Lec 7 Adrenal Insufficiency - Addison's + Steroid Dosing Flashcards
Addison’s Syndrome
Etiology
Adrenal Insufficiency
- VERY RARE
- inability to produce cortisol / aldosterone
-
Primary = Addison’s Disease
-
Autoimmune, 90% of tissue loss before S/S
- late detection
-
Autoimmune, 90% of tissue loss before S/S
- Secondary causes
- Long-Term Glucocorticoid administration
- lack of ACTH stimulators or TUMORS
Symptoms of Addison’s Syndrome
Adrenal Insufficiency
- Weakness / Weight Loss / Anorexia
- Skin Pigmentation + muscous membranes
- N/V + Abdominal Pain
- Constipation
- Syncope
- Salt craving
Diagnosis of Addison’s Disease
Cosyntropin Test
- Cosyntropin = Synthetic ACTH
- 0.25mg given IM @ 6-9am
- most predictable Cortisol Levels
- ACTH should stimulate cortisol release
- if low / no cortisol –> Addison’s Disease
- 0.25mg given IM @ 6-9am
-
Primary if ACTH is HIGH
- auto-immune, issue is @adrenals
- Secondary if ACTH is low
Cosyntropin
Synthetic ACTH
Used to diagnose for Addison’s Disease
Or to simply see if patient’s Adrenals are Working
–> should stimulate Cortisol release
Cortisol Replacement Therapy
for Addison’s Disease
-
Hydrocortisone / Cortisone Acetate (short-term GC)
- BID, ex: 15mg am -> 10mg pm
- TID
- every meal, could be easier since SAME DOSE
-
Prednisone / Dexmethasone (intermediate GC)
- QD, just a baseline level to prevent hospitilization
-
Drug Interactions
- LARGER dose may be needed w/ enzyme inducers
- Dose adjustments based on Urinary Cortisol Levels
Types of Short-Acting Glucocorticoids
= Steroids = Corticosteroids
Hydrocortisone
Cortisone Acetate
some mineralcorticoids activity –> RAISE BP
BID or TID
half life of 8-12 hours
Types of Intermediate-Acting Glucocorticoids
= Steroids = Corticosteroids
Prednisone
some mineralcorticoid activity
Triamcinalone
Methylprednisone
half life of 12-36 hours
Types of LONG Acting Glucocorticoids
= Steroids = Corticosteroids
Dexmethasone
Beamethasone
NO Mineralcorticoid activity!
half life of 36-72 hours
Supplemental Glucocorticoids Dosing
for Addison’s Disease
Need to use More GC during STRESS
HIGH DOSES, its difficult to OVERDOSE
Much worse to have TOO Little in the short term
-
Fever / Nausea
- DOUBLE total daily dose (TDD)
-
Surgery / trauma
- 3-10x TDD
-
Mild Stress (hiking)
- Patients will learn on their OWN how much they need to supplement.
Mineralcorticoid Replacement
for Addison’s Disease
Indicated for Primary Adrenal Insufficiency
Not needed in Secondary Adrenal Insufficiency
-
Fludrocortisone Acetate
- potent synthetic Mineralcorticoid
- only affects BP / Water
- adjust dose based on Potassium / BP
- potent synthetic Mineralcorticoid
-
Monitor:
- BP / Na / K / Edema
Acute Adrenal Insufficiency
- Typically caused by:
- Forgetting / Stop taking GC’s or MC’s
- Considered a Endocrine EMERGENCY
-
Flu -like symptoms that progress to:
- -> fever / hypotension / Shock
- electrolyte abnormalities
-
Flu -like symptoms that progress to:
Treatment for
Acute Adrenal Insufficiency
-
Hydrocortisone 100mg STAT -> taper off dose to normal dose
- very HIGH DOSE
- overdose is less likely, and no short term issues
- very HIGH DOSE
-
FLUIDS:
- to correct volume depletion / dehydration
- hypotension & hypoclycemia
- to correct volume depletion / dehydration
-
Remove / Treat precipitating factor
- usually by just telling them to keep taking their medications
- usually by just telling them to keep taking their medications
Patient Education for
Addison’s Disease
- Importance of medication Compliance
- S/S of acute adrena insufficiency
-
Self-Management of their disease
- know when to adjust doses / feel for ones own body
- Self-administer IM GC’s
- for rescue doses
- Supplement doses for stressful situations
- Medical ID Jewelry
Indications for Corticosteroids
-
Replacement therapy
- for Addison’s Disease
-
Anti-Inflammatory / Immunosuppresive effects
- Rheumatic / Allergic / Respiratory Disease
- Infectious / Ocular / Skin Disease
- GI / Organ transplantation / edema
Fludrocortisone
only for Mineralcorticoid Action (aldosterone)
not needed w/ Secondary adrenal insufficiancy
Raise BP / Na+ / Water retention
decrease in Potassium
PK’s of Corticosteroids
- Readily absorbed from the GI Tract
-
GUT NEEDS TO WORK for drug to work
- –> IV if the gut does not work
-
GUT NEEDS TO WORK for drug to work
-
Highly Protein Bound
- CBG / Albumin
- takes a long time to leave the system
- CBG / Albumin
- Metabolized by Liver
- Excreted Renally
Steroid Dosing Strategies
for Replacement Therapy
Typically for Addison’s Disease
- Goal it to MIMIC the Diurnal Pattern
- May also require mineralcorticoids (fludrocortisone)
-
for PRIMARY insufficiency
- = issue is w/ the adrenal gland
-
for PRIMARY insufficiency
- Adjust dose during STRESSFUL events
Steroid Dosing Strategies
