Chapter36
Page 1: Introduction to Adrenocortical Agents
Title: Adrenocortical Agents
Publisher: Wolters Kluwer Health | Lippincott Williams & Wilkins
Page 2: Indications for Use of Adrenal Agents
Uses:
Widely used to suppress the immune system.
Short-term relief of inflammation during acute illness.
Caution: Do not cure inflammatory disorders.
Page 3: Anatomy of the Adrenal Glands
Location:
Flattened bodies located atop each kidney.
Composition:
Adrenal Medulla: Inner core, part of the sympathetic nervous system (SNS).
Adrenal Cortex: Outer shell, produces hormones called corticosteroids.
Page 4: Overview of Adrenal Glands
Visual representation of the adrenal glands relative to kidneys.
Page 5: Controls and Actions of the Adrenal Glands
Key Controls:
Hypothalamus releases CRH.
Exogenous corticosteroids block CRH and ACTH release.
HPA Axis:
The anterior pituitary releases ACTH to stimulate adrenal glands.
When corticosteroids are provided externally, the adrenal cortex may atrophy.
Page 6: Feedback Control of the Adrenal Cortex
Mechanism:
Circadian rhythms affect the secretion of CRF.
ACTH stimulates glucocorticoids.
Negative feedback loop regulates cortisol levels.
Page 7: Hormone Secretion Dynamics
Cortisol Regulation:
When cortisol levels are low, CRH stimulates ACTH release.
Increased cortisol levels signal to stop CRH secretion.
Feedback examples:
Low blood cortisol leads to increased CRH and ACTH.
High blood cortisol results in decreased CRH and ACTH.
Page 8: Biological Effects of Adrenal Hormones
Functions:
Maintain glucose availability, regulate water and electrolyte balance.
Develop secondary sex characteristics, and manage responses to stress.
Page 9: Classes of Adrenal Cortical Hormones
Hormone Classes:
Glucocorticoids: e.g., cortisol.
Mineralocorticoids: e.g., aldosterone.
Androgens: Involved in sex hormone production.
Dysfunctions:
Cushing’s Syndrome: Excess of glucocorticoids.
Addison’s Disease: Deficiency of glucocorticoids.
Page 10: Types of Corticosteroids
Corticosteroid Classes:
Androgens: Male and female sex hormones.
Glucocorticoids: Increase glucose for energy.
Mineralocorticoids: Affect electrolyte homeostasis.
Page 11: Use of Adrenocortical Agents Across the Lifespan
Children:
Doses based on severity of condition, not weight/age.
Monitor growth; limit topical corticosteroids.
Adults:
Importance of morning intake; taper doses.
Avoid concurrent OTC corticosteroids; monitor for infections.
Older Adults:
More susceptible to adverse effects; dosage reductions may be required.
Page 12: Adrenal Gland Hormones
Major Hormones:
Glucocorticoids (e.g., cortisol).
Mineralocorticoids (e.g., aldosterone).
Sex steroids (e.g., testosterone).
Mnemonic: S Sugar (Glucocorticoids), S Salt (Mineralcorticoids).
Page 13: Physiologic Effects of Glucocorticoids
Low Levels:
Affect carbohydrate, protein, fat metabolism, cardiovascular stability, and stress responses.
Page 14: Mineralocorticoids Actions
Primary Role: Regulate sodium, potassium, and hydrogen.
Aldosterone effects:
Promotes sodium retention; manages blood pressure and volume.
Page 15: Site of Action
Hormonal Actions:
Mineralocorticoids: Sodium retention by kidneys.
Glucocorticoids: Affect various physiological responses.
Page 16: Causes of Adrenal Insufficiency
Primary: Damage to adrenal cortex (autoimmune disorders, cancer, trauma).
Secondary: Interference with ACTH secretion due to tumors or trauma.
Tertiary: Long-term steroid use leading to adrenal suppression.
Page 17: Mechanisms of Insufficient Hormone Production
Consequences:
Inadequate ACTH production inhibits adrenal response.
Surgical removal of glands can also cause insufficiency.
Page 18: Actions of Adrenocortical Hormones
Hormonal Actions:
Increase blood volume, release glucose, slow protein production, and block inflammation.
Page 19: Cushing’s Syndrome Presentation
Causes: Hypersecretion due to tumors or long-term therapies.
Symptoms:
Hyperglycemia, hypertension, redistribution of fat (moon face, buffalo hump).
Page 20: Clinical Presentation of Cushing’s
Signs:
Fragile skin, easy bruising, depression, purple striae.
Page 21: Goals of Therapy for Cushing's Syndrome
Therapeutic Aims:
Reduce plasma cortisol, remove tumors, restore body appearance, and prevent complications.
Page 22: Treatment Options for Cushing's
Approach:
Surgical removal - requires glucocorticoid replacement therapy.
