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DENT :D > Adrenal Insufficiency > Flashcards

Adrenal Insufficiency Flashcards

1
Q

Where is the Adrenal Gland
what important hormone does it produce
functions of this hormone?

A

Location: on top of the kidneys!
Important hormone: cortisol
others: aldosterone, androgens, epinephrine

Cortisol:
- Anti-inflammatory, decrease bone formation, decrease muscle mass, increase blood glucose, increase glomerular filtration, modulate emotions

  • antiinflammatory aspect is important to us
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2
Q

** How is cortisol level controlled/ regulated?**

A

Hypothalamic–pituitary– adrenal axis and the regulation of cortisol secretion

Regulation of cortisol secretion occurs through activity of the hypothalamic–pituitary– adrenal (HPA) axis

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3
Q

Normal pattern of cortisol secretion over a 24- hour period

A

Cortisol secretion is pulsatile and normally follows a circadian pattern.

Peak levels of plasma cortisol occur around the time of waking in the morning and are lowest in the evening and night

The normal secretion rate of cortisol over a 24-hour period is approximately 20 mg

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4
Q

When does the body increase secretion of Cortisol?

A 
Stress
• Athletic events • trauma
• illness
• burns
• fever
• Hypoglycemia
• emotional upset • Surgery
  • getting dental treatment would be one trigger for increased cortisol production
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5
Q

When does Cortisol level get secreted abnormally highly?

  • can be reduced by?
  • what can increase the level of cortisol?
A

The most pronounced response: in the immediate postoperative period after surgery. The pulses are much BIGGER and there are far fewer of them. consisten, doesn’t decrease like normal regulated cortisol pattern throughout the day

Can be reduced by:
• morphine-like analgesics
• Benzodiazepines
• local anesthesia

Pain can increase the level of cortisone

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6
Q

Glucocorticoids and Their Relative Potency

What are the three we need to know about ?

A
  • Cortisol
  • Prednisone
  • Dexamethasone
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7
Q

Cortisol Relative Potency

Duration of acting?

  • Antiinflammatory Potency
  • Mineralocorticoid Potency
  • Equivalent dose
A

Cortisol

Antiinflammatory Potency : 1
Mineralocorticoid Potency : 2
Equivalent dose : 20 mg

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8
Q

Prednisone Relative Potency

Duration of acting?

  • Antiinflammatory Potency
  • Mineralocorticoid Potency
  • Equivalent dose
A

intermediate acting (12-36 hours)

Antiinflammatory Potency : 4
Mineralocorticoid Potency : 1
Equivalent dose: 5 mg

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9
Q

Dexamethasone’s Relative Potency

  • Antiinflammatory Potency
  • Mineralocorticoid Potency
  • Equivalent dose
A

Antiinflammatory Potency : 25
Mineralocorticoid Potency : 0
Equivalent dose : 0.75 mg

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10
Q

What are the Side effects of Glucocorticoid medications?

A
  • Cushing syndrome (moon face)
  • Cataract
  • DM
  • Delayed wound healing
  • Glaucoma
  • Growth suppression
  • Hypertension
  • Increase risk of INFECTION
  • Psychosis,insomnia
  • Peptic ulcer
  • Osteoporosis
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11
Q

Effects of Longterm Corticosteroid Use and stopping medication

A

Prolonged corticosteroid use suppresses the hypothalamic– pituitary axis, which in turn inhibits ACTH production and adrenocortical production of cortisol: decreases production of cortisol

  • After Stopping medication, the HPA axis begins to regain its responsiveness, and normal ACTH and cortisol secretion eventually resume.
  • The time required to return HPA response to stress stimulation; 14 days
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12
Q

Hypoadrenalism

  • example
  • signs vs symptoms
  • visible signs
A

Addison disease
• symptoms don’t show until 90% of glandular
tissue has been destroyed
• Fatigue, irritability, depression, weakness,
• hypotension
• bronzing of skin (hyperpigmentation more in sun exposed skin and pressure points such as elbow and knees) caused by increased beta lipotropin or ACTH which can stimulate melanocyte.
• Myalgia
• GI upset, vomiting, diarrhea
• salt craving
• Brown macules

