Circadian Rhythms, adrenal insufficiency and management

Question 1

When you go to sleep, what happens to your cortisol levels?

Answer 1

They drop

Question 2

Cortisol peaks at ___ times

Answer 2

meal

Question 3

Light information goes to hypothalamus which regulates ___ secretion

Answer 3

CRH

Question 4

What hormone increases at night?

Answer 4

Melatonin

Question 5

What is Primary Adrenal insufficiency?

Answer 5

Addison’s Disease
Adrenal glands make too little cortisol

Question 6

What causes secondary adrenal insufficiency?

Answer 6

Hypopituitarism
eg macroadenoma, radiotherapy, congenital

Question 7

What can cause tertiary adrenal insufficiency?

Answer 7

Suppression of HPA
Steroids, oral, inhaler, creams

Question 8

What are common symptoms of adrenal insufficiency?

Answer 8

Fatigue, weight loss, poor recovery from illness, adrenal crisis, headache

Question 9

What are common past histories for adrenal insufficiency?

Answer 9

TB
Post partum bleed
Cancer
Family history of autoimmunity
Any steroids

Question 10

What are signs of adrenal insufficiency?

Answer 10

Pigmentation (due to high ACTH release together with melanin eg in primary adrenal insufficiency) and pallor
Hypotension
Low sodium and high potassium (due to loss of aldosterone)

Question 11

When are cortisol and ACTH tests taken?

Answer 11

8:30-9:00 am

Question 12

In primary adrenal insufficiency, what will there be lower levels of?

Answer 12

Cortisol, aldosterone and sex androgens

Question 13

In primary adrenal insufficiency, there will be increased levels of r___ due to low levels of aldosterone

Answer 13

renin

Question 14

What is a Synacthen test?

Answer 14

Blood test
Inject ACTH
after 30 minutes, test for cortisol again.
If cortisol level more than 450 nmol/l then adrenal insufficiency is unlikely

Question 15

What are the main investigations for adrenal insufficiency?

Answer 15

Cortisol and ACTH test at 9am
Synacthen Test (inject ACTH)

Question 16

How to investigate Addison’s disease

Answer 16

Send adrenal antibodies. Negative antibodies leads to CT scan of adrenals.

Very long chain fatty acid test (test for rare disease, adrenal leukodystrophy)

17-OHP test (type of androgen, raised levels suggest adrenal hyperplasia)

Imaging

Genetic testing

Question 17

Investigating Secondary adrenal insufficiency

Answer 17

Any steroids
Imaging
Genetic

Question 18

IF a healthy individual becomes unwell then they will increase production of cortisol.
However, for adrenal insufficiency patients, they need to take medication to increase cortisol eg h____

Answer 18

hydrocortisone

Question 19

For patients who get adrenal crisis, an i_____ of hydrocortisone is given so if at home, can take and call ambulance

Answer 19

injection

Question 20

If in hospital have suspected adrenal crisis, try to take blood before immediately giving h______

Answer 20

hydrocortisone

Question 21

Patients with adrenal insufficiency must carry what with them?

Answer 21

A steroid card and medic-alert (and 10 x 10mg hydrocortisone tablets)

Question 22

How to treat adrenal insufficiency

Answer 22

Glucocorticoid replacement:
Usually hydrocortisone, 3 doses each day. Given by weight.

Mineralocorticoid treatment to replace aldosterone, aim for renin in upper half of normal range

Androgen replacement, DHEA replacement

Question 23

What tablets can be given to children who require smaller doses of hydrocortisone?

Answer 23

Alkindi - have HC granules in capsules, can be sprinkled on food

Question 24

Advantages of salivary cortisol testing

Answer 24

Non-invasive
Stress-free sampling
Can be performed at home
Relatively cheap
Easy

Question 25

You can/cannot harm yourself in the short-term taking extra steroid?

Answer 25

Cannot