Adrenal Disorder Drugs/Treatments

Question 1

Glucocorticoid Toxicities

Answer 1

Cushingoid Effects: 2+ weeks of treatment w/ CSC
- Hyperglycemia, Insulin resistance, iatrogenic DM
- Central obesity
- Muscle wasting, osteoporosis, thinning/bruising of skin
- Poor wound healing
- Impaired linear growth in children
Other toxicities:
- Androgenic effects- hirsuitism, acne, sweating
- Depression, anxiety, hypomania
- Increased intraocular pressure, glaucoma, cataracts
- Peptic Ulcers
- Immunosuppressive- opportunistic bacterial/fungal infections (candida)
- Insomnia
- Hypertension- some glucocorticoids with mineralocorticoid activities

Question 2

Chronic Adrenal Insufficiency Treatments (Adison’s)

Answer 2

• Classic Replacement Therapy: hydrocortisone + fludrocortisone
• Hydrocortisone- 2-3x/day, oral, increase doses w/ stress
• Fludrocortisone- aldosterone replacement
• Prednisone (intermediate acting)
• Dexamethosone (long acting)
• Adequate tx: disappearance of hyperpigmentation and resolution of electrolyte abnormalities
• Early AM cortisol shoudn’t be suppressed but should be

Question 3

Acute Adrenal Insufficiency Treatment

Answer 3

• Potentially life threatening, IV tx needed ASAP
• Large dose of parenteral hydrocortisone
• Correct fluid-electrolyte abnormalities
• Treat underlying cause- infection, hemorrhage, trauma
• Taper off hydrocortisone when pt. improves to avoid withdrawal, then treat like chronic adrenal insufficiency

Question 4

Congenital Adrenal Hyperplasia (CAH)

Answer 4

• Dexamethasone admin. to mother during pregnancy if high risk
• Hydrocortisone replacement therapy (dose adjust for growth/bone maturation)
• Alternate day therapy w/ prednisone to increase ACTH suppression w/out growth inhibition
• Oral fludrocortisone + salt to maintain BP, PRA and electrolytes (aldosterone replacement)

Question 5

Iatrogenic Cushing’s Syndrome Treatment

Answer 5

• Taper off CSC gradually
• May take 2-12 mo. for Hypothal-pit-adrenal axis to function then another 6-9 mo. for cortisol to normalize
  CSC withdrawal Sx: Anorexia, N/V, weight loss, lethargy, headache, fever, joints and muscle pain, postural hypotension

Question 6

Endogenous Cushing’s Syndrome/Disease Treatment

Answer 6

1st line: removal of ACTH or cortisol producing tumor

2nd line: radiotherapy, pharm, bilateral adrenalectomy

Question 7

Ketoconazole & Metyrapone

Answer 7

Adrenal steroid biosynthesis inhibitors (cushing’s tx)

Question 8

Cabergoline

Answer 8

DA Receptor agonist (inhibits PRL, inhibits ACTH)

- ACTH antagonist

Question 9

Pasireotide

Answer 9

Somatostatin receptor agonist (ACTH antagonist)

Question 10

Spironolactone & Eplerenone

Answer 10

• Mineralocorticoid Receptor Antagonists
• Normalize BP and K+ level in hyperaldosteronism
• Spironolactone can also antagonize androgen and progesterone receptors w/ side effects including gynecomastia (painful), decreased libido, impotence and menstrual irregularities (decreased estrogen conversion)
• Eplerenone: MC rec. specific- no sex hormone side effects

Question 11

Pheochromocytoma Treatment

Answer 11

• Surgical resection of Pheo: stabilize BP and pulse first w/ alpha blockers then beta blockers b/c physical stimulation of pheo can cause release of stored catecholamines
  Alpha-Blockers: Phenoxybenzamine, Prazosin, Terazosin, Doxazosin, alpha block for 1-2 weeks or until there’s hypotension and tachycardio
  Beta Blockers: Atenolol, metoprolol, propanolol, 3 days tx after alpha block os complete

Question 12

Metyrosine

Answer 12

Tyrosine hydroxylate inhibitor: blocks catecholamine synthesis
- management of pheo related hypertension