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13
Q

Oral Manifestation of Addison disease

A
  1. diffuse or patchy brown macular pigmentation
  2. Delayed wound healing
  3. Susceptibility to the infections
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14
Q

Cushing Syndrome

A 
weightgain
• broad and round face (“moon facies”)
• a “buffalo hump” on the upper back
• Bruising
• Hyperglycemia
• Hirsutism
• redpurpleabdominalstriae
• Acne
• Hypertension
• Fractureandinfection(proneto)
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15
Q

Cushing Syndrome

A 
weightgain
• broad and round face (“moon facies”)
• a “buffalo hump” on the upper back
• Bruising
• Hyperglycemia
• Hirsutism
• redpurpleabdominalstriae
• Acne
• Hypertension
• Fractureandinfection(proneto)
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16
Q

What is Adrenal Crisis

- What are the manifestations?

A

life-threatening emergency
• resulting from adrenal insufficiency during emotional and physical stress such as infection, fever, sepsis, during or after a surgery

Manifestations:
• sunken eyes
• profuse sweating
• hypotension
• weak pulse
• cyanosis
• nausea, vomiting, weakness, headache, dehydration, fever,
• dyspnea, myalgias, arthralgia, hyponatremia, and eosinophilia.

** If not treated rapidly, the patient may develop hypothermia, severe hypotension, hypoglycemia, confusion, Circulatory collapse that can result in death

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17
Q

If you see the following in a patient with adrenal issues, what could be the cause?
sunken eyes
• profuse sweating
• hypotension
• weak pulse
• cyanosis
• nausea, vomiting, weakness, headache, dehydration, fever,
• dyspnea, myalgias, arthralgia, hyponatremia, and eosinophilia.

A

Adrenal Crisis
this is an EMERGENCY
must be treated immediately

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18
Q

Adrenal Crisis Management

A 
Medical emergency
• Call 911
• Apply cool wet or ice packs
• assess and monitor vital signs
• start IV saline solution
• inject 100 IV of hydrocortisone followed by 100–200mg of hydrocortisone in 5% glucose by continuous IV infusion, and transport patient to emergency medical facility

Note: IM injection results in slow absorption and is not preferred for emergency treatment.

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19
Q

Dental Management of Adrenal Insufficiency

A

Identification:
• review sign and symptoms supported by clinical manifestations or laboratory tests

Risk Assessment
• Be sure your patient is stable and well-controlled (consult with physician)

Patient at risk:
• past or present history of developing insufficiency
• History of Tuberculosis or histoplasmosis or HIV infection

Patient at risk of developing Adrenal crisis
• malignancy
• major traumatic injury or severe pain
• infection or sepsis
• liver cirrhosis, administration of medications that alter cortisol metabolism or production
• Previous history of crisis or corticosteroid dose adjustment
• recent emergency or hospitalization visits
• recently discontinued high-dose corticosteroid treatment
• an invasive or prolonged (>1 hour) procedure.

20
Q

Risks of taking corticosteroids/ hyperadrenalism for prolonged time:

A

Increased risk of having:
hypertension
Diabetes
delayed wound healing (consider if you’re doing invasive extraction, graft)
Osteoporosis** (considered if you’re doing implants)
peptic ulcer disease.

21
Q

What are the management strategies for patients taking corticosteroids for prolonged time?

A

Management strategies :
Check blood pressure at baseline and monitored during dental appointments.
Check Blood glucose levels ; invasive procedures only during periods of good glucose control

Arrange Follow-up appointments to assess proper wound healing
osteoporosis has a relationship with periodontal bone loss, implant placement, and bone fracture, periodic measures of periodontal bone loss are indicated

AVOID Aspirin and NSAIDs Because of the risk of peptic ulceration

22
Q

Considerations for BLEEDING in adrenal insufficiency?

