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Pharmacology Unit 5 > Pharmacology of Adrenal Steroids > Flashcards

Pharmacology of Adrenal Steroids Flashcards

1
Q

What are the layers of the adrenal gland (superficial to deep)?

A
  1. Zona Glomerulosa (Cortex)
  2. Zona Fasciculata (Cortex)
  3. Zona Reticularis (Cortex)
  4. Medulla
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2
Q

In what portion of the adrenal are the following steroids made?

  1. Aldosterone
  2. Androgens
  3. Cortisol
A
  1. Aldo - Zona Glomerulosa
  2. Andro - Zona Reticularis
  3. Cortisol - Zona Fasiculata and Reticularis
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3
Q

What are the naturally occuring glucocorticoids, mineralocorticoids, and sex hormones made w/i the adrenal?

A
  1. Gluc - Cortisol
  2. Mineral - Aldosterone and Deoxycorticosterone
  3. Sex Hormones - Testosterone, Estradiol, Estrone
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4
Q

Describe the general mechanism of glucocorticoid action

A
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5
Q

Describe the hypothalamic-pituitary-adrenal axis

A
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6
Q

Describe glucocorticoid metabolic effects. What is the overarching goal of these metabolic effects?

A
  1. Increase gluconeogenesis
  2. Release amino acids through muscle catabolism
  3. Inhibit peripheral glucose uptake
  4. Stimulate lipolysis

GOAL: Maintain adequate glucose for the brain

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7
Q

What are the glucocorticoid effects on inflammation?

A

Overall anti-inflammatory effects

  1. Upreg. of anti-inflamm proteins
  2. Downreg. of pro-inflamm proteins
  3. Decreased WBC presence and function at sites of inflamm
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8
Q

Four major effects of excess cortisol?

A
  1. Inhibition of bone formation (osteoporosis)
  2. Suppression of calcium absorption
  3. Delayed wound healing
  4. Catabolic effects on skin, connective tissue, msucle, peripheral fat, lymphoid tissue
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9
Q

What two proteins (mentioned in lecture) are upregulated by aldosterone?

A
  1. Na+/K+ATPase
  2. Epithelial Na+ channel expression
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10
Q

Blood concentrations of cortisol are 2000x higher than aldosterone. How then does aldo exhibit any tissue specific effect whatsoever?

A

In aldo-specific cells, 11Beta-Hydroxysteroid Dehydrogenase Type 2 converts active cortisol into inactive cortisone.

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11
Q

What are the two most significant regulators of aldosterone secretion?

A
  1. Extracellular K+ concentration
  2. Angiotensin II
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12
Q

What are the general goals of modifying molecular structure of corticosteroids?

A

MODIFY:

  1. Affinity of steroid for mineralocorticoid vs. glucocorticoid receptors
  2. Extent of protein binding
  3. Stability/t1/2
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13
Q

What is the most commonly used synthetic mineralocorticoid? What is its mineralocortioid activity compared to cortisol?

A

Fludrocortisone; 125x > cortisol

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14
Q

A patient has decreased levels of cortisol and aldosterone. ACTH is elevated. Dx?

A

Primary adrenocortical insufficiency

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15
Q

A patient has low cortisol and low ACTH. Dx?

A

Secondary adrenocortical insufficiency

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16
Q

What are two major causes of secondary adrenal insufficiency?

A
  1. Suppression from exogenous glucocorticoid Tx
  2. Hypopituitarism
17
Q

A patient presents with symptoms that make you suspect adrenal insufficiency. Since you’re a clever med student, what do you look for to differentiate betwixt the two?

A

Secondary Adrenal Insufficiency has:

  1. NO hyperpigmentation
  2. Near-normal aldosterone levels
18
Q

What are precipitating causes of acute adrenal crises?

A
  • Events such as trauma, sepsis, surgery (ie stress) in chronic adrenal insufficiency
  • Hemorrhagic destruction of gland
  • Rapid withdrawal of steroids
19
Q

Describe the method used in order to diagnose adrenal insufficiency

A
  1. Administer Cosyntropin
  2. Normal: cortisol > 18 ug/dL, Abnormal: cortisol < 18 ug/dL
20
Q

Describe the strategy for primary adrenal insufficiency treatment

A
  1. Glucocorticoid: Highest dose Hydrocortisone in the morning and lower dose in the afternoon (mimic diurnal variation)
  2. Mineralocorticoid: Fludrocortisone once a day. Liberal salt intake
21
Q

How should primary adrenal insufficiency Tx be changed in a patient with minor febrile illness? Severe stress/trauma?

A
  • Minor febrile: Increase glucocorticoid dose 2x-3x for a few days of illness. Do NOT increase mineralcorticoid
  • Stress/trauma: Inject prefilled Dexamethasone IM
22
Q

Describe the steroid coverage for those with primary AI going into surgery with moderate illness, major illness, those going into moderately stressful surgery and major surgery.

