Adrenal Flashcards by Dave Shields

What are two causes of adrenal hyperfunction?

Cushing’s disease

Hyperaldosteronism

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What is primary adrenal insufficiency called?

Addison’s disease

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What is Cushing’s disease?

Increase in adrenal function—->Increase in cortisol production

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What causes ACTH-dependent Cushing’s?

Pituitary tumor-ACTH from pituitary

Ectopic tumor: ACTH from another place

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What causes ACTH-independent Cushing’s?

Exogenous hormones
Adrenal adenoma-benign
Adrenal carcinoma

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What are some signs and symptoms of Cushing’s?

Central obesity, glucose intolerance, muscle weakness, osteoporosis, psychiatric changes, gonads-amenorrhea

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How do we confirm Cushing’s?

Elevated urine free cortisol

- ACTH levels tell us source: Pituitary, ectopic ACTH, adrenal adenoma, adrenal carcinoma

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Treatment of choice for Cushing’s?

Surgery: depends on source

Transphenoidal pituitary removal
Removal of adrenal glands: lifelong therapy of mineral corticoids and glucocorticoids

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When do we use drugs for Cushing’s?

When a pt. is not a candidate for surgery

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What drugs are used for excess ectopic ACTH?

Metyrapone

Aminoglutethimide

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What are some adverse effects of Metyrapone?

N/V
HTN
Alopecia
Hirsutism

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How does Metyrapone work?

Inhibits secretion and release of cortisol from adrenal glands

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How does aminoglutethimide work?

Inhibits conversion of cholesterol to pregnenolone in adrenal glands
Decreased production of cortisol, aldosterone, and estrogens

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What are some ADRs for aminoglutethimide?

Hypothyroidism-blocks thyroxine
N/V
Sedation

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What drug is used for adrenal adenoma?

Ketoconazole

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ADRs for Ketoconazole?

Hepatotoxicity-monitor LFTs

Gynecomastia

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Drug interactions with ketoconazole?

CYP34A drugs

Anti-acids: ketoconazole requires acidic pH so give 2 hrs. before anti-acids

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What drug is used for adrenal carcinoma?

Mitotane

-cytotoxic to adrenal cells: monitor free cortisol

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What are some ADRs for Mitotane?

N/V: give with food
Lethargy and somnolence
Hypercholesterolemia

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What causes primary hyperaldosteronism?

Usually adrenal adenoma
Bilateral adrenal hyperplasia
Screen with aldosterone-to-renin ratio

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What causes secondary hyperaldosteronism?

Stimulation of zone glomerulosa by RAA system

- Others: excess potassium intake, pregnancy, CHF, cirrhosis, renal artery stenosis

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Signs and symptoms of hyperaldosteronism?

HTN, hypervolemia
Hypokalemia, hypernatremia
Muscle weakness, fatigue
HA

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Drug of choice for hyperaldosteronism?

Spironolactone

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Treatment of choice for hyperaldosteronism if cause is adenoma?

Surgery

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What are some ADRs for Spironolactone?

Gynecomastia | Hyperkalemia

Drugs used to treat hyperaldosteronism?

Spironolactone Eplerenone Amiloride-not as effective as others; need other drug for HTN

What two drugs cause gynecomastia?

Spironolactone | Ketoconazole

What deficiencies are found in Addison's?

- Cortisol - Aldosterone - Androgens

What causes secondary adrenal insufficiency?

- Suppression of HPA axis from steroid use | - ACTH deficiency: deficiencies in cortisol and androgens; not mineralcorticoids

What are signs and symptoms of adrenal insufficiency?

Weakness, anorexia (weight loss), hypotension, salt craving, hyper pigmentation, muscle/joint symptoms, sexual dysfunction

Lab findings in chronic primary adrenal insufficiency?

Hyponatremia Hyperkalemia Hypercalcemia Azotemia

How do we test for adrenal insufficiency?

Cosyntropin test: | -Synthetic ACTH; after giving 250 mg we expect cortisol levels to rise >18, which rules out adrenal insufficiency

How is the low dose cosyntropin test administered?

IV; more sensitive than 250 mg test

Treatment for adrenal insufficiency?

Hydrocortisone (replaces glucocorticoids)

What substances need to be replaced in primary adrenal insufficiency?

Mineralcorticoids and Glucocorticoids

What are some signs of glucocorticoid excess?

Body fat redistribution Mood changes/irritability Glucose intolerance Muscle weakness

What substance is synonymous with mineral corticoids?

Aldosterone

What drug replaces missing mineral corticoids?

Only needed in primary adrenal insufficiency | -Fludrocortisone

Signs and symptoms of glucocorticoid withdrawal?

Weakness, anorexia, myalgias

Test for secondary adrenal insufficiency?

AM Cortisol levels: - If over 20, HPA axis has recovered - If <3, HPA axis still suppressed - If between 3-20: do cosyntropin test

Adverse effects of chronic glucocorticoid use?

``` Cataracts later in life Glaucoma Mood changes and Myopathy HTN and Dyslipidemia PUD ```

What are some endocrine effects of chronic glucocorticoid use?

Cushing's syndrome Adrenal suppression Glucose intolerance: DM

What counseling should we give patients taking glucocorticoids?

Take with food Wear medical ID badge and have glucocorticoids on hand for injection Adequate daily calcium intake ADRs

Treatment for acute adrenal crisis?

IV Hydrocortisone Fludrocortisone if hyperkalemic IV fluids: D5NS BP support

How do we diagnose GH excess?

Glucose tolerance test followed by GH level | -GH>1

How do we treat GH excess?

Surgery Drugs: somatostatin analogs Dopamine agonists GH receptor antagonists

What is first-line somatostatin analog for GH excess?

Octreotide

What are ADRs for Octreotide?

Hyperglycemia Arrhythmias Hypothyroidism Gallbladder stones

What dopamine agonist should we use to treat GH excess?

Bromocriptine | -Ergot alkaloid

ADRs for Bromocriptine?

Hypotension Dizziness HA N/V-most common

What is second-line therapy for GH excess?

Pegvisomant: GH receptor antagonist

ADRs for Pegvisomant?

Elevated AST and ALT | -Need LFTs

What are findings with GH deficiency?

(Congenital): Short stature: 2SDs below mean and below 3% - Large forehead - Immaturity of face - Central obesity

What is first-line treatment for GH deficiency?

Recombinant GH

What are other indications for recombinant GH?

Turner's Prader-Willi Chronic renal insufficiency AIDS wasting, short bowel, idiopathic short stature

How is recombinant GH administered?

IM or SubQ

ADRs for recombinant GH?

Slipped capital femoral epiphysis | Intracranial HTN

What do we use to treat insulin-like Growth Factor (IGF) deficiency?

Mescasermin

ADRs of Mescasermin?

Hypoglycemia Dizziness Arthralgias

What substance inhibits prolactin secretion?

Dopamine

At what level of prolactin is hyperprolactinemia diagnosed?

Over 20

What is the danger of a high prolactin level?

At 10x normal value you have inhibition of gonadotropin secretion and inhibition of sex-steroid synthesis: menopause state Can develop osteoporosis

Treatment for hyperprolactinemia?

Bromocriptine | For infertility: use barrier contraceptives until levels are normal; reduce dose to minimum before attempting conception

What is first-line treatment for prolactinomas?

Cabergoline

ADRs for Cabergoline?

Similar to Bromocriptine | -Valvular heart disease w/ high doses for long-term