Adrenal Pharm

Question 1

Causes of Hyperaldosteronism (5)

Answer 1

Primary hyperaldosteornism
Secondary: Cirrhosis, heart failure
Liddle’s syndrome: mutation in epithelial sodium channel
Deoxycorticosone mediated
Licorice ingestion (pseudohyperaldosteronism)

Question 2

Spionolactone: Action (3)

Answer 2

Mineralocorticoid antagonist

Also blocks androgen, progesterone receptors

Question 3

Spriconolactone: Uses (3)

Answer 3

Potassium sparing diuretic (HTN, CHF, cirrhosis, nephrosis)
Primary hyperaldosteronism
PCOS/hirsutism

Question 4

Spironolactone: AE (5)

Answer 4

Hyperkalemia
Volume depletion
Gynecomastia/impaired libido in men
Menstrual irregularities
Teratogenic

Question 5

Spironolactone: CI (3)

Answer 5

Renal impairment
Hyperkalemia
Pregnancy

Question 6

What is action of eplerenone?

Answer 6

Highly selective mineralocorticoid antagonist

Question 7

Eplerenone: uses (2)

Answer 7

Potassium sparing diuretic

Primary hyperaldosteronism

Question 8

Eplerenone: CI (3)

Answer 8

Renal impairment
Hyperkalemia
Pregnancy

Question 9

Amiloride: Action

Answer 9

Potassium sparing diuretic

Weak diuretic and weak antihypertensive

Question 10

Amiloride: Use

Answer 10

potassium sparing diuretic

Question 11

Amiloride: CI (2)

Answer 11

Renal impairment

Hyperkalemia

Question 12

What things need to be monitored with potassium sparing mineralocorticoid antagonists? (4)

Answer 12

Dehydration
BP
Serum electrolytes
Men: gynecomastia

Question 13

Mineralocorticoid deficiency: Causes (2)

Answer 13

Primary adrenal insufficiency

Hyporeninemia (i.e in diabetic nephropathy)

Question 14

Mineralocorticoid deficiency treatment

Answer 14

Mineralocorticoid replacement: fludrocortisone (florinef)

Question 15

What are side effects of fludrocortisone? (4)

Answer 15

Hypokalemia

Volume overload: edema, HTN, CHF

Question 16

Monitoring fludrocortisone replacement: What are your concerns? (5)

Answer 16

Presyncope, lightheadedness
Salt cravings
Swelling/edema
BP/HR
Monitor Na/K and plasma renin activity

Question 17

Hypercortisolism: Treatment options (5)

Answer 17

Surgical adrenalectomy or hypophysectomy
Mifepristone: glucocorticoid receptor antagonist
Mitotane: Adrenal cytotoxic
Inhibit enyzymes in steroidogenesis: Metyrapone, ketoconazole, aminoglutethimide
Inhibit ACTH secretion: Pasireotide (SS analog)

Question 18

Why does pasireotide work for Cushing’s syndrome?

Answer 18

Pituitary adenomas express somatostatin and dopamine receptors…pasireotide is SS analog and suppresses ACTH secretion

Question 19

What are side effects of SS analogs? (3)

Answer 19

Increase in blood glucose levels
Cardiac conduction defects
Gallstones

Question 20

How do adrenal enzyme inhibitors work?

Answer 20

Block steroid synthesis at multiple sites

Question 21

Why can’t you check urinary free cortisol in mifepristone treatment?

Answer 21

Because it blocks GCR, but doesn’t affect cortisol production

Question 22

For which treatments should you monitor LFTs?

Answer 22

Ketoconazole, pasireotide

Question 23

What are treatments for glucocrticoid deficiency? (3)

Answer 23

Cortisol replacement:
Hydrocortisone (half life=8-12hr)
Dexamethasone (half life=36-54hr)
Presdnisone (18-36hr)

Question 24

Why would you use hydrocortisone over other glucocorticoids?

Answer 24

Best approximates circadian rhythm

Question 25

What are principles of hydrocortisone treatment? (3)

Answer 25

Sick day replacement: double or triple daily dose for days with fever Stress dose replacement: taper to physiologic dose once stress is relieved Acute dose for shock/adrenal crisis: Use IV then taper to pays dose

Question 26

What is concern with high doses of hydrocortisone treatment?

Answer 26

It will overwhelm cortisol-cortisone shunt and bind mineralocorticoid receptor-->pseudohyperaldosternism

Question 27

What do we monitor for hydrocortisone replacement? (4)

Answer 27

Fatigue/appetite BP, weight Signs of over-replacement (iatrogenic Cushing's)

Question 28

Testing for Primary Adrenal Insufficiency

Answer 28

First check morning cortisol | If low cortisol, do IM cosyntropin stimulation test

Question 29

Testing for Secondary Adrenal Insufficiency

Answer 29

Meyrapone testing: If observe high levels of 11-deoxycortisol (cortisol precursor) then there is no secondary adrenal insufficiency If low levels of 11-DOC, then pituitary problem

Question 30

What is enzyme that meyrapone blocks?

Answer 30

11-ß-hydroxylase

Question 31

Monitoring in metyrapone stimulation

Answer 31

Need inpatient monitoring, especially of BP/HR (concern is hypotension) Terminate test with IV hydrocortisone to restore cortisol levels

Question 32

Use of synthetic glucocorticoids: Which ones do not affect mineralocorticoid receptors (3)

Answer 32

Methyl-prednisone Triamcinolone (topical/inhaled) Dexamethasone

Question 33

Main side effect for synthetic glucocorticoid

Answer 33

IATROGENIC CUSHING'S ALL DAY