A

Generally, this is not an issue

  • Exception; in patient on heparin or an other anticoagulant, which places them at increased risk for adrenal hemorrhage, post surgical bleeding, and hypotension
  • Minimize blood loss
23
Q

Blood Pressure considerations for adrenal insufficiency

A

Blood Pressure
• Monitor during the dental procedure
• During surgery, blood pressure should be evaluated at 5- minute intervals and before the patient leaves the office.
• RED FLAG: Hypotension; Asystolic blood pressure be low 100 mm Hg or a diastolic pressure at or below 60 mm Hg
• proper patient positioning (i.e.,head lower than feet)
• fluid replacement
• administration of vasopressors, and evaluation for signs of adrenal dysfunction versus hypoglycemia.
• If adrenal crisis is determined to be occurring, a steroid bolus is required.

24
Q

Important consideration post operation for adrenal insufficiency*

A

Plasma cortisol levels peak at 2- to 10-fold above baseline between 4 and 10 hours after the operation ( after not during the surgery)
• Postoperative pain is also contributory to elevated cortisol requirements

THUS WE MUST: provide good post operative pain control by means of long-acting local anesthetics (e.g., bupivacaine) given at the end of the procedure.

• Cortisol levels usually return to baseline within 24 to 48 hours of surgery.

24
Q

Important consideration post operation for adrenal insufficiency*

A

Plasma cortisol levels peak at 2- to 10-fold above baseline between 4 and 10 hours after the operation ( after not during the surgery)
- if they DON’T HAVE ENOUGH cortisol to surpass this peak, they can develop adrenal crisis**

• Postoperative pain is also contributory to elevated cortisol requirements

THUS WE MUST: provide good post operative pain control by means of long-acting local anesthetics (e.g., bupivacaine) given at the end of the procedure.

• Cortisol levels usually return to baseline within 24 to 48 hours of surgery.

25
Q

What are the three factors that affect recommendation for supplemental corticosteroids in adrenal insufficiency ?

A

(1) type of adrenal insufficiency (primary vs secondary)
(2) medical status and stability, and
(3) level and type of stress

26
Q

How much supplementary corticosteroids do you give for filling scaling, or RCT in adrenal insufficiency patient? primary vs secondary?

A

primary and secondary : NONE

This is considered routine dentistry, no supplementation is required

27
Q

**How much supplementary corticosteroids do you give for a minor surgery (3O min - 1 hour) in adrenal insufficiency patient? primary vs secondary?**

A

Primary adrenal insufficiency pt needing cortisol supplementation for MINOR surgery:

Preoperative: 25 mg of hydrocortisone equivalent on the day of surgery

Secondary: daily therapeutic dose, no change*

28
Q

**How much supplementary corticosteroids do you give for moderate surgical stress in adrenal insufficiency patient? primary vs secondary?*

  • what are examples of moderate surgical stress?
A

Primary adrenal insufficiency:
50–75 mg on day of surgery and up to 1 day after
-Return to preoperative glucocorticoid dose on postoperative day 2

Secondary : daily therapeutic dose, no change

29
Q

**How much supplementary corticosteroids do you give for MAJOR surgical stress in adrenal insufficiency patient? primary vs secondary?*

  • what are examples of major surgical stress?
A

i.e. procedures greater than an hour*, general anesthesia

Primary adrenaline insufficiency:
100–150 mg hydrocortisone equivalent per day of hydrocortisone equivalent given for 2–3 days
-After preoperative dose, 50 mg of hydrocortisone IV every 8 hours after the initial dose for the first 48–72 hours after surgery

Secondary: Daily therapeutic dose, no change

30
Q

What are some additional measures that are recommended to minimize the risk of adrenal crisis associated with surgery ?

