALS
o Calcium is expressed in greater concentration
compared to phosphorus. (when we talk about bone
structure)
o PTH directly acts on the bones and kidneys as the
target tissues.
o In bones, PTH is responsible by increasing the
osteoclastic activity that leads to increased bone
resorption thus to release the calcium.
o In the kidneys, it causes to increase the renal
reabsorption of calcium, WHILE decreasing the
renal clearance of the calcium at the same time.
o Indirectly acts on small intestine by means of the effect
of 1,25-dihydroxycalciferol (active form of Vitamin D3)
by increasing the intestinal reabsorption of calcium.
o PTH production is closely regulated and controlled by
the concentration of serum ionized calcium.
o In other words, any situation/scenario or tendency
toward hypocalcemia (calcium deficiency state),
perhaps brought about by calcium deficient diet is
counteracted by means of increased PTH.
o Calcium level is the stimulus whether to increase or
decrease the PTH Production.
o Decreased Calcium causes to elevate the PTH in
order to target and activate the bones and kidneys, even
the intestine.
o If there is increased amount of calcium expressed in
blood, it leads to decreased PTH secretion causing to
inactivate or inhibit bone resorption while decreasing
reabsorption of calcium both in the kidneys and intestine
whether there are applications of 1,25-
dihydroxycalciferol toward calcium homeostasis.
1
DA BARAKO’S, GFS NI TAEHYUNG (REAL!!), CADIVIDABIDA – TRANSCRIBERS
LEC
2021 – 2022
WEEK 12 2nd Semester
CCHEM 322
o The whole process is regulated by negative feedback
mechanism because of its regulatory nature.
Illustration of parathyroid gland
• Parathyroid gland (based on the illustration above) is
visualized as yellow, expressed in circular shape
• 2 at the upper pole; 2 at the lower pole.
• Microscopically, parathyroid gland is consisting of two
distinct cell type:
o Chief cells → considered to be the most abundant with
clear cytoplasm which is responsible for the production
of parathyroid hormone.
o Oxyphil cells → less abundant compared to chief cells;
has a pyknotic nucleus, which is believed to be the
senescent form or the old form of chief cells.
CLINICAL DISORDERS
Associated with parathyroid gland, whether excess or deficiency
leading to hypo- and hyperparathyroidism
• Hyperparathyroidism – increased PTH production
further subcategorized depending on the tissue
involvement.
o Primary
o Secondary
o Tertiary
• Hypoparathyroidism – decreased parathyroid activity;
decreased PTH production.
PARATHYROID GLAND (Rodriguez – Revised 2018)
• It is located on or near the thyroid capsule (region of the
thyroid gland); sometimes within the thyroid gland.
• It may also be found outside their normal anatomic site -
between the hyoid bone in the neck and mediastinum.
• Most people have 4 parathyroid glands but some have 8
or as few as two.
• Is the smallest endocrine gland in the body.
• It secretes parathyroid hormone (PTH) - hypercalcemic
hormone.
Role of PTH
• Prime role: To prevent hypocalcemia (regulates blood
calcium.)
• It preserves calcium and phosphate within normal range.
• It promotes bone resorption – release calcium into the
blood stream.
• It increases renal reabsorption of calcium.
• It stimulates conversion of inactive vitamin D to activated
vitamin D.
• Indirectly stimulates intestinal absorption of calcium.
• As calcium levels increase, PTH secretion is suppressed
allowing urinary loss of calcium and calcium to remain in
bone.
• If calcium levels decrease, PTH is released.

HYPERPARATHYROIDISM
PRIMARY HYPERPARATHYROIDISM
• “Primary” (in clinical disorders) – the physiologic problem
lies within the primary organ.
• In this case, the parathyroid gland is the organ affected.
• Physiologic defect lies with the Parathyroid gland.
o Hyper” – increase activity
o Therefore, there is excessive production of
parathyroid hormone leading to hypercalcemia and
phosphaturia because they are regulated in
opposite/reciprocal manner.
• Most common cause of hypercalcemia.
• Is due to the presence of a functioning parathyroid
adenoma.
o Usually, 80% is caused by BENIGN TUMOR or
adenoma in parathyroid gland.
o Therefore, in primary hyperparathyroidism brought by
adenoma or benign tumor expressed in parathyroid
parenchyma, the PTH production becomes
independent.
▪ It usually escaped from normal dynamics of body
physiology
▪ In effect, not regulated anymore by negative
feedback mechanism.
▪ Therefore, the secretion continues to be elevated
despite elevated calcium levels operating on
positive feedback mechanism.
• Is accompanied with phosphaturia.
• If it goes undetected, severe demineralization may occur
(Osteitis fibrosa cystica).
o Since the primary tissue target of PTH is the bone, it
causes to increase the bone osteoclastic activity to
increase the resorption activity
o It may lead to demineralization of bone leading to
removal of mineral salt responsible for the bone
hardness → condition known Osteitis Fibrosa Cystica
o Osteitis Fibrosa Cystica: condition where there is an
extensive/erosive bone disorder.
o Most common complication of Primary
hyperparathyroidism are associated with renal
manifestation that regulates the hypercalcemia leading
to possible development of nephrolithiasis (kidney
stones) or nephrocalcinosis related to renal calcium
deposit.
LABORATORY RESULTS
• PTH: Increased
• Ionized Ca: Increased
• Hypercalciuria – increased urinary calcium excretion
• Hypophosphatemia (fasting state) – decreased phosphate
levels expressed in the blood.
PRIMARY HYPERPARATHYROIDISM (Rodriguez –
Revised 2018)
• Physiologic defect lies with the PT gland.
• It is the most common cause of hypercalcemia.
• It is due to the presence of a functioning [parathyroid
adenoma.
• It is accompanied with phosphaturia.
• If it goes undetected, severe demineralization may
occur. (Osteitis fibrosa cystica)
Laboratory Results
• PTH: Increased or high normal range
• Ionized Ca: Increased
• Hypercalciuria
• Hypophosphatemia (fasting state)
SECONDARY HYPERPARATHYROIDISM
• Develops in response to decreased serum calcium.
o Either caused by vitamin D deficiency or kidney
problems thus causing to impair the activation of vitamin
D, not the primary organ.
• There is diffuse hyperplasia of all 4 glands.
DA BARAKO’S, GFS NI TAEHYUNG (REAL!!), CADIVIDABIDA – TRANSCRIBERS
2
o Parathyroid gland undergoes hyperplasia → there is
an increased mitotic cell division of the tissue → tissue
enlargement, that is in diffused form.
o Diffused form – with even enlargement of the entirety
of tissue, not localized to one particular region of
parathyroid parenchyma.
o In response to hyperplasia, there will be an increased
production of PTH, which may increase bone
resorption.
o However, since the kidneys have problems. Calcium is
not regulated properly/efficiently, leading to increase
urinary loss of calcium, forcing the bone to continue
demineralization leading to skeletal involvement.
• The patient develops severe bone disease.
CAUSES
• Vitamin D deficiency
• Chronic renal failure
LABORATORY RESULTS
• PTH: Increased
• Ionized calcium: Decreased
SECONDARY HYPERPARATHYROIDISM (Rodriguez –
Revised 2018)
• It develops in response to decreased serum calcium.
• There is diffuse hyperplasia of all 4 glands.
• The patient develops severe bone disease.
TERTIARY HYPERPARATHYROIDISM
• Happens when secondary hyperparathyroidism becomes
autonomic.
o Hyperplastic parathyroid gland becomes dependent,
and no longer controlled by negative-feedback
mechanism.
• A sort of combination of primary and secondary
hyperparathyroidism with almost the same features.
o Leads to the precipitation and consumption of
calcium and phosphate in various tissues affecting
the soft tissues.
• It occurs with secondary hyperparathyroidism.
• Develops autonomous function of the hyperplastic
parathyroid glands or of parathyroid adenoma.
• Phosphate levels: normal to high.
• Calcium phosphates precipitate in soft tissues.
TERTIARY HYPERPARATHYROIDISM (Rodriguez –
Revised 2018)
• It occurs with secondary hyperparathyroidism.
• The phosphate levels are normal to high.
• Calcium phosphates precipitate in soft tissues.
HYPOPARATHYROIDISM
• Opposite to the condition of Hyperparathyroidism.
• Happens when there is decrease in the activity of the
parathyroid gland.
• Decrease in activity translates that there is decrease in the
PTH production. Towards the decreased calcium levels.
• Is due to accidental removal of all parathyroid
glands/injury to the parathyroid glands (neck) during
surgery – postsurgical cause.
o Not all parathyroid tissues or glands are removed, but
the remaining tissues or glands undergoes vascular
supply secondary to fibrotic changes.
• In order to maintain the balance amount of calcium in the
blood, the supplementation is the primary or core
intervention given by the clinician in order to correct the
imbalance.
• Since calcium and phosphorus are regulated by the kidneys
in opposite manner:
• Low calcium – phosphate reabsorption is increased →
 acidosis
• Low calcium – activates more bicarbonate reabsorption in
the renal tubule → alkalosis
• Hallmark or Manifestation of Hypoparathyroidism:
Mixed acidosis and alkalosis state.
• The best method for PT measurement involves the use
of antibodies that detects both the amino terminal fragment
and intact PTH.

OTHER CAUSES
• Related to autoimmune problems – leading to antibody
production that destroys the parenchymal tissue of the
parathyroid glands.
• Autoimmune parathyroid destruction
• Low PTH causes elevated bicarbonate reabsorption-
alkalosis.

NOTES TO REMEMBER (Rodriguez – Revised 2018)

• In hyperparathyroidism, the distal convoluted tubule
reabsorbs bicarbonate as well as phosphate resulting in
acidosis.
• Parathyroid hormone normally interferes with
bicarbonate reabsorption in the proximal tubule.
Therefore, the renal tubular bicarbonate threshold tends
to be increased in hypoparathyroidism.
• Low PTH causes elevated bicarbonate reabsorption –
alkalosis.
• Calcium level: <6 mg/dL (1.5 mmol/L) – laryngeal stridor
and tonic-clonic seizures.
• Calcium level: <8 mg/dL (2.0 mmol/L) leads to tetany and
altered neuromuscular activity. (Chvostek’s sign and
Trousseau’s sign)

References:
• Sir Jeff’s Notes
• Bishop 7th Edition
• Rodriguez (Revised 2018)

DA BARAKO’S, GFS NI TAEHYUNG (REAL!!), CADIVIDABIDA – TRANSCRIBERS

3

TOXICOLOGY
CLINICAL CHEMISTRY 2
Instructor: John Jeffrey Pangilinan, RMT, MSMT
Date: May 13, 2022
Topic Outline
I. Toxicology
II. Exposure And Routes
III. Dose-Response Relationships
IV. Duration And Frequency Of Exposure
V. Analysis Of Toxic Agents
VI. Toxicology Of Alcohol
TOXICOLOGY
 Is the study of the xenobiotic materials, its adverse effects,
what are the diagnostic test or laboratory method for
detection, what are the antidote given to counteract the
biologic effect of poisonous substances
 It is important to take note that toxicology is strained to
examine as well as to communicate the nature of effects on
human, animal, and environmental health
 It is important to take note that toxicological research
examine the cellular, biochemical, and molecular
mechanism of action, the functional effects associated with
neurobehavioral as well as immunological, and also
assesses the probability of occurrences
 Any substances induces to human may be classified as
poison.
 Sodium chloride, oxygen, water, and other non-substances
are generally considered to be non-toxic but can be
dangerous to human health under certain conditions
 Study of the adverse effects of chemical or physical
agents on living organisms
 Study of poisonous substances
 Their actions on the living organisms
 Their detection by laboratory & other methods
 Measures taken to counteract their biologic effects
(antidote)
 Toxicologists
 Paracelsus, “The dose makes the poison”
- Any chemical can be toxic if the dose or exposure is
high. The degree of injury increases, as the dose
increases as well
DEFINITION OF TERMS
OF H+BALANCE:
1. XENEBIOTIC
- Chemicals and drugs that are not normally found in or
produced by the body hence considered to be
exogenous material without biological function in
humans
- Exogenous, no known functions
- Environmental chemicals or drug exposure
- Antibiotics, anti-depressants, and others (drugs,
medications)
2. POISON
- Agent with harmful effects related to animals, plants,
minerals and gases
- Related to animals, plant, mineral or gas
- Venom of poisonous snakes, poison hemlock, arsenic,
carbon monoxide, others
3. TOXIN
- Substances that are biologically synthesized by living
cells or microorganism
DA BARAKO’S, GFS NI TAEHYUNG (REAL!!), JUANITO– TRANSCRIBERS
LEC 2021 – 2022
WEEK 13 2nd Semester
CCHEM 3
- Virulence factors of microorganism
- Botulinum toxin, Mycotoxin
DISCIPLINES OF TOXICOLOGY
Remember: Scope of toxicology is very broad but four
disciplines can be deduced includes:
1. MECHANISTIC TOXICOLOGY
- Concerned with cellular & biochemical effects of toxins
and molecular mechanism by which chemical exert toxic
effects on living organisms
- The results of mechanistic studies are very important in
the many areas of applied toxicology example in risk
assessment = useful in demonstrating adverse
outcomes like cancer, birth defects that is actually
observed in laboratory animals directly relevant to
humans
- Basis for rational therapy design & development of tests
to assess the degree of exposure
 Mechanistic toxicology elucidates the cellular,
molecular, and biochemical effects of xenobiotics
within the context of a dose–response relationship
between the xenobiotic and the adverse effect.
 Mechanistic studies provide a basis for rational therapy
design and the development of tests to assess the
degree of exposure in individuals.
2. DESCRIPTIVE TOXICOLOGY
- Concerned directly with toxicity testing which provides
information on safety evaluation and regulatory
requirements
- Animal experimentation
- Risk assessment = The appropriate toxicity test in cell
culture system or experimental animal are designed to
yield information to evaluate the risk posed to humans
and environment exposed to specific chemicals
- Regulatory toxicology utilizes data from mechanistic
and descriptive toxicology to establish standards
- Regulatory toxicologist: has the responsibility for
deciding on the basis of data provided by descriptive
and mechanistic toxicologist whether a drug or
chemical poses a sufficiently low risk to be marketed
for a given stated purposes.
- Work in conjunction: BFAD (Bureau of Food and
Drugs administration)
 Descriptive toxicology uses the results from animal
experiments to predict what level of exposure will
cause harm in humans. This process is known as
risk assessment.
 In regulatory toxicology, interpretation of the
combined data from mechanistic and descriptive
studies is used to establish standards that define the
level of exposure that will not pose a risk to public
health or safety. Typically, regulatory toxicologists
work for, or in conjunction with, government
agencies. The Food and Drug Administration
oversees human safety issues associated with
therapeutic drugs, cosmetics, and food additives.
 The U.S. Environmental Agency has regulatory
oversight with regard to pesticides, fungicides,
 rodenticides, and industry-related chemicals that
may threaten safe drinking water and clean air.
 The Occupational Safety and Health Administration
(OSHA) is responsible for ensuring safe and healthy
work environments.
3. FORENSIC TOXICOLOGY
- Hybrid of analytical chemistry and fundamental
toxicological principle
- Concerned with Medico-legal consequences of toxin
exposure on humans and animals
- Used to generate evidence to establish cause of death
and determining the circumstances in a post mortem
examination/investigation
 Forensic toxicology is primarily concerned with the
medicolegal consequences of exposure to chemicals or
drugs. A major focus of this area is establishing and
validating the analytic performance of the methods used
to generate evidence in legal situations, including the
cause of death.
 Environmental toxicology includes the evaluation of
environmental chemical pollutants and their impact on
human health. This is a growing area of concern as we
learn more about the mechanisms of action of these
chemicals, monitor occupational health, and increase
public health biomonitoring efforts nationwide.
4. CLINICAL TOXICOLOGY
- Area of professional emphasis in the realm of medical
science that is concerned with disease caused by
uniquely associated toxic substances
- Generally, clinical toxicologist are physicians who
receives specialized training in emergency medicine
and poison management
- Inter-relationships between toxin exposure & disease
state
- Both diagnostic testing & therapeutic intervention
 Clinical toxicology is the study of interrelationships
between xenobiotics and disease states. This area
emphasizes not only diagnostic testing but also
therapeutic intervention.
EXPOSURE AND ROUTES
- Human actions that may lead to toxic episodes can be
categorized whether:
1. INTENTIONAL EXPOSURES
- Suicidal attempts or recreational use
- It can be in form of recreational and suicidal attempts
- Individual is fully aware of exposure and effects of
poisonous substances
2. UNINTENTIONAL EXPOSURES
- Individual is unwillingly exposed due to accidental or
occupational hazards associated with industrial
companies and agricultural setting
- Accidental
- Homicide or occupational
A. ROUTES OF EXPOSURE
 Inhalation (lungs)
 Ingestion (GIT)
 Transdermal (topical, percutaneous or dermal
absorption)
- Toxic agents generally produced greatest effect and
the most rapid response when given directly in the
blood stream known as intravenous route
 Descending order: Inhalation, intraperitoneal,
DA BARAKO’S, GFS NI TAEHYUNG (REAL!!), JUANITO– TRANSCRIBERS
subcutaneous, intramuscular, intradermal, oral, and
dermal
- Ingestion of toxin: most commonly observed
in clinical setting
 Factors: rate of dissolution, gastrointestinal motility,
resistance to degradation and interaction with other
substances
- Toxins that are not absorbed from the GIT
tract do not produces systemic effects but
local effects such as diarrhea, bleeding,
malabsorption of nutrient which may cause
systemic effects secondary to toxin exposure
DOSE-RESPONSE RELATIONSHIPS
 Take note: characteristic of exposure and spectrum of toxic
effects come together in a correlated fashion and
relationship.
- Exist in two forms: Individual dose response and
Quantal dose response
1. Individual dose response: describe the response of
an individual to a varying dose of chemical known as
graded/gradient response because the measured
effect is continuous over a range of doses.
2. Quantal dose: characterize the distribution of
individual responses to different doses in a population
of individual organism
 TOXICITY, TOXIC RESPONSE
- Refers to the effects manifested by an organism in
response to a toxins
 DOSE-RESPONSE RELATIONSHIP
- The degree of injury increases as the dose increases
- Individual dose response, Quantal dose response
- TD50—test developed to quantify toxicity
 The widely used statistical approach for estimating
the response of a population to a toxic exposure is
toxic dose 50, predict to produce the toxic effect or
response of the 50% of the population
- LD50—test developed to quantify lethality
 If the monitored response is death or fatality, the
LD dose will predict the death in the 50% of the
population
- ED50—test developed to quantify therapeutic benefit
 Effective dose, predicts the effective or therapeutic
benefits in the 50% of the population
- Therapeutic index—ratio of TD50 or LD50 to the
ED50
 Take note: the drugs that has large therapeutic index
have few toxic adverse effects when the dose of the
drugs is in therapeutic range. Any substance has a
potential to cause harmful effects if not given a correct
dosage according to Paracelsus (coined the concept
of the dose mix the poison)

