Adrenal Pathology Flashcards
Adrenal Fatigue: HPA axis activity is measured by
Chronic Fatigue Syndrome, Post-traumatic stress disorder
- Cortisol awakening response (CAR)
- *Peak values at 30-45 minutes after waking of 50-100%
- *ACTH also rises in the first 30 minutes and rises before waking
- Trier social stress test (TSST)
- Also high CRH and ACTH response
- High cortisol response normal if person feels situation is uncontrolled, forced failure, or social judgment
- *Also high CRH and ACTH response
Adrenal Fatigue:
Most affected
CHILDREN PARTICULARY OF LOW SOCIOECONOMIC STATUS & geriatric pts.
Burn out/Exhaustion phase-> Looks like Addisons
Suppression/resistance phase-> looks like Cushing’s
Adrenal Fatigue:
Early High Cortisol Production
- Melatonin may have a direct impact on reduction of hypercortisolemia
- DHEA supplementation may decrease 24 hour cortisol levels
- Use of Rhodiola rosea at a dose of 144mg of Rhodiola extract 4:1 in 70% alcohol demonstrated a blunting of the cortisol response upon waking over 28 days of the trial.
Adrenal Fatigue:
Late Cortisol Too Low?
- Considered in MSS 3 when production is too low.
- Glycyrrhiza glabra is a cortisol agonist by inhibition of 11B-OHSD
- Cortisol->Minerals->HTN
Adrenal Fatigue:
Treatment for MSS-1
Nervines: Scutellaria, Passiflora, Valerian, Cimicifuga, Humulus lupinus, Piper methysticum B-complex vitamins, vitamin C melatonin exercise meditation recreation & relaxation
Adrenal Fatigue:
Maladaptive Stress Syndrome “MSS”
1) Alarm reaction (AR): the initial stage of reaction to stress
2) Stage of resistance (SR): the second stage of reaction to continuing stress
3) Stage of exhaustion (SE): the end stage of reaction to stress
Adrenal Fatigue:
Treatment for MSS-2-excessive cortisol (like Cushings)
- DHEA (cortisol antagonist)
- potassium, sodium restriction, pyridoxine (fluid retention)
- chromium (glucose regulation)
- ascorbates, zinc, glucosamine sulfate (connective tissue support)
- calcium, magnesium (osteoporosis prevention)
- omega-3 fatty acids (lipid metabolism)
- Phosphatidyl-serine 400mg in chronic high stress
- Hypericum perf., tyrosine (depression)
Adrenal Fatigue:
MSS-3 Contributing Factors
- history of steroid use
- systemic disease
- chronic disease
- nutritional deficiencies
- inherited conditions (pyroluria, histapenia, pernicious anemia …)
- functional hypoglycemia
- stress
Adrenal Fatigue:
Treatment for MSS-3
*Botanicals: Glycyrrhiza, Eleutherococcus, Rosemarinus , Crataegus, Rhodiola, Withania, Astragalus, Dioscorea, Schizandra
*Nutrients: pantothenic acid, vitamin C, vitamin B12
Hypoglycemic diet
Sodium chloride
*Anabolic amino acids: arginine-ornithine-lysine
Graduated moderate exercise
Stress management
Reduce antigenic load
Adrenal Thyroid Axis:
Thyroid Chicken or Adrenal Egg First?*
What we know:
- Overt hypothyroidism increases cortisol levels by reducing metabolism and feedback at the hypothalamus and pituitary
- Elevated TSH and cortisol have a positive relationship down to a TSH level of 2.5 uIU/L
- Overt hypercortisolemia (such as in Cushing’s or corticosteroids) suppresses TSH.
- Overt hypocortisolemia increases TSH
So….
- Elevated TSH due to reduced thyroid function increases cortisol
- Elevated cortisol suppresses TSH
Adrenocortical Insufficiency:
Type of Adrenal Insufficiency….
Primary: Addison Disease
Secondary: ACTH and Glucocorticoid therapy
- Primary Adrenal Insufficiency due to inability to produce glucocorticoids and mineralocorticoids
- Secondary Adrenal Insufficiency due to impaired stimulation of adrenal gland – from hypothalamus and pituitary gland
- Addisonian crisis: acute exacerbation caused by either primary or secondary adrenal insufficiency
Addison’s Dz:
can be precipitated by stress or trauma
can be precipitated by withdrawal from corticosteroids
Acute Adrenal Insufficiency Presentation
Symptoms: Hypotension and shock N/V Mental status change – confusion and agitation Lethargy
Signs:
Hypotension
Vomiting
Addison’s picture
Your patient is a 40 year old male with a chief concern of weight loss, fatigue, and dizziness when standing.
He states that his job is stressful yet he has strong family support and sees meaning and purpose in his life.
Lately he has been craving salty foods, and reports diarrhea on ROS.
Year Round tan (hyper pigmentation)–> JFK!
Adrenocortical Excess:
Cushing syndrome
Cushing Disease-(Tumor)
Cushing Disease: caused by pituitary tumor secreting ACTH
Cushing Syndrome: any chronic glucocorticoid excess
- Most common cause of Cushing Disease is a microadenoma which produces ectopic ACTH without suppression response
- Cushing syndrome commonly caused by chronic steroid use
- Cushing’s syndrome can be caused by exogenous or endogenous corticosteroid excess, functional hypercortisolism (MSS-2).
