Adrenal Hormones

Question 1

Adrenal insufficiency

Answer 1

Most common cause is autoimmune
Clotting disorders- hemorrhage
Amyloidosis
Adrenoleukodystrophy- young boys have long chain fatty acids and demyelination, accumulate in adrenals

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Question 2

Secondary AI

Answer 2

adrenal gland atrophy from ACTH
most often due to exogenous glucocorticoid use
Panhypopituitarism
isolated ACTH def

-low circulating ACTH levels because of hypothalamic or pituitary release as a consequence cortisol levels are low

no aldosterone deficiency

Question 3

Primary adrenal insufficiency

Answer 3

-circulating ACTH is elevated because of negative feedback effects of low circulating cortisol

will have hyperpigmentation in palmar creases

Question 4

Diagnosis of AI

Answer 4

morning cortisol value less than 4 mg/dl

cosyntropin (ACTH) stimulation test is gold standard- rise in cortisol to 18 and or change in 9 (after cosyntropin is given) is a normal response

Question 5

tx of adrenal insufficiency

Answer 5

IV fluids, high dose IV glucocorticoids

chronic- mineralocorticoids (hydrocortisone or prednisone), dosage inc for stress

Question 6

Hydrocortisone

Answer 6

short acting steroids
mimic diurnal rhythm and 100% bioavailable
once in morning and once in afternoon

Question 7

Long actnig steroids

Answer 7

dexamethasone and prednisone

for non compliant pts

Question 8

fludrocortisone

Answer 8

potent steroid mainly mineralocorticoid
for pts with primary adrenal insufficiency
-helps sodium retention
hypokalemia common side effect

Question 9

steroid side effects

Answer 9

• at high doses
• immunosuppression, hypertension, weight gain, osteoporosis or bone loss, insomnia, mood swings, peptic ulcers, redistribution of body fat
• thinning of skin
• reduces growth in children

Question 10

Cushing’s disease

Answer 10

excessive glucocorticoid exposure either from adrenals or exogenous

-obesity, htn, glucose intolerance, striae

-

Question 11

diagnosis of cushings

Answer 11

24 hr urine cortisol excretion 3 times the upper limit of normal (150 mg/dl)

-late evening salivary cortisol

Question 12

tx for pituitary cushings

Answer 12

transphenoidal surgery to remove pituitary adenoma

Question 13

ketoconazole

Answer 13

nonselective inhibitor of adrenal and gonadal steroids 
for adrenal cushing's 
-can cause headaches, sedation, nausea
potential hepatotoxicity
blocks 17 hydroxylase and 17,20 lyase

Question 14

Mitotane

Answer 14

nonselective cytotoxic agent for adrenal cortex
-reserved for pts with adrenal carcinoma
severe toxicity

Question 15

Mifepristone

Answer 15

glucocorticoid receptor antagonist
-rapidly effective for diabetes related to cushing’s
substantial side effects like hypokalemia and QT prolongation

Question 16

Primary aldosteronism

Answer 16

asymptomatic htn and easily provoked hypokalemia
edema usually absent
aldosterone promotes reabsorpion of sodium by distal tubule with excretion of potassium

Question 17

diagnosis of primary aldosteronism

Answer 17

urinary potassium >30 meq/l

-screen by plasma aldo/plasma renin ratio (>20 in primary aldosteronism, <10 in secondary aldosteronism)

24 hr urine for aldosterone and sodium or salt loading test

Question 18

Secondary aldosteronism

Answer 18

htn, hypokalemia, inc aldosterone, inc plasma renin activity

due to renal artery stenosis

Question 19

tx of aldosteronism

Answer 19

surgery- unilateral adrenalectomy unless poor surgical risk
dietary salt restriction and spironolactone to block aldosterone receptor
amiloride or triamterene

Question 20

spironolactone and eplerenone

Answer 20

mineralocorticoid antagonist
limits potassium loss
may cause hyperkalemia
gynecomastia (not with eplerenone)

Question 21

Congenital adrenal hyperplasia

Answer 21

90% due to 21 hydroxylase deficiency
full or partial block of glucocorticoid and mineralocorticoid production and spillover into androgen pw

low cortisol levels stimulate continued ACTH production and overproduction of precursors that are diverted to biosynthesis of sex hormones

females- ambiguous genitalia

males- no overt signs of disease

Question 22

untreated congenital adrenal hyperplasia

Answer 22

rapid somaic growth, advanced bone age, premature epiphyseal fusion and short stature, acne

Question 23

tx for CAH 21 OH def

Answer 23

Glucocorticoids in lowest dose
-long acting steroids such as dexamethasone is used to reduce ACTH levels, which suppresses androgen levels and maintains ormal growth

-mineralocorticoids in salt wasting form

No GC in asymptomatic children

Question 24

100% glucocorticoids

Answer 24

dexamethasone