DURATION AND FREQUENCY OF EXPOSURE
Remember: Toxicologist divide the exposure of experimental
animals to chemical in three categories:
1. ACUTE TOXICITY
- Single, short-term exposure to a substance
- Toxic response results from single dose
- Exposure to chemical for less than 24 hours, in other
words it is single administration or repeat exposure
maybe given within 24 hours tine for some slightly toxic
or non-toxic materials.
2. CHRONIC TOXICITY
- Repeated frequent exposure for extended periods
- Toxicity after months to years of exposure
- More than three months to a year of repeated dosing
- Chronic exposure: related to accumulation of toxic
materials leading to toxic effects within the individual
- Affect different systems than those associated with
acute toxicity
3. SUB-CHRONIC/SUB-ACUTE
- Several weeks to months of exposure
- Repeated of exposure to chemical for a month to three
months
ANALYSIS OF TOXIC AGENTS
 Routine screening, Targeted testing
- Includes environmental risk of exposure or
known exposure and compliance to
government regulatory bodies like OSHA and
to confirm suspicion in poisoning
 Sample: Urine, Blood
- In general, it is performed in the 24-hour urine
or blood samples
- In selecting the best specimen for a selected
test, it is important to recognize toxic agent
exhibit unique absorption, distribution and
metabolism and elimination kinetics
- In addition, exposure could be missed and
tardy if testing is performed inappropriate or
non-suitable specimen.
 Evacuated tube: Royal Blue top (trace element free),
Tan-stoppered for Lead testing
Two steps:
 Screening: Immunoassays
- Fast, simple, economical, qualitative & technically
simple to perform
- Without value: Presence or Absence of analyte
- Does not require sophisticated equipment and much
technical expertise
 Confirmatory: Gas Chromatography with Mass
spectrometry as detector (GC-MS)
- Specific, Quantitative approach
- Gas Chromatography: widely used for both qualitative
and quantitative evaluation of many volatile
substances, the reference method for quantitative
identification of the most organic compound using
mass spectrometry as detector.
- Only performed when positive in screening test
TOXICOLOGY OF ALCOHOL
 Alcohol is CNS Depressant not a Stimulant
- Stimulation is due to blockage of inhibitory
centers leading to a perception of being
stimulated
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- Major initial effect of alcohol: increased in
heart rate and blood pressure simultaneously
there would enhance vasodilation of
peripheral blood vessels accompanied by
feeling of warmth due to expansion of vessels
which actually increases the rate of
dissipation of heat. Conversely, the arteries in
the vicinity of the heart are constrict raising
the blood pressure
 General and specific. Exposure to alcohol, like exposure
to most volatile organic cause’s disorientation,
confusion, and euphoria, which can progress to
unconsciousness, paralysis, and even death (high level
of exposure)
 Methanol, ethylene glycol, di-ethylene glycol,
propylene glycol, ethanol, and isopropanol are rapidly
absorbed from the gastrointestinal tract.
- Once absorbed they have a volume of
distribution similar to the body water with peak
blood concentration occurring 30-60 minutes.
- Absorption from GIT is rapid therefore the
gastric lavage induces emesis or use of
activated charcoal must be initiated withing
30-60mins of ingestion to make it beneficial or
effective
 Liver as the chief organ for alcohol metabolism and
excreted by the kidneys
- Oxidation of alcohol catalyze by liver enzyme
known as alcohol dehydrogenase or ADH,
this process is the most critical step in the
biotransformation of alcohol, subsequently the
product is the aldehyde is converted by
aldehyde dehydrogenase leading to formation
of acids and isopropanol
 ALCOHOL (ADH) → ALDEHYDE or KETONE (ALDH) →
ACID (except isopropanol)
APPROXIMATE ETHANOL CONTENT OF ALCOHOLIC
BEVERAGES
BEVERAGE ETHANOL CONTENT (%)
 Beer 3–6
 Ciders 4–5
 Wines 8 – 15
 Sherry, 18 – 20
Madeira,
Port
 Whisky, Gin 40 – 45
 Vodka 40 – 50
 Brandy 45 – 50
 Rum 50 – 70
 Ethanol is consumed in a wide variety of beverages
 Alcohol content is often expressed as proof, twice the
percentage of your ethanol in the beverage.
- Example: would be a 90 fruit vodka that contain 45%
ethanol
- When considering the effects of drinking glass with be
concerned with the total amount of your ethanol intake
in a given period glass not of how many drinks a
person consume

Alcohols
 The toxic effects of alcohol are both general and specific.
 Exposure to alcohol, like exposure to most volatile organic
solvents, initially causes disorientation, confusion, and
euphoria, but can progress to unconsciousness, paralysis,
and, with high-level exposure, even death.
 Most alcohols display these effects at about equivalent
molar concentrations.
 This similarity suggests a common depressant effect on
the central nervous system (CNS) that appears to be
mediated by changes in membrane properties. In most
cases, recovery from CNS effects is rapid and complete
after cessation of exposure.
ETHANOL
 Ethanol is the most common and widely used toxic
substance, fatal
 Most readily available
 One of the most lethal agents
 Alcoholism is a serious socio-economic as well as health
problems not just in the Philippines but throughout the
world
 Ethanol → Acetaldehyde → Acetic acid
 Ethanol metabolism and rate of its absorption varies
- Amount and type of food in the stomach
- Body weight
- Gender
 Alcohol consume after a meal, containing fat, protein or
carbohydrate is absorb 3x more slowly compared to alcohol
consume on an empty stomach
- Women
 absorbs and metabolize alcohol differently than in
men
 susceptible or prone to developing alcohol
related disease
 Consumption of ethanol during pregnancy may lead to fetal
alcohol syndrome or fetal alcohol distress
- Both is associated with delayed motor as well as
mental development among children.
 Toxic effect of ethanol ingestion on the liver and CNS
are believe to be the result of either the alcohol itself or
its chief metabolite acetaldehyde
 Base on algorithm of metabolic pathways or catabolism of
your alcohol ethanol
 Alcohol dehydrogenase  acetaldehyde that affects
eyes, a highly reactive substance
 Acetaldehyde is the chief causative agent of liver
damage, including liver fibrosis and collagen formation
 The metabolite, acetaldehyde is readily attaches to
components of the cell membrane
- forming a destructive duct that damage cells directly or
create a new antigenic stimulant
 Acetaldehyde is rapidly converted to acetic acid by
aldehyde dehydrogenase which enters the Krebs Cycle
as Acetyl CoA where Final metabolism actually occurs
 Ethanol affects the metabolism of many medications
- Increasing the drug effect for some
- Decreasing the activity for others
 Example: Acetaminophen / paracetamol / analgesic
if taken is DANGEROUS after binge or heavy
drinkers or among heavy drinkers
 Performance of any task which requires skill, thought or
attention diminishes (affected) even light ethanol intake
the person’s ability to see or hear decreases.
- 10% of it are distorted, with time appearing to pass
DA BARAKO’S, GFS NI TAEHYUNG (REAL!!), JUANITO– TRANSCRIBERS
more rapidly
- The speed of moving object is other estimated often
leading to a tragic consequence
Ethanol
 Ethanol exposure is common, and excessive
consumption, with its associated consequences, is a
leading cause of economic, social, and medical problems
throughout the world.
 Many social and family problems are associated with
excessive ethanol consumption, and the burden to the
health care system is significant.
 Ethanol-related disorders are consistently one of the top
ten causes of hospital admissions, and approximately 20%
of all hospital admissions have some degree of alcohol-
related problems.
 Consumption of ethanol during pregnancy may lead to
fetal alcohol syndrome or fetal alcohol effects, both of
which are associated with delayed motor and mental
development in children.
 Determinations of blood ethanol concentration by the
laboratory may be used in litigation of drunken driving
cases and requires appropriate chain-of-custody
procedures for specimen collection and documentation of
acceptable quality control performance, instrument
maintenance procedures, and proficiency testing records.
 The pathologic sequence starts with the accumulation of
lipids in hepatocytes. With continued consumption, this
may progress to alcoholic hepatitis.
 Of those who do not progress to toxic hepatitis,
progression to liver cirrhosis is common.
 Cirrhosis of the liver can be characterized as fibrosis
leading to functional loss of the hepatocytes.
 Progress through this sequence is associated with
changes in many laboratory tests related to hepatic
function including liver enzymes.
 Several laboratory indicators have the required diagnostic
sensitivity and specificity to identify excessive ethanol
consumption and most correlate well to the progression of
ethanol-induced liver disease.
 Hepatic metabolism of ethanol is a two-step enzymatic
reaction with acetaldehyde as a reactive intermediate.
 Most ethanol is converted to acetate, or acetic acid, in this
pathway; however, a significant portion of the
acetaldehyde intermediate is released in the free state
 Extracellular acetaldehyde is a transient species as a
result of rapid adduct formation with amine groups of
proteins.
 Many of the pathologic effects of ethanol have been
correlated with the formation of these adducts, and
formation of acetaldehyde adducts has also been shown
to change the structure and function of various proteins.
 Ethanol  Acetaldehyde  Acetate  Acetaldehyde
Adducts
BLOOD ALCOHOL CONCENTRATION (BAC)
*Table on Last Page
 Associated signs and symptoms, we can deduce as low
concentration of the alcohol in the blood increases, severity
of manifestations also increases
 Directly proportional
METHANOL
 Also known as Methyl alcohol or Wood alcohol
 A colorless volatile
 Toxic liquid having specific gravity of 0.81, boiling point
of 65’C
 Use in industrial production
- A component of windshield wiper fluid, antifreeze, and
even in de-icing solution, airplane fuel, varnishes, paint
thinner, and others
 Methyl alcohol cost cheap, therefore it is a potent adulterant
used in recit or adulterate liquors as an ethanol
 substitution.
 Methanol is a common solvent that may ingested
accidentally as a component of many commercial product or
a contaminant of your homemade liquor.
 Methanol is initially metabolized by your Hepatic Alcohol
Dehydrogenase to intermediate product Formaldehyde
 Formaldehyde impairs retinal oxidative phosphorylation
- Rapidly converted to Formic Acid by Hepatic Aldehyde
Dehydrogenase or your ALTH
 Formation of Formic Acid
- Causes Severe Acidosis which may lead to death
- Responsible for an Optic Neuropathy that may lead to
blindness
 Methanol → Formaldehyde → Formic acid
 Methanol Intoxication results by:
- Accidental ingestion
- Products containing methanol
- Ingestion as a method of attempting suicide. Where taken
??, when ethanol is in short supply
 Hallmark:
- Optic neuropathy
- Metabolic acidosis
- Tissue problem
 Competition between Methanol and Ethanol or your Alcohol
dehydrogenase falls the phases of the use of Ethanol as
an Antidote in Methanol Poisoning
 Antidote: Ethanol therapy or Fomepizole (4-methylpyrazole)
+ hemodialysis + diuretics
- Administration of your Ethanol or Fomepizole to
attenuate the metabolism of your alcohol is an integral
part of the therapy.
- Although Methanol is never been approve by the FDA
for this particular purpose being the antidote of your
methanol poisoning. It has been used in the treatment
of methanol as well as in ethylene glycol intoxication
for many years.
- Ethanol
 Has 10-20 times greater affinity for alcohol
dehydrogenase than other type of alcohol.
- Fomepizole (4-methylpyrazole)
 Has approximately 500-1000 times greater affinity
for alcohol dehydrogenase than ethanol
 Can completely inhibit enzyme alcohol
dehydrogenase at much lower serum concentration.
 Effect when given orally is limited compared to
intravenous preparation
 Methods: GLC with flame ionization detector , Headspace
analysis
Methanol
 Methanol is a common laboratory solvent that is also found
in many household cleaners.
 It may be ingested accidentally as a component of many
commercial products or as a contaminant of homemade
liquors.
 Methanol is initially metabolized by hepatic ADH to the
intermediate formaldehyde.
 Formaldehyde is then rapidly converted to formic acid by
hepatic ALDH.
 The formation of formic acid causes severe metabolic
acidosis, which can lead to tissue injury and possible death.
 Formic acid is also responsible for optic neuropathy that can
lead to blindness.
ISOPROPANOL
 Rubbing alcohol
 Utilized in various industrial product as cleaning agent as
well as deicers and others
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 Isopropanol Intoxication results from:
 Accidental ingestion
 Suicide attempts
 Ethanol substitution
- May result to severe acute phase, ethanol like
manifestations or symptoms that may persist for an
extended period of time
 Isopropanol is metabolized by hepatic alcohol
dehydrogenase to Acetone the primary metabolic
products
 Both Isopropanol and Acetone have CNS Depressive effect
similar with ethanol
 Acetone
- Has long half-life compare to ethanol
 Isopropanol → Acetone
 S/S:
- CNS depression
- fruity breath
- hypotension
- CV complication
- Coma
 Methods: GLC with flame ionization detector, (+) Sodium
nitroprusside tablet test
 Treatment: Hemodialysis
Isopropanol
 Isopropanol, also known as rubbing alcohol
 Is also commercially available.
 It is metabolized by hepatic ADH to acetone, which is its
primary metabolic end product.
 Both isopropanol and acetone have CNS depressant
effects similar to ethanol; however, acetone has a long
half-life, and intoxication with isopropanol can therefore
result in severe acute-phase ethanol-like symptoms that
persist for an extended period.
ETHYLENE GLYCOL
 1,2 ethane-diol (di-hydric alcohol)
 Used in industrial production with many types of your alcohol
that is present in many automobiles Poland’s, heat transfer
fluids in runway deicers
 Colorless and odorless with sweet taste
- Ingestion by children is relatively common because of its
sweet taste
 Immediate effect of ethylene glycol ingestion are similar
with ethanol
 Metabolism by
• Hepatic alcohol dehydrogenase
• Aldehyde dehydrogenase
- Result in the formation of several toxic tissues,
including oxalic acid, glycolic acid. Resulting to Severe
Metabolic Acidosis
- Accompanied by rapid formation and deposition of
calcium oxalate crystals in renal tubule with high
levels of consumption
- Calcium Oxalate Crystal formation:
• May result in renal tubular damage
 Metabolic Acidosis
- In organ dysfunction primarily result from the
generation of Glycolic and Oxalic from your
metabolism of Ethylene Glycol
- Accumulation of Glycolic Acid is the primary cause of
metabolic acidosis that it carries Cellular Respiration
and this effect can contribute to the development of
Lactic Acidosis
  Acute Renal Failure, Myocardial Dysfunction,
Neurologic Function and possibly Pulmonary
Dysfunction
- Result from deposition of Oxalate with Calcium in the
kidney, heart, brain and lungs
 Deposition of Calcium Oxalate in Tissues
- Produces Hypocalcemia which depresses carbon
function and blood pressure
 Within 12 – 24 hours after ingestion
- Neurologic signs and symptoms can become more
profound
- Focal signs may actually appear
- Base on autopsy findings or studies, cerebral edema
with calcium oxalate crystals in the brain Tissues.
 Common component of hydraulic fluid and antifreeze
 Ethylene Glycol → Glycol-aldehyde → Glycolic acid →
Glyoxylic acid → Oxalic acid
 S/S: CNS depression, hypertension, renal tubular failure,
hypocalcemia
 Autopsy Finding: Cerebral edema
 Method: GLC with flame ionization detector
 Antidote: Ethanol therapy + hemodialysis + diuretics
 Methanol gives rise to the greatest increment in serum
osmolality, followed by ethanol, isopropanol, ethylene glycol,
propylene glycol as well as di-ethylene glycol in that order.
 The normal serum osmolality of 285-290 mOsm/L is due to
sodium and its counter balancing ion like bicarbonate and
chloride as well as glucose and urea.
Ethylene Glycol
 Ethylene glycol (1,2-ethanediol) is a common component
of hydraulic fluid and antifreeze.
 Ingestion by children is relatively common because of its
sweet taste.
 The immediate effects of ethylene glycol ingestion are
similar to those of ethanol; however, metabolism by
hepatic ADH and ALDH results in the formation of several
toxic species including oxalic acid and glycolic acid, which
result in severe metabolic acidosis.
 This is complicated by the rapid formation and deposition
of calcium oxalate crystals in the renal tubules.
 With high levels of consumption, calcium oxalate crystal
formation in the kidneys may result in renal tubular
damage.
METHODOLOGY
1. OSMOMETRY
- Osmolality is measured by freezing point depression, an
increase in serum osmolality correlates well with
increases in serum ethanol concentration.
- Serum osmolality increases by about 10 mOsm/kg for
each 60 mg/dl increase in serum ethanol.
- screening method
2. GAS CHROMATOGRAHY
- Reference method for Ethanol determination
- This method can simultaneously quantitate other
alcohols, like methanol and isopropyl alcohol.
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CARBON MONOXIDE
 Colorless, odorless, tasteless gas
 Produced by incomplete combustion of organic matter
 200-250x affinity
 Atmospheric pressure: automobile exhaust, improperly
ventilated furnaces, wood and plastic fires, and cigarrete
smoke
 Leftward shift in oxygen-dissociation curve
 Cob has a cherry red appearance
 Methods: Gas chromatography, Spot test using NaOH
 Specimen: Whole blood anti-coagulates with heparin or
EDTA
 Treatment: Oxygen therapy
 Very toxic substance
 When CO binds with hemoglobin, it is referred as
CARBOXYHEMOGLOBIN (COHb)
 200-250x affinity to hemoglobin than Oxygen
 Upon exposure to CO, oxyhemoglobin is converted to
carboxyhemoglobin which reduces the delivery of oxygen to
the tissues resulting to tissue hypoxia and anoxia
 Normally produced by the body in small quantity by heme
catabolism.
 If the inspired air contains roughly 0.1% of CO by volume, it
results in 50% carboxyhemoglobinemia at equilibrium
 Symptoms of CO poisoning: oxygen deprivation to organs
particularly those critical organs that demands oxygenation
like heart and brain tissue that includes nausea, headache,
malaise, light headedness, dizziness, loss of consciousness,
seizure and death
 Histopathology of:
a. Nerve tissue injury: necrosis in globus pallidus,
substancia nigra, hippocampus, cerebrum and
cerebellum
b. Heart muscle: presence of patch myocardial
necrosis
 Treatment: 100% oxygen therapy only
- Administration of 100% oxygen through mask
decreases the half-life of carboxyhemoglobin from 200
minutes to 90 minutes
- Hyperbaric oxygen therapy is more effective, but is
reserve to more severe conditions. The half-life is much
greatly reduced at 20 minutes.
 Spot test
- 5 mL of 40% NaOH is added to 5 mL aqueous dilution
of whole blood.
- Result: Persistence of pink coloration is consistent of
carboxyhemoglobin level of 20% or greater.
 2 primary quantitative assays for carboxyhemoglobin
a. Gas chromatography
- accurate and precise reference method for
 determination of carboxyhemoglobin
b. Spectrophotometric methods
- most common method and the basis for automated
systems
- this works on the principle of measuring the absorbance
of different forms of hemoglobin present on different
spectro absorbance curve
Carbon Monoxide
 The primary environmental sources of carbon monoxide
include gasoline engines, improperly ventilated furnaces,
and wood or plastic fires.
 Because both carbon monoxide and oxygen compete for
the same binding site, exposure to carbon monoxide
results in a decrease in the concentration of
oxyhemoglobin.
 The net effect of carbon monoxide exposure is a
decrease in the amount of oxygen delivered to the tissue,
producing hypoxia.
CAUSTIC AGENT: CYANIDE
 Super-toxic substance
 Component of insecticides & rodenticides; Pyrolysis
product from plastics & urea foams
 Expresses toxicity by binding to heme iron & mitochondrial
cytochrome oxidase
 S/S: Cephalgia, dizziness, respiratory depression →
seizure, coma & death
 Methods: Ion specific electrode methods, photometric
analysis following two-well microdiffusion & determination
of urinary thiocyanate concentration
 super toxic substance that may exist in the form of gas, solid
and in a solution - found in many household products and
occupational setting
 aspiration and ingestion of cyanide pose a great hazard to
health
 aside from burning of plastics and urea foams for home
insulation, other potential source include fruit seeds of
apricot and cherries contains toxic amount of cyanide
 Toxicity: the cyanide binds (high affinity) with ferric irons
which prevents it from reduction to ferrous state involve in
cytochrome oxidase electron transport system - inhibits ATP
production and force cells to produce its own energy via
anaerobic metabolism
 Signs and symptoms: exhibits hypoxia similar to CO
poisoning
 Laboratory findings in relation to hypoxia: severe anion
gap acidosis produced by lactic acidosis
 Treatment for cyanide poisoning: it's focused on
preventing the cyanide from reaching its target point which is
cytochrome c-oxidase. Since cyanide has high affinity to
ferric irons, ferric iron in the form of oxidized hemoglobin can
be provided and accomplished through administration of
sodium nitrite - converting the hemoglobin to
methemoglobin. This methemoglobin produced competes
with the cyanide for cytochrome c-oxidase forming
cyanmethemoglobin and eventually converted
thiocyanate by enzyme rhodanese which is miscible and
excretable through urine.
 Evaluation of cyanide exposure requires rapid turnaround
time. The most common methodology for cyanide
determination is photometric analysis following two-well
microdiffusion.
Caustic Agent: Cyanide
 Carbon monoxide and cyanide exposure may account
for a significant portion of the toxicities associated with
smoke inhalation.
 Ingestion of cyanide is a common suicide agent.
 Cyanide clearance is primarily mediated by rapid
enzymatic conversion to thiocyanate, a nontoxic product
rapidly cleared by renal filtration. Cyanide toxicity is
associated with acute exposure at concentrations
sufficient to exceed the rate of clearance by this
enzymatic process.
SALICYLATES
 Acetylsalicylic acid
 Analgesic, antipyretic, anti-inflammatory drug
 Inhibit cyclooxygenase pathway, reduced Thromboxane A2
& prostaglandin
 Reyes syndrome = Viral infection + aspirin ingestion
(epidemiologic relationships)
 Immediate mixed acid-base disturbances
 S/S: Stomach irritation & decreased platelet function
 Methods: Trinder reaction (Ferric nitrate), GLC or HPLC
 Treatment: neutralize & eliminate excess acid &
maintaining electrolyte balance
Aspirin
 Chemical name: acetylsalicylic acid
 Property: analgesic (pain reliever), antipyretic (lowering
body temperature in fever), and anti-inflammatory drugs
(antithrombotic)
 Toxicity: acute or chronic ingestion which result in increased
serum concentration
 It reduced the Thromboxane A2 and prostaglandin formation
by inhibiting the cyclooxygenase pathway of arachidonic acid
metabolism
 Administration of this drug is a contraindication to children
because there's association to viral infection like varicella
and influenza and possible development of Reye's
syndrome, manifested as fatty encephalopathy
Hallmark of Reye's syndrome: increased plasma ammonia
level; the higher the level above the reference point, the
poorer the prognosis and survival of an individual
 Excessive ingestion of salicylates is associated with
metabolic acidosis since drug is acid in the first place. It is
also a direct stimulator of respiratory center, in effect,
hyperventilation produces respiratory alkalosis. The effect of
each phenomenon induces immediate mixed-acid base
disturbances.
 Gas Chromatography and Liquid Chromatography
provides highest analytic sensitivity and specificity, but not
clinically useful due to its high expense and technical
difficulty.
 Chromogenic reaction (Trinder reaction) is the most
common screening method base on the principle in which
to
salicylates reacts with ferric nitrate to form colored complex
and evaluated spectrophotometrically.
Salicylates
 Salicylates inhibit the Krebs cycle, resulting in excess
conversion of pyruvate to lactate. In addition, at high
levels of exposure, salicylates stimulate mobilization and
use of free fatty acid, resulting in excess ketone body
formation. All these factors contribute to a metabolic
acidosis that may lead to death. Treatment for overdose
involves neutralizing and eliminating the excess acid and
maintaining electrolyte balance.
DA BARAKO’S, GFS NI TAEHYUNG (REAL!!), JUANITO– TRANSCRIBERS

