Adrenal

Question 1

Which hormones come from adrenal glands?

Answer 1

1. Mineralocorticoids like Aldosterone
2. Glucocorticoids like cortisol
3. Anabolic and sex hormones

Question 2

What does cortisol do?

Aldosterone?
Androgens? (DHEA, Androstenedione)

Answer 2

1. Metabolism, immune system, stress response, decr inflamm, vasoconstriction
2. Na+ reabs, Water reabs, K+ excretion
3. Regulate gonadotropin secretion, sex drive
   improves cognition memory and mood

Question 3

Adrenal Excess is called?
What are the clinical presentations of cushing’s ?

Answer 3

Cushing’s Syndrome

Moon face, buffalo hump, hirsutism, edema, thin extremeties, Amenorrhea, purple striae, bruises, Osteoporosis, Glucose interolence, gynecomastia in males, WEIGHT GAIN , incr infection risk

Question 4

Cushing’s Tx
1st line ?

Answer 4

1. Discontinue unnecessary corticosteroid therapy (include all routes of admin).
   -identify DDI’s with CYP 3A4 inhibitors due to incr in glucocorticoid effects

-Surgical resection of causative tumors

Question 5

Cushing’s Tx : second line?

Name some drugs in each class
1. Steroidgenesis Inhibs that block cortisol production

2. Pituitary directed which act directly on tumors to inhibit ACTH production
3. Glucocorticoid receptor blockers

Answer 5

1. Ketoconazole, Osilodrostat, Mitotane, levoketoconazole
2. Cabergoline, pasireotide, pasireotide LAR
3. Mifepristone

Question 6

Adrenal Insufficiency

1. Primary AI is called ___. Destruction of ALLL ___ which decreases ____ and increases ___

Answer 6

1. Addison’s disease
   -adrenal cortical zones
   -cortisol, aldosterone, and testosterone
   -ACTH, CRH and renin

Question 7

Primary AI Presentation ? Name 10

Answer 7

Hyperpigmentation
GI issues
Chronic malaise
generalized weakness
fatigue worsened by exertion
anorexia
weight loss
hyponatremia
hyperkalemia
hypoglycemia

Question 8

Secondary AI
-What causes this?
-Presentation

Answer 8

1. Pituitary disorder !
2. Weakness, fatigue, Psych sx’s. HYPOnatremia but not hyperkalemia, HYPOGLYCEMIA, NO HYPERPIGMENTATION, less GI and hypotension

Question 9

tertiary AI
-What happens?

Answer 9

1. Steroid withdrawl syndrome
   -supression of HPA axis fro endog steroid use
   -disorder of hypothal

Question 10

Primary AI TX
1. Glucocorticoid replacement
-1st line?
-2nd line?

Answer 10

1. Hydrocort 15-25 mg/day split in 2 divided doses

Prednisolone 3-5 mg/day by mouth QAM can be used in pt’s with low adherence

Question 11

Systemic Corticosteroid Relative Potency

Name 2 short acting, dose, and mineralocorticoid activity and route of admin

Answer 11

1. Cortisone 25 mg , ++, PO
2. Hydrocort 20 mg , ++, PO, IV, IM

Question 12

3 Intermediate Acting
-Dose
-Mineralocorticoid activity
-route of admin

1 Long acting

Answer 12

1. Prednisone, 5 mg, +, PO
2. Prednisolone, 5 mg, + , PO
3. Methylpred , 4 mg, 0, PO,IV,IM
4. Dexamethasone, 0.75 mg, 0, PO,IV,IM

Question 13

Fludrocortisone only has ___
When is it used?
Common dose?
AE’s?

Answer 13

Mineralocorticoid effects.

Primary AI, with aldosterone deficiency
-0.05-0.2 mg PO daily
-0.1 mg PO daily

Hypertension, GI upset, insomnia

Question 14

Acute Adrenal Crisis : life threat emerg

1. Occurs when?
2. Typically in ___ pt’s with ___ like ?
   -Abrupt ___ of chronic steroids

Answer 14

1. Adrenal requirements exceed the ability to respond
2. primary AI, physical stress, trauma, surgery infection
   -discontinuation

Question 15

Acute Adrenal Crisis signs and sx’s

N,H,D,W,U,S,C,F,H

Answer 15

-Nausea/vomiting , abdominal pain
-Hypotension
-Decr consciousness
-Weakness, fatigue, lethargy
-Unexplained hypoglycemia
-Seizure
-Coma
-Fever
-Hyponatremia, hyperkalemia

Question 16

TX for adrenal crisis

1. Fluid resus and hemodynamic support using?
2. Steroid replacement using?

Answer 16

1. Typically 1L of 0.9% NS IV over 1 hr. may require vasopressors
   -tirtate to BP , volume status
2. Replace GC and MC
   -taper IV therapy after 1-3 days
   - Convert to PO maintenance dose

Question 17

What drug is preferred for Adrenal Crisis?

Answer 17

Hydrocort
-100 mg IV as slow IV push given immed
-followed by 200 mg/day either as continuous infusion or 50 mg IV q6 hrs . For 24-48 hrs until pt can take oral medication.
-Taper back to home dose once stable.

Add fludrocort 0.1 mg PO daily for pt’s with persistant hyperkalemia

Question 18

AE’s of Steroids?
Neuro
Opthal
Cardio
GI
Musculskel
Derm
Immuno

Answer 18

1. Altered mood, emotional lability. Insomnia, euphoria, depression or psychosis.
2. Cataracts or glaucoma
3. HTN, Fluid retention
4. Peptic ulcers, GI bleeds
5. Osteoporosis, myopathy
6. acne, purple striae, hirutism
7. Incr susc to infections, delayed wound healing

Question 19

Managing steroid ADE’s

Use dosage forms that minimize ___
-How to decr side effects?

Answer 19

1. Toxicity
2. Alternate day oral dosing

Question 20

Consider tapering Steroids if?

1. Course is greater than __ weeks of > ____ daily.
2. Pt has received ___ for total exposure of > ____ in past 6 months
3. treating ____
4. ___ is of concern
5. pt is ___ or ___
6. Patient has ___ sx’s
7. Patient has evidence of ___

Answer 20

1. 3 weeks, 7.5 mg
2. multiple courses 3 weeks
3. poison ivy oak or sumac
4. Disease flare
5. frail, severely ill
6. cushingoid
7. adrenal insuffiency

Question 21

Consider not tapering if …
1. Course is less than __
2. Pt treated for ___
3. Reason for stopping steroid is due to ___ such as ___

Answer 21

3 weeks

allergic rxn that’s resolved

severe AE’s , psychosis