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Pharmacy > Adrenal > Flashcards

Adrenal Flashcards

0
Q

Fascicata

A

Secretes cortisol

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1
Q

Glomerulosa

A

Secretes aldosterone

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2
Q

Reticula

A

Secretes DHEA

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3
Q

Rate limiting step

A

Cholesterol conversion is ACTH dependent

ACTH production and release of cortisol

Downstream production of cortisol and aldosterone via 11beta

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4
Q

Cortisol (glucocorticoid) influences

A

Hemodynamics
Metabolism: gluconeogenesis, uptake
Immune system: antiinflammatory, immunosuppressive, moderate inflammation
Body water distribution

If impaired, deranged metabolism and inability to deal with stressors

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5
Q

Primary adrenal insufficiency

Addison’s Disease

A

Defect in adrenal gland

Etiology: hemorrhage, ketoconazole, rifampin, phenytoin
Suspect with thyroid failure

Causes hyperpigment, hypotension, weight loss, weakness, salt craving
HypoNa, hyperK

Reduced CO -> vasopressin secrete -> water retention more hyponatremia

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6
Q

Secondary adrenal insufficiency

A

Defect in hypothalamus/pituitary

Etiology: prolonged glucocorticoid therapy > 2 weeks

Aldosterone system still functional
Electrolytes should be ok

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7
Q

Mineral corticoids

A

Involve the retention of sodium

Endogenous: aldosterone

Fludrocortisone

Acutely critical for life!

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8
Q

Glucocorticoids

A

Bind to glucocorticoid receptor (nuclear receptor)

Decreases inflammation
Transactivation, transrepression

Hydrocortisone

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9
Q

Hypothalamus

A

Secretes CRH (corticotropin releasing)

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10
Q

Pituitary gland

A

Secretes ACTH

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11
Q

Adrenal cortex

A

Secretes aldosterone and cortisol

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12
Q

Adrenal insufficiency (addisons)

A

Decrease aldosterone, hyperkalemia
Decrease cardiac output, weakness, hyperpigmentation

Response to secrete vasopressin (ADH)

Acute Treat with normal saline
IV hydrocortisone 100mg q 8

Chronic hydrocortisone (dexa or prednisone are longer acting) and Fludrocortisone replacement if primary

Minor stress 3x replacement dose for 3 days. Major stress IV hydrocortisone

Dexamethasone at home for emergency, high salt diet, med bracelet

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13
Q

Rapid ACTH stimulation test

Give Cortrosyn

A

Adrenal/HPA insufficiency suspected

Primary cortisol not getting produced/released

Abnormal if cortisol does not rise > 18

Should go up by 9 points

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14
Q

Steroid coverage for surgery (stress)

A

Hydrocortisone 100mg IM

Increase to 200mg if fever, hypotension

Taper to maintenance dose

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15
Q

Adrenal crisis

Cortisol is essential for survival in times of stress

A

HypoNa, hyper K, volume depletion, hypotension

Unable to increase steroid during stress
COPD, asthma,
hypothyroidism treatment

Tx: fluids NS, steroid replacement 200mg hydrocortisone or dexamethasone IV.
First time: dexa doesn’t influence lab cortisol levels

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16
Q

Cushing’s syndrome

A

Too much cortisol, ACTH tumor

Hypertension, moon face, obesity, glucose intolerance, osteoporosis

Treat: ketoconazole, etomidate if ICU
Cabergoline for refractory 3rd line

Surgery for adrenal adenoma

17
Q

Cushing diagnosis

A

Exclude exogenous glucocorticoid before testing:

Late night saliva
Overnight dexamethasone suppression
24 hour urine cortisol >90

DST error of excess estrogen, 3A4
DST should be <1.8

18
Q

Cortisol levels

A

Should be high in the morning, low at night

Cortisol: active
Cortisone: inactive

19
Q

Aldosterone

A

Na retention

Potassium excretion

20
Q

Hyperaldosteronism

A

Hypertension, hypokalemia , muscle weakness, polyuria

HTN resistant to treatment

High PAC low PRA (aldosterone:renin) ratio >20 (neg feedback on renin)

Treat spironolactone (gynecomastia)
Eplerenone better side effect profile
21
Q

Congenital adrenal hyperplasia

A

Impaired cortisol synthesis
21 hydroxylase deficiency

Genital ambiguity excess testosterone
Early puberty
Neonatal low aldosterone death