ACETAMINOPHEN
 Paracetamol
 Non-steroidal anti-inflammatory drug
- Anti-inflammation
- Analgesic
- Antipyretic
 Hepatotoxicity, delayed manifestation that occurs within
24 hours – 48 hours
 Treatment: Gastric lavage, Activated charcoal
 Method: Immunoassay, HPLC
 Nonsteroidal anti-inflammatory drugs due to its
prostaglandin inhibition
 Oral administration: the peak plasma concentration
attains in 30-60 minutes; however, the drug is inactivated in
the liver by conjugation to glucuronic acid
 Toxic dosage: 2-3x higher than the maximum therapeutic
dose leading to hepatotoxicity. This occurs 24-48 hours
after acetaminophen ingestion.
 Treatment: Gastric lavage followed by administration of
activated charcoal
 HPLC (High Performance Liquid Chromatography) -
reference method for quantification of acetaminophen level
in serum, however, not widely used due to its expensive
cost and technical difficulty
 Immunoassays - most common analytic method used in
serum acetaminophen determination
Acetaminophen
 Absorbed acetaminophen is bound with high affinity to various
proteins, resulting in a low free fraction. Thus, renal filtration of
the parent drug is minimal. Most is eliminated by hepatic uptake,
biotransformation, conjugation, and excretion.
 The time frame for the onset of hepatocyte damage is relatively
long. In an average adult, serum indicators of hepatic damage do
not become abnormal until 3 to 5 days after ingestion of a toxic
dose.
 It is also noteworthy that chronic, heavy consumers of ethanol
metabolize acetaminophen at a more rapid rate than average,
resulting in a more rapid formation of reactive intermediates and
an increased possibility of depleting glutathione. Therefore,
alcoholic patients are more susceptible to acetaminophen
toxicity, and using the nomogram for interpretation in these
patients is inappropriate.
PESTICIDES
 Organophosphates, Carbamates & halogenated HC
 Inhibits acetylcholinesterase, acetylcholine
(neurotransmitter)
 S/S: Salivation, lacrimation, involuntary urination &
defecation, bradycardia, muscular twitching, cramps,
respiratory failure
 Antidote: Pralidoxime (oxime)
Method: Serum Pseudo-cholinesterase (SChE)
 This are substances that have been intentionally added to
the environment in order to kill undesirable life form. The
purpose is (1) in order to control vector borne diseases and
urban pest and (2) improve agricultural productivity.
 Contamination of pesticides to food is the major route of
exposure to the general population
 Organophosphates and carbamates are the most common
form of pesticides which functions to inhibit
acetylcholinesterase, enzyme present in both insects and
mammals.
 ACETYLCHOLINE is a neurotransmitter of central and
peripheral nervous sytem. It is responsible for the stimulation
of muscle cells and several enfocrine and exocrine glands.
The action of acetylcholine is terminated by the action of the
DA BARAKO’S, GFS NI TAEHYUNG (REAL!!), JUANITO– TRANSCRIBERS
membrane-bound postsynaptic acetylcholinesterase,
therefore, inhibit of this enzyme by pesticide results to the
prolonged presence of acetylcholine on its particular
receptor which produces a wide range of systemic effect.
 Lower-level exposure: salivation, lacrimation, involuntary
urination and defecation
 Higher level exposure: bradycardia, muscular twitching,
cramps, apathy, slurge speech, and behavioral changes
 Worst case scenario: death due to respiratory failure
associated with pesticide poisoning
Pesticides
 Ideally, the actions of pesticides would be target specific.
Unfortunately, most are nonselective and result in toxic
effects to many nontarget species, including humans.
 Organophosphates are the most abundant pesticides and
are responsible for about one third of all pesticide
poisonings.
 Absorbed organophosphates bind with high affinity to
several proteins, including acetylcholinesterase. Protein
binding prevents the direct analysis of organophosphates.
Thus, exposure is evaluated indirectly by the measurement
of acetylcholinesterase inhibition. Inhibition of this enzyme
has been found to be a sensitive and specific indicator of
organophosphate exposure. Because acetylcholinesterase
is a membrane-bound enzyme, serum activity is low.
 An alternative test that has become commonly available is
the measurement of serum pseudocholinesterase (SChE)
activity. This enzyme is inhibited by organophosphates in
a similar manner to the erythrocytic enzyme. Unlike the
erythrocytic enzyme, however, changes in the serum
activity of SChE lack sensitivity and specificity for
organophosphate exposure.
 SChE is a screening test for pesticide poisoning.
AMPHETAMINE, METHAMPHETAMINE
 Therapeutic drug used for narcolepsy & attention deficit
disorder
 Amphetamine-like compounds: allergy & cold
medications
 Specimen: Urine
 Methods: Immunoassays, Gas Chromatography or Liquid
chromatography
 Drug Interference: Ephedrine, Phenylpropanolamine
 Ecstacy, Methylenedioxymethamphetamine (MDMA)
 ROA: orally, inhalation, injection, smoking
 Desired effects: Hallucination, euphoria, visual &
tactile sensitivity
 Adverse effects: Anxiety, impaired memory, violent
behavior, hypertension, etc.
 Used for the treatment of narcolepsy (uncontrolled sleeping)
and attention deficit disorder (hyperactive children)
 In the past, this drug is used to treat obesity by encouraging
weight loss which suppresses the appetite of an individual,
where it shown to be less effective compared to diet
restriction alone.
 It produces alertness, foster increase in mood and reduces
the feeling of fatigue
 It produces state of physical independency, common
manifestation in addictive drugs
 It is frequently utilized by people who needs to stay alert and
awake for long period of time among drivers and students.
 Athletes abuse the use of amphetamine to enhance their
performance and diminish feeling of tiredness during
competition
 Small doses: sleeplessness and anxiety
 Large doses (increased used): mood swings, delusion,
and hallucination become common
 Extreme abuse (chronic users): panic state and psychosis
 Withdrawal to the drugs: results to marked depression,
long period of sleep and extreme appetite
 Usually administered through oral or intravenous route and
 most of the amphetamine are excreted unchanged in the
urine within the few hours after administration allowing easy
detection of amphetamine use by urine-drug screening
technique
 On-set of effect: 30-60 minutes
 Duration: 3-4 hours
 Desired effects: hallucination, euphoria, emphatic and
emotional responses, increased visual and tactile
sensitivity
 MDMA is an elicit amphetamine-derivative commonly
referred to as ecstasy. MMDA and its analog are primarily
administered orally in tablets and less frequent in inhalation,
injection and smoking.
 Immunoassays are commonly utilized as screening
procedure, however, because of variable cross-reactivity
with over-the-counter medication that contain amphetamine-
like substance or compound like ephedrine and
phenylpropanolamine, a positive result of immunoassays are
considered presumptive.
 Gas chromatography or liquid chromatography is used
to confirm the immunoassay result.
ANABOLIC STEROIDS
 Compounds related to testosterone
 Previously used to treat male hypogonadism
 Chronic hepatitis, accelerated atherosclerosis, aggregation
of platelets, cardiomegaly
 Male: Testicular atrophy, sterility & impotence
 Female: male-like traits, breast reduction & sterility
 Methods: RIA, GCMS
CANNABINOIDS
 Psychoactive compounds found in marijuana, hashish
(processed form)
 Cannabis sativa
 Delta-9-tetrahydrocannabinol (THC) is most potent &
abundant
 Manifestations: Well-being, euphoria, impairment of
memory & intellectual function
 Lipophilic nature responsible for retention
 Half-life: 1 day (acute), 3-5 days (chronic)
 Urinary metabolite: 11-nor-tetrahydrocannabinol-9-
carboxylic acid (THC-COOH), basis for screening test of
marijuana
 Positive test could be seen after 1 hour of smoking
 Methods: Immunoassays, Gas Chromatography with MS
Cannabinoids
 The major urinary metabolite is 11-nor-
tetrahydrocannabinol-9-carboxylic acid (THC-COOH).
 This metabolite can be detected in urine for up to 5 days
after a single use or up to 4 weeks following chronic, heavy
use.
 Immunoassay tests for THC-COOH are used to screen for
marijuana consumption, and GC–MS is used for
confirmation.
 Both methods are sensitive and specific and because of the
low limit of detection of both methods, it is possible to find
THC-COOH in urine as a result of passive inhalation.
 Urinary concentration standards have been established to
discriminate between passive and direct inhalation
COCAINE
 Formerly known as Benzoylmethylecgonine
 Local anesthetic
 Potent CNS stimulator that elicits sense of excitement &
DA BARAKO’S, GFS NI TAEHYUNG (REAL!!), JUANITO– TRANSCRIBERS
euphoria
 ROA: Insufflation, Intravenous, Inhalation (crack—free base
form)
 Half-life: 30 minutes to 1 hour
 Specimen: Urine (benzoylecgonine, ecgonine methyl
esters—metabolite )
 Methods: Immunoassays or Gas Chromatography with MS
Cocaine
 Cocaine is an effective local anesthetic with few adverse
effects at therapeutic concentrations.
 At higher circulating concentrations, it is a potent CNS
stimulator that elicits a sense of excitement and
euphoria.
 Cocaine is an alkaloid salt that can be administered
directly (e.g., by insufflation or intravenous injection) or
inhaled as a vapor when smoked in the free base form
known as crack.
 The half-life of circulating cocaine is brief; approximately
30 minutes to 1 hour. Acute cocaine toxicity is associated
with hypertension, arrhythmia, seizure, and myocardial
infarction.
 The half-life of benzoylecgonine is 4 to 7 hours; however,
it can be detected in urine for up to 3 days after a single
use. The presence of this metabolite in urine is a
sensitive and specific indicator of cocaine use.
 Confirmation testing is most commonly performed using
GC–MS.
OPIATES
 Analgesic, sedative & anesthetic effects
 Derived from opium poppy (Papaver somniferum)
 Opium, morphine, & codeine (Natural)
 Heroin, hydromorphone (dilaudid), oxycodone (percodan)
(Chemically modified)
 Meperidine (Demerol), methadone (Dolophine),
propoxyphene (Darvon), pentazocine (Talwin), fentanyl
(sublimaze) (Synthetic)
 Respiratory acidosis, myoglobinuria, cardiac damage (↑
CKMB, Troponin)
 Treatment: Naloxone hydrochloride (Narcan), Naltrexone
 Methods: Immunoassays, Gas Chromatography with MS
Opiates
 Opiates are a class of substances capable of analgesia,
sedation, and anesthesia. All are derived from or
chemically related to substances derived from the opium
poppyOpiates have a high abuse potential, and chronic
use leads to tolerance with physical and psychological
dependence.
 Acute overdose presents with respiratory acidosis due to
depression of respiratory centers, myoglobinuria, and
possibly an increase in serum indicators of cardiac
damage (e.g., CKMB, troponin)
 High-level opiate overdose may lead to death caused by
cardiopulmonary failure. Treatment of overdose includes
the use of the antagonist naloxone. Laboratory testing for
opiates usually involves initial screening by
immunoassay.
 Most immunoassays are designed to detect the
presence of morphine and codeine; however, cross-
reactivity allows for detection of many of the opiates
including naturally occurring, chemically modified, and
synthetic forms. GC–MS is the method of choice for
confirmation testing.
 PHENCYCLIDINE (PCP)

 Illicit drug with stimulant, depressant, anesthetic &

hallucinogenic properties
 Lipophilic drug
 Overdose is associated with stupor & coma
 ROA: Ingested or inhaled
 Specimen: Urine
 Methods: Immunoassays, Gas Chromatography with mass
spectrometry

Phencyclidine
 Phencyclidine (PCP) is an illicit drug with stimulant,
depressant, anesthetic, and hallucinogenic properties.
Adverse effects are commonly noted at doses that
produce the desired subjective effects, such as agitation,
hostility, and paranoia.
 Overdose is generally associated with stupor and coma.
 It is a lipophilic drug that rapidly distributes into fat and
brain tissue.
 In chronic, heavy users, PCP can be detected up to 30
days after abstinence. Immunoassay is used as the
screening procedure with GC–MS as the confirmatory
method.
 Approximately 10% to 15% of an administered dose is
eliminated and unchanged in urine, which allows for
identification of the parent drug in urine. In chronic, heavy
users, PCP can be detected up to 30 days after
abstinence.

SEDATIVE-HYPNOTICS

 Tranquilizers: Sedation, Sleep, CNS depressant

 Barbiturates: Secobarbital, Pentobarbital, Phenobarbital
 Benzodiazepines: Diazepam (valium), Chlordiazepoxide
(Librium), Lorazepam (Ativan)
 Respiratory depression as the serious toxic effects
 Methods: Immunoassays, Liquid Chromatography, Gas
Chromatography

Sedatice-Hypnotics
 These drugs often become available for illegal use
through diversion from approved sources. Barbiturates
and benzodiazepines are the most common types of
sedative–hypnotics abused. Although barbiturates have
a higher abuse potential, benzodiazepines are more
commonly found in abuse and overdose situations. This
appears to be a result of availability.
 Overdose with sedatives–hypnotics initially presents with
lethargy and slurred speech, which can rapidly progress
to coma. Respiratory depression is the most serious toxic
effect of most of these agents though hypotension can
occur with barbiturates as well. The toxicity of many of
these agents is potentiated by ethanol use.
 Immunoassay is the most common screening procedure
for both barbiturates and benzodiazepines. Broad cross-
reactivity within members of each group allows for the
detection of many individual drugs. GC or LC methods
can be used for confirmatory testing.

