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Roomies Collab Deck 2: Endocrinology and NeuroPsych > Cushing's syndrome > Flashcards

Cushing's syndrome Flashcards

1
Q

Cushing’s syndrome results from chronic exposure to (?) cortisol

A

Excess cortisol

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2
Q

Cushing’s syndrome results from chronic exposure to excess (?)

A

Cortisol

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3
Q

What is the most common cause of Cushing’s syndrome?

A

Exogenous corticosteroid use

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4
Q

What are the endogenous causes of Cushing’s syndrome?

A
  1. ACTH-secreting pituitary tumours (Cushing’s disease)
  2. Cortisol-secreting adrenal tumours
  3. Ectopic ACTH-secreting tumours (rare)
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5
Q

What is Cushing’s disease?

A

ACTH-secreting pituitary tumours

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6
Q

How are most endogenous Cushing’s syndrome treated?

A

Surgically

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7
Q

Metyrapone is a competitive inhibitor of (?) in the adrenal cortex; the resulting inhibition of cortisol (and to a lesser extent aldosterone) production leads to an increase in ACTH production which, in turn, leads to increased synthesis and release of cortisol precursors.

A

11β-hydroxylation

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8
Q

Metyrapone is a competitive inhibitor of 11β-hydroxylation in the adrenal cortex; the resulting inhibition of (?) (and to a lesser extent aldosterone) production leads to an increase in ACTH production which, in turn, leads to increased synthesis and release of cortisol precursors.

A

cortisol

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9
Q

Metyrapone is a competitive inhibitor of 11β-hydroxylation in the adrenal cortex; the resulting inhibition of cortisol (and to a lesser extent aldosterone) production leads to an increase in (?) production which, in turn, leads to increased synthesis and release of cortisol precursors.

A

ACTH

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10
Q

What are the indications for the use of metyrapone? (3)

A
  1. Differential diagnosis of ACTH-dependent Cushing’s syndrome
    - Oral: 750 mg every 4 hours for 6 doses
  2. Management of Cushing’s syndrome
    - Oral: usual dose 0.25-6g daily
  3. Resistant oedema to increased aldosterone secretion in cirrhosis, nephrotic syndrome, congestive heart failure (with glucocorticoid replacement therapy)
    - Oral: 3 g daily in divided doses
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11
Q

What is the contraindication for the use of metyrapone?

A

Adrenal insufficiency

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12
Q

What are the common side effects of the drug metyrapone? (6)

A 
Dizziness
Headache
Hypotension
Nausea
Sedation
Vomiting
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13
Q

Can a pregnant patient take the drug metyrapone?

A

NO

May impair biosynthesis of fetal-placental steroids

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14
Q

What do you need to tell a patient about driving if they are taking metyrapone?

A

Drowsiness may affect the performance of skilled tasks (e.g. driving)

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15
Q

Which two drugs are licensed for the treatment of Cushing’s syndrome?

A

Metyrapone

Ketaconazole (only endogenous Cushing’s syndrome)

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16
Q

Which type of Cushing’s syndrome is the drug ketaconazole licensed to treat?

A

Endogenous Cushing’s syndrome

Ketaconazole: An imidazole derivative which acts as a potent inhibitor of cortisol and aldosterone synthesis by inhibiting the activity of 17α-hydroxylase, 11-hydroxylation steps and at higher doses the cholesterol side-chain cleavage enzyme.

It also inhibits the activity of adrenal C17-20 lyase enzymes resulting in androgen synthesis inhibition, and may have a direct effect on corticotropic tumour cells in patients with Cushing’s disease.

17
Q

Ketaconazole MOA

An imidazole derivative which acts as a potent inhibitor of (?) and (?) synthesis by inhibiting the activity of 17α-hydroxylase, 11-hydroxylation steps and at higher doses the cholesterol side-chain cleavage enzyme.

It also inhibits the activity of adrenal C17-20 lyase enzymes resulting in androgen synthesis inhibition, and may have a direct effect on corticotropic tumour cells in patients with Cushing’s disease.

A

Cortisol

Aldosterone

18
Q

Ketaconazole MOA

An imidazole derivative which acts as a potent inhibitor of cortisol and aldosterone synthesis by inhibiting the activity of 17α-hydroxylase, 11-hydroxylation steps and at higher doses the cholesterol side-chain cleavage enzyme.

