Addison's and Cushings

Question 1

When looking at cortisol and adrenals, you may also want to check what?

Answer 1

Cholesterol

Question 2

Addison’s (Primary Adrenal Insufficiency):

Many causes, but primary cause is?

Answer 2

autoimmune adrenalitis

Question 3

This antibodies will help with autoimmune diagnosis Addison’s.

Answer 3

Anti 21-hydroxylase antibodies

from Pituitary.

Question 4

Addison’s:

General Treatment

Answer 4

• IV glucocorticoids are administered “Steroids” (Prednosone, Cordisone, Cortisol)
  Acute adrenal crisis is a life-threatening emergency and needs to be treated immediately

Question 5

Mineralocorticoid replacement is usually needed to prevent what?

Answer 5

Sodium loss, volume depletion and hyperkalemia in primary adrenal insufficiency.

Question 6

Most common form of androgen replacement.?

Answer 6

DHEA

Question 7

Glucocorticoid Replacement:

Short acting regimens?…

Answer 7

Short-acting glucocorticoids (Hydrocortisone)

*used in 2-3 divided doses (lowest dose possible) starting in the morning - can cause abrupt changes in symptoms.

It is sometime helpful to have patients wake early to take short acting agents and then go back to sleep.

Cortisol concentrations will rise within 30 min of dosing
Best mimics the body’s natural rhythm.

Question 8

Glucocorticoid Replacement:

Long acting regimens?…

Answer 8

Long-acting glucocorticoids (Prednisone,Dexamethasone)

• can be given at bedtime will avoid abrupt changes in serum glucocorticoid levels, but metabolism can vary and make dosings inconsistent.
• Short acting doses can be added mid-afternoon if single dose is not effective.

Question 9

Glucocorticoid Side Effects – Chronic Use

Answer 9

Mostly if doses are consistently too high for individual

• Hypothalamic-Pituitary Suppression – reduces CRH and ACTH
• Cushing’s Syndrome – can occur within 1 month of high-dose steroid treatment.
• Osteoporosis – can increase the risk of vertebral fracture and impair growth in children.
• Hyperglycemia/Diabetes
• Cataracts and Glaucoma – more common with doses > 10mg/day prednisone

Question 10

Addison’s:

Hydrocortisone (Cortef) Treatment Indication –

Answer 10

Adrenal Insufficiency – Short Acting.

*Dosing Adult: 15 – 25mg po in 2-3 divided doses (10/5/2.5mg) cc
Tip: make sure last dose is given no later than 4-6 hours before bed.
*Monitoring: blood pressure, blood glucose, electrolytes, bone mass density (chronic use), growth (children)

Question 11

Addison’s:
Hydrocortisone (Cortef)
side effects?

Answer 11

hyperglycemia, HPA axis suppression, Cushings, glaucoma, osteoporosis, cataracts.

Question 12

Addison’s:

Hydrocortisone (Cortef) Avoid combination with the following supplements/foods:

Answer 12

Grapefruit,
Lily-Of-The-Valley (Convallaria),
St. John’s Wort (Hypericum).

Can try alternate dosing with long-acting steroids which may decrease side effects.
Has some mineralocorticoid activity so fludrocortisone replacement should be decreased.

Question 13

Addison’s:
Dexamethasone
Treatment Indication

Answer 13

Adrenal Insufficiency – Long Acting

Question 14

Addison’s:

Dexamethasone Dosing

Answer 14

Dosing Adult: 0.25 – 0.75mg po qhs cc (use lowest dose possible)
Monitoring: blood glucose, electrolytes, growth (children)

Question 15

Addison’s:

Dexamethasone Dosing side effects

Answer 15

Main SE: hyperglycemia, HPA axis suppression, Cushings, glaucoma, osteoporosis, cataracts.

Question 16

Addison’s:

Dexamethasone- Avoid combination with the following supplements/foods:

Answer 16

Grapefruit, Lily-Of-The-Valley (Convallaria), St. John’s Wort (Hypericum)

For use in patients that are not compliant with multi-day dosing.

Question 17

Addison’s:

Prednisone Treatment Indication –

Answer 17

Adrenal Insufficiency – Long Acting

Question 18

Addison’s:

Prednisone Dosing Adult:

Answer 18

Dosing Adult: 2.5 – 7.5mg po qhs cc (use lowest dose possible)
Monitoring: blood glucose, electrolytes

Question 19

Addison’s:

Prednisone side effects:

Answer 19

Main SE: hyperglycemia, HPA axis suppression, Cushings, glaucoma, osteoporosis, cataracts.

Question 20

Addison’s:

Avoid combination with the following supplements/foods:

Answer 20

Grapefruit, Lily-Of-The-Valley (Convallaria), St. John’s Wort (Hypericum)

For use in patients that are not compliant with multi-day dosing.

Question 21

Addison’s:

Fludrocortisone (Florinef) Treatment Indication

Answer 21

Treatment Indication – Primary Adrenal Insufficiency, mineralocorticoid replacement

Dosing Adult: 0.1mg po qd (0.05mg if using with hydrocortisone), may need to increase to 0.2mg qd if using prednisone/dexamethasone.

Monitoring: blood pressure, edema, electrolytes, plasma renin, growth (children).

Question 22

Addison’s:

Fludrocortisone (Florinef) side effects

Answer 22

hypertension, edema, cushing’s syndrome, hyperglycemia, hypokalemia

Question 23

Addison’s:
Fludrocortisone (Florinef)
Avoid combination with the following supplements/foods:

Answer 23

Lily-Of-The-Valley (Convallaria), St. John’s Wort (Hypericum)

Potent mineralocorticoid – lower dosage if primary hypertension occurs in combination with sodium restriction. Do NOT prescribe diuretics.

Question 24

Cushing’s Syndrome:
Causes:
Sx’s:
Labs:

Answer 24

Many causes – oral glucocorticoid ingestion should be ruled out.

It is important to assess the extent of hyperandrogenism as well.

Symptoms are progressive: weight gain (most specifically in the face, neck, trunk abdomen), striae, atrophy, easy bruising, menstrual irregularities, androgen excess, muscle wasting/weakness, hypertension.

Lab testing for diagnosis: late night salivary cortisol (2x), 24 hr urinary free cortisol (2x), overnight 1mg dexamethasone suppression test.

Question 25

Cushings: General Treatment

Answer 25

Treatment should be aimed at the cause (pituitary, ACTH tumor, adrenal tumor).

Goal is to avoid permanent use of medications over time and to reduce hormone deficiency – this is often done with surgery to remove whatever is overproducing cortisol.

Transphenoidal surgery is commonly done when a circumscribed microadenoma is detected in Cushing’s disease.

Adrenal gland removal common in primary adrenal disease followed by glucocorticoid therapy.
If surgery is not an option – adrenal enzyme inhibitors are used (ketoconazole, mitotane)