DA BARAKO’S, GFS NI TAEHYUNG (REAL!!), JUANITO– TRANSCRIBERS

 BLOOD ALCOHOL CONCENTRATION

Amount 2 ounces 4 ounces 6 ounces 8 ounces 16 ounces 24 ounces

(80 proof) ( 30 ml) (60 ml) ( 90 ml) (120 ml) (240 ml) (480 ml)

% of
alcohol in 0.01 - 0. 03 - 0.12% 0.09 - 0.25% 0.18 - 0.30% 0.27 – 0.40% 0.35 - 0.50%
blood 0.05%
No Usual legal Mild Mental confusion Impaired Coma and possible death
apparent limit for driving Confusion, Staggering consciousness - cardiac
effect a motor vehicle Loss of critical Slurred speech Unable to walk arrest
Emotional judgment Marked Hypotension - Respiratory
response erratic Memory depression in Tachycardia arrest
Mild euphoria impairment stimulus response Bradypnea Aspiration of gastric
May have Diminished Nausea, Seizures contents
Symptoms increased reaction time Vomiting Absent
aggressiveness, Rapid pulse Drowsiness, reflexes
talkativeness, Vertigo Stupor
muscle Diaphoresis Muscle
incoordination incoordination
Slowed
reaction time
Decreased
inhibition

DA BARAKO’S, GFS NI TAEHYUNG (REAL!!), JUANITO– TRANSCRIBERS

 LEC 2021 – 2022
THERAPEUTIC DRUG MONITORING
CLINICAL CHEMISTRY 2 WEEK 13 2nd Semester
Instructor: John Jeffrey Pangilinan, RMT, MSMT CCHEM
Date: May 13, 2022

Topic Outline medication. Pharmaceutical may be given in

I. General Information either liquid or solid preparation by mouth
II. Drug Metabolism 2. Into the circulation (Intravenous)
III. Drug Elimination  Passes directly into the circulatory system that
IV. Cardioactive Drugs offers the most direct route
V. Antibiotics 3. Into muscles (Intramuscular)
VI. Psychoactive Drugs  Medication is injected into the muscle having
VII. Immunosuppressive
VIII. Antineoplastics controlled time released of drug in the
IX. Anti-Epileptic Drugs (Aeds) circulation. The rate of absorption varies
considerably depending on the amount of
muscles mass of an individual
o Other Routes:
GENERAL INFORMATION 4. Subcutaneous
 Measurement of drug levels in the body fluids provide 5. Inhaled
information for clinical purposes: 6. Absorbed through the skin
1. Determination of drug abuse / overdose 7. Rectal delivery
2. Therapeutic drug monitoring ABSORPTION AND TRANSPORT
 Concepts of therapeutic drug monitoring is relatively recent
based on realization that not all patient respond in the same  For Orally Administered Drugs the factors affecting the
manner to the same amount of medication even if the efficiency of drug absorption from the gastrointestinal
allowance is made for body mass tract to its bioavailability in the bloodstream
 Response of any patient given by drug is highly individual - Dissociation from its administered form
and variable depending on age, physical condition, genetic - Solubility in gastrointestinal fluids
make-up, and other parameters - Diffusion across gastrointestinal membranes
 Since the response of pharmacologic treatment varies  Certain drug formulations require dissociation before being
among patients, administration and even management of absorbed like tablets and capsules.
drug should be dealt with on an individual basis  Tablets and capsules require dissolution before being
 The purpose of therapeutic drug monitoring: absorbed
1. Ensure that the given drug dosage is within the  Once Drugs enter blood circulation and reach the
range that produces maximal therapeutic benefit appropriate site of action often inside the cell.
2. Identify if the drug is above or below therapeutic  Liquid solutions have a tendency to be more rapidly
value or range which may lead to inefficacy or absorbed
toxicity  Most drugs are partially soluble in water. Many drugs are
 For most drug therapies, dosage regiments that are safe and partially soluble in the Aqueous phase of blood hence
effective in most of the population is established and require carrier protein as means of transport: albumin,
therefore therapeutic drug monitoring is necessary lipoprotein, and other globulins.
 Involves the analysis, assessment and evaluation of  Most drugs are absorbed by passive diffusion.
circulating concentrations of drugs in the plasma, serum, or  Degree of binding varies from 1 drug to another due to
whole blood solubility and other factors
 Quantitative procedure for measuring drugs with narrow - Acidic drugs primarily bind to albumin.
therapeutic index - Basic drugs primarily bind A1-acid glycoprotein
 To ensure that the drug produces maximal therapeutic index - Some drugs bind to both
and minimal side effects DRUG ABSORPTION
 GOAL: To achieve safe and effective patient drug therapy  Some drugs are subject to uptake by active transport
mechanisms intended for dietary constituents; however,
1. Identifying non-compliance in patients most are absorbed by passive diffusion from the
2. Preventing the consequences of overdosing gastrointestinal tract into the bloodstream.
and under-dosing  This process requires that the drug be in a hydrophobic, or
3. Maximizing therapeutic effect nonionized, state. Because of gastric acidity, weak acids
4. Optimizing a dosing regimen based on drug– are efficiently absorbed in the stomach, but weak bases
drug interactions are preferentially absorbed in the intestine where the pH
is more alkaline.
ADMINISTRATION  For most drugs, absorption from the gastrointestinal tract
OF H+BALANCE: occurs in a predictable manner in healthy people;
 The basis of TDM includes consideration of the route of however, changes in intestinal motility, pH, inflammation,
administration, rate of absorption and transport, drug as well as the presence of food or other drugs may
metabolism, and even the rate of elimination dramatically alter absorption rates.
 BIOAVAILABILITY – Unchanged fraction present in  For instance, a patient with inflammatory bowel syndrome
may have a compromised gastrointestinal tract, which
systemic circulation may affect normal absorption of some drugs.
 ROUTE OF ADMINISTRATION:  Absorption can also be affected by coadministration of drugs
o Major Routes: that affect gastrointestinal function such as antacids,
1. Oral kaolin, sucralfate, cholestyramine, and antiulcer
 Most prevalent technique for giving medications.