A
  1. Moderate illness: Hydrocortisone (HC) 50 mg PO BID/IV
  2. Severe Illness: HC 100 mg IV Q 8hr
  3. Moderate Surgery: HC 100 mg IV just before procedure
  4. Major Surgery: HC 100 mg IV before anesthesia and then Q8 hr for first 24hr
23
Q

Describe the process of treating a patient with an acute adrenal crisis

A
  1. Obtain blood for serum cortisol, renin, ACTH but do not delay Tx while waiting for definitive proof of Dx
  2. Large amounts of IV fluid
  3. High-dose IV glucocorticoids: Dexamethasone 4 mg IV every 12-24 hr if no previous Dx of adrenal insufficiency, Hydrocortisone 100 mg IV every 6 hrs until stable
  4. Gradual tapering
24
Q

Why should hypotonic solution not be used in acute renal crises?

A

It will worsen hyponatremia

25
1. Two examples of ACTH-dependent glucocorticoid excess? 2. Two examples of ACTH-independent glucocorticoid excess?
1. Pituitary Adenoma (Cushing's disease), Ectopic ACTH production (SCLC) 2. Adrenal adenoma or carcinoma
26
Describe the procedure used to diagnose Cushing's syndrome.
* Measure ACTH * 24 hr cortisol excretion * **Low-dose overnight dexamethasone suppression test** * Midnight salivary cortisol level **Dx requires at least TWO of these tests to be positive**
27
Describe the findings of a dexamethasone suppression test on a patient with Cushing's Syndrome
Normally, a patient would have suppressed ACTH and cortisol, but in a patient with CS, cortisol remains high
28
What will be the general lab findings of ACTH and Cortisol in a patient with: 1. ACTH independent process? 2. ACTH dependent process?
1. Low ACTH, High Cortisol 2. High ACTH, High Cortisol
29
What is a risk of surgical treatment of Cushing's Syndrome?
Patients are at risk for adrenal insufficiency due to abrupt drop in cortisol levels
30
What are the 5 medications to treat Cushing's Syndrome? Mechanisms?
* Aminoglutethimide - Blocks cholesterol conversion to pregnenolone * Ketoconazole - Nonselective inhibitor of adrenal and gonadal steroid synthesis * Mitotane - Nonselective cytotoxic action on adrenal cortex * Metyrapone - 11Beta-Hydroxylase inhibitor (Blocks conversion of 11-Deoxycortisol to cortisol) * Mifepristone - glucocorticoid receptor antagonist
31
What is the utility of the Metyrapone test? What would be the findings of a healthy patient?
The metyrapone test is used to test the anterior pituitary. A patient is given a dose of metyrapone which blocks the conversion of 11-deoxycortisol (DOC) to cortisol. Therefore, in a normal patient, ACTH and DOC should increase.
32
What are clinical indicators to test for aldosteronism?
* HTN w/ hypokalemia * Tx-resistant HTN * Adrenal incidentaloma * Early-onset HTN * Severe HTN * Whenever considering secondary HTN
33
What are screening tests that should be performed if primary aldosteronism is suspected? Findings in a patient with primary aldo.?
1. Plasma aldo concentration (**Increased**) 2. Plasma renin activity (**Decreased**) 3. PAC/PRA ratio (**\>20 ng/dL**) 4. Urine collection (**Elevated aldo and decreased Na+**)
34
What are the surgical and medical treatments for primary aldosteronism?
* Surgery - remove unilateral adenoma * Medical - spironolactone (AR antag.) or Eplerenone
35
What is the most common enzyme deficiency in congenital adrenal hyperplasia? How does this lack of enzyme perturb steroid levels and what are clinical manifestations of these perturbations?
* **21-Hydroxylase Deficiency** resulting in defective conversion of 17-hydroxyprogesterone to 11-deoxycortisol (and progesterone to DOC) * Reduced **cortisol** causes reduced negative feedback and increased **ACTH**. **Adrenal androgen** production is increased causing **hirsutism,** other forms of **virilization**, and **salt wasting**
36
How is late-onset 21Beta-Hydroxylase deficiency diagnosed?
Cosyntropin stimulation test: with a 21Beta-hydroxylase deficiency, there will be increased levels of plasma 17-hydroxyprogesterone
37
What is a serious sequela of chronic supraphysiologic steroid use? What is the risk of rapid steroid withdrawal?
1. Iatrogenic Cushing's Syndrome (osteoporosis, diabetes, infection, etc.) 2. Acute Adrenal Crisis
38
What is the purpose of alternate day steroid Tx? What is a contraindication for this strategy? Medications used for this strategy?
To minimize side effects of: * Hypothalamic-Pituitary-Adrenal suppression * Iatrogenic Cushing's syndrome Contraindicated for Tx of adrenal insufficiency Prednisone, Prednisolone, Methylprednisolone

Pharmacology Unit 5 (7 decks)

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