Confirm with 17OHP test
Goal: decrease adrenal androgens
Tx: hydrocortisone, Fludrocortisone, NaCl supplement

22
Q

Adrenal enzyme inhibitors

A

For Cushing’s syndrome, non respectable tumor

Ketoconazole, fluconazole
Inhibit testosterone, cortisol production
Caution 3A4 inhibition
Requires acidic stomach

Etomidate for ICU intubation

23
Q

Metyrapone

A

Treat Cushing for cortisol control

Inhibit gluco/mineralcorticoid synthesis by inhibiting 11Bhydroxylase

AE: Decrease cortisol, increase ACTH, increase androgen precursors acne

24
Q

Etomidate

A

Ultrashort acting hypnotic
Blocks adrenal steroid synthesis

ICU IV only for rapid control

25
Q

Mitotane

A

Inhibits 11hydroxylase

Destroys adrenocortical cells

Use for 5-6 years

Obliterate adrenal gland function for inoperable adrenal carcinoma

Spares zone glomerulosa MinC
Need to add statin, GC replacement: dexamethasone or prednisone

26
Q

Mifepristone

A

Progesterone antagonist (abort)

High dose-glucocorticoid antagonist

For cortisol induced psychosis

Does not influence synthesis pathway

27
Q

Taper steroids

A

Up to 3 weeks

Withdrawal possible for if >3 week prednisone

28
Q

Septic shock

Supply right antibiotic, fluid, IV vasopressor

A

Major stress, surgery, severe infection
Want to supply glucocorticoid

Can cause reduced cortisol breakdown
Renal impairment more cortisol

Give IV 50mg hydrocortisone & PO Fludrocortisone (pressor dependent)

Improved shock reversal unclear benefit in mortality

29
Q

Pheochromocytoma

Chromaffin tumors

A

Adrenal medulla tumor causing HTN

Catecholamine production

Tx: tumor surgery high risk!
Prior to surgery meds
Alpha blocker: phenoxybenzamide (irreversible)
Don’t use alpha with beta blockers

30
Q

Hypertensive crisis during surgery

A

Sodium nitroprusside fastest acting

Phentolamine (IV alpha blocker)

Nicardipine (IV CCB) PO conversion

31
Q

Diabetes insipidus

A

Inability to conserve water, polyuria, thirst, dilute urine

Central: Decreased ADH secretion
Nephrogenic: ADH resistance

High plasma sodium due to water loss

Primary polydipsia h2o overload low Na, low urine osmolality

Tx: desmopressin ADH replacement
Nephro: give thiazide

32
Q

Syndrome of inappropriate antidiuretic hormone secretion (SIADH)

A

Inappropriate ADH secretion (water retention) at hyponatremic levels,
Concentrated urine, cerebral edema

Can be caused by carbamazepine, clofibrate, chlorpropamide

Hyponatremia in the absence of peripheral edema or dehydration

Tx: fluid restriction, IV saline
ADH a antagonist conivaptan
Loop diuretic

33
Q

SIADH treatment

A

Acute treat hyponatremia if Na <0.5 mEq/L/hour
Or else osmotic brain injury

Chronic: restrict fluids
Furosemide and increased Na intake

34
Q

Catecholamines

A

Synthesized:phenylalanine and tyrosine

Metabolized by COMT, MAO in liver

Short t1/2=60sec
Activate GPCRs

35
Q

Ketoconazole

A

Inhibits P450c17, specific for glucocorticoid synthesis, 11beta, p450 scc

Decreases testosterone, libido

AE: hepatotoxicity

36
Q

Gaq

A

Alpha 1

PLC/IP3

37
Q

Gas, Gai

A

AC/cAMP

Beta Gas

Alpha 2 Gai

38
Q

Cabergoline

A

Target pituitary, Dopamine agonist

Treat high prolactin

Make pituitary more functional

3rd line

39
Q

Osteoporosis

A

Effect of Cushing cortisol excess

Long term steroid use

Supplement calcium

40
Q

Aminoglutemide

A

Inhibit P450scc cholesterol conversion to Pregnenolone

Inhibit corticoids synthesis

41
Q

Bilateral adrenal hyperplasia

A

Treat with spironolactone

Or eplerenone for less gynecomastia

Pharmacy (63 decks)

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