DA BARAKO’S, GFS NI TAEHYUNG (REAL!!)– TRANSCRIBERS

  Morphine may also slow gastrointestinal motility, thereby
influencing the rate of drug absorption.
 Drug absorption rates may change with age, pregnancy, or
pathologic conditions. In these instances, predicting the
final circulating concentration in blood from a standard
oral dose can be difficult. However, with the use of TDM,
effective oral dosage regimens can be determined
DRUG METABOLISM
 First-pass metabolism
 All substances absorbed from the intestine enter the hepatic
portal system
 Most drugs are xenobiotics
 Biotransformation - The enzymatic processes involved in
metabolizing drugs thru metabolic process generating a
therapeutically active metabolite
 Conversion of drug metabolism takes place anywhere in the
system.
 Most drug biotransformation occurs in the liver known as
first-pass metabolism, particularly for orally administered
preparation.
 Liver metabolism may not be the same process for every
patient as it is influenced by genetics. Genetic variations is
examine under discipline of pharmacogenomics
 Enzyme system of liver hepatocytes does not metabolize
specific drugs but produces changes in classes of
drugs due to structural similarities
 Example of which system responsible for the addition of
hydroxyl group in benzene ring. Any drug having benzene
ring in structure is treated same way through hydroxylation
in liver hepatocyte
 Biochemical pathway responsible for a large portion of drug
metabolism hepatic mixed function oxidase known as MFO
system. Divide 2 function phases
 Two Divisions of Enzyme involved in the MFO system
1. Phase I reactions
- reactive intermediate product
2. Phase II reactions
- conjugate functional group
DRUG METABOLISM
 In this system, circulating blood from the gastrointestinal
tract is routed through the liver before it enters into
general circulation.
 Certain drugs are subject to significant hepatic uptake and
metabolism during passage through the liver. This
process is known as first-pass metabolism.
 These variations in drug metabolism related to genetics are
examined in the discipline of pharmacogenomics.
 In genetic variation, a patient with impaired liver function
may have reduced capacity to metabolize drugs
 This is a particularly important consideration if the efficacy
of a drug depends on metabolic generation of a
therapeutically active metabolite. This enzymatic process
is referred to as biotransformation
 Patients with liver disorders may require reduced dosages
of the drug as the rate of metabolism and the subsequent
elimination process may be slowed.
 Most drugs are xenobiotics, which are exogenous
substances that are capable of entering biochemical
pathways intended for endogenous substances.
 There are many potential biochemical pathways in which
drugs can be acted on or bio transformed.
 . The basic function of this system involves taking
hydrophobic substances and, through a series of
enzymatic reactions, converting them into water-soluble
products.
 These products can then either be transported into the bile
or released into general circulation for elimination by renal
filtration.
 Phase I reactions produce reactive intermediates.
 Phase II reactions conjugate functional groups, such as
glutathione, glycine, phosphate, and sulfate, to reactive
sites on the intermediates resulting in water-soluble
products.
 The MFO system is nonspecific and allows many different
endogenous and exogenous substances to go through
this series of reactions.
DRUG METABOLISM
1. There are many potential substrates for this pathway, the
products formed from an individual substance are
specific. For example, acetaminophen is metabolized in
the MFO pathway ultimately leading to the formation of a
glutathione conjugate following phase II reactions oral
dose can be difficult. However, with the use of TDM,
effective oral dosage regimens can be determined
2. In the presence of too much acetaminophen, as in the case
of an overdose, the MFO system may be overwhelmed
and cannot effectively metabolize it to a safe, water-
soluble end product for elimination by the kidneys.
3. In this case, the conjugating group for a given drug can
become depleted in phase II reactions and an
accumulation of phase I products occurs. Excessive
phase I products may result in toxic effects, and in the
case of acetaminophen, irreversible damage to
hepatocytes may occur
4. Because many potential substrates enter the MFO system,
competitive and noncompetitive drug–drug interactions
can result in altered rates of elimination of the involved
drugs. Interactions are not limited to drug–drug, but may
also include drug–food (i.e., grapefruit) or drug–beverage
(i.e., alcohol and caffeine).
5. Example, metabolism of acetaminophen by the MFO
system is altered in the presence of alcohol rendering it
more toxic. In most instances, the degree of alteration is
unpredictable.
6. Changes in hepatic status can also affect the concentration
of circulating drugs eliminated by this pathway
7. Induction of the MFO system typically results in accelerated
clearance and a corresponding shorter drug half-life.
8. For example, cirrhosis results in irreversible damage and
fibrosis of the liver, rendering hepatocytes nonfunctional.
9. Consequently, xenobiotics may not be effectively
metabolized by the MFO system, thereby reducing the
rate of metabolism and elimination while increasing the
opportunity for toxicity. In these situations, TDM aids in
appropriate dosage adjustment.
10. For some drugs, there is considerable variance in the rate
of hepatic and nonhepatic drug metabolism within a
normal population.
11. This results in a highly variable rate of clearance, even in
the absence of disease. Establishing dosage regimens for
these drugs is, in many instances, aided by the use of
TDM.
12. With the use of molecular genetics, it is now also possible
to identify common genetic variants of some drug-
metabolizing pathways, and identification of these
individuals may assist in establishing an individualized
dosage regimen.
DRUG ELIMINATION
 Hepatic metabolism or renal filtration or a combination of
the two, eliminates most drugs. Like any other substance,
the main route is through the kidney.
 Drugs are converted to more water-soluble forms then
filtered in glomerulus and excreted in urine.
 Impairment of liver or kidney functions will compromise drug
DA BARAKO’S, GFS NI TAEHYUNG (REAL!!)– TRANSCRIBERS
 metabolism and excretion. Any clinical conditions that
reduce Kidney function impairs drug excretion.
 As a result of drug excretion, Plasma level of given
medication decreases concentration. If drug dosage is not
lowered the medication may accumulate inducing adverse
effects.
 Toxicity
DRUG ELIMINATION
 Drugs can be cleared from the body by various
mechanisms.
 The plasma free fraction of a parent drug or its metabolites
is subject to glomerular filtration, renal secretion, or both.
 For those drugs not secreted or subject to reabsorption, the
elimination rate of free drug directly relates to the
glomerular filtration rate.
 Decreases in glomerular filtration rate directly result in an
increased drug half-life and elevated plasma
concentration.
 Aminoglycoside antibiotics and cyclosporine, an
immunosuppressant drug, are examples of drugs that are
not secreted or reabsorbed by the renal tubules.
 Independent of the clearance mechanism, decreases in the
plasma drug concentration most often occur as a first-
order process indicating an exponential rate of loss.
 This implies that the rate of change of drug concentration
over time varies continuously in relation to the
concentration of the drug.
 Drugs are eliminated through hepatic metabolism, renal
filtration, or a combination of the two.
 For some drugs, elimination by these routes is highly
variable and functional changes in either organ system
may result in changes in the rate of elimination
 In these situations, information regarding elimination rate
and estimating the circulating concentration of a drug after
a given time period are important factors in establishing
an effective and safe dosage regimen
SAMPLE COLLECTION & CONSIDERATIONS
 Timing of specimen collection
- single most important factor in therapeutic drug
monitoring
 Tract concentration for most drugs are drawn right before
the next dose.
 Peak concentrations are drawn an hour after orally
administration dose.
 This rule of time is used within the clinical context of the
situation except for digoxin.
 Serum or plasma as the specimen of choice for circulating
concentration of drugs
- Heparinized plasma
 suitable for drug analysis
- Unsuitable
 not suitable due to chelating property of
anticoagulant
o EDTA
o Citrate
o Oxalate
 Certain drugs have a tendency to be absorbed into the gel
of certain serum separator collection tubes
- SPS (Serum Separator Tube)
 Thixotropic gel not utilized because it can absorb
certain drugs that results in false decrease values
during testing leads to false interpretation of
results.
SAMPLE COLLECTION.
1. Accurate timing of specimen collection is the single
most important factor in TDM.
2. In general, trough concentrations are drawn right
before the next dose, and peak concentrations are
drawn 1 hour after an orally administered dose.
3. This rule of thumb must always be used within the
clinical context of the situation.
4. Drugs that are absorbed at a slower rate may
require several hours before peak drug
concentrations can be evaluated.
5. In all situations, determination of serum drug
concentrations should be performed only after
steady state has been achieved.
6. Serum or plasma is the specimen of choice for the
determination of circulating concentrations of
most drugs.
7. Care must be taken that the appropriate container is
used when collecting these specimens as some
drugs have a tendency to be absorbed into the gel of
certain separator collection tubes.
8. It is necessary to follow manufacturer
recommendations when this pre-analytical effect is
possible as failure to do so may result in falsely low
values.
9. Heparinized plasma is generally suitable for most
drug analyses.
10. Calcium-binding anticoagulants add a variety of
anions and cations that may interfere with analysis
or cause a drug to distribute differently between
cells and plasma.
11. As a result, specimen tubes that contain
ethylenediaminetetraacetic acid (EDTA), citrate,
or oxalate are generally considered unacceptable
specimen types for TDM.
CARDIOACTIVE DRUGS
 Many cardiac conditions are treated with drugs, of which,
only a few require TDM
 Cardiac glycoside and anti-arrhythmic are 2 classes of drug
that requires assessment and evaluation of serum
concentration that aids in decision regarding dosage
regimen.
.
DIGOXIN
 cardiac glycoside
 Derived from Digitalis lanata, Digitalis purpurea
 For treating Congestive heart failure
 Function to inhibit Na-K-ATPase altered excitability of
cardiac muscle due to intracellular decrease in potassium
and increase intracellular calcium in cardiac myocytes.
 Inotropic effect
- Increase intracellular calcium improve cardiac
contractile function.
 Absorption of orally admin digoxin variable influence by
dietary factors, gastrointestinal motility, formulation of
drugs.
 In Drug circulation, about 25% is protein bound, the
remainder are unbound or in Free states that are
sequestered in muscle cells.
 Free drug is sequestered in the muscle
 Peak level: 2-3 hours after an oral dose
 Half-life: 38 hours
- Major contributing factor in extended half-life is the
slow release of digoxin back to circulation.
- Half-life-the time required to reduce the
concentration of drugs by 50%.
- Half-life is different from each drug and must be
experimentally determined.
 Toxic level: > 2 ng/mL
DA BARAKO’S, GFS NI TAEHYUNG (REAL!!)– TRANSCRIBERS
 Toxic effects:
- nausea, vomiting, visual disturbances, premature
ventricular contractions, atrioventricular node blockage
- Therapeutic function and Toxicity of digoxin influence by
concentration of serum electrolytes and Thyroid
status.
- Low serum potassium potentiate Digoxin.
Hypothyroid patients are resistant to digoxin action.
Opposite of hypothyroid patient are more sensitive
 Method: Immunoassay
- Cross-reactions:
 Newborn
 Pregnant women
 patients with uremia or late-stage liver disease
Digoxin
 Digoxin (Lanoxin) is a cardiac glycoside used in the
treatment of congestive heart failure.
 The increased intracellular calcium improves cardiac
contractility. This effect is seen in the serum
concentration range of 0.8 to 2 ng/mL (1 to 2.6 nmol/L).
 Higher serum concentrations (>3 ng/mL [3.8 nmol/L])
decrease the rate of ventricular depolarization.
 Although this level can be used to control ventricular
tachycardia, it is not frequently used because of toxic
adverse effects, including nausea, vomiting, and visual
disturbances, that occur at plasma concentrations
greater than 2 ng/mL.
 Adverse cardiac effects, such as premature ventricular
contractions (PVCs) and atrioventricular node blockage,
are also common.
 The unbound or free form of digoxin is sequestered into
muscle cells, and at equilibrium, the tissue
concentration is 15 to 30 times greater than that of
plasma.
 Elimination of digoxin occurs primarily by renal filtration of
unbound digoxin.
 The remainder is metabolized into several products by the
liver. The half-life of plasma digoxin is 38 hours in an
average adult. The major contributing factor to the
extended half-life is the slow release of tissue digoxin
back into circulation.
 Because of variable gastrointestinal absorption, establishing
a dosage regimen usually requires assessment of plasma
concentrations after initial dosing to ensure that effective
and nontoxic plasma concentrations are achieved.
 Changes in glomerular filtration rate can have a dramatic
effect on plasma concentrations.
 Frequent dosage adjustments, in conjunction with
measurement of plasma digoxin concentrations, should
be performed in patients with renal disease.
 The therapeutic benefits and toxicities of digoxin can also be
influenced by the concentration of electrolytes in the
plasma. Low potassium and magnesium potentiate
digoxin actions.
 Adjustment of plasma concentrations below the therapeutic
range may be necessary to avoid toxicity. Thyroid status
may also influence the actions of digoxin. Hyperthyroid
patients display a resistance to digoxin actions, and
hypothyroid patients are more sensitive. 3
Digoxin
1. The timing for evaluation of peak digoxin
concentrations is crucial.
2. In an average adult, plasma concentrations peak
between 2 and 3 hours after an oral dose;
however, uptake into the tissues is a relatively slow
process
3. Peak plasma concentrations do not correlate well
with tissue concentrations.
4. It has been established that the plasma
concentration 8 to 10 hours after an orally
administered dose correlates well with the tissue
concentration, and specimens should be drawn
within this window. Specimens collected before
this time are misleading and are not considered a
valid representation of the patient's drug status.
5. Immunoassays are used to measure total digoxin
concentration in serum.
6. 2 With most commercial assays, cross-reactivity with
hepatic metabolites is minimal; however, newborns,
pregnant women, and patients with uremia or late-
stage liver disease produce an endogenous
substance that cross-reacts with the antibodies used
to measure serum digoxin.
7. In patients with these digoxin-like immunoreactive
substances, falsely elevated concentrations are
common and should be considered along with the
clinical context.
QUINIDINE
 Naturally occurring drug for treating arrhythmia
- Remember: It is a drug used to treat various
cardia arrhythmic conditions, the two most
common formulation is quinidine sulfate and
quinidine gluconate
- Most common route of delivery: Oral
administration
- The peak serum concentration is reached
about two hours after oral administration of
sulfate while gluconate is slowly released
- Mostly eliminated/excreted by: Hepatic
metabolism and induction of barbiturates
increases the rate of clearance
 Obtained from the bark of Cinchona tree (with antimalarial
properties)
 Quinidine sulfate and Quinidine Gluconate
 Measurement: Trough Level
 Therapeutic range: 2.3 to 5 ug/mL
 Toxic Range: > 5 ug/mL
 Toxic effects: nausea, vomiting, abdominal discomfort,
cardiovascular toxicity
 Method: The plasma quinidine concentration is determined
by: Chromatography or Immunoassay
 Peak serum concentrations are reached about 2 hours
after an oral dose of the sulfate. The gluconate is a slow-
release formulation.
 Peak serum concentration is reached 4 to 5 hours after
an oral dose. The most predominant toxic adverse
effects of quinidine are nausea, vomiting, and abdominal
discomfort. Cardiovascular toxicity, such as PVCs, may
be seen at twice the upper limit of the therapeutic range.
In most instances, monitoring of quinidine involves only
determination of the trough level to ensure it is within the
therapeutic range.
 Peak assessment is performed only when symptoms of
toxicity are present. Because of its slow rate of
absorption, trough levels of the gluconate are usually
drawn 1 hour after the last dose. Absorbed quinidine is
about 70% to 80% bound to serum proteins.2 Most is
eliminated by hepatic metabolism. Induction of this
system, such as by barbiturates, increases the clearance
rate. Impairment of this system, as seen in late-stage
liver disease, may extend the halflife of this drug.
 Plasma quinidine concentrations can be determined by
chromatography or immunoassay.
 The production of quinidine may contain active
contaminants such as dihydroquinidine. Early
immunoassay detected quinidine only.
 Most current immunoassays cross-react with these
DA BARAKO’S, GFS NI TAEHYUNG (REAL!!)– TRANSCRIBERS
 bioactive contaminants. This provides for assessment of
total quinidine potential.
PROCAINAMIDE
 Used to treat cardiac arrhythmia
 Administered: Orally
- Gastrointestinal absorption is rapid and
complete
- Peak plasma concentration: About an hour
- Eliminated by: combination of renal filtration
and hepatic metabolism in which they end as
N-acetyl procainamide (NAPA) is the hepatic
metabolite of the parent compound.
- Increased concentration result to:
myocardial depression and arrythmia both
procainamide and its active metabolites may
be measured by immunoassay.
 Hepatic metabolite: N-acetyl procainamide
 Peak serum level: one hour after the dose
 Eliminated: renal filtration and hepatic metabolism
 Toxic effects: reversible lupus like syndrome nephrotic
syndrome, urticaria
 Method: Immunoassay
 Therapeutic range: 4-8 ug/mL
DISOPYRAMIDE
 Norpace (brand name)
 Used to treat cardiac arrhythmia; substitute for
quinidine when quinidine adverse effects are excessive
 Administered orally and completely absorbed
 Peak Concentration: 1-2 hours
- Can be measured by Chromatography or
Immunoassay
 Therapeutic range: 3 – 7.5 ug/mL
 It has anticholinergic effect: dry mouth and
constipation (>4.5 ug/mL)
 Toxic effect: bradycardia, and atrioventricular node
blockage (> 10 ug/mL) (normally associated at higher
concentration)
- Primary toxicities are those dependents that
includes dry mouth and constipation at
smaller doses
 Eliminated thru renal filtration and hepatic metabolism
Primarily eliminated by kidney by lesser extent of liver
ANTIBIOTICS
AMINOGLYCOSIDES
 Remember: It is a group of chemically related antibiotic used
for the treatment of gram-negative bacterial infection that
are resistant to less toxic antibiotics
- Most commonly encountered aminoglycoside
that inhibit bacterial protein synthesis:
1. Gentamicin
2. Tobramycin
3. Amikacin
4. Kanamycin
 Administered IM or IV
- Because not well absorbed by GIT it is limited
to this administration
 Eliminated by renal filtration
 Cause damage to the 8th cranial nerve (vestibule-
cochlear) at toxic level
- All aminoglycosides shared common
mechanism of actions and adverse effect such
as nephrotoxicity and ototoxicity.
 Ototoxicity effect: involves
destruction of vestibule-cochlear
membranes resulting in hearing loss
and balance impairment that is
irreversible.
 Toxic range:
 >30 ug/mL (Amikacin and Kanamycin)
 > 15 ug/mL (Gentamicin and Tobramycin)
 Impairs the function of the PCT (reversible)
- Aminoglycosides impairs the function of
proximal tubules of the kidney result to
electrolytes imbalance and possible
proteinuria but reversible in nature.
 Method: Chromatography and Immunoassays
- Primary methods for aminoglycoside
determination
VANCOMYCIN
 Effective against gram positive bacteria (cocci and bacilli)
 Administered IV
 Only requires trough concentration
 Eliminated through renal filtration and excretion
 Toxicity occurs in therapeutic range (5 to 10 ug/mL)
 Toxic side effects: Red man’s syndrome (erythemic
rashing of the extremities), nephrotoxicity (> 10 ug/mL)
and ototoxicity (>40 ug/mL)
- both renal and hearing effects are similar to
aminoglycosides
- Primary eliminated by: renal filtration and
secretion
- Assayed by: Chromatography and
Immunoassays
 Vancomycin is a glycopeptide antibiotic that is effective
against gram-positive cocci and bacilli. Because of poor
oral absorption, vancomycin is administered by IV
infusion. Unlike other drugs, a clear relationship between
serum concentration and toxic adverse effects has not
been firmly established. Indeed, many of the toxic effects
occur in the therapeutic range (5 to 10 μg/mL [3.45 to 6.9
μmol/L]).4
 The major toxicities of vancomycin are red man
syndrome, nephrotoxicity, and ototoxicity. Red man
syndrome is characterized by an erythemic flushing of the
extremities.
 The renal and hearing effects are similar to those of the
aminoglycosides. It appears that the nephrotoxic effects
occur more frequently at trough concentrations that are
greater than 10 μg/mL (6.9 μmol/L). The ototoxic effect
occurs more frequently when peak serum concentrations
exceed 40 μg/mL (27.6 μmol/L). Because vancomycin
has a long distribution phase, in most instances, only
trough levels are monitored to ensure the serum drug
concentration is within the therapeutic range.
 Vancomycin is primarily eliminated by renal filtration and
secretion. It is assayed by immunoassay and
chromatographic methods.
PSYCHOACTIVE DRUGS
LITHIUM
 Manic depressive illness (bipolar disorders)
 Drug of choice for the prevention of chronic cluster
headache
 Orally administered
DA BARAKO’S, GFS NI TAEHYUNG (REAL!!)– TRANSCRIBERS
 It inhibits thyroid hormone synthesis and release - inhibits
iodine uptake
 Therapeutic range: 0.5 to 1.2 mmol/L
 Toxic Levels: 1.5 to 2 mmol/L- apathy, lethargy, speech
difficulties, and muscle weakness.
 Method: ISE, FEP, AAS
TRICYCLIC ANTI-DEPRESSANTS
 Depression, insomnia, extreme apathy and loss of libido
 Orally administered
 Highly protein bound (85-95%)
 Examples (most relevant):
1. Imipramine
2. Amitriptyline
3. Doxepin
 Desipramine and nortriptyline are active metabolic products
of imipramine and amitriptyline, respectively
 Toxic effects: drowsiness, blurred vision, memory loss,
seizure, cardiac arrhythmia, parkinsonian syndrome,
unconsciousness
 Peak serum concentration after oral administration: 2-12
hours
 Therapeutic Level: 100-300 ng/mL
 Major Metabolite: Desipramine
 TCA and metabolites can be assayed via immunoassays
using polyclonal antibodies and chromatographic methods
that provide simultaneous evaluation of both the parent drug
and the metabolites.
Tricyclic Anti-depressants
 The TCAs are highly protein bound (85% to 95%). For
most TCAs, the therapeutic effects are not seen for the
first 2 to 4 weeks after initiation of therapy.
 The half-life of TCAs varies considerably among patients.
The rate of elimination can also be influenced by the
coadministration of other drugs that are eliminated by
hepatic metabolism.
 The toxicity of TCAs is dose dependent. At serum
concentrations about twice the upper limit of the
therapeutic range, drowsiness, constipation, blurred
vision, and memory loss are common adverse effects.
Higher levels may cause seizure, cardiac arrhythmia, and
unconsciousness.
 Many of the immunoassays for TCAs use polyclonal
antibodies, which cross-react among the different TCAs
and their metabolites and are used for TCA screening
rather than blood concentration monitoring and TDM.
 Chromatographic methods provide simultaneous
evaluation of both the parent drugs and metabolites,
which provides a basis for unambiguous interpretation of
results.
CLOZAPINE
 Treatment for refractory schizophrenia
 Therapeutic range: 350 to 420 ng/mL
 Atypical antipsychotic drugs for refractory
schizophrenia, suicidal tendencies and various types of
cognitive deficiencies
 Beneficial effects have been demonstrated at
concentration 350-420 ng/mL
OLANZAPINE
 Administered as a fast-acting IM injection at a dose of 2.5 to
10 mg per injection
 Administered orally and is 85% absorbed, although it is
approximately 40% inactivated by first-pass metabolism
 Therapeutic range: 20-50 ng/mL
 Antipsychotic drugs effective to treat schizophrenia, acute
manic episodes, and recurrence of bipolar disorders
 Usually administered intramuscularly
 Women and nonsmokers tend to have lower clearance as
compared with men and smokers
IMMUNOSUPPRESSIVE DRUGS
CYCLOSPORINE
 Inhibits cellular immune response by blocking interleukin-
2 production
 Use for suppressing GVHD
 Orally administered with 5-50% absorption
 Specimen of Choice: whole blood (with lysis of RBC to
yield the total amount)
 Toxic effects: renal tubular and glomerular dysfunction
 Toxic range: 350-400 ng/mL
 potent immunosuppressive drugs with primary clinical use of
suppression of host vs. graft rejection of heterotrophic
transplanted organs
 toxic effects may result to hypertension
 chromatographic methods are used for separation and
quantitation of parent drug from metabolites
Cyclosporine
 Circulating cyclosporine sequesters in cells, including
erythrocytes.12 Erythrocyte content is highly
temperature dependent; therefore, evaluation of plasma
concentration requires rigorous control of specimen
temperature. To avoid this preanalytical variable, whole
blood is the specimen of choice.
 Cyclosporine is eliminated by hepatic metabolism to
inactive products.
 Immunosuppression requirements differ depending on
the organ transplanted. Cardiac, liver, and pancreas
transplants have the highest requirement (300 ng/mL
[250 nmol/L]). Whole blood concentrations in the range
of 350 to 400 ng/mL (291 to 333 nmol/L) have been
associated with toxic effects.
TACROLIMUS
 FK-506, Prograf
 100x more powerful than cyclosporine
 Orally administered; GIT uptake is variable
 Toxic effect: Thrombus formation
 Both have comparable degrees of nephrotoxicity at
therapeutic concentrations
 High-performance liquid chromatography–mass
spectrometry
 it is more potent than cyclosporine that' why it requires
low/less dosage
 similar pharmacokinetics with cyclosporine which is
eliminated by hepatic metabolism
DA BARAKO’S, GFS NI TAEHYUNG (REAL!!)– TRANSCRIBERS
 most common determination is HPLC coupled with MS,
however, other immunoassays are also available for the
determination of the drugs
Tacrolimus
 Early use of tacrolimus suggested a low degree of toxicity
compared with cyclosporine at therapeutic
concentrations. However, after extensive use in clinical
practice, it has been demonstrated that both have
comparable degrees of nephrotoxicity at therapeutic
concentrations. At concentrations above therapeutic,
tacrolimus has been associated with thrombus formation.
 Tacrolimus is eliminated almost exclusively by hepatic
metabolism. Metabolic products are primarily secreted
into the bile. Increases in immunoreactive tacrolimus may
be seen in cholestasis as a result of cross-reactivity with
several of these products. Because of the high potency
of tacrolimus, circulating therapeutic concentrations are
low.
 This limits the methodologies capable of measuring
whole blood concentrations. The most common method
is high-performance liquid chromatography–mass
spectrometry; however, several immunoassays are also
available.
SIROLIMUS
 Also known as Rapamycin
 An antifungal agent with immunosuppressive activity
approved for patient receiving kidney transplantation.
Commonly used in conjunction with cyclosporine or
tacrolimus. Adverse effects include:
- Thrombocytopenia
- Anemia
- Leukopenia
- Infections
- Hyperlipidemia
 Sirolimus is rapidly absorbed after once-daily oral
administration, with peak blood levels at about 1 hour and a
long half-life of 62 hours. Usually assayed using
chromatography. The oral bioavailability is 15% when taken
in conjunction with cyclosporine
Sirolimus
 This drug is also extremely potent and requires TDM due
to its inherent toxicity.
 Sirolimus binds more readily to lipoproteins than plasma
proteins making whole blood the ideal specimen for
analysis. 17 Approximately 92% of circulating sirolimus is
bound.
 A therapeutic range of 4 to 12 μg/L is used when sirolimus
is administered in conjunction with cyclosporine, and a
range of 12 to 20 μg/L is used if cyclosporine therapy is
not used or discontinued.
MYCOPHENOLIC ACID
 Mycophenolate mofetil
 Prodrug → Mycophenolic acid (MPA)
 Decreases renal allograft rejection
 Lymphocyte proliferation inhibitor
- utilized as supplemental therapy with cyclosporine
and tacrolimus in renal transplant patient that is
orally administered
- can be assayed through plasma specimen either
chromatography or immunoassay principles
 95% protein-bound
 Therapeutic serum concentrations have been documented
at 1.0 to 3.5 μg/Ml
Mycophenolic Acid (Myfortic)
 Mycophenolate mofetil (Myfortic) is a prodrug that is
rapidly converted in the liver to its active form,
mycophenolic acid (MPA).
 Interindividual variation of gastrointestinal tract physiology
influences the degree of absorption of MPA; however,
peak concentrations are generally achieved 1 to 2 hours
post dose. Once in circulation, MPA is 95% protein bound.
The degree to which MPA is protein bound varies both
intraindividually and interindividually and is dependent on
circulating albumin concentrations, renal function, and the
concentration of other drugs that may competitively bind
to plasma albumin.
 As with most immunoassay methods, cross-reactivity
between MPA and its active metabolite (AcMPAG) should
be taken into account along with the clinical picture when
evaluating a dosage regimen.
ANTINEOPLASTICS
METHOTREXATE
 Cell cycle drug that inhibits cell replication during a specific
phase of the cell cycle leading to inhibition of DNA
Synthesis.
 Effective therapy for a variety of neoplastic conditions; also
an immunosuppressive agent
 Inhibits DNA synthesis in all cells
 Also an anti-metabolite drug taken orally, parenterally
 Individualized- meaning, the drugs are for patients based
on body size
 Leucovorin is used to reverse the effects of methotrexate
 Toxic effects: Leukopenia, GI ulceration,
thrombocytopenia, cirrhosis
ANTI-EPILEPTIC DRUGS (AEDS)
PHENOBARBITAL
 Slow-acting barbiturates that controls the tonic clonic
seizure and focal epileptics
 Controls several types of seizure, slow but complete.
 Inactive proform: Primidone (Mysoline)
 Half-life: 70 – 100 hours
 Peak serum level: 10 hours after an oral dose
 Therapeutic range: 20-40 ug/mL (phenobarbital), 5 – 12
ug/mL (primidone)
 Toxic effects: Calciness, fatigue, depression, reduced
mental capacity
PHENYTOIN (DILANTIN)
 It controls seizures and short-term prophylactic agent in the
brain injury to prevent loss of functional tissues
 Administered IV, GIT absorption is incomplete
 Toxicity: Teratogenic action (cleft lip and palate) and
nystagmus, hirsutism, gingival hyperplasia, vitamin D
deficiency, and folate deficiency
VALPROIC ACID (Depakene)
 Used for the treatment of petit mal (absence seizure)
and grand mal
 Administered orally, gastrointestinal absorption is rapid
and complete
 Therapeutic level: 50-120 ug/mL
 Toxic effects: nausea, lethargy, weight gain, pancreatitis,
hallucination
DA BARAKO’S, GFS NI TAEHYUNG (REAL!!)– TRANSCRIBERS
 ETHOSUXIMIDE (Zarontin)
 Drug of choice for controlling petit mal
 Therapeutic levels: 40 – 100 ug/mL
 Toxic levels: >100 ug/mL
 Toxic effects: GI disturbance, SLE, aplastic anemia and
pancytopenia
 Done so that serum concentration is in therapeutic range
value.
LEVETIRACETAM

 Orally administered, does not bind to protein

 Dedicated for partial to generalized seizure
 Half-life: 6-8 hours
 Rate of elimination are increased in children and pregnant
women and decreased among elderly
 Therapeutic range: 8–26 ug/mL

DA BARAKO’S, GFS NI TAEHYUNG (REAL!!)– TRANSCRIBERS

 THYROID ENDOCRINOLOGY LEC
CLINICAL CHEMISTRY 2 2021 – 2022
Instructor: John Jeffrey Pangilinan, RMT, MSMT
WEEK 15 2nd Semester
CCHEM 3
Date: May 27, 2022

TOPIC OUTLINE thyroid surgery, when injury could lead to hypocalcemia or

I. Thyroid gland permanent hoarse voice.
a) Functions of the thyroid gland
b) Biosynthesis of the thyroid gland
c) Major thyroid hormones FUNCTIONS OF THE THYROID GLAND
d) Thyroid autoantigens
e) Thyroid autoantigens  Thyroid exerts its influence over many organs and various
II. Clinical disorders metabolic processes including heat production, oxygen
III. Hyperthyroidism utilization, and energy expenditure in affecting most aspect
IV. Hypothyroidism of carbohydrates and lipid metabolism.
V. Thyroid function test  That’s why it plays a very crucial role in growth, maturation,
VI. Summary of thyroid disorders and lab tests sexual development, increasing heart rate and
gastrointestinal motility (peristalsis).
 The thyroid hormone binds and form complexes with nuclear
THYROID GLAND receptor leading to the production of messenger RNA that
actually in turn leads to the production of proteins that
 Found in the neck region, anterior to trachea that is between influence metabolism and tissue development and even
the cricoid cartilage suprasternal notch maturation
 Normally having 15 grams in size 1. For tissue growth
 Highly vascular 2. For development of the CNS
 Soft in consistency 3. Elevated heat production
 Butterfly-shaped gland 4. Control of oxygen consumption
 It is consisting of two lobes, located in the lower part of the 5. It influences carbohydrate and protein metabolism
neck, just below the voice box (larynx) 6. For energy conservation
 The lobes are connected by a narrow band called the
isthmus in the center
BIOSYNTHESIS OF THE THYROID GLAND
 By 11 weeks gestation, the gland begins to produce
measurable amount of hormone (thyroid hormone synthesis)  Take note: during the synthesis of the thyroid hormone,
 FOLLICLE iodine is considered to be the major element crucial for the
- The fundamental structural unit of the thyroid gland production of thyroid hormones whether T4-T3.
 2 Types of Cells in the Thyroid Gland  The initial step leading to thyroid hormone synthesis is
a) Follicular Cells trapping of the iodide in the flood and pumping this into the
- secrete (T3 and T4) cells of the follicle considered an energy dependent and
- 200 micrometer within diameter active transport mechanism
- Each particular follicle/sphere is made from epithelial  Iodine is the most important element in the biosynthesis of
tissue with apical and basal orientation. Apical is thyroid hormones
narrower than basal and oriented toward the interior - Important in the diet, any deficiency or deficit will limit
surface. The basal aspect is oriented exteriorly opposite the hormone production leading to hypothyroidism
to apical region - Defines the functionality of the thyroid hormone
b) Parafollicular or (C Cells) according to location and numbers in relation to the
- secrete Calcitonin structure of the thyroid hormone
 THYROGLOBULIN  RDI (recommended iodine intake)– 150 ug
- Acts as a preformed matrix, containing tyrosyl groups; - Normally obtain in seafoods and dairy products
glycoproteins stored in the follicular colloid of the thyroid  The activity of thyroid hormone is dependent on the location
gland and number of iodine atoms
- Epithelial cell that constitutes the follicle produces the  Found in the seafood, dairy products, iodine-enriched
thyroglobulin. It is a glycoprotein that is secreted toward breads, and vitamins
the interior. And the central or middle portion of each  Iodination of tyrosine residues in thyroglobulin results in
follicle is consist of proteinaceous material known as formation of monoiodotyrosine (MIT) and diiodotyrosine
colloid that receives and stores the thyroglobulin. It is (DIT)
within the follicular cell and colloid where thyroid - Iodide is oxidize in the thyroid cell to become iodine and
hormone is synthesized attaches to the tyrosine residues of thyroglobulin in
BISHOP order to form MIT and DIT
 The thyroid gland is responsible for the production of two - Iodination is a major biochemical process in the
hormones: thyroid hormone and calcitonin. Calcitonin is formation of the thyroid hormone precursor through
secreted by parafollicular C cells and is involved in calcium adding of tyrosine residues of the thyroglobulin
homeostasis. Thyroid hormone is critical in regulating - MIT and DIT are enzymatically coupled in order to form
body metabolism, neurologic development, and numerous T3 and T4
other body functions. - Thyroglobulin combines the storage mechanism since
 Posterior to the thyroid gland lie the parathyroid glands— the uniform T3 and T4 remain attached until need for
which regulate serum calcium levels—and the recurrent release
laryngeal nerves innervating the vocal cords. The  Conversion of T4 to T3 through the process of deiodination
locations of these structures become important during (an enzyme catalyze reaction that is facilitated either type I

