Adrenal Pharm Flashcards
Causes of Hyperaldosteronism (5)
Primary hyperaldosteornism
Secondary: Cirrhosis, heart failure
Liddle’s syndrome: mutation in epithelial sodium channel
Deoxycorticosone mediated
Licorice ingestion (pseudohyperaldosteronism)
Spionolactone: Action (3)
Mineralocorticoid antagonist
Also blocks androgen, progesterone receptors
Spriconolactone: Uses (3)
Potassium sparing diuretic (HTN, CHF, cirrhosis, nephrosis)
Primary hyperaldosteronism
PCOS/hirsutism
Spironolactone: AE (5)
Hyperkalemia Volume depletion Gynecomastia/impaired libido in men Menstrual irregularities Teratogenic
Spironolactone: CI (3)
Renal impairment
Hyperkalemia
Pregnancy
What is action of eplerenone?
Highly selective mineralocorticoid antagonist
Eplerenone: uses (2)
Potassium sparing diuretic
Primary hyperaldosteronism
Eplerenone: CI (3)
Renal impairment
Hyperkalemia
Pregnancy
Amiloride: Action
Potassium sparing diuretic
Weak diuretic and weak antihypertensive
Amiloride: Use
potassium sparing diuretic
Amiloride: CI (2)
Renal impairment
Hyperkalemia
What things need to be monitored with potassium sparing mineralocorticoid antagonists? (4)
Dehydration
BP
Serum electrolytes
Men: gynecomastia
Mineralocorticoid deficiency: Causes (2)
Primary adrenal insufficiency
Hyporeninemia (i.e in diabetic nephropathy)
Mineralocorticoid deficiency treatment
Mineralocorticoid replacement: fludrocortisone (florinef)
What are side effects of fludrocortisone? (4)
Hypokalemia
Volume overload: edema, HTN, CHF
Monitoring fludrocortisone replacement: What are your concerns? (5)
Presyncope, lightheadedness Salt cravings Swelling/edema BP/HR Monitor Na/K and plasma renin activity
Hypercortisolism: Treatment options (5)
Surgical adrenalectomy or hypophysectomy
Mifepristone: glucocorticoid receptor antagonist
Mitotane: Adrenal cytotoxic
Inhibit enyzymes in steroidogenesis: Metyrapone, ketoconazole, aminoglutethimide
Inhibit ACTH secretion: Pasireotide (SS analog)
Why does pasireotide work for Cushing’s syndrome?
Pituitary adenomas express somatostatin and dopamine receptors…pasireotide is SS analog and suppresses ACTH secretion
What are side effects of SS analogs? (3)
Increase in blood glucose levels
Cardiac conduction defects
Gallstones
How do adrenal enzyme inhibitors work?
Block steroid synthesis at multiple sites
Why can’t you check urinary free cortisol in mifepristone treatment?
Because it blocks GCR, but doesn’t affect cortisol production
For which treatments should you monitor LFTs?
Ketoconazole, pasireotide
What are treatments for glucocrticoid deficiency? (3)
Cortisol replacement:
Hydrocortisone (half life=8-12hr)
Dexamethasone (half life=36-54hr)
Presdnisone (18-36hr)
Why would you use hydrocortisone over other glucocorticoids?
Best approximates circadian rhythm
What are principles of hydrocortisone treatment? (3)
Sick day replacement: double or triple daily dose for days with fever
Stress dose replacement: taper to physiologic dose once stress is relieved
Acute dose for shock/adrenal crisis: Use IV then taper to pays dose
What is concern with high doses of hydrocortisone treatment?
It will overwhelm cortisol-cortisone shunt and bind mineralocorticoid receptor–>pseudohyperaldosternism
What do we monitor for hydrocortisone replacement? (4)
Fatigue/appetite
BP, weight
Signs of over-replacement (iatrogenic Cushing’s)
Testing for Primary Adrenal Insufficiency
First check morning cortisol
If low cortisol, do IM cosyntropin stimulation test
Testing for Secondary Adrenal Insufficiency
Meyrapone testing:
If observe high levels of 11-deoxycortisol (cortisol precursor) then there is no secondary adrenal insufficiency
If low levels of 11-DOC, then pituitary problem
What is enzyme that meyrapone blocks?
11-ß-hydroxylase
Monitoring in metyrapone stimulation
Need inpatient monitoring, especially of BP/HR (concern is hypotension)
Terminate test with IV hydrocortisone to restore cortisol levels
Use of synthetic glucocorticoids: Which ones do not affect mineralocorticoid receptors (3)
Methyl-prednisone
Triamcinolone (topical/inhaled)
Dexamethasone
Main side effect for synthetic glucocorticoid
IATROGENIC CUSHING’S ALL DAY