for Suppressive Therapy
-
Short Term / High dose
- Asthma / anaphylaxis
- acute adrenal insufficiencies
- Asthma / anaphylaxis
-
Long Term / High Dose
- inflammed temporal artery
-
Long Term / low dose
- adjuvant therapy for RA, lupus, erythrematosus
- MONTHS, want to use a VERY LOW DOSE
- adjuvant therapy for RA, lupus, erythrematosus
Types of Adverse Effects
of Corticosteroids
- Can be caused by BOTH:
- Withdrawal of steroid therapy
- Continued use of supraphysiological doses
- Longer the steroid use the GREATER the risk for side effects
- IV/IM > Oral >> Inhaled
- in order of more side effects
- IV/IM > Oral >> Inhaled
Glucocorticoid Side Effects (Continued Use)
INCREASES / STIMULATES:
-
Fluids / Electrolytes
- Aldosterone-Like Effects
-
GI
- abdominal pain –> PUD
-
Behavorial
- Insomnia / Nervousness
- Cataracts
- HYPERlipidemia / HYPERglycemia
-
Teratogenic
- Pregnancy category C
Glucocorticoid Side Effects (continued Use)
Decreases / Weakens
-
Immune Response
- inhibits immune system / inflammatory response
- Hematologic
-
Myopathy
- weakness of proximal limb muscles
-
Wound Healing
- decrease in collagen / fibroblast
- Osteoporosis
Hematologic Side Effects
from continued use of Glucocorticoids
-
Lymphocytopenia / Eosinopenia / Monocytopenia
- low WBC
- decreases circulating count to other body parts
- typically lowest 4-6 hours post dose
-
Neutrophilia (increase in NEUTROPHILS, first responders)
- stimulate bone marrow releas
- Management:
-
Rule out infection first
- test labs after 24 hours after dose
-
Rule out infection first
Wound Healing Side Effects
from continued use of Glucocorticoids
-
Decreases collagen production
- and fibroblastic therapy
-
Inhibits vascularization and collagen deposition
- as well as stabilization of lysosomal membranes
-
TREATMENT:
-
Vitamin A
- MVI qd
-
Vitamin A
Osteoporosis Side Effects
from continued use of Glucocorticoids
-
Inhibits OsteoBLAST activity
- less building of bones
- Risk is INCREASED for:
- female / small frame
- RA / DM
- Immobilized patient
-
PREVENTATIVE THERAPY:
- Calcium / Vit D
- weight-bearing exercise
- bisphosphates (alendronate)
HYPERglycemia Side Effects
from continued use of Glucocorticoids
- Stimulates GNG
- Inhibits peripheral utilization of glucose
- Promotes glycogenolysis
- by stimulating glycogen release ->
- Increased glucose levels seen within 2 weeks
-
PREVENTION:
- __Educate symptoms of DM
- Achieve / maintain IBW
Adverse Effects of Inhaled Glucocorticoid
- Hoarseness / Throat irritation / candidiasis
- Bone Densisty reduction @ lumbar spine & hip
- Glaucoma
- Skin Bruising
- Can Inhibit Growth for children
-
MANAGEMENT:
- Use proper technique / spacer
-
Rinse & Spit
- –> THRUSH from immune supression
Interventions to Minimize Adverse Effects
for Glucocorticoid Use
- Lowest Dose & Lowest Duration
- NOT long-acting agents
- DO NOT STOP CHRONIC THERAPY ABRUPTLY!
- Monitor likely side effects:
- Calcium / Glucose / Lipids
- WBC / RBC
Side effects of Withdrawal of Therapy
of Corticosteroids
-
Disease Flare-Up
- underlying disease relapses / flares
- the original disease that the steroids were prescribed for
- underlying disease relapses / flares
-
Acute Adrenal Insufficiency
-
HPA-axis suppression
- Adrenocorticol atrophy / unresponsiveness
- lack of ACTH secretion from pituitary
- Symptoms are similar to addison’s syndrome
-
HPA-axis suppression
Determining HPA-Axis Suppression
after D/C of corticosteroids
- Factors are Dose / Duration / Type of Steroid
- Cotisol base levels are very VARIENT from person to person
- so it is best to use Intermediate / unsure
-
Categories of supression:
- HPA LIKELY Supressed
- Intermediate / Unsure
- HPA NOT Likely supressed
-
If you’re unsure if adrenal’s work use
- COSYNTROPIN TEST
Indications for HPA-Likely Supressed
for D/C of corticosteroids
- Prednisone (or equivilance)
- > 20mg/day
- OR
- > 3 weeks
-
Prednisone @ night
- > 5mg for more than 3 weeks
-
Cushingoid Apperance
- HYPERCortisolism
- moon face / obesity / buffalo hump
- HYPERCortisolism
Indications for Intermediate / Unsure HPA-Supression
for D/C of corticosteroids
- Prednisone doses of:
- 10mg - 20mg Daily
-
We typically ASSUME patient is at these levels,
- since cortisol base levels VARY from patient to patient
Indications for HPA Not Likely Supressed
for D/C of corticosteroids
Prednisone doses of:
< 10mg daily
Duration of:
< 3 weeks
Goals / Principles
for D/C of corticosteroids
- Goals:
- Prevent Relapse of disease
- Safe & Conventional taper regimen
- Allow HPAaxis to Recover
- Principles:
- Taper by 10-20% each step
- Step down doses every 1-2weeks
- Once dose gets closer to 5-20 mg qd prednisone:
- (estimate physiological levels of cortisol)
-
GO EVEN SLOWER
- to allow for gland to start working on its OWN
- Taper by 10-20% each step
