Adrenal Insufficiency Flashcards
Where is the Adrenal Gland
what important hormone does it produce
functions of this hormone?
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
** How is cortisol level controlled/ regulated?**
Hypothalamic–pituitary– adrenal axis and the regulation of cortisol secretion
Regulation of cortisol secretion occurs through activity of the hypothalamic–pituitary– adrenal (HPA) axis
Normal pattern of cortisol secretion over a 24- hour period
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
When does the body increase secretion of Cortisol?
Stress • Athletic events • trauma • illness • burns • fever • Hypoglycemia • emotional upset • Surgery
- getting dental treatment would be one trigger for increased cortisol production
When does Cortisol level get secreted abnormally highly?
- can be reduced by?
- what can increase the level of cortisol?
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
Glucocorticoids and Their Relative Potency
What are the three we need to know about ?
- Cortisol
- Prednisone
- Dexamethasone
Cortisol Relative Potency
Duration of acting?
- Antiinflammatory Potency
- Mineralocorticoid Potency
- Equivalent dose
Cortisol
Antiinflammatory Potency : 1
Mineralocorticoid Potency : 2
Equivalent dose : 20 mg
Prednisone Relative Potency
Duration of acting?
- Antiinflammatory Potency
- Mineralocorticoid Potency
- Equivalent dose
intermediate acting (12-36 hours)
Antiinflammatory Potency : 4
Mineralocorticoid Potency : 1
Equivalent dose: 5 mg
Dexamethasone’s Relative Potency
- Antiinflammatory Potency
- Mineralocorticoid Potency
- Equivalent dose
Antiinflammatory Potency : 25
Mineralocorticoid Potency : 0
Equivalent dose : 0.75 mg
What are the Side effects of Glucocorticoid medications?
- Cushing syndrome (moon face)
- Cataract
- DM
- Delayed wound healing
- Glaucoma
- Growth suppression
- Hypertension
- Increase risk of INFECTION
- Psychosis,insomnia
- Peptic ulcer
- Osteoporosis
Effects of Longterm Corticosteroid Use and stopping medication
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
Hypoadrenalism
- example
- signs vs symptoms
- visible signs
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
Oral Manifestation of Addison disease
- diffuse or patchy brown macular pigmentation
- Delayed wound healing
- Susceptibility to the infections
Cushing Syndrome
weightgain • broad and round face (“moon facies”) • a “buffalo hump” on the upper back • Bruising • Hyperglycemia • Hirsutism • redpurpleabdominalstriae • Acne • Hypertension • Fractureandinfection(proneto)
Cushing Syndrome
weightgain • broad and round face (“moon facies”) • a “buffalo hump” on the upper back • Bruising • Hyperglycemia • Hirsutism • redpurpleabdominalstriae • Acne • Hypertension • Fractureandinfection(proneto)
What is Adrenal Crisis
- What are the manifestations?
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
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.
Adrenal Crisis
this is an EMERGENCY
must be treated immediately
Adrenal Crisis Management
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.
Dental Management of Adrenal Insufficiency
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.
Risks of taking corticosteroids/ hyperadrenalism for prolonged time:
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.
What are the management strategies for patients taking corticosteroids for prolonged time?
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
Considerations for BLEEDING in adrenal insufficiency?
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
Blood Pressure considerations for adrenal insufficiency
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.
Important consideration post operation for adrenal insufficiency*
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.
