Pharm: endocrine cases

Question 1

causes of primary adrenal insufficiency

Answer 1

• anatomic destruction of gland
  1. idiopathic atrophy (autoimmune, ALD)
  2. surgical removal
  3. infection (TB, fungal, viral)
  4. hemorrhage
• metabolic failure in hormone production
  1. CAH
  2. medications: metyrapone, ketoconazole, mitotane

Question 2

causes of secondary adrenal insufficiency

Answer 2

1. hypopituitarism due to H-P disease

2. suppression of H-P axis

Question 3

primary adrenal insufficiency symptoms

Answer 3

all three zones of adrenal cortex involved - result is inadeuqate secretion of glucocorticoids, mineralcorticoids, and androgens - onset is usually gradual, if untreated can eventually result in shock

Question 4

how does primary adrenal insufficiency typically present?

Answer 4

manifests as shock in a previously undiagnosed patient who is subjected to stress

Question 5

what are the non specific symptoms associated with primary adrenal insufficiency?

Answer 5

anorexia, nausea, vomiting, abdominal pain, weakness, fatigue, lethargy, confusion, or coma, fever without cause, amenorrhea, decreased axillary/pubic hair, loss of libido, depression

Question 6

symptoms of long standing primary adrenal insufficiency

Answer 6

hyperpigmentation and weight loss

Question 7

symptoms of mineralocorticoid deficiency

Answer 7

hyponatremia (glucocorticoid deficiency), hyperkalemia (aldosterone deficiency)

Question 8

how does glucocorticoid deficiency cause hyponatremia

Answer 8

elevated AVP (arginine vasopressin) levels result in increased free water retention, decreased sodium pump activity, and decreased GFR

Question 9

difference in symptoms between primary and secondary adrenal insufficiency

Answer 9

no hyperpigmentation or dehydration in secondary adrenal insufficiency
-secondary also might show evidence of a pituitary or hypothalamic tumor

Question 10

hypoglycemia is more common in secondary or primary adrenal insufficiency?

Answer 10

secondary

Question 11

how is diagnosis of adrenal insufficiency made?

Answer 11

check cortisol levels, check ACTH, values less than 10 for cortisol under stress highly suggestive of insufficiency, cosyntropin given (check again in 60 min - should raise)

Question 12

treatment of adrenal insufficiency

Answer 12

• immediate
• initial goal: reverse hypotension and electrolyte abnormalities
• large volumes of NS
• dexamethasone infused
• maybe hydrocortisone
• fludrocortisone after saline stopped

Question 13

complications of chronic steroid therapy

Answer 13

• HPA axis suppression

- cushing’s syndrome

Question 14

features more common in iatrogenic vs endogenous cushing’s

Answer 14

aggravation of glaucoma, cataracts, aseptic necrosis, osteoporosis
-HTN, hirsuitism, acne rarely seen

Question 15

where does steroid induced bone loss primarily occur?

Answer 15

trabecular bone

Question 16

glucocorticoid mechanism to steroid induced bone loss

Answer 16

1. increased RANKL = more osteoclast activity
2. increased PPAR gamma 2 and decreased Wnt signaling = decreased osteoblastogenesis and increased apoptosis
3. activation of caspase 3 = increased apoptosis of osteocytes = decreased bone formation

Question 17

treatment/prevention of patients on GC to protect bone loss

Answer 17

maintain adequate calcium and vit D, exercise, don’t smoke, bisphosphonates