Chapter 24: Endocrine Disorders Part 3

What are the two main parts of the adrenal gland?

- Cortex

- Medulla

Which part of the adrenal gland is located on the inside?

Medulla

What hormones does the adrenal medulla release?

- Epinephrine

- Norepinephrine

Which part of the adrenal gland is located on the outside?

Cortex

What hormones does the adrenal cortex release?

- Glucocorticoids

- Cortisol

- Androgens

- Mineralocorticoids

- Aldosterone

What is secondary adrenal insufficiency caused by?

Decreased ACTH (from the pituitary gland, which controls cortisol production)

What is primary adrenal insufficiency also known as?

Addison's disease

What is Addison's disease?

A disease where adrenal glands do not produce sufficient amounts of cortisol and aldosterone

What causes primary adrenal insufficiency (Addison's disease)?

Autoimmune destruction of the adrenal cortex

What types of antibodies are involved in Addison's disease?

Antibodies to the adrenal cortex and antibodies to steroid enzymes

Why is cortisol important during stress?

A deficiency in cortisol during stress can lead to death

What is another cause of hypoadrenalism besides disease?

Exogenous (external) glucocorticoid use

What happens to CRF-ACTH signaling with prolonged glucocorticoid use?

It becomes suppressed

What happens to adrenal gland receptors with prolonged steroid use?

They downregulate

Why should steroid use not be stopped abruptly?

The body may be unable to respond to stressors

What is the recommended approach to steroid dosing?

Use the smallest dose needed

Why are steroid prescriptions time-limited?

To prevent adrenal gland atrophy

What are common symptoms of adrenal insufficiency?

- Weakness

- Hypotension

- Tachycardia

- Dizziness

- Fatigue

- Emotional lability

- Anorexia

- Hypoglycemia

- Electrolyte Imbalances (Hyponatremia and Hyperkalemia)

- Tanned apperance due to MSH

- Women may have loss of pubic and axillary hair or amenorrhea

Why do patients with adrenal insufficiency have a tanned appearance?

Due to increased melanocyte-stimulating hormone (MSH)

What is the relationship between ACTH and MSH?

They arise from the same precursor molecule

What skin change is seen in Addison's disease?

Brown pigment of the skin

What blood glucose change occurs in Addison's disease?

Hypoglycemia

What blood pressure change occurs in Addison's disease?

Postural hypotension

What happens to body hair in Addison's disease?

Changes in distribution of body hair

What GI symptoms occur in Addison's disease?

- Abdominal pain when eating (feed small meals like Ensure)

What happens to muscle strength in Addison's disease?

Muscle Weakness

Why do patients lose weight in Addison's disease?

Due to poor appetite

What is adrenal crisis?

A life-threatening complication of adrenal insufficiency

What are symptoms of adrenal crisis?

- Profound fatigue

- Dehydration

- Vascular collapse (low BP → shock)

- Renal Shutdown

What electrolyte changes occur in adrenal crisis?

Low serum sodium and high serum potassium

If a patient has low sodium, what should the nurse look for?

Craving salty foods (if continuous → serious problem)

What test is used to diagnose adrenal insufficiency?

Rapid ACTH test

What is the normal response to ACTH administration?

Cortisol should rise within 30 minutes

What does no cortisol rise indicate?

Adrenal cortex insufficiency

What is the treatment for adrenal insufficiency?

Daily replacement of glucocorticoids and mineralocorticoids

When are parenteral steroids needed?

During major stress, trauma, or surgery

What is prednisone?

A synthetic corticosteroid that mimics cortisol

What are the actions of prednisone?

- Suppresses inflammation - decreases immune response

What conditions is prednisone used for?

- Autoimmune disorders

- Allergic reactions

- Chronic inflammatory conditions (Crohn's)

- Adrenal insufficiency

- Transplant patients

When should prednisone NOT be used?

- Increased infection risk

- Hypersensitivity to corticosteroids

- Do NOT administer live vaccines if they are immunocompromised or on a corticosteroid 

What should be used with caution when taking prednisone?

- Raises blood glucose

- Long-term use can lead to osteoporosis and peptic ulcer disease

- Adrenal suppression

- Infection risk

What are common adverse effects of prednisone?

- Mood swings

- Hyperactivity

- Hyperglycemia (short-term),

- Increased appetite ("Munchies")

- Moon face (long-term)

What drug interactions occur with prednisone?

- NSAIDs increase risk of GI bleeding (so use cautiously)

- If on anticoagulants can alter effects of anticoagulants

What should the nurse monitor for patients on prednisone?

- CBC

- Glucose

- Electrolytes

- Signs of infection

- Blood pressure

What should patients be taught about prednisone?

- Take with food

- Do NOT stop abruptly (must taper)

- Avoid being around sick people

- Take in the morning if once a day pill (bc it will keep you up at night)

If a pt stops prednisone abruptly what will happen?

rebound effect of adrenal insufficiency

What is hyperadrenalism also known as?

Hypercortisolism

What is Cushing's disease?

Elevated ACTH due to a pituitary tumor

What is Cushing's syndrome?

Elevated cortisol due to adrenal cortex hyperfunction

What is the most common cause of Cushing's syndrome?