Page 23: Addison’s Disease Characteristics
Symptoms:
Low blood pressure, weight loss, hyperpigmentation (due to low corticosteroids).
Page 24: Cushing's Characteristics
Manifestations:
High blood pressure, high glucose, truncal obesity, moon facies, purple striae.
Page 25: Addison’s Disease Overview
Clinical Presentation:
Weakness, hypotension, hypoglycemia, increased skin pigmentation.
Page 26: Addison's Disease Symptoms
Signs:
Bronze skin pigmentation, weakness, postural hypotension, adrenal crisis symptoms (fatigue, dehydration).
Page 27: Therapeutic Considerations
Glucocorticoid Replacement Therapy:
Should mimic normal secretion patterns, can increase in times of stress.
Page 28: Treatment Approaches for Addison’s Disease
Primary Therapy:
Replacement therapy involving hydrocortisone (both glucocorticoid and mineralocorticoid).
Page 29: Acute Adrenal Insufficiency
Clinical Presentation:
Hypotension, fatigue, dehydration, GI symptoms.
Causes:
Adrenal or pituitary failure, inadequate corticosteroid dosing, or abrupt withdrawal.
Page 30: Adrenal Crisis Signs and Treatment
Signs:
Physiological exhaustion, hypotension, potential shock.
Medical Response:
Rapid infusion of replacement steroids and monitoring.
Page 31: Managing Acute Adrenal Insufficiency
Urgent Treatment:
Fluid, salt, and glucocorticoid replacement.
Page 32: Replacement Needs in Insufficiency
Corticosteroid Necessity:
Glucocorticoid is always needed; fludrocortisone for mineralocorticoid replacement.
Page 33: Question on Glucocorticoid Use
Inquiry: True or False regarding glucocorticoids used systemically?
Page 34: Response to Question
Answer: True. Prolonged corticosteroid use has contraindications.
Page 35: List of Glucocorticoids #1
Examples:
Beclomethasone, Betamethasone, Budesonide, Cortisone, Dexamethasone, Hydrocortisone, Methylprednisolone.
Page 36: List of Glucocorticoids #2
Additional Examples:
Prednisolone, Prednisone, Triamcinolone.
Page 37: Glucocorticoid Actions
Actions:
Bind to receptors, initiate anti-inflammatory reactions.
Indications:
Short-term treatment of inflammatory disorders, symptom relief.
Page 38: Glucocorticoid Pharmacokinetics
Behavior:
Well absorbed, metabolized by liver, excreted in urine.
Contraindications: Known allergy, acute infection, lactation.
Page 39: Adverse Effects & Interactions
Adverse Effects:
Route-related; risks include endocrine disorders.
Drug-Drug Interactions:
Various interactions with common medications affecting glucocorticoid efficacy.
Page 40: Nursing Considerations
Assessment Needs:
Complete physical exam, monitor for differences in responses, and educate on dosing and administration.
Page 41: Prototype Summary of Prednisone
Actions: Binds to intracellular receptors for anti-inflammatory effects.
Pharmacokinetics: Details on absorption, duration, and metabolism highlighted.
Page 42: Hydrocortisone Overview
Use: Management of adrenal insufficiency, allergic conditions, and inflammation.
Adverse Effects: Risks include adrenal suppression and Cushing’s syndrome in high doses.
Page 43: Long-Term Corticosteroid Adverse Effects
Varieties of Events:
Behavioral changes, eye problems, metabolic effects, immune suppression, osteoporosis.
Page 44: Oral Therapy Options
Preferred Drugs: Replacement therapy with hydrocortisone; cortisone as prodrug.
Page 45: Mineralocorticoids #1
Examples: Cortisone, Fludrocortisone, Hydrocortisone.
Page 46: Mineralocorticoids #2 Actions and Indications
Actions: Sodium retention, potassium excretion.
Use: Replacement therapy in adrenal insufficiency.
Page 47: Mineralocorticoids Contraindications
Considerations:
Known allergies, hypertension, cardiac conditions, and infection states.
Page 48: Adverse Effects of Mineralocorticoids
Effects: Can lead to increased fluid retention and allergic reactions.
Interactions: Various medications can alter their effectiveness.
Page 49: Nursing Considerations for Mineralocorticoids
Assessment: Comprehensive evaluation for history, allergies, and adverse effect monitoring.
Page 50: Prototype Summary of Fludrocortisone
Indications: Replacement in cortical insufficiency, salt-losing conditions.
Adverse Effects: Varied effects including headaches and edema.
Page 51: Care Plan Priorities for Addison’s Disease
Key Outcomes: Increasing glucocorticoid doses during stress periods, wearing medical alert identifiers, and effective dose scheduling.
Page 52: Assessing for Cushing’s Syndrome
Clinical Manifestations: Respondents should identify symptoms including osteoporosis, moon facies, glycosuria, etc.