adrenal disorders

Question 1

autoimmune destruction of adrenal glands

Answer 1

70% of cases have another autoimmune disorder

Question 2

primary and secondary adrenal insufficiencies requires lifelong treatment with

Answer 2

steroid replacement

Question 3

what does tertiary adrenal insufficiency develop from

Answer 3

long term use of exogenous steroids

This required careful management to prevent patients from developing signs of hypoadrenalism

Question 4

what is adrenal over activity called?

Answer 4

cushings

predominantly treated surgically

Question 5

Adrenal glands are situated where

Answer 5

above kidneys

Question 6

the inner medulla is part of

Answer 6

sympathomimetic nervous system and is responsible for synthesising and secreting catecholamines

Question 7

the outer cortex

Answer 7

is involved in producing steroids hormones and is divided into

• the zona glomerulosa - secretes aldosterone n response to hyperkalaemia, hyponatraemia and RAAS
• the zona fasciculate - secretes cortisol
• the zona retucularis

Question 8

Primary adrenal insufficiency

Answer 8

Addison’s disease
caused by damage to the adrenal gland itself
deficient of all three hormonesL aldosterone, cortisol and to a lesser extent androgens

Caused by autoimmune or infections for example TB

Diagnosis - low morning cortisol ( we want >300) followed by a short synacthen test. (test 30 mins after we wants >450)

Question 9

what do we use to treat primary adrenal insufficiency?

Answer 9

Hydrocortisone TDS usually
lowest dose possible e.g. 10, 5, 5
largest dose AM mimics body natural release of hormone

Question 10

when is fludrocortisone used

Answer 10

to treat mineralcotricoid deficiency only in primary adrenal insufficiency at doses of 50-200mcg/day

not used in secondary as only cortisol is impaired

Question 11

general recommendations:

Answer 11

• glucocorticosteroid dose should be doubled if a patient has a fever or prescribed ABX
• hydrocortisone 20mg should be taken by mouth with oral fluids if they feel nauseated
• parenteral hydrocortisone should be self administered and get advice if vomit
• hydrocortisone 20mg given in event of major injury
• diarrhoea - get help
• strenuous exercise - increase dose up to double
• less strenuous 50-10mg HCS before activity

Question 12

Secondary adrenal insufficiency

Answer 12

inadequate secretion of ACTH (adrenocorticotrophic hormone) regulated the levels of cortisol. So results in deficient cortisol.

Caused by tumours, irradiation, infection, genetic

They do not get salt craving or low sodium or low potassium in this one.hyperpigmentation is also absent.

Question 13

How do we test for this compared to primary

Answer 13

long synacthen test

measure cortisol for 24 hours

Same treatment as primary however fludrocortisone is not required as aldosterone is not affects here

Question 14

Tertiary adrenal insufficiency

Answer 14

suppression of CRH secretion from the hypothalamus

main cause is long term use of high dose exogenous glucorticosteroids.

Occurs in patients wish bushings and is sometimes drug induced

manage by gradual withdrawal of steroid

Question 15

adrenal crisis management

Answer 15

• hydrocortisone 100mg IV or IM - aggressive fluids

follow by IV hydrocortisone 50-100mg every 6 hours or by continuous IV infusion 200mg over 24 hours.

fludrocortisone is not required here as high doses of hydrocortisone have an appropriate mineralocorticoid effects

Question 16

hydrocortisone IV

Answer 16

hydrocortisone sodium succinate is preferred due to the pain and parasthesia associated with the sodium phosphate injection.

Question 17

clinical features of cushings

Answer 17

• moonfaced, weight gain
• violaceous striae
• muscle weakness
• bone fracture/osteoporosis
• impaired glucose tolerance/ DM
• susceptibiltiy to infections
• mood disturbances
• acne/hirtuism
• low libido/impotence/menstrual disturbance

Question 18

how to test for cushings

Answer 18

dexamethasone suppression tes

oestrogen can interfere with this.

1mg of deb administered at 11pm with cortisol measured at 9am. If cortisol <50 then the patient has shown adequate suppression and does not have bushings

Question 19

long dexamethasone suppression test

Answer 19

500microgram at strict 6 hour intervals for 2 days starting at 9am

cortisol is measured at the beginning and at 48 hours.

This test is more accurate

Question 20

how do we treat bushings

Answer 20

surgery

metyrapone 250mg TDS (inhibits cortisol and aldosterone synthesis) - can increase testosterone

ketoconazole 400-600mg (divided) titrated to a max 1200mg daily dose. - hepatotoxicity

Question 21

if LFT’s are > 3 times upper limit what do we do

Answer 21

STOP

if it is less we can monitor closer

Question 22

Signs and symptoms of adrenal insufficiency - PRIMARY

Answer 22

• weak / fatigue
• anorexia/weight loss
• N and V
• constipation, diarrhoea, abdo pain
• dizziness, syncope
• hyperpigmintation
• salt craving
• hyponatraema
• hyperkalaemia

Question 23

Thinking of the skin is due to

Answer 23

Adrenal overactivity

Question 24

Hypotension is caused by

Answer 24

adrenal insufficiency

Question 25

Adrenal insufficiency

Answer 25

low sodium
high potassium
weight loss
loss of appetite
hypotension

Question 26

adrenal overactivity

Answer 26

thining of the king

psychosis

acne

Question 27

gradual reducing regime of steroids needs to be done for

Answer 27

• patients who take prednisolone at night
• patients who take 60mg for ten days
• patient with known addison disease

Question 28

fludrocortisone is adjusted based on

Answer 28

BP and biochemical results

Question 29

should a patients fludrocortisone be increased in adrenal crisis?

Answer 29

NO

hydrocortisone covers the mineralcorticosteroid activity.

Question 30

Primary adrenal insufficiency is caused by inadequate secretion of ACTH from the pituitary gland true or false?

Answer 30

False

It is caused by damage to the adrenal gland itself