Adrenal Conditions

Question 1

ACTH

Answer 1

• Adrenocorticotropic hormone: corticotropin, released from anterior pituitary
• ACTH stimulates adrenal gland to release cortisol, aldosterone and androgens

Question 2

BAH

Answer 2

-Bilateral adrenal hyperplasia

Question 3

HPA

Answer 3

Hypothalamic-pituitary adrenal

Question 4

APA

Answer 4

aldosterone producing adenoma

Question 5

Cushing syndrome

Answer 5

• 80% of cushing syndrome comes from overproduction of ACTH by pituitary gland (dependent)
• 20% of cushing syndrome are ACTH independent

Question 6

Symptoms of cushing

Answer 6

• Central obesity (facial rounding)
• peripheral obesity and fat accumulation
• supraclavicular fat pads
• striae in lower abdomen
• HTN
• Glucose intolerance
• often meets criteria for metabolic syndrome

Question 7

Dx of cushing

Answer 7

• Step 1: establish presence of hypercortisolism
• Step 2: Differentiate between etiologies
• Circadian rhythm: serum cortisol peaks around 8am declines reaching a nadir between 1-3am (lost in patients w/ cushing syndrome)

Question 8

Cushing tx

Answer 8

• Surgical resection of tumor (pituitary adenoma, adrenal adenoma, adrenal carcinoma)
• Management of comorbidities (diabetes, htn cad)
• Pharmacological tx is 2nd line

Question 9

Cushing tx: Steroidogenesis inhibitors

Answer 9

• Block production of cortisol
• Metyrapone
• Etomidate
• Ketoconazole

Question 10

Cushing Tx: Metyrapone

Answer 10

• Sudden decrease in cortisol concentration within hours; compensatory rise in plasma ACTH
• Cortisol is blocked
• Only compassionate use

Question 11

Cushing tx: Etomidate

Answer 11

• Inhibits 11-beta hydroxylase, aldosterone synthase and has antiproliferative effects
• IV therapy use only
• Usually can use lower doses than for anesthesia
• Monitor for excess sedation

Question 12

Cushing tx: Ketoconazole

Answer 12

• Effects after several weeks
• Also affects androgenic activity due to inhibitors in men, GI issues, derm reactions
• Monitor liver enzymes
• May be used in combo with metyrapone

Question 13

Cushing tx: Adrenolytic agents: Mitotane

Answer 13

• Cytotoxic, resembles insecticide
• Inhibits the 11-deoxycortisol and 11-deoxycorticosterone in adrenal cortex
• Atrophy of adrenal cortisol
• neurologic and GI side effects

Question 14

Other agents for cushing syndrome

Answer 14

• Neuromodulatory agents
• Ritanserin & Ketanserin
• Bromocriptine & Cabergoline
• Octreotide & lanreotide
• Pasireotide

Question 15

Cushing syndrome tx: Glucorticoid-receptor blocking agents

Answer 15

Milfeprostine: Potent progesterone and glucocorticoid receptor antagonist

Question 16

Hyperaldosteronism

Answer 16

• Primary cause are -Bilateral adrenal hyperplasia
• 10% of htn patient have primary aldosteronism
• leading cause of secondary htn and apparent resistant htn
• Women>men; 3rd-6th decade of life
• s/s: arterial htn, hypokalemia, muscle weakness, fatigue, HA
• BP> 150/110 on 3 different days or resistant htn should be screened

Question 17

Dx of hyperaldosteronism

Answer 17

• Screen patients with HTN + hypokalemia or resistant htn
• plasma-aldosterone-concentration: plasma-renin activity
• Commonly will find decreased renin activity, elevated plasma aldosterone concentration, hypernatremia, hypokalemia, hypomagnesium, elevated bicarbonate, glucose intolerance
• Confirm w/ IV or oral saline loading, fludrocortisone suppression test (FST), genetic testing

Question 18

Hyperaldosteronism tx: Spironolactone (Gold standard) BAH dependent

Answer 18

• Competes with binding at the aldosterone receptor
• Reassess after 4-6 weeks
• Check electrolytes and BP
• caution with patients with renal impairment
• Don’t use with salicylates

Question 19

Hyperaldosteronism Tx BAH dependent

Answer 19

-Eplerenone & Amiloride are alternatives

Question 20

Addisons Disease-primary adrenal insufficiency

Answer 20

• Primary adrenal insufficiency: destruction of all regions of adrenal cortex
• Deficiencies in cortisol, aldosterone, other androgens
• ACTH and CRH increase

Question 21

Addison Disease: Secondary adrenal insufficiency

Answer 21

• Reduced glucocorticoid production, secondary to decreased ACTH
• -Exogenous steroid use

Question 22

Addisons dx

Answer 22

• hyperpigmentation of skin is seen only in Addison disease; palor with secondary
• Aldosterone secretion not affected in secondary adrenal insufficiency
• May have wt loss, dehydration, hyponatremia, hyperkalemia, increased BUN
• Abnormal response to short corticotropin stimulation tests
• Plasma ACTH levels are usually elevated

Question 23

Management of adrenal insufficiency

Answer 23

• Pt education is paramount
• Hydrocortisone, cortisone, and prednisone
• Fludrocortisone acetate for primary insufficiency

Question 24

Steroid withdrawal

Answer 24

• Long-term steroids should be tapered

- ACTH test or check serum cortisol