A

Schedule surgery in the morning when cortisol levels are highest.
• Stress reduction strategies such as Nitrous oxide– oxygen inhalation and benzodiazepine sedation because fear and anxiety increase cortisol demand
• inhibitors of corticosteroid production should be discontinued at least 24 hours before surgery, with the consent of the patient’s physician.

31
Q

Question 1
A patient who has until recently been on prolonged corticosteroid therapy may have
A. increased bleeding time.
B. hyposensitivity to pain.
C. decreased tolerance to physiological stress.
D. an increased metabolic rate. E. high level of plasmatic cortisol.

A

c

32
Q 
Question 2
• Which of the following is the most potent corticosteroid? 
A. Cortisone.
B. Dexamethasone. 
C. Hydrocortisone.
D. Prednisone.
E. Triamcinolone.
A

Dexamethasone (25!! vs 4 and 1)

seems like she’s refering to antiiinflammatory protency

33
Q 
Question 3
• A patient complains of irritability, fatigue and weakness. She is losing weight and has diarrhea. The clinical examination shows diffuse brown macular pigmentation of the oral mucosa. The pigmentation appeared recently. The most likely diagnosis is
A. iron deficiency anemia.
B. Addison disease.
C. acute myeloid leukemia.
D. Crohn disease.
A

B. addisons = adrenal insufficiency

brown macules is the giveaway

34
Q 
Question 4
• Which of the following is the most likely cause of osteoporosis, glaucoma, hypertension and peptic ulcers in a 65-year old with Crohn’s disease?
a. Uncontrolled diabetes.
b. Systemic corticosteroid therapy.
c. Chronic renal failure.
d. Prolonged NSAID therapy
e. Malabsorption syndrome
A

B. Systemic corticosteroid therapy

35
Q

Question 6
A patient receiving a daily replacement dose of corticosteroid for the past 6 years requires surgical extraction of tooth 3.8. Prior to the surgery, this patient’s drug therapy should be modified by
a. stopping corticosteroid therapy for one week.
b. stopping corticosteroid therapy for the day of operation.
c. increasing corticosteroid intake for one week.
d. increasing corticosteroid intake for the day of operation, and up to one day after.

A

D.

I guess this would be considered a moderate or severe surgical stress procedure

36
Q 
Question 8
Adrenal corticosteroids
a. increase heart rate.
b. cause vasodilation.
c. increase protein synthesis. 
d. reduce inflammation
A

D. reduce inflammation, has anti-inflammatory effect

doesn’t it ALSO increase HR though?

37
Q 
Question 9
Adrenal corticosteroids
A. increase heart rate.
B. cause vasodilation.
C. increase gastric motility. 
D. reduce inflammation.
A

D

38
Q

Question 10
Asthmatic patients using corticosteroid inhalers may develop candidiasis on the dorsal surface of the tongue because of
a) a systemic antibacterial action.
b) local destruction of normal oral flora.
c) prolonged local vasoconstriction.
d) cross-reacting antigens in the tongue.
e) local immunosuppression

A

E!!

39
Q 
Q11. A patient has been taking a systemic corticosteroid for 10 years. Which skeletal disorder would the patient most likely have as a result of this medication?
A. Osteopetrosis.
B. Osteogenesis imperfecta.
C. Skeletal hyperostosis. 
D. Osteoporosis.
E. Osteoarthritis.
A

D. osteoporosis

40
Q

Question 12
One of the physiologic functions of adrenal corticosteroids is to
A. reduce glycemia.
B. increase salivation.
C. promote retention of sodium and fluids.
D. reduce arterial blood pressure.
E. increase the immune response to infection.

A

C.

41
Q

Function of Aldosterone

A

regulates salt and water balance by affecting renal distal tubules

42
Q

role of androgens

A

sexual maturation

43
Q

Role of epinephrine

A

Increases cardiac output

44
Q

Role of norepinephrine

A

Increases arterial pressure, increases peripheral resistance

DENT :D (7 decks)

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