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 or type II deiodinase) takes place in many tissues,
particularly the liver and kidney
- The largest fraction of the deiodinase are actually
produced by the liver; therefore, it is the major tissue
where deiodination takes place
 FREE HORMONES (FT3 and FT4)
- Physiologically active portions of the thyroid hormones
- Biologically active form that is actually released slowly
therefore expressed in the very minute concentration or
quantities
- If they are bound or attached to a carrier protein are
considered to be biologically inactive = express in
greatest or largest fraction
 Protein Bound Hormones
- Metabolically inactivate
- Do not enter cells
- Biologically inert
- Function as storage site for circulating thyroid hormone
 The hypothalamic-pituitary-thyroid axis is the
neuroendocrine system that regulates the production and
secretion of the thyroid hormones
 Iodine intake below 50 ug/day (Benchmark limit) =
deficiency of hormone secretion
- Prolonged or chronic deficiency may lead to
hypothyroidism and increase is known as
hyperthyroidism if not controlled or regulated by TSH
(major regulator) produce by the lobe of anterior pituitary
gland through negative feedback mechanism
- TSH is under positive stimulation by the TRH produced
by hypothalamus
 Thyroid hormones affect synthesis, degradation,
intermediate metabolism of adipose tissue circulating lipids
BISHOP
Thyroid cells are organized into spheres surrounding a
central core of fluid called colloid. These structures are called
follicles. The major component of colloid, thyroglobulin, is a
glycoprotein manufactured exclusively by thyroid follicular
cells and rich in the amino acid tyrosine. Some of these tyrosyl
residues will be iodinated, producing the building blocks of
thyroid hormone. On the outer side of the follicle, iodine is
actively transported into the thyroid cell by the Na+/I−
symporter located on the basement membrane. Inside the
thyroid cell, iodide diffuses across the cell to the apical side of
the follicle, which abuts the core of colloid. Here, catalyzed by
a membrane-bound enzyme called thyroid peroxidase (TPO),
concentrated iodide is oxidized and bound with tyrosyl
residues on thyroglobulin. This results in production of
monoiodothyronine (MIT) and diiodothyronine (DIT). This
same enzyme also aids in the coupling of two tyrosyl residues
to form triiodothyronine (T3) (one MIT residue + one DIT r
sidue) or thyroxine (T4) (two DIT residues). These are the two
active forms of thyroid hormone. This thyroglobulin matrix, with
branches now holding T4 and T3, is stored in the core of the
thyroid follicle. Thyroid-stimulating hormone (TSH) signals the
follicular cell to ingest a microscopic droplet of colloid by
endocytosis. Inside the follicular cell, these droplets are
digested by intracellular lysosomes into T4, T3, and other
products. T4 and T3 are then secreted by the thyroid cell into
the circulation
Biosynthesis of thyroid hormone. Thyroid hormone
synthesis includes the following steps: (1) iodide (I−) trapping
by thyroid follicular cells; (2) diffusion of iodide to the apex of
the cell and transport into the colloid; (3) oxidation of inorganic
iodide to iodine and incorporation of iodine into tyrosine
residues within thyroglobulin molecules in the colloid; (4)
combination of two diiodotyrosine (DIT) molecules to form
tetraiodothyronine (thyroxine, T4) or of monoiodotyrosine
(MIT) with DIT to form triiodothyronine (T3); (5) uptake of
thyroglobulin from the colloid into the follicular cell by
endocytosis, fusion of the thyroglobulin with a lysosome, and
proteolysis and release of T4 and T3; and (6) release of T4
and T3 into the circulation.
Iodothyronine 5-deiodinase
Take note: Responsible for activation and deactivation of the
thyroid hormones. It is an enzyme that facilitates the removal of
one atom of iodine in the structure of T4 leading to T3 production
considered to be the more biologically active and potent than T4
1. Type 1 Iodothyronine 5-deiodinase
- The most abundant form (predominant)
- Found mostly in liver and kidney
- Responsible for the largest contribution to the circulating
T3 pool
2. Type 2 Iodothyronine 5-deiodinase
- Found in the brain and pituitary gland
- Maintains the constant level of T3 in the central nervous
system (CNS)
- Its activity is decreased when levels of circulating T4 are
high and increased when levels are low
BISHOP
Type 1 iodothyronine 5′-deiodinase
 Certain drugs (e.g., propylthiouracil, glucocorticoids, and
propranolol) slow the activity of this deiodinase and are
used in the treatment of severe thyroid hormone excess,
or hyperthyroidism.
Type 2 iodothyronine 5′-deiodinase
 Activity of the deiodination enzymes gives another level of
control of thyroid hormone activity beyond the thyrotropin-
releasing hormone (TRH) and thyrotropin (TSH) control of
the hypothalamic-pituitary–thyroid axis
Thyroid Hormones Binding Proteins
Take note: Once the thyroid hormone are released in the
circulation, they immediately become bound and attached to the
transport proteins just like with TBG, TBP and TBA
1. Thyroxine-Binding Globulin (TBG)
- Transports 70-75% of total T4
- Transports majority of T3 (affinity for T3 is weaker than
T4)
- Major transport mechanism, affinity between the
hormone and carrier protein is strong roughly around at
99 – 99.97%
2. Thyroxine-Binding Prealbumin
- Also known as Transthyretin
- Transports 15-20% of total T4
- T3 has a very weak or sometimes has no affinity for
prealbumin
3. Thyroxine-Binding Albumin
- Transports remaining T3
- Transports 10% of T4
 More protein, more THBP, increased TT3 and TT4
 Tight binding allows very slow or gradual release of the
hormone to the target tissue
MAJOR THYROID HORMONES
1. Triiodothyronine (T3)
- Has the most active thyroid hormonal activity
 Most physiologically active and potent hormone mainly
a product of T4 deiodination
- Almost 75-80% is produced from the tissue deiodination
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 of T4 Thyroiditis/ De Quervain’s Thyroiditis (painful
- Principal application of this hormone is for diagnosing thyroiditis)
T3 Thyrotoxicosis  Excess circulating thyroid hormones
 Diagnostic tool primarily used to diagnose Major cause: increased thyroid output
Thyrotoxicosis (elevated levels of thyroid hormone),  Signs and Symptoms:
prognostic indicator of hyperthyroidism a. Tachycardia
 Elevated T3 in the absence of increase TD diagnostic of b. Tremors
T3 thyrotoxicosis c. Weight loss
- Better indicator of recovery from hyperthyroidism as well d. Heat intolerance -excessive sweat
as the recurrence of hyperthyroidism e. Emotional Lability
- An increase in the plasma level is the first abnormality f. Menstrual Changes
seen in the cases of hyperthyroidism  Primary Hyperthyroidism
- Reference Values: - Elevated T3 and T4
o 80 to 200 ng/dL or 1.2 to 3.1 nmol/L (adults) - Decreased TSH
o 105 to 245 ng/dL or 1.8 to 3.8 nmol/L - Decreased TRH
(children)  The problem lies on the organ that produces the
thyroid hormone - the thyroid gland.
2. Tetraiodothyronine (T4)  Secondary Hyperthyroidism
- Principal secretory product - Increased TSH and FT4
 Major secretory form of thyroid hormone after the - (due to the primary lesion in the pituitary gland)
combination of the 2 molecules of DIT  The problem lies on the organ that immediately
- Major fraction of organic iodine in the circulation controls the thyroid activity - the organ that provides
- A prehormone for T3 production stimulus.
 Mainly regulated by the TSH coming from Anterior PG
 Increase T4 suppresses TSH release and activity
- All circulating T4 originates from the thyroid gland THYROTOXICOSIS
- The amount of serum T4 is a good indicator of thyroid  Is applied to a group of syndromes caused by high levels of
secretory rate free thyroid hormones in the circulation
- Elevated thyroxine cause inhibition of TSH secretion  TSH is low
and vice versa  FT4 is normal
- Reference Values
 Increased FT3
o 5.5 to 12.5 ug/dL or 71 to 161 nmol/L (adults)
 T3 Thyrotoxicosis also known as Plummer’s Disease
o 11.8 to 22.6 ug/dL or 152 to 292 nmol/L
(neonates)  State of thyroid hormone excess and not synonymous with
hyperthyroidism.
 Affects peripheral tissues
THYROID AUTOANTIGENS SIGNS SYMPTOMS
 Responsible for autoimmune thyroid disorders 1. Tachycardia 1. Nervousness,
- Autoimmune = associated formation of autoantibodies 2. Tremor irritability, anxiety
or self AB directed to self AG 3. Warm, moist, 2. Tremor
1. Thyroid peroxidase flushed, smooth skin 3. Palpitation
- Microsomal antigen (TPO) 4. Lid lag, widened 4. Fatigue, weakness,
- Autoantibodies = associated with hypothyroidism of palpebral fissures decreased exercise
Hashimoto’s disease and primary myxedema 5. Ophthalmopathy tolerance
- Found in the lesser extent than TG in graves diseases (Grave’s disease) 5. Weight loss
2. Thyroglobulin 6. Goiter 6. Heat intolerance
- Autoantibodies = associated with hypothyroidism of 7. Brisk deep tendon 7. Hyperdefecation
Hashimoto’s disease and primary myxedema reflexes 8. Menstrual changes
3. TSH receptor 8. Muscle wasting and (oligomenorrhea)
- Autoantibodies to the TSH receptor is responsible for weakness 9. Prominence of
hyperthyroidism in graves disease 9. Dermopathy/Pretibial eyes
Myexedema
(Grave’s disease)
CLINICAL DISORDERS 10. Osteopenia,
 Screening of thyroid disorders is recommended when a osteoporosis
person reaches 35 years old and 5 years thereafter - All processes are increased which affects
 2 Major Disorders various tissues in the body.
a. Hyperthyroidism
b. Hypothyroidism

HYPERTHYROIDISM
 Diseases:
a. Thyrotoxicosis
b. Grave’s Disease (Diffuse Toxic Goiter)
c. Riedel’s Thyroiditis
d. Subclinical Hyperthyroidism
e. Subacute granulomatous/ Subacute Nonsuppurative

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  Thyroidal peroxidase (TPO) antibodies are absent
 ESR and thyroglobulin levels are elevated
 Also known as Subacute Non-suppurative Thyroiditis /
de Quervain’s disease
 Most common cause of painful thyroid gland
 Painful thyroiditis is usually caused by radiation, trauma,
or infection while painless thyroiditis is caused by
autoimmune disease process or medication.

HYPOTHYROIDISM
 Diseases:
a. Primary Hypothyroidism
 Hashimoto’s disease
 Myxedema
b. Secondary Hypothyroidism
c. Tertiary Hypothyroidism
d. Congenital Hypothyroidism/ Cretinism
e. Subclinical Hypothyroidism
 Occurs when there is deficiency of your thyroid hormone,
opposite to hyperthyroidism
 Like your hyperthyroidism it can be overt or subclinical
 Subclinical means being asymptomatic with hormone
thyroid level remaining in the normal reference value
 TSH
o Is a very sensitive indicator to changes in
circulating T4 and T3
o Even minor decreases can cause TSH to rise or
increase in response to particular condition
 Develops whenever insufficient amounts of thyroid
hormone are available to tissues
 Treated with thyroid hormone replacement therapy
(levothyroxine)
 Hypothyroidism is manage by replacing lacking hormone
through the use of your levothyroxine either administered
orally or via intravenous route.
GRAVES’S DISEASE (DIFFUSE TOXIC GOITER)  Signs and Symptoms (Following manifestation observable
among patient with this particular conditions)
 Most common cause of thyrotoxicosis - Accounts for 70% a. Bradychardia
of thyrotoxicosis but its prevalence varies among the b. Weight Gain
population depending on high iodine content. c. Coarsened skin
- More often on females and not in males. d. Cold intolerance
 An autoimmune disease in which antibodies are produced e. Mental dullness
that activate the TSH receptor f. Skin and hair changes
 Features: Exophthalmia (bulging of the eyes) and pritibial - Brought about by decrease T3 and T4
myxedema BISHOP
 Physical Test: Classic Triad of Symptoms; Hypothyroidism
Hyperthyroidism, Bulging eyes, and Goiter.  defined as a low free T4 level with a normal or high TSH
 Diagnostic Test: TSH Receptor Antibody Test  One of the most common disorders of the thyroid gland,
occurring in 5% to 15% of women over the age of 65.
RIEDEL’S THYROIDITIS  Symptoms of hypothyroidism vary, depending on the
degree of hypothyroidism and the rapidity of its onset
 Thyroid turns into woody or stony hard mass  Symptoms of hypothyroidism vary, depending on the
 Very rare autoimmune inflammatory disease of thyroid degree of hypothyroidism and the rapidity of its onset
gland. Has been reported in a very few cases of thyroid  On physical examination to those with severe
surgery which shows fibroticness. hypothyroidism :
- low body temperature
SUBCLINICAL HYPERTHYROIDISM - slowed movements
- bradycardia
 No clinical symptoms - Without manifestations. - delay in the relaxation phase of deep tendon reflexes
 TSH is low - yellow discoloration of the skin (from
 FT3 and FT4 are normal hypercarotenemia)
- hair loss
SUBACUTE GRANULOMATOUS THYROIDITIS - diastolic hypertension
- pleural and pericardial effusions
 Associated with neck pain, low grade fever, and swings in - menstrual irregularities
thyroid function tests - periorbital edema

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 Signs & Symptoms of Hypothyroidism  Has a half-life of approximately 7 days.
SIGNS SYMPTOMS  Primary hypothyroidism
1. Delayed relaxation 1. Cold intolerance  the goal of therapy is to achieve a normal TSH level.
phase of deep 2. Depression  Hypothyroidism is of secondary or tertiary origin
tendon reflex testing 3. Mental retardation  TSH levels will not be useful in managing the condition,
2. Bradycardia (infants), slowed and a midnormal free T4 level becomes the treatment
3. Diastolic cognition target.
hypertension 4. Menorrhagia  When doses of thyroid hormone are changed, it is
4. Coarsened skin, 5. Growth failure important to wait at least five half-lives before rechecking
yellowing of skin (children) thyroid function tests in order to achieve a new steady
(carotenemia) 6. Pubertal delay state
5. Periorbital edema 7. Dry skin
6. Thinning of 8. Edema BISHOP
eyebrows/ loss of 9. Constipation Types of Hypothyroidism
lateral aspect of 10. Hoarseness  Primary
brows 11. Dyspnea on
- Thyroid gland dysfunction
7. Slowed exertion
movements/speech  Secondary
8. Pleural/pericardial  Pituitary dysfunction
effusion  Tertiary
9. ascites  Pituitary dysfunction

BISHOP Causes of Hypothyroidism

 Because of the diffuse distribution of thyroid hormone Condition Comments
receptors and the many metabolic effects of thyroid Chronic Lymphocytic TPOAb or TgAb
hormone, hypothyroidism can lead to a variety of other thyroiditis (Hashimoto’s positive in 80%-99%
abnormalities. Primary Thyroiditis) of cases
 Hyponatremia Treatment for toxic History and physical
- can occur from the combination of increased goiter – subtotal exam (neck scar) are
urinary sodium excretion and an inability to thyroidectomy or key to diagnosis
maximally dilute urine due to inappropriate radioactive iodine
release of antidiuretic hormone; Excessive iodine intake History and urinary
- significant degrees of hypothyroidism can lead to iodine measurement
 Myopathy useful
 elevated levels of creatine kinase (CK) Subacute Thyroiditis Usually transient
 anemia can also be seen, Secondary Hypopituitarism Caused by adenoma,
- either as a result of a decreased demand for radiation therapy or
oxygen carrying capacity or through an associated destruction of pituitary
autoimmune pernicious anemia. Tertiary Hypothalamic Rare
 Fifty percent or more of those with uncorrected dysfunction
hypothyroidism will have hyperlipidemia that improves TgAb, thyroglobulin antibodies; TPOAb, thyroid peroxidase
with thyroid hormone replacement. antibodies.
 Presence of these clinical abnormalities
- Hyponatremia BISHOP
- unexplained elevation of creatine phosphokinase  Individuals with risk factors or symptoms: goiter, presence
[CPK] of other autoimmune disease, first-degree relative with
- anemia, or hyperlipidemia autoimmune thyroid disease, lithium use, and amiodarone
- Evaluation for hypothyroidism as a potential use
secondary cause should be considered.

 This disorder is an autoimmune disease targeting the
thyroid gland, often associated with an enlarged gland,
or goiter.
 TPO antibody testing is positive in 80% to 99% of
patients with chronic lymphocytic thyroiditis.
 Other common causes of hypothyroidism include iodine
deficiency, thyroid surgery, and radioactive iodine
treatment
 Individuals will experience transient hypothyroidism
associated with inflammation of the thyroid gland.
 Examples of transient hypothyroidism include
- recovery from nonthyroidal illness a
- The hypothyroid phase of any of the forms of
subacute thyroiditis (painful thyroiditis, postpartum
thyroiditis, and painless thyroiditis).
 Hypothyroidism is treated with thyroid hormone
replacement therapy
 Levothyroxine (T4 ) is the treatment of choice.

