Management of Adrenal Failure

Question 1

How can we use dexamethosone to diagnose Cushings?

Answer 1

Low dose dexamethasone suppression test, normal people will suppress cortisol to zero, Cushings will not

Question 2

What is dexamethosone?

Answer 2

Highly potent artificial steroid

Question 3

How is Cushing’s treated?

Answer 3

First work out if its pituitary, adrenal or ectopic

Metyrapone or ketoconazole (inhibit steroid biosynthesis)

Question 4

How does metyrapone work?

Answer 4

Inhibits 11 hydroxylase, no cortisol or aldosterone produced

Question 5

How does ketoconazole work?

Answer 5

Blocks 17 hydroxylase reducing cortisol levels

Question 6

Does 11 deoxycortisone have negative feedback?

Answer 6

No

Question 7

Who is metyrapone given to? When and why?

Answer 7

Control Cushings prior to surgery (they have poor wound healing so this helps with surgery recovery)
Control Cushings after radiotherapy

Question 8

What are side effects of metyrapone?

Answer 8

Excess 11 deoxycortisone= high BP, low K

Excess testosterone= hirtuism

Question 9

Who is ketoconazole given to? What must we also do?

Answer 9

Control Cushings prior to surgery

Make sure to check liver function as it can damage the liver

Question 10

What are surgical options for Cushing’s?

Answer 10

Pituitary surgery
Bilateral adrenalectomy
Unilateral adrenalectomy for adrenal mass

Question 11

What is Conn’s syndrome? What happens to aldosterone levels?

Answer 11

Benign adrenal tumor of zone glomerulosa

Excess aldosterone= hypertension and hypokalaemia

Question 12

How is Conn’s diagnosed?

Answer 12

Renin - angiotensin system should be suppressed (exclude secondary hyperaldosteronism)

Question 13

How is Conn’s treated?

Answer 13

Spironolactone or epleronone

Question 14

How does spironolactone work?

Answer 14

Antagonist of mineralocorticoid receptor

Blocks na resorption and k secretion

Question 15

What are side effects of spironolactone?

Answer 15

Menstrual irregularites

Gynaecomastia

Question 16

How does epleronone work?

Answer 16

Mineralocorticoid antagonist

Question 17

What are phaeochromocytomas? What hormone do they effect and how?

Answer 17

Tumors of adrenal medullas that secrete catecholamines

Question 18

How does phaeochromocytoma present?

Answer 18

Hypertension (especially in young people is uncommon so think phaeo/cushings/cohns)
Episodic severe hypertension- can cause myocardial infarction or stroke
Panic attacks

Question 19

How can we differentiate between phaeochromocytoma and Cohn’s?

Answer 19

Phaeo= episodic sever hypertension

Question 20

What do you have to treat phaeos as?

Answer 20

A medical emergency

Question 21

How is phaeo treated?

Answer 21

Surgery but cant do this straight away as tumor cannot be touched
First step= give alpha blocker after saline (to prevent severe BP fall)
IV fluid as alpha blockade commences
Beta blocker to prevent tachycardia
Once crisis is over then do surgery (weekend before massively block with alpha and beta blockade)

Question 22

Do phaeos have to be in the adrenal?

Answer 22

No, they can be extra adrenal and make adrenaline anyways