Exogenous steroid use

What are causes of hyperadrenalism?

- Pituitary adenoma

- Cushing's disease

- Cushing's syndrome

- Adrenal hyperplasia

- Adrenal neoplasm

- Carney complex, McCune-Albright syndrome

- ACTH-secreting tumors

What is Carney complex?

A genetic disorder

What is McCune-Albright syndrome?

Associated with Cushing's syndrome and precocious puberty

What body systems are affected in McCune-Albright syndrome?

Bone and skin

How does McCune-Albright affect bones?

Scar-like tissue develops, making bones weaker

What are the signs and symptoms for hyperadrenalism?

- Weight gain

- Redistribution of body fat to the face, trunk, and abdomen

- "Moon Fascies"

- "Buffalo hump" (Extra subcutaenous fat in the cervicothoracic area)

- Increase in the waist- to - hip circumference ratio

- Striae

- Easy bruising

- Poor wound healing

- Emotional lability

- HTN

- Osteoporosis

- Centrally located obesity

- Immunosuppression

What symptoms do women experience with hyperadrenalism?

- Hirsutism (facial hair)

- Male-pattern hair growth

- Amenorrhea

What skin conditions occur in hyperadrenalism?

- Acne

- Purpura

- Skin ulcers

- Poor wound healing

What are some symptoms of Cushing's disease?

- Personality changes

- CNS irritability

- Hyperglycemia

- Red Face

- Fat Round "Moon" Face

- Increased susceptibility to infection

- Fluid retention (edema)

- Thin extremities

- GI distress due to increased acid

What skin changes occur in Cushing's disease?

- Purple striae

- Thin skin

- Bruising

- Petechiae

What bone condition occurs in Cushing's disease?

Osteoporosis (increased fracture risk)

What occurs in males with Cushing's disease?

Gynecomastia

What occurs in females with Cushing's disease?

Amenorrhea and hirsutism

How does cortisol affect insulin?

Blocks the action of insulin

What metabolic effects result from high cortisol?

Glucose intolerance and hyperglycemia

How does cortisol affect bones?

Inhibits bone formation and increases bone reabsorption

What bone conditions result from high cortisol?

Osteopenia and osteoporosis

How does cortisol affect the immune system?

Suppresses immune response

What cardiovascular effect occurs with high cortisol?

Hypertension

What lab findings are seen in hyperadrenalism?

Elevated WBCs, hyperglycemia, hypokalemia

What cortisol tests are used for diagnosis?

Salivary cortisol and 24-hour urine cortisol

What is the dexamethasone suppression test?

Dexamethasone is given and cortisol should be suppressed

What result indicates Cushing's syndrome in this test?

No cortisol suppression

What imaging is used for diagnosis?

MRI and CT scan

What are treatments for Cushing's syndrome?

Surgery and ketoconazole

What is the purpose of ketoconazole in Cushing's?

Suppress cortisol

What is ketoconazole used for off-label?

Cushing's disease to control excess cortisol

What is the action of ketoconazole?

Antifungal that inhibits steroid synthesis by blocking adrenal enzymes, reducing cortisol

When should ketoconazole NOT be used?

Liver disease and prolonged QT intervals

What are adverse effects of ketoconazole?

- Hepatic toxicity

- Nausea/ Vomiting

- Abdominal pain

- Gynecomastia

- Menstrual irregularities

What drug interactions occur with ketoconazole?

- QT-prolonging drugs

- Be careful with anticoagulants, benzodiazepines, statins

What should NOT be given with ketoconazole?

Antacids (must be given hours apart)

What should the nurse monitor for ketoconazole?

- Liver function tests (before and during med)

- Cortisol levels

- EKG

What should patients be taught about ketoconazole?

- Take with food

- Watch for jaundice/RUQ pain/dark urine

- Avoid alcohol

- Do NOT stop abruptly

- Use contraception

What is a pheochromocytoma?

A tumor of the adrenal medulla

What does a pheochromocytoma secrete?

Epinephrine and norepinephrine

What does this cause?

Excessive sympathetic stimulation

What are symptoms of pheochromocytoma?

- Hypertension

- Tremors

- Increased cardiac contractility

- Arrhythmias

-Tachycardia

How is pheochromocytoma diagnosed?

24-hour urine for catecholamine metabolites

What is MEN?

A disorder with tumors in multiple endocrine glands (several forms)

What is the most common type of MEN?

MEN1

What causes MEN?

Defective tumor suppressor gene

What glands are most affected in MEN?

Parathyroid, pituitary, pancreas

What is the overall effect of MEN?

Problems with all hormones

Can tumors in MEN be benign or malignant?

Yes, both (can be life-threatening if malignant)

What does the pineal gland produce?

Melatonin

When is more melatonin produced?

During dark/light cycle changes (more in darker months → depression)

What can a pineal tumor cause?

Pressure on brain structures and blockage of CSF

What symptoms occur with pineal gland dysfunction?

- Headache

- Nausea

- Vomiting

- Seizures

- Memory issues

- Visual changes

What other effects can occur with pineal gland dysfunction?

Insomnia and abnormal thyroid function