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PRIMARY HYPOTHYROIDISM
 It is a known fact that iodine deficiency remains to be the
most common cause of hypothyroidism that occurs
worldwide despite the fact ??tion of your various food
products to prevent iron deficiency
 Problem is thyroid gland: organ who produces thyroid
hormone
 We could actually observed that there is:
o decreased T3 and T4
o in response, Increased TSH as part of negative
feedback regulatory mechanism
 Due to deficiency of elemental Iodine
 Decreased T3 and T4, increased TSH
 Caused by destruction of the thyroid gland
 Major etiology associated with primary hypothyroidism is due
to:
1. Surgical and nonsurgical management or treatment to
correct hypothyroidism initially, causing to affect the
thyroid gland activities and its hormone secretion
capacity
 Other Causes
1. Surgical removal of the gland
2. Used of radioactive iodine for hyperthyroidism treatment
3. Radiation exposure
4. Drugs such as lithium
BISHOP
Primary hypothyroidism
 results from any defect that causes failure of the thyroid
gland to synthesize and secrete thyroid hormone.
 This results in a common disease known as congenital
hypothyroidism (CH), which is present in 1 of 4,000
births and is screened for in all newborns in the
developed world.
 Untreated patients with this disease have severe mental
retardation with unusual facial appearances.
 Treatment by thyroid replacement therapy is usually
successful when diagnosis is established.
 The best diagnostic test is to measure TSH levels in
blood spots from newborns or serum if CH is suspected
in later childhood. TSH levels are high as a result of
failure of the long feedback loop
 Thyroid hormone levels, typically total T4 but also free
T4 , in untreated patients are very low.
Hashimoto’s Disease
 Also known as Chronic autoimmune thyroiditis or
Chronic Lymphocytic Thyroiditis
o Brought about infiltration of thyroid tissue by the
lymphocytes as well as by the plasma cells
 Hashimoto’s Thyroiditis
o is an autoimmune disease
- In which thyroid globulin autoantibodies are
present in very high concentration in the early
stage
- Eventually replaces by the thyroid peroxidase
antibodies (TPO) is the later stage / later part of
disease process. In which this particular condition
occurs 3x more frequently among females when
compared to males
 Thyroid is replaced by a nest of lymphoid tissue - sensitized
T lymphocytes or autoantibodies bind to cell membrane
causing lysis and inflammatory reaction
 Associated with enlargement of the thyroid gland (goiter)
 Methods for testing:
o TPO antibody – (+) result
o TSH- increased
 Laboratory Findings
o Decreased T3 and T4
- As a result of tissue destruction
o Increased TSH
- in response to low circulating thyroid hormone
BISHOP
Chronic lymphocytic thyroiditis—commonly known as
Hashimoto's thyroiditis
 is at the other end of the autoimmune continuum.
 In this condition, antibodies lead to decreased thyroid
hormone production by destruction of the thyroid gland,
which is the most common cause of hypothyroidism in the
developed world.
 The best test for this condition is the TPO antibody, which
is present in 10% to 15% of the general population and
80% to 99% of patients with autoimmune hypothyroidism
Myxedema
 Its actually a syndrome found among patient with severe
hypothyroidism
 Syndrome in a sense that its govern or found to have
plethora or many manifestations
o The skin on the face, hands, feet, tongue and vocal
cords thickens brought about mucopolysaccharide
deposition and accumulation
o On top of it They should experience mild hypothermia
and progressive physical and mental lepcargy or
exhausting
 Describes the peculiar nonpitting swelling of the skin
 Skin becomes infiltrated by mucopolysaccharide
 Clinical features:
1. “puffy” face
2. weight gain
3. slow speech
4. eyebrows thinned
5. dry and yellow skin
6. Anemia
 Myxedema coma- severe form of primary hypothyroidism
SECONDARY HYPOTHYROIDISM
 Problem: is the organ who immediately controls the
thyroid activity which is the Pituitary Gland
 Effect:
o Low: TSH, T3 and T4 (thyroid hormone)
 Major cause
o Is associated with pituitary tissue destruction by any
means and mechanism that includes:
- Radiation
- Could be infection
- Others
 TRH: Elevated / increased
 Due to pituitary destruction or pituitary adenoma
 T3 and T4 are low
 TSH is low
BISHOP
Secondary hypothyroidism
 is a result of the failure of the pituitary gland to secrete
 TSH, which results in lack of thyroid gland stimulation and
subsequent low production of thyroid hormone.
 The differential diagnosis is established by measuring low
circulating TSH levels.
 Because the pituitary is involved with all major endocrine
DA BARAKO’S, GFS NI TAEHYUNG, JUANITO - TRANSCRIBERS
 systems, it is important to study the other pituitary
pathways to determine if hypothyroidism is the result
of an isolated TSH defect or due to
panhypopituitarism involving all other pathways.
 Panhypopituitarism i
 clinically complex and may include features of
hypoglycemia, salt loss, poor somatic and bone growth,
failure to thrive, and, in later childhood, failure to develop
secondary sexual characteristics.
TERTIARY HYPOTHYROIDISM
 Problem: hypothalamus that provide signals and control
the pituitary TSH production and release.
o Anything that depresses the activity of
hypothalamus either a disease or chemical
exposure and other mechanism may lead to:
- Decrease: TSH, T3 and T4
 TRH: Decreased / low
 Differentiate Secondary and tertiary Hypothyroidism is the
TRH Elevated in Secondary but Decreased in Tertiary
 Due to hypothalamic disease
 T3 and T4 are low
 TSH is low
CONGENITAL HYPOTHYROIDISM / CRETINISM
 Also known as Cretinism
 There is a severe hypothyroidism among children and
infants
 Causes include:
o Thyroid dysgenesis
- Deficiency in the amount of thyroid tissue
o Inborn defects in thyroid hormone synthesis and
pituitary or hypothalamic disorders
o Iodine Deficiency during the process of stage
development affects the physical and mental
development of the child leading to retardation
 Defects in the development or function of the gland
 Physical and mental development of the child are retarded
 Screening test: T4 (decreased)
 Confirmatory: TSH (increased)
SUBCLINICAL HYPOTHYROIDISM
 Without manifestation or asymptomatic
 T3 and T4 normal
 TSH is slightly increased
BISHOP
 In subclinical hypothyroidism, the TSH is minimally
increased while the free T4 stays within the normal range.
Thyroid-Stimulating Hormone
 The most useful test for assessing thyroid function is the
TSH, currently in its third generation.
 
THYROID FUNCTION TEST
BISHOP
 The most useful test for assessing thyroid function is the
TSH, currently in its third generation.
1. TRH STIMULATION TEST
 That can detect abnormalities before thyroid hormone
concentration fall outside the reference limit
 It is a useful marker or test that is responsible for
distinguishing between pituitary and hypothalamic
hypothyroidism
o High levels or Increased level TRH: Primary
hypothyroidism
o Decreased level: Hyperthyroidism
 Used in confirming borderline euthyroid condition and
grade disease a form of thyrotoxicosis
 Perform: By injecting 200-500 ug of synthetic TRH after
determining baseline of TSH collection of your TSH
determination are done at 15, 30 and 60 minutes time
 Invasive procedure
o Side effects
- Headache
- Nausea
- Chest tightness
- Mild hypotension apart from time consuming
 Measures the relationship between TRH and TSH secretion
 Used to differentiate euthyroid and hyperthyroid patients
who both had undetectable TSH level
 May also be helpful in the detection of thyroid hormones
resistance syndromes
 Used to confirm borderline cases of euthyroid and Grave
disease
 Dose Needed: 500 ug TRH by IV
 Increased Levels: Primary Hypothyroidism
 Decreased Levels: Hyperthyroidism
2. TSH TEST
 Hypothyroidism
o TSH are significantly elevated in primary
o T3 and T4 is Low
 Pituitary Malfunction is suspected or known as Secondary
Hypothyroidism
o TSH remains low or low normal
o Decreased thyroid hormone
 Thyroid Dysfunction
o Because of TRH even at the very low level
o TRH becomes the test of choice or initial diagnosis
 TSH are useful for monitoring patients receiving
o Levothyroxine – for hypothyroidism as hormone
replacement therapy
 Most important thyroid function test; best screening test
 Most clinically sensitive assay for the detection of primary
thyroid disorders
 Helps in the early detection of hypothyroidism
 Used to differentiate primary from secondary
hypothyroidism
 Used to monitor and adjust thyroid hormone replacement
therapy
The sensitivity of the third generation TSH assays has led to
the ability to detect what is termed subclinical disease- or a
mild degree of thyroid dysfunction
 Reference values: 0.5 to 5 μU/mL
A. Second-Generation TSH Immunometric Assays
- Immunoassay Technology may possible to
measure TSH levels or the Thyroid Stimulating
hormone levels in the blood and immune assay
remains to be standard method if choice for TSH
and the laboratory
DA BARAKO’S, GFS NI TAEHYUNG, JUANITO - TRANSCRIBERS
 - Older Immunoassay or radio immunoassay autoantibodies or TSH antibodies
where able to detect TSH in Normal to Elevated  Secondary and Tertiary Hypothyroidism
ranges BUT Lack sufficient sensitivity or o Decrease TSH are normal seen in condition where
accuracy to quantitate abnormally low levels elevated T3 and T4 are actually observe
concentration of TSH o Affecting both pituitary and hypothalamus but not
- RIA (Radio Immunoassay) Thyroid gland
• Represent the first generation that have the
detection limit between 1-2 mU/L BISHOP
- Second generation Interpretation of Thyroid Tests
• Associated with immunometric assay with Secondary Subclinical Hyperthyroidism
improve sensitivity at 0.1-0.2 mU/L hypothyroidism hyperthyroidism
- with detection limits of 0.1 mU/L LOW Severe Nonthyroidal
- screen for hyperthyroidism TSH
nonthyroidal illnes
illnes
BISHOP Normal Artifact
 Second-generation TSH immunometric assays, with TSH Secondary Normal Pituitary
detection limits of 0.1 mU/L, effectively screen for hypothyroidism hyperthyroidism
hyperthyroidism Laboratory draw
within 6-9 hrs of
B. Third-generation TSH chemiluminometric assays thyroxine dose
- Further advances of the technology lead to the Test artifact
development of third and fourth generation Secondary Subclinical Pituitary
immunoassay for TSH, that employs High hypothyroidism hyperthyroidism hyperthyroidism
chemiluminescence with the detection limit at TSH
Thyroid
0.01-0.02 mU/L hormone
- with detection limits of 0.01 mU/L, (euthyroidism resistance
and hyperthyroidism)
- routinely used to monitor and adjust thyroid
hormone replacement therapy 3. RADIOACTIVE IODINE UPTAKE (RAIU)
- screen both hyperthyroidism and hypothyroidism.  Used to measure the ability of the thyroid gland to trap
iodine.
BISHOP  Helpful in establishing the cause of hyperthyroidism
Third-generation
 High uptake indicates metabolically active (active hormone
 TSH chemiluminometric assays, with increased sensitivity production). Because TSH stimulates iodine uptake by the
to detection limits of 0.01 mU/L, give fewer false-negative thyroid gland, it is important to interpret the scan in
results and more accurately distinguish between conjunction with an assessment of TSH levels.
euthyroidism and hyperthyroidism.  High uptake + TSH deficiency = autonomous thyroid
 he sensitivity of the third-generation TSH assays led to activity
the ability to detect what is termed subclinical disease—  Increase uptake of radioactive iodine is seen in
or a mild degree of thyroid dysfunction— due to the large HYPERTHYROIDISM as the metabolic activity of the cell is
reciprocal change in TSH levels seen for even small increased.
changes in free T4 .
Fourth-generation assay exists
BISHOP
 it is used for research purposes and the third-generation
Radioactive Iodine Uptake
TSH assays are the preferred method for monitoring and
 Radioactive iodine is useful in assessing the metabolic
adjusting thyroid hormone replacement therapy and
screening for abnormal thyroid hormone production in the activity of thyroid tissue and assisting in the evaluation and
clinical setting treatment of thyroid cancer. When radioactive iodine is
given orally, a percentage of the dose is taken up by the
thyroid gland. This percentage is called the radioactive
Increased TSH Decreased TSH iodine uptake (RAIU).
Primary Hypothyroidism Primary Hyperthyroidism  An undetectably low TSH should turn off the thyroid
Secondary and Tertiary gland’s uptake of iodine. If the uptake is high despite an
Hashimoto’s Thyroiditis
Hypothyroidism undetectable TSH, the thyroid must be acting either
Thyrotoxicosis due to autonomously without regard to the hypothalamus–
Treated Grave’s Disease
Pituitary Tumor pituitary–thyroid feedback system or through a TSH
TSH Antibodies Euthyroid Sick Disease surrogate.
Thyroid Hormone Over Replacement Hormone
Resistance in Hypothyroidism
4. Thyroglobulin Assay or TG
 Thyroid disorders and related disorders of pituitary and  Normally used as a postoperative marker of thyroid
hypothalamus where TSH values are elevated and cancer
decreased  Used in monitoring the course of metastatic or recurrence
 Thyrotoxicosis of thyroid cancer
o Anything that decreases and depresses the T3 and T4  When measuring thyroglobulin as a tumor marker for
production normally has a related TSH in response to thyroid cancer, always check a simultaneous sample for
it thyroglobulin antibodies
o Brought about pituitary tumor and TSH
 used to measure follicular or papillary thyroid cancer
DA BARAKO’S, GFS NI TAEHYUNG, JUANITO - TRANSCRIBERS
  thyroid malignancies result in the leakage of thyroglobulin
from the follicle into the patient serum
 tumor marker for either remission or recurrence
 last parameter to normalize after thyrotoxicosis and
therefore useful in resolving thyroid history in the presence
of normal T3 and T4 level with clinical symptoms.
 Increased Levels:
- Untreated and metastatic differentiated thyroid cancer,
hyperthyroidism
 Decreased Levels:
- Infants with goiterous hypothyroidism, thyrotoxicosis
factitial
Thyrotoxicosis factitial - false form of thyrotoxicosis
 Reference Values:
- 3 to 42 ng/mL or ug/mL (adults)
- 38 to 48 ng/mL or ug/mL (infants)
 Methods
- Double antibody RIA, ELISA, IRMA, ICMA
BISHOP
Thyroglobulin
 Thyroglobulin is a protein synthesized and secreted
exclusively by thyroid follicular cells. This prohormone in
the circulation is proof of the presence of thyroid tissue,
either benign or malignant.
 This fact makes thyroglobulin an ideal tumor marker for
thyroid cancer patients.
 The accuracy of the thyroglobulin assay is primarily
dependent on the specificity of the antibody used and the
absence of antithyroglobulin autoantibodies.
5. Reverse T3 (rT3)
 Used to assess borderline or conflicting laboratory
results
 Identifies patient with euthyroid sick sydrome
 rT3 is formed by removal of one iodine from the inner ring of
T4 and end product of T4 metabolism
 This is the metabolically inactive isomer of T3.
 Increased level is severe systemic illness as the result of
decreased conversion of T4 to T3 and inhibition of T3
degradation; elevated in hyperthyroidism and low in
hypothyroidism.
 Measurement principle is RADIOIMMUNOASSAY.
 Reference values: 38 to 44 ng/dL
6. Free Thyroxine Index
 Also known as FT4I or T7
 Indirectly assess the level of free T4 in the blood
 Based on equilibrium relationship of bound T4 and FT4
 Important in correcting euthyroid individuals
 Elevated in hyperthyroidism and decreased in
hypothyroidism
 Compilation of normalizing total T4 and thyroid hormone
binding ratio (THBR) or T3 uptake in the presence of protein
alterations as a consequence of various pathologic condition
such as pregnancy, estrogen therapy, nutrition and liver
diseases
 Multiplication of total T4 to THBR provides an index of
effective concentration independent of changes in protein
binding
 Reference method: equilibrium dialysis
 Reference values: 1.5 to 4.5%
 FT4I = TT4 x T3U (%)/100 or TT4 x THBR
7. Total T3 (TT3), FT3 and FT4
 FT4 test is used to differentiate drug induced TSH elevation
and hypothyroidism
 The value of TT3 or FT3 is in confirming hyperthyroidism
 Direct/reference method: Equilibrium dialysis (FT4)
TT3 (Total T3)
 useful in evaluating suspected thyrotoxicosis while the FT4 is
normal
 elevated TT3 in the absence of increased TBG
(Thyroglobulin) is diagnostic of T3 Thyrotoxicosis
 Method of analysis: enzyme immunoassays and
chemiluminescence
 Reference value: 80-180 ng/dL
Note:
 FT4 is measured in lower values, however, it's best indicator
as compared to TT4.
 FT4 moves inside the cells and convert the metabolically
active potent T3, hence, used to differentiate drug-induced to
hypothyroidism
8. T3 Uptake Test
 Measures the number of available binding sites of the
thyroxine-binding proteins, most notably TBG
 Elevated TBG results to decrease T3 uptake and vice versa
 It does not measure the level of thyroid hormones in serum;
reflects the level of TBG
 A known amount of radiolabeled T3 is added to the test
serum
 Estrogen increases TBG while androgens depress TBG
 Originally named after its reagent, radioactive labelled T3
 Designed to reflect the unsaturated binding capacity of
thyroid hormone carrier primarily the TBG
 Accurately reflect the thyroid function in conditions where
there are variations in level of TBG
 T3 uptake inversely related with the changes of TBG
 Increased level:
- Hyperthyroidism, euthyroid patient, chronic liver disease
 Decreased levels:
- Hypothyroidism, oral contraceptives, pregnancy and
acute hepatitis
 Reference Values:
- 25 to 35%
9. Thyroxine Binding Globulin (TBG) test
 Used to confirm results of FT3 or FT4 or abnormalities in
the relationship of the total thyroxine (TT4) and THBR
test
 Useful to distinguish between hyperthyroidism causing
high thyroxine levels and euthyroidism with increased
binding by TBG and increased T4
Euthyroidism - normal thyroid states
 Total Serum T3 and T4 are dependent on the amount of TBG
 Alterations of thyroid hormone binding proteins, such as
TBG, affect total concentration but not free concentration of
T4 and T3
 Patient with large changes of TBG is associated with liver
disease and congenital abnormalities thus direct detection
of the binding capacity of the hormone must be done via
RIA and IEA.
 Increased levels:
- Hypothyroidism, pregnancy, estrogen
 Decreased levels
- Anabolic steroids, nephrosis
DA BARAKO’S, GFS NI TAEHYUNG, JUANITO - TRANSCRIBERS
 Nonthyroidal illness.
10. Fine Needle Aspiration  Thyroid hormone resistance exhibits NORMAL TO
HIGH values.
 Most accurate tool in the evaluation of thyroid nodules

BISHOP
Fine Needle Aspiration
 The routine use of FNA biopsy allows prompt identification
and treatment of thyroid malignancies and avoids
unnecessary surgery in most individuals with benign
thyroid lesions.
 FNA biopsy results are reported according to six
categories: nondiagnostic, malignant, suspicious for
malignancy, indeterminate or suspicious for neoplasm,
follicular lesion of undetermined significance, and benign.
These categories dictate subsequent treatment, ranging
from routine ultrasound monitoring to surgical excision.

