Adrenal Insufficiency Flashcards
Cushing’s (sx)
Adrenal EXCESS
SX:
-Moon face, fat hump, obesity
-Emotional/dep/irritability
-Glucose intolerance
-Osteoporosis, musc weak
-Hirsutism, gynecomastia
-Edema, htn, NaF ret
-Amenorrhea
-Thin skin, striae, bruises
Cushing’s TX
- D/C unnecessary corticosteroid therapy
- Surgical resection of tumors (GC replacement may be needed 3-12 months post surgery)
- Pharmacotherapy (when surgery not possible)
*steroidogenesis inhibitors, pituitary directed, gc receptor blockers
Addison’s Disease
Adrenal Insufficiency
SX:
-Hyperpigmentation
-GI (NVD, abd pain, cons)
-Malaise, weakness, fatigue
-Hyponatremia
-Anorexia, weight loss
Secondary AI
-NO hyperkalemia
-Hypoglycemia (more common here)
-NO hyperpigmentation
-Less hypotension and GI effects
Primary AI TX
- Glucocorticoid replacement
- #1: Hydrocortisone 15-25 mg/day in 2 divided doses
- #2: Prednisolone 3-5 mg/day by mouth QAM can be used in patients with low adherence
Give 2/3 in AM and 1/3 in PM
-Titrate every 6-8 weeks, use lowest effective dose
Systemic Corticosteroid Relative Potency
CH PPMD
25,20,5,5,4,0.75
Cortisone and prednisone are ____
prodrugs (liver converts to active HC and prednisolone), decreased response in liver dysfunction
Steroids (INC/DEC effects)
- Increased effects
– Low albumin
– Estrogen, oral contraceptives
– CYP3A4 inhibitors - Decreased effects
– CYP3A4 inducers
Mineralocorticoid Replacement for Adrenal Insufficiency
For primary adrenal insufficiency with aldosterone deficiency
Fludrocortisone (Florinef®): 0.05-0.2 mg PO daily
-start at 0.1 mg PO daily
-ae: hypertension, GI upset, insomnia, edema
Androgen Replacement for PAI
– Consider 6-month trial in women with low libido, depression, anxiety, and fatigue on optimal GC and MC therapy
– Discontinue if no obvious improvement in 6 months
DHEA: 10-25 mg PO daily
AE: oily skin, hirsutism, acne, sweat/odor, low HDL
Acute Adrenal Crisis SX
-NV, abd pain
-Hypotension, hypoglycemia
-Seizure, coma, fever
-Weak, fatigue, lethargy, dec consciousness
-Hyponatremia, hyperkalemia
Adrenal Crisis TX
Fluid resuscitation and hemodynamic support
* 1L of 0.9% NS IV over 1 hr (maybe vasopressor)
Steroid replacement
* replace GC and MC, taper IV after 1-3 days, convert to PO for maintenance
-Hydrocortisone preferred: 100 mg IVP then 200 mg/day (50 mg q6hr) until oral can be taken
-Add fludrocortisone 0.1 mg PO daily for pts with persistent hyperkalemia
Steroids AE
- Potential side effects
– Early: anticipate insomnia, weight gain, ↑ appetite
– May worsen HTN, DM, PUD
– Chronic: HPA suppression, ↓ wound healing, moon face or increase abdominal girth
HPA Axis Suppression occurs when:
- Patient is on > 7.5 mg prednisone or prednisone equivalent for > 3 weeks
- Patient has cushingoid symptoms (despite dose)
-Consider stress coverage for patients on prednisone >7.5 mg/day for >2-4 weeks in the past 6 months
How to Taper Steroids
If disease flare is not a concern:
-↓ by 20-50% every few days until physiologic dose
If disease flare is possible: ↓ slowly over weeks to months
-Decrease by 10-20% every 1-2 weeks or slower until physiological dose
Once at physio dose:
* Option 1: 5mg daily x1 week, 2.5mg daily x1 week, then stop
* Option 2: taper prednisone by 0.5 mg – 1mg every 2-4 weeks or switch to hydrocortisone 20mg once daily & reduce by 2.5 mg steps over weeks to months
* If any AI symptoms or disease flare, then increase dose and slow taper
