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PDAT2 > Lec 7 Adrenal Insufficiency - Addison's + Steroid Dosing > Flashcards

Lec 7 Adrenal Insufficiency - Addison's + Steroid Dosing Flashcards

1
Q

Addison’s Syndrome

Etiology

A

Adrenal Insufficiency

  • VERY RARE
    • inability to produce cortisol / aldosterone
  • Primary = Addison’s Disease
    • Autoimmune, 90% of tissue loss before S/S
      • late detection
  • Secondary causes
    • Long-Term Glucocorticoid administration
    • lack of ACTH stimulators or TUMORS
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2
Q

Symptoms of Addison’s Syndrome

A

Adrenal Insufficiency

  • Weakness / Weight Loss / Anorexia
  • Skin Pigmentation + muscous membranes
  • N/V + Abdominal Pain
  • Constipation
  • Syncope
  • Salt craving
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3
Q

Diagnosis of Addison’s Disease

A

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
  • Primary if ACTH is HIGH
    • auto-immune, issue is @adrenals
  • Secondary if ACTH is low
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4
Q

Cosyntropin

A

Synthetic ACTH

Used to diagnose for Addison’s Disease

Or to simply see if patient’s Adrenals are Working

–> should stimulate Cortisol release

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5
Q

Cortisol Replacement Therapy

for Addison’s Disease

A
  • 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
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6
Q

Types of Short-Acting Glucocorticoids

= Steroids = Corticosteroids

A

Hydrocortisone

Cortisone Acetate

some mineralcorticoids activity –> RAISE BP

BID or TID

half life of 8-12 hours

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7
Q

Types of Intermediate-Acting Glucocorticoids

= Steroids = Corticosteroids

A

Prednisone

​some mineralcorticoid activity

Triamcinalone

Methylprednisone

half life of 12-36 hours

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8
Q

Types of LONG Acting Glucocorticoids

= Steroids = Corticosteroids

A

Dexmethasone

Beamethasone

NO Mineralcorticoid activity!

half life of 36-72 hours

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9
Q

Supplemental Glucocorticoids Dosing

for Addison’s Disease

A

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.
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10
Q

Mineralcorticoid Replacement

for Addison’s Disease

A

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
  • ​Monitor:
    • BP / Na / K / Edema
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11
Q

Acute Adrenal Insufficiency

A
  • 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
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12
Q

Treatment for

Acute Adrenal Insufficiency​

A
  • Hydrocortisone 100mg STAT -> taper off dose to normal dose
    • very HIGH DOSE
      • overdose is less likely, and no short term issues
  • ​​FLUIDS:
    • to correct volume depletion / dehydration
      • hypotension & hypoclycemia
  • Remove / Treat precipitating factor
    • usually by just telling them to keep taking their medications​
      ​
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13
Q

Patient Education for

Addison’s Disease

A
  • 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
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14
Q

Indications for Corticosteroids

A
  • Replacement therapy
    • for Addison’s Disease
  • Anti-Inflammatory / Immunosuppresive effects
    • Rheumatic / Allergic / Respiratory Disease
    • Infectious / Ocular / Skin Disease
    • GI / Organ transplantation / edema
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15
Q

Fludrocortisone

A

only for Mineralcorticoid Action (aldosterone)

not needed w/ Secondary adrenal insufficiancy

Raise BP / Na+ / Water retention

decrease in Potassium

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16
Q

PK’s of Corticosteroids

A
  • Readily absorbed from the GI Tract
    • GUT NEEDS TO WORK for drug to work
      • –> IV if the gut does not work
  • Highly Protein Bound
    • CBG / Albumin
      • takes a long time to leave the system
  • Metabolized by Liver
  • Excreted Renally
17
Q

Steroid Dosing Strategies

for Replacement Therapy

A

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
  • Adjust dose during STRESSFUL events
18
Q

Steroid Dosing Strategies

for Suppressive Therapy

A
  • Short Term / High dose
    • ​Asthma / anaphylaxis
      • acute adrenal insufficiencies
  • 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
19
Q

Types of Adverse Effects

of Corticosteroids

A
  • 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
20
Q

Glucocorticoid Side Effects (Continued Use)

INCREASES / STIMULATES:

A
  • Fluids / Electrolytes
    • ​Aldosterone-Like Effects
  • GI
    • ​abdominal pain –> PUD
  • Behavorial
    • ​Insomnia / Nervousness
  • Cataracts
  • HYPERlipidemia / HYPERglycemia
  • Teratogenic
    • Pregnancy category C
21
Q

Glucocorticoid Side Effects (continued Use)

Decreases / Weakens

A
  • Immune Response
    • inhibits immune system / inflammatory response
  • Hematologic​
  • Myopathy
    • ​weakness of proximal limb muscles
  • Wound Healing
    • ​decrease in collagen / fibroblast
  • Osteoporosis
22
Q

Hematologic Side Effects

from continued use of Glucocorticoids

A
  • 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
23
Q

Wound Healing Side Effects

from continued use of Glucocorticoids

A
  • Decreases collagen production
    • ​and fibroblastic therapy
  • ​Inhibits vascularization and collagen deposition
    • ​as well as stabilization of lysosomal membranes
  • ​TREATMENT:
    • ​Vitamin A
      • MVI qd
24
Q

Osteoporosis Side Effects

from continued use of Glucocorticoids

A
  • 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)
25
Q

HYPERglycemia Side Effects

from continued use of Glucocorticoids

A
  • 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
26
Q

Adverse Effects of Inhaled Glucocorticoid

A
  • 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
27
Q

Interventions to Minimize Adverse Effects

for Glucocorticoid Use

A
  • Lowest Dose & Lowest Duration
  • NOT long-acting agents
  • DO NOT STOP CHRONIC THERAPY ABRUPTLY!
  • Monitor likely side effects:
    • Calcium / Glucose / Lipids
    • WBC / RBC
28
Q

Side effects of Withdrawal of Therapy

of Corticosteroids

A
  • Disease Flare-Up
    • underlying disease relapses / flares
      • ​the original disease that the steroids were prescribed for
  • Acute Adrenal Insufficiency
    • HPA-axis suppression
      • ​Adrenocorticol atrophy / unresponsiveness
      • lack of ACTH secretion from pituitary
    • ​Symptoms are similar to addison’s syndrome
29
Q

Determining HPA-Axis Suppression

after D/C of corticosteroids

A
  • 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
30
Q

Indications for HPA-Likely Supressed

for D/C of corticosteroids

A
  • Prednisone (or equivilance)
    • > 20mg/day
    • OR
    • > 3 weeks
  • ​Prednisone @ night
    • > 5mg for more than 3 weeks
  • ​Cushingoid Apperance
    • HYPERCortisolism
      • moon face / obesity / buffalo hump
31
Q

Indications for Intermediate / Unsure HPA-Supression

for D/C of corticosteroids

A
  • Prednisone doses of:
    • 10mg - 20mg Daily
  • ​We typically ASSUME patient is at these levels,
    • since cortisol base levels VARY from patient to patient
32
Q

Indications for HPA Not Likely Supressed

for D/C of corticosteroids

A

Prednisone doses of:

< 10mg daily

Duration of:

< 3 weeks

33
Q

Goals / Principles

for D/C of corticosteroids​

A
  • 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

PDAT2 (22 decks)

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