Adrenal disorder

physiology of adrenal

±Multiple steps involved in cortisol release

±Multiple things that can be affected

±CRH: corticotropin-releasing hormone

±ACTH: adrenocorticotropic hormone

cortisol issues

• cushing’s syndrome: excess cortisol

• addison’s disease: insufficient cortisol

cushing’s vs addinson’s chart

Cushing’s	Addison’s
too much cortisol	too little cortisol
hyperglycemia	hypoglycemia
hypernatremia	hyponatremia
hypokalemia	hyperkalemia
hypertension	hypotension

cushing’s syndrome causes

• pituitary ademoma

• adrenocorticotropic hormone (ACTH) secreting tumors

• adrenal tumors

• hypersecretion due to excess corticotropic releasing hormone

• iatrogenic: includes contributing medications

glucocorticoid affects

cushing’s syndrome treatment

• Adenoma/Tumors: surgical and/or radiation preferred options whenever possible

• Medications (potentially used around procedures or as palliative)

  • Steroidogenesis inhibitors

    • cholesterol is a precusor for ACTH synthesis

    • inhibit 11-β-hydroxlase, final step to cortisol production

  • Adrenolytic agents

  • Neuromodulatory agents

  • Glucocorticoid Blockers

steroidogenesis inhibitor medications

• metyrapone

• ketoconazole

• etomidate

• osilodrostat

metyrapone

primarily aid for Cushing’s diagnosis

• rapid onset

• BP and electrolyte effects

• androgenic effects

ketoconazole

• takes weeks to work

• drug interactions

etomidate

anesthetic

• IV only

• for acute use only

osilodrostat

• specific indications for Cushing’s adjunct if surgery not feasible/sufficient

• electrolyte and QT monitoring

adrenolytic agent for cushing

mitotane

mitotane AE

• cytotoxic

• significant neuro and GI effects

neuromodulators

°D2 agonists: cabergoline/bromocriptine

°Somatostatin analogs: may not work well

°Cyproheptadine: may cause drowsiness, weight gain

mifepristone indication

glucocorticoid receptor blocker

• indication: hyperglycemia with Cushing’s

• also used for medication-induced abortion

iatrogenic-steroid

• Long-term steroid causes symptoms like Cushing’s

• Long-term usually more than 1-3 weeks; also consider dose

• Some variation in tapering regimens, partly due to differences in patients

• Will take longer with higher doses/duration

• May take months-year

• May require supplemental steroids for up to a year during stressful situations

fludrocortisone used for what

• addison’s disease

• administered to help blood pressure issues

• a mineralocorticoid so more specific to bring up blood pressure

addison’s disease treatment

• Need to replace natural cortisol

• Hydrocortisone or cortisone generally used

  • Shorter half life

  • Better able to mimic natural cortisol release pattern

• Sample treatment

  • Hydrocortisone 20 mg in morning, 10 mg late afternoon

  • Take with food

• Can consider other steroids if needed to simplify regimen

• Need to check equivalency for doses

Addisonian crisis

±Need additional doses in times of stress

±Stressful situations, surgery, illness, trauma

±May need IV treatment acutely

±May be given access to suppositories or injectable

±Recommended to carry a card/bracelet to let professionals know about Addison’s

what is hyperaldosteronism

overactivation of Renin-angiotensin system (RAS) system

hyperaldosteronism causes

°Can be from various causes, underlying issue must be addressed

°Can cause hypertension and hyperkalemia

hyperaldosteronism treatment

°Treatment of choice is spironolactone

°Eplerenone is alternative: reduced gynecomastia

°Amiloride: may not be as effective but option for tolerability

hyperaldosteronism monitor

monitor potassium

hypoaldosteronism treatment

give fludrocortisone to manage hypotension