Review of Steroid Related Disorders

Question 1

Primary, secondary, and tertiary adrenal insufficiency:

Answer 1

1: Addison’s disease
2: deficient pituitary ACTH secretion
3: Deficiency hypothalamic CRH secretion

Question 2

Besides a bunch of non-specific symptoms in adrenal insufficiency, what could be present?

Answer 2

1. Think abdo tenderness on deep palpation w/o localizing signs
2. Long-standing adrenal insufficiency could show hyperpigmentation or weight loss
3. Maybe fever

Question 3

Hyponatremia occurs mostly with

Answer 3

glucocorticoid deficiency (due to elevated AVP levels, resulting in increased free water retention, decreased Na pump activity, decreased GFR)

Question 4

Main differences b/w primary and secondary adrenal insufficiency:

Answer 4

1. Hyperpigmentation NOT present in secondary if ACTH levels not elevated
2. Dehydration WON’T occur, and hypotension less prominent; NO HYPERKALEMIA

Question 5

Cortisol increases with; with intermediate levels, what should be done?

Answer 5

stress; they are highest in the am and lessen throughout the day until midnight;
cosyntropin (in case you have values in b/w 10 and 20)

Question 6

If concerned about secondary AI, what can you do?

Answer 6

1 mcg cosyntropin test; give some time in b/w glucocorticoid admin and this test so the former doesn’t suppress the axis

Question 7

Treatment of adrenal insufficiency:

Answer 7

1. Give NS IV immediately
2. Give dexa immediately (can give hydrocortisone ever 6-8 hrs for first 24 hrs)
3. Mineralocorticoid takes several days to work, so you can give fludrocortisone after saline’s stopped;

give dexa at its low dose, prednisone at its dose at bedtime, or give HC in am and then again in early afternoon for glucocorticoid replacement

Question 8

When do we consider HPA axis suppression?

Answer 8

Doses greater than 20 mg of prednisone a day for greater than 3 weeks

Question 9

Complications of chronic therapy: Cushing’s: what could you see in iatrogenic form?

Answer 9

1. Aggravation of glaucoma, cataracts, aseptic necrosis, and osteoporosis
2. Loss of muscle mass, weakness, worsening of DM, increased infection, poor wound healing, weight gain, psych disturbances

Question 10

What can put you at increased risk of fracture?

Answer 10

Once on glucocorticoids (glucocorticoid induced osteoporosis)

Question 11

Steroid induced bone loss occurs primarily in

Answer 11

trabecular bone (osteoblast number and function affected; bone resorption parameters elevated with increases seen in eroded surfaces, osteoclast covered surfaces, and osteoclast number)

Question 12

For GCOP, GCs inhibit; treat those who are on

Answer 12

intestinal absorption of Ca and cause hypercalciuria; may have mild hyperparathyroidism;
greater than 5 mg/day for greater than 3 mos (use lowest effective dose for as short as possible; adequate Ca and vit D intake, do weight-bearing exercise and don’t smoke; maybe use bisphosphonates)