B5.034 Prework 2 Endogenous Steroids and Adrenal Insufficiency

Question 1

what is adrenal insufficiency (AI)

Answer 1

hypofunction of the adrenal cortex (production of cortisol)

Question 2

why does AI arise?

Answer 2

destruction of the adrenal gland itself (primary AI, Addisons disease (AD))
lack of ACTH (secondary AI)

Question 3

most common cause of AD

Answer 3

autoimmune destruction of the adrenal gland (80%)

Question 4

infectious causes of AI

Answer 4

viral, mycobacterial, fungal

AIDs the most common

Question 5

hemorrhagic causes of AI

Answer 5

anticoagulants/ coagulopathy, sepsis, thrombosis

Question 6

metastatic cancers causing AI

Answer 6

brast, lung, GI, renal

Question 7

infiltrative causes of AI

Answer 7

amyloidosis, sarcoidosis, hemochromatosis, demyelination

Question 8

what causes secondary AI

Answer 8

adrenal gland atrophy from ACTH deficiency
most often results from:
-pituitary corticotroph atrophy owing to previous exogenous glucocorticoid use (prednisone)
-panhypopituitarism
-isolated ACTH deficiency

Question 9

diagnosis of AI

Answer 9

demonstrate diminished responsiveness of the hypothalamic-pituitary-adrenal axis to stimulation

• morning cortisol value less than 4 mg
• cosyntropic (ACTH) stimulation test usually required and is the gold standard

Question 10

describe the cosyntropin stimulation test

Answer 10

rise in cortisol level to 18, or a change in 9 in 30-60 min after 250 mg of cosyntropin (ACTH) administration is normal response

Question 11

what causes hyperpigmentation in primary AI

Answer 11

excess ACTH can interact with melanocytes

usually occurs in areas exposed to light and pressure

Question 12

acute therapy for AI

Answer 12

IV fluid

high dose IV glucocorticoids

Question 13

chronic therapy for AI

Answer 13

physiologic oral glucocorticoid replacement
mineralocorticoid replacement (for primary)
patient education
-medic alert bracelet
-dosage increases for stress and surgery
-parenteral admin is oral not an option

Question 14

agents used for oral glucocorticoid replacement

Answer 14

prednisone

Question 15

agent for IV glucocorticoids

Answer 15

hydrocortisone

Question 16

mineralocorticoid activity

Answer 16

maintains BP

Question 17

general rule of AI during sickness

Answer 17

double current steroid for 3 days

if major surgery or critical illness change to IV steroids

Question 18

physiologic effects of cortisol

Answer 18

affects vascular and bronchial smooth muscles with the relationship to catecholamines
in absence of cortisol there is vasodilation and hypotension

Question 19

physiologic effect of glucocorticoids

Answer 19

stimulate gluconeogenesis and glycogen synthesis in the fasting state
increase serum glucose by inhibiting uptake of glucose in the muscle
stimulates hormone sensitive lipase and lipolysis (minor effect)

Question 20

action of short acting steroids

Answer 20

hydrocortisone
may mimic diurnal rhythm best, 100% bioavailability
short half life, generally recommended once in the morning and once in the early afternoon

Question 21

action of long acting steroids

Answer 21

dexamethasone and prednisone provide longer duration of action
better for noncompliance
greater inter individual variability

Question 22

what is fludrocortisone

Answer 22

potent steroid which is mainly a mineralocorticoid
dose 0.1 mg per day
given to individuals with primary AI that have little or no mineralocorticoid steroids

Question 23

function of fludrocortisone

Answer 23

helps sodium retention at the level of the kidney

has a side effect of hypokalemia due to excessive mineralocorticoid activity

Question 24

steroid side effects

Answer 24

immunosuppression
hypertension
weight gain
osteoporosis
insomnia
mood swings
peptic ulcers
redistribution of fat