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Roomies Collab Deck 2: Endocrinology and NeuroPsych > Adrenal insufficiency > Flashcards

Adrenal insufficiency Flashcards

1
Q

What are the symptoms of adrenal insufficiency? (7)

A
  1. Fatigue
  2. GI upset
  3. Anorexia
  4. Weight loss
  5. Musculoskeletal symptoms
  6. Salt cravings
  7. Dizziness or syncope due to hypotension
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2
Q

What are the life-threatening symptoms of adrenal crisis? (7)

A
  1. Severe dehydration
  2. Hypotension
  3. Hypovolaemic shock
  4. Altered consciousness
  5. Seizures
  6. Stroke
  7. Cardiac arrest
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3
Q

Which drugs (when stopped) most commonly causes adrenal insufficiency

A

Glucocorticoids

If glucocorticoids are stopped or decreased too quickly after prolonged use, endogenous glucocorticoid production may not be sufficient to meet the body’s needs

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4
Q

What card should all patients with adrenal insufficiency and steroid dependence carry with them?

A

Steroid Emergency Card

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5
Q

What are the treatment aims for adrenal insufficiency?

A
  1. Reduce symptoms
  2. Reduce the risk of complications (e.g. adrenal crisis)
  3. Improve overall quality of life
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6
Q

Which 3 drug options can be used in adrenal insufficiency for glucocorticoid replacement?

A
  1. Hydrocortisone (most similar to cortisol)
  2. Prednisolone
  3. Dexamethasone (rarely used)
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7
Q

Which glucocorticoid replacement therapy is most similar to cortisol?

A

Hydrocortisone

Modified release (oral): 20-30 mg once daily (in the morning)

Immediate-release (oral): 20-30 mg daily in divided doses

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8
Q

Which drug is used in primary adrenal insufficiency for mineralocorticoid replacement?

A

Fludrocortisone acetate
- Oral: 50-300 micrograms once daily

For aldosterone deficiency

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9
Q

Patients with primary adrenal insufficiency need both (?) replacement AND (?) replacement

A

Glucocorticoid replacement (hydrocortisone)

Mineralocorticoid replacement (fludrocortisone acetate)

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10
Q

When a patient with adrenal insufficiency is undergoing “stress”, which medication do they need to increase to prevent an adrenal crisis?

A

Glucocorticoid replacement (hydrocortisone)

Stress = surgical or invasive procedures, intercurrent illness

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11
Q

For a patient with adrenal insufficiency and moderate intercurrent illness (fever or infection requiring antibacterial), by how much should their daily glucocorticoid replacement be increased?

A

Doubled

Patients with adrenal insufficiency on long-acting hydrocortisone preparations should switch to short-acting, more rapidly absorbed preparations during an intercurrent illness

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12
Q

For a patient with adrenal insufficiency and severe intercurrent illness (e.g. persistent vomiting from GI viral illness), what change should they make to their glucocorticoid replacement?

A

IM or IV hydrocortisone should be given

Patients with adrenal insufficiency are at higher risk of glucocorticoid deficiency if they are vomiting or have diarrhoea.

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13
Q

What type of illness result in a higher risk of glucocorticoid deficiency in patients with adrenal insufficiency?

A

Vomiting and diarrhoea

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14
Q

If you suspect a patients is having an adrenal crisis, should you wait for investigations before giving them a bolis of hydrocortisone?

A

NO

There is no adverse consequence of initiating a life-saving bolus dose of hydrocortisone treatment.

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15
Q

What is the treatment of an adrenal crisis?

A

Prompt glucocorticoid replacement with hydrocortisone
AND
Rehydration using a crystalloid fluid (e.g. sodium chloride 0.9%)

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16
Q

Why do you not need to give increased mineralocorticoid replacement (fludrocortisone) to a patient with an adrenal crisis?

A

High-dose hydrocortisone has sufficient mineralocorticoid effect to cover this

17
Q

During an adrenal crisis, particular care is required in patients with which disease?

A

Diabetes insipidus

They are at risk of uncontrolled diabetes insipidus if doses of desmopressin are omitted or hyponatraemia if excess fluid is given.

