Management of Adrenal Failure

Question 1

Clinical features of Cushing’s syndrome

Answer 1

high cortisol
centripetal obesity 
moon face buffalo hump
proximal myopathy
hypertension hypokalaemia
red striae thin skin bruising 
osteoporosis diabetes

Question 2

list causes of Cushing’s

Answer 2

taking too much steroids
pituitary dependent Cushing’s disease
ectopic ACTH from lung cancer
adrenal adenoma secreting cortisol

Question 3

Investigations to determine cause of Cushing’s syndrome

Answer 3

24h urine collection (measure free cortisol)
blood diurnal cortisol levels
low dose dexamethasone suppression test
+ve result (any cause of Cushing’s will fail to suppress cortisol)

Question 4

Cut off for Cushing’s diagnosis for cortisol and LDDST tests

Answer 4

basal cortisol 800nM

end of LDDST 680nM

Question 5

pharmacological manipulation of steroids via

Answer 5

enzyme inhibitors

receptor blocking drugs

Question 6

Conn’s syndrome

Answer 6

excess aldosterone

Question 7

List examples of inhibitors of steroid biosynthesis

Answer 7

metyrapone

ketoconazole

Question 8

List examples of mineralocorticoid receptor antagonists.

Answer 8

spironolactone

epleronone

Question 9

Metyrapone inhibits what enzyme?

Answer 9

11b hydroxylase

Question 10

in metyrapone use steroid synthesis is arrested at what stage?

Answer 10

11deoxycortisol stage

Question 11

Uses of metyrapone

Answer 11

control of Cushing’s prior to surgery
(better post op recovery)
control of Cushing’s after radiotherapy

Question 12

side effects of metyrapone

Answer 12

hypertension in long-term

hirsutism

Question 13

why was ketoconazole withdrawn as an anti fungal agent?

Answer 13

risk of hepatotoxicity

Question 14

Surgical treatment of Cushing’s

Answer 14

depends on cause
pituitary surgery
bilateral adrenalectomy
unilateral adrenalectomy

Question 15

cause of Conn’s syndrome

Answer 15

benign adrenal cortical tumour

zona glomerulosa

Question 16

pharmacokinetics of spironolactone

Answer 16

orally active

highly protein bound and metabolised in the liver

Question 17

mechanism of action of spironolactone

Answer 17

converted to several active metabolites e.g. canrenone (competitive antagonist of MR)
blocks Na+ resorption/K+ excretion

Question 18

side effects of spironolactone

Answer 18

menstrual irregularities

gynecomastia

Question 19

what is epleronone?

Answer 19

mineralocorticoid receptor antagonist

Question 20

epleronone vs spironolactone

Answer 20

epleronone less binding to androgen and progesterone receptors so it’s better tolerated

Question 21

What are phaemochromocytomas?

Answer 21

tumours of adrenal medulla secretes catecholamines

Question 22

Clinical features of phaemochromocytomas

Answer 22

hypertension in young people

episodic severe hypertension (on abdo palpation)

Question 23

Why are phaemochromocytomas medical emergencies?

Answer 23

severe hypertension > MI/stroke

high adrenaline > ventricular fibrillation +death

Question 24

Management of phaemochromocytomas

Answer 24

eventually surgery by careful prep required as anaesthetic can > hypertensive crisis

Question 25

Pharmacological treatment of phaemochromocytomas

Answer 25

alpha blockade (may need IV)
beta blockade to prevent tachycardia