11. Recombinant Human TSH

 Used to test patients with thyroid cancers for the presence of

residual or recurrent disease

12. Tanned Erythrocyte Hemagglutination Method

 A test for antithyroglobulin antibodies

13. Serum Calcitonin Test

 Tumor marker for detecting residual thyroid metastasis in

Medullary Thyroid Carcinoma

14. Thyroid Ultrasound

 The significance of thyroid ultrasound in the assessment of
thyroid anatomy and characterization of palpable thyroid
abnormalities has progressively increased in the last several
years.
 Thyroid ultrasounds are capable of detecting even thyroid
nodules of such a small size as to be of unclear or even no
clinical significance; depending upon age, in up to 50% of
clinically normal thyroid glands, small <1cm) thyroid nodules
can be seen.

SUMMARY OF THYROID DISORDERS AND LAB TESTS

 All of the disease generates NORMAL TBG result.

 All levels are ELEVATED in Grave's disease except
TSH.
 All levels are DEPRECIATED/NORMAL in Primary
hypothyroidism and Hashimoto's thyroiditis except TSH.
 LOW TO NORMAL values are associated with

DA BARAKO’S, GFS NI TAEHYUNG, JUANITO - TRANSCRIBERS

 Endocrinology: Anterior Pituitary
CLINICAL CHEMISTRY 2
Instructor: John Jeffrey Pangilinan, RMT, MSMT
Date: May 27, 2022
TOPIC OUTLINE
I. Growth Hormone
a. Modifiers which Stimulate GH Secretion
b. Modifiers which Inhibit GH secretion
c. Somatotropin
II. Gonadotropin (LH & FSH)
III. Thyroid Stimulating Hormone
IV. Adrenocorticotrophic Hormone (ACTH)
V. Prolactin
a. Hyperprolactinemia
b. Panhypopituitarism
GROWTH HORMONE
• Of all the hormones present and produced by the cells of
the anterior globo-pituitary gland, the growth hormone is
found in highest concentrations
• Synthesized by the somatotrophs
o Somatotropin – somatotrophs
• The somatotrophs comprise over 1/3 of normal pituitary
weight
• Stimulated by GHRH (somatocrinin)
o The secretion of growth hormones is controlled by the
hypothalamus, through the actions of the growth-
hormone releasing hormone known as the
somatocrinin
• Secretion is inhibited by somatostatin
o It is counter regulated by the somatostatin
• Peak occurring at the onset of sleep
• Structurally related to prolactin and human placental
lactogen
o A polypeptide based on structure
o Contains 191 amino acids, structurally similar or
homologous to prolactin
• Overall function: anabolic in most tissues, stimulates the
new synthesis of new proteins except adipocytes
o It induces lipolysis or lipid-breakdown
o Have both anabolic and catabolic functions, that is
why it is classified as amphibolic hormone
• An amphibolic hormone → directly influences both
anabolic and catabolic processes
• Required for the growth and development of cartilage and
bone
o Action is indirect
• Main function of GH: promote synthesis and secretion of
small protein known as insulin growth-like factors or
somatomedins
• GH has direct and indirect effects on many tissues –
somatomedins
• Directly antagonizes the effect of insulin on glucose
metabolism,
o Promotes hepatic gluconeogenesis
o Stimulates lipolysis
• Induce the production of an additional factor that stimulated
the incorporation of sulfate into cartilage
o In the response to human GH, the cells in the liver, the
skeletal muscle, cartilage, bones, and other tissues
actually secretes insulin-like growth factors that can
either enter the blood stream into the liver or locally in
other tissues autocrine or paracrine in its reaction
1 DA BARAKO’S, GFS NI TAEHYUNG, JUANITO – TRANSCRIBERS
LEC
2021 – 2022
WEEK 15 2nd Semester
CCHEM 322
• Also known as insulin-like growth factor (IGF) because of
its structural homology to proinsulin,
• Somatomedin C – the major growth factor
• Have cell surface receptors that are distinct from insulin
• IGF-binding protein III (IGFBP-III) – serum binding
proteins for IGFs
• GH deficiency in children may be accompanied by
hypoglycemia; in adults, hypoglycemia may occur if both
GH and ACTH are deficient
GROWTH HORMONE (Bishop, 8th edition)
• The pituitary is vital for normal growth. Growth ceases if
the pituitary is removed, and if the hormonal products
from other endocrine glands that are acted on by the
pituitary are replaced (thyroxine, adrenal steroids, and
gonadal steroids), growth is not restored until GH is
administered.
• However, if GH is given in isolation without the other
hormones, growth is not promoted. Therefore, it takes
complete functioning of the pituitary to establish
conditions ripe for growth of the individual. It also takes
adequate nutrition, normal levels of insulin, and overall
good health to achieve a person's genetic growth
potential.
• GH, also called somatotropin, is structurally related to
prolactin and human placental lactogen. A single peptide
with two intramolecular disulfide bridges, it belongs to the
direct effector class of anterior pituitary hormones.
• The somatotrophs, pituitary cells that produce GH,
constitute over one-third of normal pituitary weight.
• Release of somatotropin from the pituitary is stimulated
by the hypothalamic peptide growth hormone–releasing
hormone (GHRH); somatotropin's secretion is inhibited
by SS.
• GH is secreted in pulses, with an average interpulse
interval of 2 to 3 hours, with the most reproducible peak
occurring at the onset of sleep.
• Between these pulses, the level of GH may fall below the
detectable limit, resulting in the clinical evaluation of GH
deficiency being based on a single, challenging
measurement. Ghrelin, an enteric hormone that plays
important roles in nutrient sensing, appetite and in
glucose regulation, is also a potent stimulator of GH
secretion.
MODIFIERS WHICH STIMULATE GH SECRETION
Several modifiers or factors that may stimulate the secretion of
growth factor hormone:
• Sleep
• Exercise
• Physiologic stress
• Amino acid (e.g., Arginine)
• Sex steroids (e.g., Estradiol)
• Alpha-agonists (e.g., Norepinephrine)
• Beta-blockers (e.g., Propanolol)
*These modifiers are the ones responsible in increasing the
release and secretion of the GH

MODIFIERS WHICH INHIBIT GH SECRETION
• Glucose loading
• Beta-agonists (e.g., Epinephrine)
• Alpha-blockers (e.g., Phentolamine)
• Emotional/psychogenic stress
• Nutritional deficiencies
• Insulin deficiency
• Thyroxine deficiency
*These are the factors or considerations that causes the
prevention of the secretion of the growth hormones
SOMATOTROPIN
DISORDERS
➢ Children with pituitary dwarfism retain normal proportions
and show no intellectual abnormalities – deficiency of
growth hormone
➢ Acromegaly / Gigantism – due to overproduction of GH (>
50 ng/mL)
o Acromegaly in adults after epiphyseal plate closure,
and even pituitary gland gigantism among children
affected by this condition prior or before epiphyseal
plate closure
➢ Acromegaly is a chronic disease generally affects the
middle age group, characterized by elongation and
enlargement of the bones
o Affects the extremities and head bones, particularly the
frontal and jaw bones
o Enlargement of the nose, lips, and thickening of the
soft tissues of the face may also be observed
o Increased growth hormones brought about by
adenoma, leads to insulin-like growth factor or
somatomedin, increased somatomedin, leads to
increased tissue growth, affecting the different
dimensions of the tissues
TREATMENT FOR ACROMEGALY
• Tumor ablation – utilizes thermal energy by decreasing
the invasiveness of the tumor by the application of heat
• Trans-sphenoidal adenectomy is the procedure of choice
• External beam or focused irradiation
• Administration of pharmacologic drugs as
chemotherapeutic agents, these drugs decrease or
combats the hyperactivity of the affected cells or tissues
• Drugs:
o SS analogs (octreotide and lanreotide)
o Dopaminergic agonists (cabergoline and bromocriptine)
o GH receptor antagonists (pegvisomant)
TESTS
Specimen requirement: Fasting serum; complete rest 30
minutes before blood collection
• GH deficiency test:
In this test, failure of growth hormone to rise above 5
ng/mLapplicable for adults, and more than 10 ng/mL in
children, is concerned to be abnormal
o Insulin tolerance (Insulin induced hypoglycemia test):
Gold standard for confirmatory test
o Arginine stimulation test: second confirmatory test
• Screening test for Acromegaly
o Somatomedin C or insulin-like Growth factor 1
o IGF-1 is increased in patients with acromegaly
o IGF-1 is low in GH deficiency
• Confirmatory test for Acromegaly
o Glucose Suppression test – OGGT (75 g Glucose)
2
Glucose counteracts the growth hormone production or
synthesis, even secretion
▪ Blood is collected every after 30 mins for 2 hours;
requires fasting sample
▪ If the GH fails to decline <1 ng/mL, it is
acromegaly
▪ A normal response for this test is a suppression of
GH <1 ng/mL
GONADOTROPIN (LH & FSH)
• Produced by Gonadotrophs of anterior pituitary gland,
regulated by Gonadotropin releasing hormone
• Important markers in diagnosing fertility and menstrual
cycle disorders
• Present in the blood of both male and female at all ages
• FSH – aids in spermatogenesis (male) and assists in the
maturation of ovarian follicle or early folliculogenesis
(female)
• LH – helps the Leydig cells for Testosterone production
(male) and ovulation and final follicular growth and
maturation (female)
• LH – acts on theca cells to cause the synthesis of
androgens, estrogens (estradiol and estrone) and
progesterone
• Elevation of FSH is a clue in the diagnosis of premature
menopause
• Increase of FSH and LH after menopause is due to lack
of estrogen
THYROID STIMULATING HORMONE
• Also known as thyrotropin, produced by the anterior
pituitary gland particularly by thyrotrophs.
• TSH is a dimer, with alpha and beta subunits
• Alpha subunit has the same amino acid sequences of LH,
FSH, and HCG
o Alpha subunit is homologous to gonadotropins
• Beta subunit carries the specific information to the
binding receptors for expression of hormonal activities
o Beta subunit confers the hormonal and immunological
specificity
• Main stimulus for the uptake of iodide by the thyroid
gland
o TSH stimulates the thyroid gland to produce T4 and T3
o TSH secretion is controlled by TRH, hypothalamus, and
thyroid hormones via negative feedback mechanism.
• It acts to increase the number and size of follicular cells
of follicular cells; it stimulates thyroid hormone synthesis
ADENOCORTICOTROPHIC HORMONE (ACTH)
• An anterior pituitary hormone derived from precursor,
known as proopiomelanocortin
• The primary target tissue of ACTH is the adrenal cortex
o Once the ACTH binds to a receptor located in the
adrenal cortex, this causes the initiation and production
of steroid hormone known as steroidogenesis
o Cortisol is the final hormone product
• Regulation of ACTH is through the actions of hypothalamic
hormone CRH and via the negative feedback action of
the cortisol
• For the secretion of cortisol
• Produce in response to low serum cortisol; regulator of
adrenal androgen synthesis
• Deficiency of ACTH will lead to atrophy of the zona
glomerulosa and zona reticularis (layers of adrenal cortex)
DA BARAKO’S, GFS NI TAEHYUNG, JUANITO – TRANSCRIBERS
 o When there is deficit amount of ACTH, that should
evoke adrenal cortex cells activity, there will be
reduction in the size and mass of the adrenal cortex
brought by the diminish stimulation from ACTH
• Highest level is between 6 to 8 AM
o ACTH is found to be at highest in morning
• Lowest level is between 6 to 11 PM
o ACTH has lowest concentration at night
• Specimen for testing should not be allowed to have contact
with glass because ACTH adheres to glass surface
o Never use glass tube because of its negative bias
• Specimen requirement: blood should be collected into
prechilled polystyrene (plastic) tubes
o Blood specimen for ACTH analysis should be drawn
only, by utilizing plastic tubes, specifically the
polystyrene type
o That should be pre-chilled either EDTA or heparinized
plasma
o Never use whole blood because of unstable nature of
ACTH
o Sample can be frozen, if not, analyzed immediately on
the day of collection
• Increased levels: Addison’s disease, Ectopic tumors, after
protein-rich meals
o Increased ACTH are both observed in pathologic and
non-pathologic conditions like Addison’s disease and
Ectopic tumors, also after consumption of meal with
high-protein value.
• Radioimmunoassay (RIA) is the method of choice for
ACTH analysis
PROLACTIN
• Produced by the cells of anterior lobe of pituitary gland
known as lactotrophs or mammotrophs
• Similar with growth hormone in terms of structures and
amino acid sequences
• A pituitary lactogenic hormone; a stress hormone; also
important for parturition
• Function in the initiation and maintenance of lactation
o In post-partum women, prolactin induces milk
production as part of lactation process.
o For us to tell that there is lactation, there should be milk
production and injection as well.
o In effect, both the PRL (prolactin) and oxytocin function
for lactation to happen.
• Also acts in conjunction with estrogen and progesterone to
promote breast tissue development
o In conjunction with number of other hormones help the
stimulate the development of the breast tissue needed
for the lactation
• Main inhibitory factor: dopamine
o Secretion of prolactin is under the control of dopamine
o Dopamine is an inhibitory factor that comes from the
hypothalamus
o If dopamine levels declined, prolactin will be secreted
o On the other hand, if dopamine is increased, prolactin
secretion is inhibited or suppressed.
o There is no specific prolactin reducing factor, but
TRH (Thyrotropin releasing hormone) has minor role in
increasing the prolactin production
PROLACTIN (Bishop, 8th edition)
• Prolactin is structurally related to GH and human
placental lactogen.
• Considered as stress hormones, it has vital functions in
relationship to reproduction.
3
• Prolactin is classified as a direct effector hormone (as
opposed to a tropic hormone) because it has diffuse
target tissue and lacks a single endocrine end organ.
• Prolactin is unique among the anterior pituitary
hormones because its major mode of hypothalamic
regulation is tonic inhibition rather than intermittent
stimulation.
• Prolactin inhibitory factor was once considered a
polypeptide hormone capable of inhibiting prolactin
secretion;
• Dopamine, is the only neuroendocrine signal that
inhibits prolactin and is now considered to be the elusive
PIF.
• Any compound that affects dopaminergic activity in the
median eminence of the hypothalamus will also alter
prolactin secretion.
• Any disruption of the pituitary stalk causes an elevation
in prolactin as a result of interruption of the flow of
dopamine from the hypothalamus to the lactotrophs, the
pituitary prolactin-secreting cells.
• TRH directly stimulates prolactin secretion and
increases in TRH elevate prolactin levels.
• The feedback effector for prolactin is unknown. Although
the primary regulation of prolactin secretions is tonic
inhibition (e.g. dopamine), it is also regulated by several
hormones including GnRH, TRH, and vasoactive
intestinal polypeptide.
• Stimulation of breasts, as in nursing, causes the release
of prolactin-secreting hormones from the hypothalamus
through a spinal reflex arc.
• The physiologic effect of prolactin is lactation.
• The usual consequence of prolactin excess is
hypogonadism, either by suppression of gonadotropin
secretion from the pituitary or by inhibition of
gonadotropin action at the gonad.
• The suppression of ovulation seen in lactating
postpartum mothers is related to this phenomenon.
HYPERPROLACTINEMIA
• Excess secretion in prolactin is associated with pituitary
tumor. It affects the normal traffic or flow of dopamine to
increase secretion of PRL and associate activity brought
about by less inhibition or suppression
• Many causes and etiologies may also cause increase
PRL or prolactin either related to pathology like
acromegaly, hypothyroidism and chronic renal failure
or by certain medication or drugs.
• Disruption of the pituitary stalk (e.g., tumors, trauma, or
inflammation)
o Causes an elevation in prolactin as a result of
interruption of the flow of dopamine from the
hypothalamus to the lactotropes, the pituitary prolactin-
secreting cells.
• Hyperprolactinemia may also be seen in renal failure, and
polycystic ovary syndrome
• Physiologic stressors, such as exercise and seizures, also
elevated prolactin.
• Example of medications that causes hyperprolactinemia
include: This leads to increase prolactin
o Phenothiazines
o Butyrophenones
o Metoclopramide
o Reserpine
o Tricyclic antidepressants
▪ Methyldopa, and antipsychotics that antagonize the
DA BARAKO’S, GFS NI TAEHYUNG, JUANITO – TRANSCRIBERS
 dopamine D2 receptor. • Pulsatile GnRH infusions have induced puberty and
restored fertility in patients with Kallmann's syndrome,
CLINICAL PRESENTATION OF PATIENT WITH and gonadotropin preparations have restored
HYPERPROLACTINEMIA ovulation/spermatogenesis in people with gonadotropin
• Manifestation of patient with hyperprolactinemia depends deficiency.
on the age and gender plus the size and degree of
behavioral characteristics of the tumor
• In women, increase prolactin induces continuous milk PROLACTIN – Specimen Requirement
flow known as galactorrhea even in the absence of • Specimen is fresh, non-hemolyzed fasting serum
stimulus sample
• Causes to terminate prematurely the menstruation called • Time of sample collection is recorded since the levels of
the amenorrhea. prolactin varies in time affecting the circadian rhythm.
• In Men, increase prolactin induces gynecomastia and • Prior to collection, patient must be relaxed, since this
hypogonadism that may lead to decreased hormone is considered to be stress hormone. Affected by
testosterone and libido of the patient emotional distress and anxieties
• Menstrual irregularity / amenorrhea, infertility, or • Specimen requirement: blood should be collected 3-4
galactorrhea hours after individual has awakened; fasting sample
• Pituitary mass, such as headaches or visual complaints • Highest level in the morning is between 4 AM and 8 AM, in
• Reduced libido or complaints of erectile dysfunction the evening, between 8 PM and 10 PM
(men)
• Consequence of prolactin excess is hypogonadism either
by Book references:
o Suppression of gonadotropin secretion from the • Sir Jeff’s Notes
pituitary • Bishop 8th edition
o Inhibition of gonadotropin action at the gonad
PANHYPOPITUITARISM
• “Pan” means all “hypo” means decreased
• “Pituitarism” related to pituitary gland
• Generalized hypofunction of pituitary gland with decreased
in all pituitary hormone
• Associated when there is extensive or severe damage in
the pituitary gland with many causes and varied mechanism
• Failure of either the pituitary or the hypothalamus results in
the loss of anterior pituitary function
• Patient inflicted with panhypopituitarism suffer from
thyroid adrenal and gonadal insufficiency
• Majority in under lobe pituitary hormones, it actually
controls those particular said organ
• Monotropic hormone deficiency – loss of only a single
pituitary hormone
• Treatment – (Replacement of deficient hormone)
replacement therapy (thyroxine, glucocorticoids, and
gender-specific sex steroids).
• Causes
o Pituitary tumors
o Parapituitary/hypothalamic tumors
o Trauma
o Radiation therapy / Surgery
o Infarction
o Infection
o Infiltrative disease
o Immunologic
o Familial
o Idiopathic

TREATMENT OF PANHYPOPITUITARISM (Bishop, 8th

edition)
• In the average patient, replacement therapy for
panhypopituitarism is the same as for primary target
organ failure. Patients are treated with thyroxine,
glucocorticoids, and gender-specific sex steroids.
• It is less clear about GH replacement in adults, and
additional studies are needed to clarify this issue.
Replacement becomes more complicated in
panhypopituitary patients who desire fertility.

DA BARAKO’S, GFS NI TAEHYUNG, JUANITO – TRANSCRIBERS

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