18
Q

Following an adrenal crisis and prior to hospital discharge, all patients should be referred to an endocrinologist for… (2)

A
  1. Advice on ongoing treatment

2. Education around ‘sick day rules’

19
Q

Fludrocortisone has very high (glucocorticoid/mineralocorticoid?) activity and insignificant (glucocorticoid/mineralocorticoid?) activity

A

Fludrocortisone has very high MINERALOCORTICOID activity and insignificant GLUCOCORTICOID activity

20
Q

Hydrocortisone has (equal/unequal?) glucocorticoid and mineralocorticoid activity

A

equal

21
Q

Can hydrocortisone muco0-adhesive buccal tablets be used to treat adrenal insufficiency?

A

NO

Only indicated for local use in the mouth for aphthous ulceration

22
Q

In elderly patients talking corticosteroids, when would you consider the prescription to be potentially inappropriate (STOPP criteria)? (4)

A
  1. If used instead of inhaled corticosteroids for maintenance therapy in moderate to severe COPD (unnecessary exposure to long-term side-effects)
  2. As long-term (> 3 months) monotherapy for rheumatoid arthritis
  3. For treatment of osteoarthritis other than for periodic intra-articular injections for monoarticular pain
  4. With concurrent NSAIDs without proton pump inhibitor prophylaxis
23
Q

For patients receiving systemic corticosteroids (or those who have used them within the previous 3 months) who have NOT had the chickenpox, what should they receive?

A

Passive immunisation with varicella-zoster immunoglobulin

24
Q

What is the concern if a patient taking systemic corticosteroids gets the chickenpox

A

Risk of severe (fulminant) chickenpox

Manifestations of fulminant illness - pneumonia, hepatitis, DIC

25
Q

If a patient taking systemic corticosteroids gets chickenpox should you stop treatment with corticosteroids?

A

NO

Dosage may need to be increased

26
Q

If a patient taking systemic corticosteroids is exposed to measles, what prophylactic treatment may be needed?

A

IM normal immunoglobulin

27
Q

What are the psychiatric side effects associated with systemic corticosteroids?

A
  1. Euphoria
  2. Insomnia
  3. Irritability
  4. Mood lability
  5. Suicidal thoughts
  6. Psychotic reactions
  7. Behavioural disturbances
28
Q

Can psychiatric reactions occur during withdrawal of corticosteroid treatment?

A

Yes, rarely

They most commonly occur with high-doses of corticosteroids

29
Q

What needs to be monitored if children are taking prolonged corticosteroids?

A

Height and weight (annually)

30
Q

For a disease that is unlikely to relapse, what are the other reasons should you consider a gradual withdrawal of systemic corticosteroids? (6)

A
  1. Received more than 40 mg prednisolone (or equivalent) daly for more than 1 week
  2. Been given repeat doses in the evening
  3. Received more than 3 weeks’ treatment
  4. Recently received repeated courses (particularly if taken for longer than 3 weeks)
  5. Taken a short course within 1 year of stopping long-term therapy
  6. Other possible causes of adrenal suppression
31
Q

When can you consider stopping systemic corticosteroids abruptly in adults?

A

Disease is unlikely to relapse
AND
Have received treatment for 3 weeks or less
AND
Not included in the patient groups below:
- Received more than 40 mg prednisolone (or equivalent) daly for more than 1 week
- Been given repeat doses in the evening
- Received more than 3 weeks’ treatment
- Recently received repeated courses (particularly if taken for longer than 3 weeks)
- Taken a short course within 1 year of stopping long-term therapy
- Other possible causes of adrenal suppression

32
Q

During corticosteroid withdrawal the dose may be reduced rapidly down to psychological doses. What is the equivalent of psychological doses in prednisolone?

A

7.5 mg daily prednisolone

Then reduce more slowly

33
Q

Who should be given a Steroid Emergency Card? (5)

A
  1. Primary adrenal insufficiency
  2. Adrenal insufficiency due to hypopituitarism requiring corticosteroid replacement
  3. Taking corticosteroids at doses equivalent to, or exceeding, prednisolone 5 mg daily for 4 weeks or longer acress all routes of administration
  4. Taking corticosteroids at doses equivalent to, or exceeding, prednisolone 40 mg daily for longer than 1 week, or repeated short oral courses
  5. Taking a course of oral corticosteroids within 1 year of stopping long-term therapy

Roomies Collab Deck 2: Endocrinology and NeuroPsych (49 decks)

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