Adrenal Gland Disorder

Adrenal can be categorized into several areas

Groups:

(a) Zona glomerulosa

,

(b) Zona fasciculata

,

(c) Zona reticularis

,

(d) Medulla

• Aldosterone

• immunosuppression

• Control Sodium & potassium balance

• Fight-flight response of SNS

• increase osteoclast activity

• Androgens

• Testosterone & estradiol

• Glucocorticoid

• increase glucagon secretion

• Catecholamine

• Noradrenaline & adrenaline

• decrease insulin secretion

• Cortisol

• Modulate primary & secondary sex characterizations

• Increase gluconeogenesis

• Mineralocorticoid

• Metabolised carbs, protein, and lipid

The following is an example of diseases under adrenal hyperfunction

• Cushing's syndrome

• Hyperaldosteronism

• Pheochromocytoma

• Adrenal insufficiency

• Addison's disease

The following is true regarding area-hormone-disease pairs of adrenal gland disorder

• Zona glomerulosa - mineralocorticoid - hyperaldosteronism

• Zona fasciculata - glucocorticoid - Cushing's syndrome, Addison's disease

• Zona reticularis - androgens - Adrenal insufficiency

• Medulla - catecholamines - pheochromocytoma

• All of the above

The following is true regarding Cushing's syndrome

• caused by exposure to high circulating levels of cortisol

• resulted from exogenous administration

• resulted from endogenous overproduction by adrenal gland

• resulted from abnormal adrenocortical tissues

• may interchangeably called hyperaldosteronism

The following is the etiology of Cushing's syndrome

Groups:

(a) ACTH-dependent

,

(b) ACTH-independent

• Stimulates adrebal gland causing bilateral adrenal hyperplasia

• Adrenal nodular hyperplasia

• Adrenal carcinoma

• Ectopic ACTH production: tumor of pancreas, thyroid, or lungs

• Pituitary adenoma: Secretes excess ACTH

• Cushing's disease

• Iatrogenic: exogenous glucocorticoid

• Adrenal adenoma

First line tests in suspected Cushing's syndrome includes

• Overnight PO dexamethasone 1mg suppression test at midnight and measured at 8am

• 24-H urinary free cortisol (UFC) normal <280nmol/24H

• 48-H dexamethasone suppression test

• Performed after iatrogenic etiology is ruled out

• Should be performed prior to drug history taking

The following is symptoms of Cushing's syndrome

a

b

c

d

e

f

g

bone thining

striae

weight gain

easy bruising

moon face

thin extremities

buffalo hump

Treatment goal of Cushing's syndrome is

• limit detrimental outcomes/complications

• return patient to normal functional state

• remove source of hypercortisolism

• minimizing pituitary or adrenal deficiencies

• lower treatment dependencies

The following is treatment option in Cushing's syndrome based on etiology

• Tapering

• Adrenal adenoma

• Surgery, chemotherapy, irradiation

• Iatrogenic

• Trans-sphenoidal surgery, radiotherapy

• Ectopic ACTH syndrome

• Adrenalectomy, palliative therapeutics

• Adrenal carcinoma

• Adrenalectomy, lifelong hydro. & fludro.

• Pituitary dependent

Tapering steroid depends on the prednisone doses or equivalent

• <5mg/day

• 2.5mg/day every 2-3 weeks

• >40mg/day

• 5mg/day every 1-2 weeks

• 10-5mg/day

• 0.5mg/day every 2-4 weeks

• 40-20mg/day

• 5-10mg/day every 1-2 weeks

• 20-10mg/day

• 1mg/day every 2-4 weeks