Tutorial 6 - Therapeutic Uses of Adrenal Steroids Flashcards
(17 cards)
CASE 1
Male
7 day old male neonate
Brought to the hospital casualty department.
Presenting Complaint/History of PC/Examination
- Appears dehydrated
- Mother complains that he has been listless
- Vomiting for the last 24 hours
- Baby has lost a lot of weight since delivery
- Apyrexia
- Low blood pressure
- Tachycardia.
Serum Electrolyte Results
- Na+ = 120
- K+ = 5.9
What does listless mean?
[CASE 1]
Characterized by lack of interest, energy, or spirit
What is the reference range for K+?
[CASE 1]
3.5-5.3 mmol/L
What is the reference range for Na+?
[CASE 1]
133-146 mmol/L
What is the most likely diagnosis?
[CASE 1]
Congential Adrenal Hyperplasia
What investigations will help to confirm the diagnosis?
[CASE 1]
Check precursor levels
- measure 17 OH Progesterone
- would be high
Synacthen (Synthetic ACTH)
- cortisol remains low
- 17-OHP would increase
Measure ACTH
Measure androgens
- not diagnostic alone
Genotyping
24hr Urine profile - look for enzyme defects
What is the first therapeutic step?
[CASE 1]
IV Saline (0.9% normal saline)
Hydrocortisone
- large amount
What are the principles of treatment?
[CASE 1]
IV Saline (0.9% normal saline) - replace fluid and salt
Hydrocortisone (or 2 other types)
- to replace cortisol
- large amount initially also replaces aldosterone
Fludrocortisone
- to replace aldosterone long-term
May need genetic counselling, reproductive surgery
Often have trouble with fertility
CASE 2 pt.1
Woman
55 year old
Presenting Complaint/History of PC/Examination
- Undergoes trans-sphenoidal pituitary surgery for a non-functioning pituitary adenoma
- Pre-operatively pituitary function tests confirmed that she was making sufficient amounts of cortisol
What steroid replacement does she need peri-operatively and how would you give it ?
[CASE 2 pt.1]
Pre-medicate with hydrocortisone
IM or IV
What does perioperative mean?
[CASE 2]
(of a process or treatment) occurring or performed at or around the time of an operation.
What is a non-functioning pituitary adenoma?
[CASE 2 pt.1]
A benign pituitary tumour not making any excess pituitary hormones
What does perioperative mean?
[CASE 2 pt.1]
(of a process or treatment) occurring or performed at or around the time of an operation.
CASE 2 pt.2
She makes a good recovery after surgery and on post-operative day 5, she is ready to go home.
A 9AM cortisol that morning (before her medications) is low.
Does she need to go home on steroid medication? What advice do you give her about this?
[CASE 2 pt.2]
Oral glucocorticoids, given in the morning to mimic diurnal release
If cortisol is below 350, she needs steroids for 6 weeks
Precaution: double dose when sick, if vomiting get injection of hydrocortisone, medical alert steroid bracelet
How could you assess whether she needs long-term steroid replacement?
[CASE 2 pt.2]
Insulin Tolerance Stress
- Cause hypoglycaemia by giving insulin
- glucose below 2.2
- cortisol should go above 500
This test is contraindicated in elderly, heart disease and epilepsy
- in these conditions you use glucagon tolerance test
The nurse looking after the patient calls you back to the ward after you have finished the ward round. The patient is anxious about taking steroids. ‘She has heard bad things about steroids, like they puff you up’. How can you reassure the patient?
[CASE 2 pt.2]
Not giving her a supraphysiological dose, just a dose to replace what she has already lost.
If she gets symptoms of Cushing’s symptoms, then she should be concerned.
