3. Corticosteroid responsive conditions

Question 1

Cushing’s syndrome or disease

Answer 1

Cushing’s syndrome is a set of symptoms caused by high cortisol levels

Cushing’s disease refers to a tumour in the pituirtary gland leading to high cortisol levels

Question 2

Cushing’s disease symptoms

Answer 2

Similar to the glutocorticoid side effect of cortisosteroids

• psychiatric reactions
• skin thinning
• purple red stretch marks
• muscle wasting
• Fat characteristically accumulates in the belly, but arms and legs remain slim
• Fat acummulates in the face - Moon face
• Fat acummulates in the back of the neck -buffallow hump

Question 3

Cushing’s disease treament

Answer 3

If caused by steroids: can review treatment

If caused by tumour: can surgically remove it or use a drug that blocks cortisol such as oral ketoconazole (causes liver disorders!) or metyrapone

Ketoconazole is a potent inhibitor of BOTH cortisol and aldosterone so can cause adrenal insufficiency (signs include: N/V, hypotension, fatigue, hyPOnatraemia, hyPERkalaemia, hyPOglycaemia)

NOTICE: ketoconazole side effects are the OPPOSITE of the mineralocortic

Question 4

Primary Adrenal insufficiency and the disease

Answer 4

When the adrenal glands do not make enough glucocorticoids (cortisol) and mineralocorticoids (aldosterone).
The disease is: Addison’s disease

Question 5

Addison’s disease treatment

Answer 5

Replacement steroids

• Hydrocortisone (most similar to natural cortisol, so will replace it). Given in two doses, a larger dose in the morning and a smaller dose in the evening to mimic natural cortisol secretion. Given as an injection during adrenal crises
• Fludrocortisone (replaces aldosterone)

Question 6

Symptoms of adrenal crises

Answer 6

• Low blood pressure
• Shivering
• Nausea, vomiting, diarrhea
• Drowsiness
• Confusion
• Stomach ache
• Aching muscles, joints

Question 7

Adrenal insufficiency sick day rules

Answer 7

During periods of stress = higher demand for cortisol. Therefore during injury, illness or trauma, patient will temporarily require higher dose of steroid.

• Double the daily dose during an illness that causes a fever and that requires na antibiotic
• If a patient is taking a long acting preparatiom, they should switch to a short acting one
• If there is persistent vomiting from gastrointestinal illness, IM/IV hydrocortisone should be given. Patient/carers must be taught how to administer this in an emergency.
  Patients must go to hospital if vomiting or diarrhoea continues.