It also inhibits the activity of adrenal C17-20 lyase enzymes resulting in (?) synthesis inhibition and may have a direct effect on corticotropic tumour cells in patients with Cushing’s disease.

A

androgen

19
Q

Ketaconazole MOA

An imidazole derivative which acts as a potent inhibitor of cortisol and aldosterone synthesis by inhibiting the activity of 17α-hydroxylase, 11-hydroxylation steps and at higher doses the cholesterol side-chain cleavage enzyme.

It also inhibits the activity of adrenal C17-20 lyase enzymes resulting in androgen synthesis inhibition and may have a direct effect on (?) tumour cells in patients with Cushing’s disease.

A

Corticotropic

20
Q

Ketaconazole MOA

An imidazole derivative which acts as a potent inhibitor of cortisol and aldosterone synthesis by inhibiting the activity of 17α-hydroxylase, 11-hydroxylation steps and at higher doses the cholesterol side-chain cleavage enzyme.

It also inhibits the activity of adrenal C17-20 lyase enzymes resulting in androgen synthesis inhibition and may have a direct effect on corticotropic tumour cells in patients with Cushing’s (?).

A

disease

21
Q

In addition to the treatment and management of fungal disease, what is the other indication for the use of ketoconazole?

A

Endogenous Cushing’s syndrome
- Oral: Initially 400–600 mg daily in 2–3 divided doses, increased to 800–1200 mg daily; maintenance 400–800 mg daily in 2–3 divided doses,

22
Q

What are the contraindications for the use of ketoconazole? (3)

A
  1. Acute porphyrias
  2. Acquired or congenital QTc prolongation
  3. Concomitant use of hepatotoxic drugs
23
Q

Which drinks improve the bioavailability of ketoconazole?

A

Carbonated drinks (e.g. cola)

24
Q

What happens if you drink a carbonated drink (e.g. cola) when taking ketaconazole?

A

Improves the bioavailability of ketaconazole

25
Q

What are the common side effects of the drug ketoconazole if taken orally?

A 
Adrenal insufficiency
Diarrhoea
GI discomfort
Nausea
Vomiting
26
Q

What is a rare but potentially life-threatening side effect of ketoconazole?

A

Hepatotoxicity

Reduce dose if hepatic enzymes increased to less than 3 times the upper limit of normal.

Discontinue permanently if hepatic enzymes at least 3 times the upper limit of normal

27
Q

What action should you take if hepatic enzymes increase to less than 3 times the upper limit of normal in a patient taking ketoconazole?

A

Reduce dose of ketoconazole

28
Q

What action should you take if hepatic enzymes increase to 3 or more times the upper limit of normal in a patient taking ketoconazole?

A

Discontinue ketoconazole permanently

29
Q

Can pregnant women take ketoconazole orally?

A

NO

Teratogenic in animal studies

30
Q

Women of childbearing potential must use effective (?) is taking oral ketoconazole

A

Contraception

Teratogenic in animal studies

31
Q

Should a woman breastfeed if taking oral ketoconazole?

A

No

Present in breast milk

32
Q

Should a patient with hepatic impairment take oral ketoconazole?

A

No

33
Q

What monitoring is required prior to the initiation of oral ketoconazole? (2)

A
  1. ECG

2. Liver function

34
Q

What needs to be monitored one week after the initiation of oral ketaconazole?

A
  1. ECG
  2. Adrenal function
  3. Liver function
35
Q

Once cortisol levels are normalised or close to the target, how often should you monitor adrenal function in a patient taking oral ketoconazole?

A

Every 3-6 months

There is a risk of autoimmune disease development or exacerbation after normalisation of cortisol levels

36
Q

When should liver function be checked in a patient taking oral ketoconazole? (3)

A
  1. Before initiation of treatment
  2. Weekly for 1 months after initiation
  3. Monthly for 6 months
37
Q

What advice do you need to give patients (or carers) taking oral ketoconazole?

A
  1. Signs of liver disorder (anorexia, nausea, vomiting, fatigue, jaundice, abdominal pain, dark urine)
  2. Signs of adrenal insufficiency (fatigue, anorexia, nausea, vomiting, hypotension, hyponatraemia, hyperkalaemia, hypoglycaemia)
38
Q

What advice about driving do you need to give to patients taking oral ketoconazole?

A

Dizziness and somnolence may affect the performance of skilled tasks (e.g. driving)

Roomies Collab Deck 2: Endocrinology and NeuroPsych (49 decks)

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