Week 12 - Cases 1-3 Flashcards
what five clinical features prompt a GP to consider Cushing’s syndrome
- Recent rapid weight gain
- Truncal or central obesity
- Fullness of face or “moon face”
- Increased blood pressure
- Glycosuria (associated with insulin resistance)
what are the BMI readings
healthy weight: 18.5–24.9 kg/m2
overweight: 25–29.9 kg/m2
obesity I: 30–34.9 kg/m2
obesity II: 35–39.9 kg/m2
obesity III: 40 kg/m2 or more.
what is saxenda
a GLP1 analogue that slows gastric emptying, increased satiety
what is the name of Saxenda and when is this a possible treatment on the NHS
Liraglutide (Saxenda) is available on the NHS as a possible treatment for managing weight in adults, if they have: a body mass index (BMI) of at least 35 (or at least 32.5 for some black or ethnic minority people, because their weight-related health risks can be higher at a lower BMI); high blood sugar, which increases their risk of developing diabetes, and high risk of cardiovascular problems such as heart attacks and strokes.
when is surgery considered for obese patients
If BMI > 40 or BMI 35-40 with other significant weight-related disease
Tried all non-surgical approaches
Has been or is willing to receive Tier 3 weight management services
what kind of obesity is found in Cushing’s
truncal obesity
is gynacomastia found in Cushing’s
yes
the society of Endocrinology recommend testing for Cushing’s syndrome in what groups
Patients with unusual features for age (e.g., osteoporosis, hypertension)
Patients with multiple and progressive features, particularly those who are more predictive of Cushing’s syndrome
Children with decreasing height percentile and increasing weight
Patients with adrenal incidentaloma compatible with adenoma
what are the dexamethasone suppression test results
Normal subject: Reduction in cortisol levels following low-dose dexamethasone.
Cushing’s disease: No reduction in cortisol output after low-dose dexamethasone, but inhibition of cortisol output following high-dose dexamethasone.
Adrenal tumour or ectopic ACTH: No reduction in steroid production after low or high dose dexamethasone.
what is cyclical cushing’s
a very rare entity characterised by alternating excess and normal endogenous cortisol secretion and thus can have variable clinical features
if clinical suspicion is high, even if the initial tests are negative, a repeat follow up testing is required. Urinary free cortisol or late-night salivary cortisol are preferred screeing options
what are the ACTH dependent cushing syndrome causes
Pituitary Adenoma (Cushing’s Disease) – 65-70%
Ectopic ACTH 5-10% (Bronchial carcinoid commonest)
Unknown source of ACTH <1%
what are the ACTH independent causes of cushing syndrome
Adrenal Adenoma – 10-18%
Adrenal Carcinoma 6-8%
Adrenal Hyperplasia
what is next test carried out after failure to suppress dexamethasone test
measure ACTH
what happens if ACTH-Independent CS (i.e., ACTH <5 pg/mL)
Arrange CT Adrenals to assess adrenal tumour or hyperplasia.
what happens if ACTH Dependent CS (pituitary dependent) (i.e., ACTH >20 pg/mL)
Arrange a pituitary MRI; presence of pituitary adenoma > 6mm, is highly consistent with Cushing’s Disease.
Arrange non-invasive tests (High-Dose Dexamethasone Suppression Test (HDDST) and Corticotropin-Releasing Hormone (CRH) stimulation test, if consistent confirms Cushing’s Disease.
what happens if Intermediate ACTH (i.e., ACTH 5-20 ng/mL)
Repeat testing and if value remains consistently intermediate then consider Corticotropin-Releasing Hormone test (CRH). The presence of ACTH response suggests ACTH Dependent (Cushing’s Disease), while absence of a response suggest ACTH Independent (Adrenal disease) or ectopic ACTH secretion.
Arrange Inferior Petrosal Sinus Sampling (IPSS) with CRH stimulation for individuals with unclear MRI (lesion <6 mm) or non-concordant HDDST+CRT to distinguish between ectopic ACTH secretion and Cushing’s Disease.
what do patients who have a pituitary tumour surgery require
hydrocortisone replacement therapy after the operation
what are the consequences of removing all or part of the anterior pituitary gland
The hormones affected and needing replacement could be any of those produced from the anterior pituitary gland:
TSH (Thyroxine)
GH (growth hormone therapy in selected few)
ACTH (hydrocortisone therapy)
FSH/LH (Testosterone or Oestrogen/Progesterone hormone replacement).
Prolactin does not need to be replaced. The posterior pituitary hormones:
(ADH, Endorphins, Oxytocin) do not need replacement as they are not secreted by the pituitary gland but merely stored.
Only, few cases require Desmopressin (synthetic ADH) where ADH secretion is affected because of the damage to posterior pituitary or hypothalamus causing Diabetes Insipidus
what are the different types of pituitary tumours
Adenomas arising from different cells are as below:
Gonadotroph adenoma – mostly non-functioning
Thyrotroph adenoma – TSH producing
Corticotroph adenoma – ACTH producing (Cushing’s disease)
Lactotroph adenoma – Prolactin producing
Somatotroph adenoma – GH producing (Acromegaly)
what is the name of the cortisol synthesis inhibitor that is used to reduce his adrenal steroid output before going under a bilateral adrenalectomy
Metyrapone
what are the hormonal consequences of removing both adrenal glands
no production of glucocorticoid and mineralcorticoid.
he will therefore require glucocorticoid and mineralcorticoid replacement therpay
what are the sick day rules in place for people with Cushing’s
requirement to double the dose of glucocorticoids in the event of any medical illness, physical and mental stress, and trauma including surgical procedures
LOOK AT SICK DAY RULES ON 1MED.
what kind of deficiency is primary adrenal insufficiency associated with
both glucocortocoids and mineralcorticoid deficiency and always needs replacement with cortisol and aldosterone
