EXAM #2: ADRENAL INSUFFICIENCY

Question 1

What is the definition of adrenal insufficiency?

Answer 1

Clinical manifestations of deficiency of hydrocortisone

Question 2

What is the difference between primary and secondary adrenal insufficiency? Specifically, what is the difference in hormone deficiencies?

Answer 2

Primary= destruction of adrenal gland causing deficiency in:

• Corticosteroids
• Mineralcorticoids
• Adrenal androgens

Secondary= damage to the hypothalamus causing deficiency in CORTICOSTEROIDS ONLY

Question 3

Why are deficiencies in catecholamines and adrenal androgens spared in adrenal insufficiency?

Answer 3

• Extra-adrenal sites–paragnaliomas–produce catecholamines
• Ovaries and testes are the major source of DHEA

Thus, other organs are primarily responsible for the synthesis of these hormones

Question 4

Why is aldosterone production unaffected by secondary adrenal insufficiency?

Answer 4

Aldosterone is NOT regulated by ACTH; rather, the RAA, which increases aldosterone secretion in response to:

1) Renal hypotension
2) Decreased Na+ delivery to distal tubules

Question 5

What effect does aldosterone have on Na+ and K+?

Answer 5

1) Conserves Na+

2) Excretes K+

Question 6

What are the four major functions of ANGII?

Answer 6

1) Release of aldosterone from adrenal cortex
2) Release of ADH from posterior pituitary
3) Vasoconstriction
4) Increased renal Na+ retention

Question 7

When do cortisol levels peak? When are they the lowest?

Answer 7

Peak= early morning 
Low= evening

Question 8

What stimuli will cause the secretion of CRH, ultimately leading to increased cortisol?

Answer 8

1) Stress
2) Hypoglycemia
3) Cold temp.
4) Pain

Question 9

What is the larger precursor peptide to ACTH? What are the three derivatives from this peptide?

Answer 9

Propiomelanocortin (POMC)

• ACTH
• Lipotropin
• MSH

Question 10

What is the most common cause of primary adrenal insufficiency in developed countries?

Answer 10

Autoimmune destruction (Addison’s Disease)

Question 11

Worldwide, what is the most common cause of primary adrenal insufficiency?

Answer 11

TB

Question 12

What hormonal deficiencies are seen in primary adrenal insufficiency?

Answer 12

1) Cortisol
2) Aldosterone
3) DHEA

Question 13

What lab findings are seen in primary adrenal insufficiency?

Answer 13

1) Decreased cortisol with increased ACTH
2) Decreased aldosterone with increased renin
3) Decreased DHEA

Question 14

What two clinical manifestations are unique to primary adrenal insufficiency?

Answer 14

1) Hyperpigmentation

2) Hyperkalemia

Question 15

How is primary adrenal insufficiency diagnosed?

Answer 15

1) Random cortisol less than 5 mcg/dL or am cortisol less than 3 mcg/dL
2) Simultaneously elevated ACTH
3) Cortrosyn stimulation test

Question 16

What is the expected response to a cortrosyn stimulation test?

Answer 16

Cortisol greater than 18 mcg/dL

Question 17

How is primary adrenal insufficiency treated?

Answer 17

1) Hydrocortisone twice daily or prednisone once daily
2) Fludrocortisone*

*Synthetic corticosteroid with moderate glucocorticoid potency and much greater mineralocorticoid potency.

Question 18

What endpoints do you want to monitor in the treatment of primary adrenal insufficiency treated?

Answer 18

1) Weight
2) Blood pressure
3) Electrolytes
4) Sense of well-being

Question 19

What major consideration do you need to keep in mind about patients with primary adrenal insufficiency?

Answer 19

Stress dosing

• Minor= 30-60mg/day
• Major= 200-300 mg/day

Question 20

How is an adrenal crisis treated?

Answer 20

5s

1) Saline
2) Sugar: dextrose
3) Steroids: hydrocortisone
4) Support
5) Search (underlying cause)

Question 21

What are the two major etiologies of secondary adrenal insufficiency?

Answer 21

Transient= iatrogenic steroid use 
Permanent= panhypopituitarism

Question 22

What is the most common cause of secondary adrenal insufficiency?

Answer 22

Abrupt cessation of exogenous glucocorticoids

*Drug suppresses CRH/ACTH and then it takes time for the HPA axis to “wake-up”

Question 23

What hormonal changes are expected in secondary adrenal insufficiency?

Answer 23

Decreased ACTH and Cortisol

Question 24

Why can a Cortrosyn stimulation test show a lack of cortisol stimulation in secondary adrenal insufficiency?

Answer 24

Corticol atrophy

Question 25

What are two methods of stimulating ACTH production?

Answer 25

1) Metyrapone (reduces cortisol–should increase ACTH)

2) Insulin induced hypoglycemia (stress should increase ACTH)

Question 26

How is secondary adrenal insufficiency treated?

Answer 26

Replacement of cortisol BUT NOT aldosterone