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adrenal Flashcards

(51 cards)

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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

Study These Flashcards
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

Study These Flashcards
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

Study These Flashcards
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

Study These Flashcards
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
high dose dexamethasone test
get baseline cortisol level give dexamethasone 2 mg every 6 hr for 48h if you having Cushing Disease your cortisol level decreases
26
treatment targets for cushing syndrome
1. inhibit adrenal hormone synthesis 2. destroy adrenocortical cells 3. inhibit ACTH 4. glucocorticoid receptor antagonist
27
drugs that are steroidogenesis inhibitors
ketoconazole metyrapone etomidate
28
what to know about ketoconazole
blocks cortisol & aldosterone ANTI-ANDROGENIC ACTIVITY side effects are elevated liver enzymes, gynecomastia, n/v, teratogenic
29
what to know about metyrapone
blocks cortisol (NOT ANDROGENS) so androgenic side effects like acne, hirsutism, edema, blood pressure, electrolytes--> usually give with ketoconazole to avoid those
30
what to know about etomidate
it is an anesthetic, causes adrenal suppression long term, usually reserved for rescue
31
what is the adrenolytic agent
mitotane
32
what to know about mitotane
it destroys cells; high doses of steroid replacement therapy are often needed it is a CYP3A4 inducer, neuro & GI effects, avoid pregnancy/nursing
33
what is the glucocorticoid receptor antagonist
mifepristone
34
what to know about mifepristone
it terminates pregnancy it is used to treat hyperglycemia in cushing syndrome
35
what is the somatostatin analog that targets ACTH
pasireotide
36
what to know about pasireotide
for cushing DISEASE causes hyperglycemia/increased A1c, GI, hypotension
37
what are the kinds of hyperaldosteronism and what causes them
primary (adrenal gland): Conn syndrome, adrenal hyperplasia secondary (stimulation of zona glomerulosa): pregnancy, excessive potassium, oral contraceptives, CHF, cirrhosis
38
how do you treat hyperaldosteronism
spironolactone
39
types of adrenal insufficiency and how you know which one it is
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
diagnosis of adrenal insufficiency
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
addison's (primary adrenal insufficiency) treatment
mineralocorticoid + glucocorticoidd
42
distinguishing feature of addison's
hyperpigmentation in areas of increased friction
43
treatment of secondary/tertiary adrenal insufficiency
glucocorticoid ONLY NO mineralocorticoid
44
what do you give for glucocorticoid replacement
hydrocortisone or cortisone: give in the AM and then 8 hrs later
45
monitoring for glucocorticoid replacement
body weight, postural BP, energy levels
46
glucocorticoid replacement: what to give before strenuous activities like exercise
extra 5-10 mg hydrocortisone
47
glucocorticoid replacement: what to give if there is febrile illness or injury
double the daily dose
48
glucocorticoid replacement: what to give if there is trauma, surgery, critically ill
10x the daily dose
49
what to give for mineralocorticoid replacement
fludrocortisone: 0.05-0.2 mg once daily
50
what to monitor for fludrocortisone
body weight, BP, ECG side effects are GI, edema, HTN, hypokalemia, diabetes
51
how do you treat adrenal crisis
IV fluids with glucose high dose IV glucocorticoids

Endocrinology (10 decks)

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