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Endocrinology > adrenal > Flashcards

adrenal Flashcards

1
Q

adrenal gland is composed of

A

medulla- 10%
cortex- 90%

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2
Q

adrenal cortex is composed of

A

zona glomerulosa
zona fasciculata
zona reticularis

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3
Q

What happens in adrenal medulla

A

tyrosine is converted to epi and norepi in response to stress

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4
Q

what happens in zona glomerulosa

A

RAAS, aldosterone produced

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5
Q

what happens in zona fasciculata

A

cortisol
controlled by HPA, ACTH

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6
Q

what happens in zona reticularis

A

androgens
controlled by HPA, ACTH

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7
Q

the adrenal cortex synthesizes what 2 classes of steroids
and how many carbons do they have

A

corticosteroids (glucocorticoids and mineralocorticoids): 21 carbons
androgens: 19 carbons

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8
Q

main mineralocorticoid

A

aldosterone

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9
Q

main glucocorticoids

A

cortisol, corticosterone

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10
Q

endogenous cortisol= exogenous _________

A

hydrocortisone

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11
Q

hydrocortisone usefulness

A

1:1 anti-inflammatory:mineralocorticoid
useful for adrenal insufficiency: Addison’s, sepsis

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12
Q

prednisolone, prednisone modifications to cortisol

A

a double bond: increases anti-inflammatory effect

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13
Q

methylprednisolone modifications to cortisol

A

a methyl group: increase anti-inflammatory effect
high glucocorticoid activity useful for immunologic flares like MS, rejection

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14
Q

fludrocortisone modifications to cortisol

A

fluoro group: increases mineralocorticoid effect
useful for addison’s disease: treat hyperkalemia, hypotension

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15
Q

dexamethasone modifications to cortisol

A

has a methyl group, double bond, and fluoro group
NO mineralocorticoid at all
100% anti-inflammatory: good for meningitis or anti-emetic

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16
Q

main buckets: hyperfunction of adrenal gland

A

Cushing syndrome
Hyperaldosteronism

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17
Q

2 main buckets of cushing syndrome

A

ACTH dependent: Cushing DISEASE, or ectopic ACTH secretion by a nonpituitary tumor

ACTH independent: adrenocortical adenoma or carcinoma

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18
Q

broad 3 main steps for diagnosis of cushing syndrome

A

1: rule out iatrogenic causes
2: establish presence of hypercortisolism
3: determine if ACTH dependent or independent

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19
Q

how do you establish the presence of hypercortisolism

A

most common is the low dose dexamethasone test: give 1 mg dexamethasone PO btwn 11 pm-midnight, then draw levels at 8am. if dexamethasone is detectable and cortisol is high, diagnosed hypercortisolism

other options: 24hr urinary free cortisol conc, late night salivary cortisol conc

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20
Q

what if there is hypercortisolism but plasma ACTH is undetected

A

then it is adrenocorticol adenoma or carcinoma

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21
Q

what if there is hypercortisolism and plasma ACTH is elevated

A

it is ACTH-dependent Cushing syndrome so you need to get an MRI to look at pituitary

22
Q

what if MRI is normal in ACTH-dependent Cushing Syndrome

A

then it is ectopic ACTH secreting non-pituitary tumor: check IPSS or JVS to completely rule out Cushing disease

23
Q

what if MRI is abnormal in ACTH-dependent Cushing Syndrome

A

then it is probs Cushing DISEASE.
need to do a CRH test or a high dose dexamethasone test to confirm

24
Q

CRH test

A

100 ug of ovine CRH (corticorelin) IV–> measure cortisol & ACTH every 15 minutes

if you have cushing disease you respond with a rise in cortisol and ACTH

25
Q

high dose dexamethasone test

A

get baseline cortisol level
give dexamethasone 2 mg every 6 hr for 48h

if you having Cushing Disease your cortisol level decreases

26
Q

treatment targets for cushing syndrome

A
  1. inhibit adrenal hormone synthesis
  2. destroy adrenocortical cells
  3. inhibit ACTH
  4. glucocorticoid receptor antagonist
27
Q

drugs that are steroidogenesis inhibitors

A

ketoconazole
metyrapone
etomidate

28
Q

what to know about ketoconazole

A

blocks cortisol & aldosterone
ANTI-ANDROGENIC ACTIVITY

side effects are elevated liver enzymes, gynecomastia, n/v, teratogenic

29
Q

what to know about metyrapone

A

blocks cortisol (NOT ANDROGENS) so androgenic side effects like acne, hirsutism, edema, blood pressure, electrolytes–> usually give with ketoconazole to avoid those

30
Q

what to know about etomidate

A

it is an anesthetic, causes adrenal suppression long term, usually reserved for rescue

31
Q

what is the adrenolytic agent

A

mitotane

32
Q

what to know about mitotane

A

it destroys cells; high doses of steroid replacement therapy are often needed

it is a CYP3A4 inducer, neuro & GI effects, avoid pregnancy/nursing

33
Q

what is the glucocorticoid receptor antagonist

A

mifepristone

34
Q

what to know about mifepristone

A

it terminates pregnancy
it is used to treat hyperglycemia in cushing syndrome

35
Q

what is the somatostatin analog that targets ACTH

A

pasireotide

36
Q

what to know about pasireotide

A

for cushing DISEASE
causes hyperglycemia/increased A1c, GI, hypotension

37
Q

what are the kinds of hyperaldosteronism and what causes them

A

primary (adrenal gland): Conn syndrome, adrenal hyperplasia

secondary (stimulation of zona glomerulosa): pregnancy, excessive potassium, oral contraceptives, CHF, cirrhosis

38
Q

how do you treat hyperaldosteronism

A

spironolactone

39
Q

types of adrenal insufficiency and how you know which one it is

A

primary: adrenal steroid is decreased but ACTH and CRH are increased

secondary: adrenal steroid and ACTH are decreased. CRH is increased

tertiary: adrenal steroid, ACTH, and CRH are all decreased

40
Q

diagnosis of adrenal insufficiency

A

abnormal cosyntropin stimulation test: measure serum cortisol levels at baseline and then 30-60 minutes after injection

if cortisol remains low and does not increase more than 10 ug/dL above the baseline, then adrenal insufficiency is diagnosed

41
Q

addison’s (primary adrenal insufficiency) treatment

A

mineralocorticoid + glucocorticoidd

42
Q

distinguishing feature of addison’s

A

hyperpigmentation in areas of increased friction

43
Q

treatment of secondary/tertiary adrenal insufficiency

A

glucocorticoid ONLY

NO mineralocorticoid

44
Q

what do you give for glucocorticoid replacement

A

hydrocortisone or cortisone: give in the AM and then 8 hrs later

45
Q

monitoring for glucocorticoid replacement

A

body weight, postural BP, energy levels

46
Q

glucocorticoid replacement: what to give before strenuous activities like exercise

A

extra 5-10 mg hydrocortisone

47
Q

glucocorticoid replacement: what to give if there is febrile illness or injury

A

double the daily dose

48
Q

glucocorticoid replacement: what to give if there is trauma, surgery, critically ill

A

10x the daily dose

49
Q

what to give for mineralocorticoid replacement

A

fludrocortisone: 0.05-0.2 mg once daily

50
Q

what to monitor for fludrocortisone

A

body weight, BP, ECG

side effects are GI, edema, HTN, hypokalemia, diabetes

51
Q

how do you treat adrenal crisis

A

IV fluids with glucose
high dose IV glucocorticoids

Endocrinology (10 decks)

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