Adrenocorticosteroids & Adrenocortical Antagonists

Question 1

What do the adrenal glands produce?

Answer 1

steroid molecules

Question 2

What controls secretion of the adrenal glands?

Answer 2

pituitary release of corticotropin (ACTH)

Question 3

What controls the secretion of the salt retaining hormone aldosterone?

Answer 3

Angiotensin

Question 4

What hypothalamic hormone stimulates the release of adrenocorticotropin from the adrenals?

Answer 4

Corticotropin-releasing hormone (CRH) (+)

Question 5

The release of ACTH from the pituitary stimulates the ____ to release ____?

Answer 5

adrenal cortex

cortisol

Question 6

What are the 3 pathways involved in adrenocortical hormone biosynthesis?

Answer 6

mineralocorticoid pathway
-aldosterone

glucocorticoid pathway
-cortisol

androgen & estrogen pathway

Question 7

What are the physiologic effects of the adrenal hormones?

Answer 7

Regulation of intermediary metabolism

CV func

Growth

Immunity

Synthesis and secretion tightly regulated by CNS

Question 8

The release of cortisol causes negative feedback on the ___ and ____.

Answer 8

anterior pituitary

hypothalamus

Question 9

How much cortisol (hydrocortisone) do we release daily?

Answer 9

10-20mg

Question 10

What controls circadian rhythm?

Answer 10

pulses of ACTH

peak in the early AM and after meals

Question 11

What is corticosteroid binding globulin?

Answer 11

α2 globulin synthesized by the liver

Binds about 90% of the circulating cortisol under normal circumstances

Question 12

What increases CBG? What decreases it?

Answer 12

pregnancy, estrogen administration, hyperthyroidism

hypothyroidism, genetic defects in synthesis, protein deficiency states

Question 13

When are the actions of glucocorticoids most apparent?

Answer 13

in the fasting state when they contribute to maintenance of an adequate glucose supply to the brain

Question 14

What is the half life? What can increase it?

Answer 14

60-90 mins

hydrocortisone when admin in large amounts, stress, hypothyroidism, liver disease

Question 15

Where is cortisol metabolized? where is it excreted?

Answer 15

liver

urine

Question 16

What are some adrenal cortex diseases?

Answer 16

Acute Adrenocortical Insufficiency
—Adrenal crisis

Chronic Adrenocortical Insufficiency
—-Addison’s Disease

Hypercortisolism
—Cushing’s Syndrome

Hyperaldosteronism

Question 17

What is an adrenal crisis?

Answer 17

emergency state due to insufficient cortisol

Question 18

Adrenal crisis is MCly seen in…

Answer 18

primary adrenal insufficiency, Addison’s Disease, than is disorders of the pituitary gland

Question 19

Sxs of adrenal crisis?

Answer 19

Low blood pressure, dehydration, skin pigmentation may be increased

Weakness, abdominal pain, fever, confusion, N/V/D

Question 20

How can you test for acute adrenocortical insufficiency?

Answer 20

Cosyntropin unable to stimulate an increase in serum cortisol to > 20mcg/ml

Question 21

Tx for adrenal crisis?

Answer 21

Hydrocortisone 100-300mg IV, then 50-100mg Q6-8hrs

Fludrocortisone Acetate

-consider if pts not response to fluids/vasopressors

Question 22

Examples of short-medium acting glucocorticoids…

Answer 22

Hydrocortisone*

Prednisone

Cortisone

Prednisolone

Methylprednisolone

Question 23

Example of intermediate acting glucocorticoid?

Answer 23

Triamcinolone

Question 24

What kind of steroid is fludrocortisone?

Answer 24

mineralocorticoid

Question 25

Name two long acting glucocorticoids. Which one is super potent??

Answer 25

Betamethasone Dexamethasone***

Question 26

Cause of primary adrenal insufficiency?

Answer 26

dysfunction or absence of the adrenal cortices

Question 27

s/s of chronic adrenal insufficiency (Addison's disease)

Answer 27

Skin pigmentation Hypotension, small heart Low serum sodium Elevated K+, Ca++, BUN

Question 28

Tx for addison's disease?

Answer 28

hydrocortisone +/- fludrocortisone

Question 29

how is hydrocortisone dosed in Addison's disease?

Answer 29

15–30 mg orally daily is drug of choice with 2/3 of dose given in the am and 1/3 given in the late afternoon

Question 30

What kind of effect can be seen in pt taking Fludrocortisone acetate?

Answer 30

potent sodium retaining effect

Question 31

When might you increase dose of Fludrocortisone acetate? when might you decrease?

Answer 31

if patient is experiencing: Postural hypotension Hyponatremia Or hyperkalemia OR fatigue Edema Hypokalemia OR hypertension

Question 32

S/s of cushing's syndrome

Answer 32

Central obesity, muscle wasting Thin skin, hirsutism, purple striae Psychological changes Osteoporosis, hypertension, poor wound healing elevated Sr cortisol hyperglycemia

Question 33

Tx for cushing's syndrome caused by pituitary adenoma?

Answer 33

transsphenoidal surg radiation chemo Supplement with 6-37 mos of corticosteroids until func. of pituitary normalizes

Question 34

MOA of Ketoconazole in tx of cushing syndrome? contraindications?

Answer 34

blocks production of cortisol hepatic disease

Question 35

If surg is not an option in pt with cushing disease, what medications can you try?

Answer 35

Mitotane, Metyrapone, Mifepristone, Cabergoline, Pasireotide

Question 36

What can cause hyperaldosteronism?

Answer 36

excess aldosterone secretion low levels of angiotensin II

Question 37

What are the 2 forms of hyperaldosteronism?

Answer 37

Primary: aldosterone producing adenoma (Conn's syndrome) Secondary: low (suppressed) levels of plasma renin activity and angiotensin II

Question 38

Sxs of hyperaldosteronism?

Answer 38

Hypertension with hypokalemia or resistant HTN Tetany/paralysis Polydipsia/nocturnal polyuria

Question 39

What drugs can be used in the tx of hyperaldosteronism?

Answer 39

Amiloride Eplerenone Spironolactone

Question 40

ADEs of Amiloride? What should you monitor?

Answer 40

Electrolyte abnormalities (hyperkalemia), hypotension, N/V/D, HA Monitor: Sr Cr, K, BP

Question 41

ADEs of Eplerenone? What should you monitor?

Answer 41

Electrolyte abnormalities (hyperkalemia), hypotension, dizziness, headache; gynecomastia and menstrual irregularities are uncommon Monitor: Sr Cr, K, BP

Question 42

ADEs of Spironolactone? What should you monitor?

Answer 42

GI discomfort, impotence, gynecomastia, menstrual irregularities, electrolyte abnormalities (hyperkalemia), hypotension Monitor: Sr Cr, K, BP

Question 43

What's the MC cause of cushing's?

Answer 43

exogenous steroids