slide1 n.
Download
Skip this Video
Loading SlideShow in 5 Seconds..
Janet A. Schlechte, M.D. PowerPoint Presentation
Download Presentation
Janet A. Schlechte, M.D.

Loading in 2 Seconds...

play fullscreen
1 / 69

Janet A. Schlechte, M.D. - PowerPoint PPT Presentation


  • 151 Views
  • Uploaded on

Cushing’s, Adrenal Insufficiency and Other Glucocorticoid Related Issues Family Practice Residency Program Waterloo, IA September 11, 2013 Janet A. Schlechte, M.D. Disclosure of Financial Relationships. Janet A. Schlechte, M.D.

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'Janet A. Schlechte, M.D.' - ferrol


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
slide1

Cushing’s, Adrenal Insufficiency and Other Glucocorticoid Related IssuesFamily Practice Residency ProgramWaterloo, IASeptember 11, 2013Janet A. Schlechte, M.D.

janet a schlechte m d

Disclosure of Financial Relationships

Janet A. Schlechte, M.D.

has no relationships with any proprietary entity producing health care goods or services consumed by or used on patients.

objectives
Objectives
  • Approach to glucocorticoid excess
  • Management of adrenal insufficiency
  • Peri-op management of glucocorticoids
  • Steroid taper
cushing s syndrome causes
Cushing’s Syndrome Causes
  • ACTH secreting pituitary tumor
  • Adrenal adenoma/carcinoma
  • Ectopic ACTH production
  • Exogenous glucocorticoid
classic features of cushing s
Classic Features of Cushing’s
  • Centripetal obesity
  • Violaceous striae
  • Proximal muscle weakness
  • Amenorrhea
  • Thin skin
  • Bruising
other features of cushing s
Other Features of Cushing’s
  • Hypertension
  • Glucose intolerance
  • Diabetes
  • Hypokalemia
  • Bone loss
causes of cushing s syndrome
Causes of Cushing’s Syndrome
  • ACTH secreting pituitary tumor
  • Adrenal adenoma/carcinoma
  • Ectopic ACTH production
  • Exogenous glucocorticoid
ectopic acth secretion
Ectopic ACTH Secretion
  • Severe hypokalemia
  • Metabolic alkalosis
  • Muscle weakness
  • Few of the classic stigmata
  • Hyperpigmentation
cushing s syndrome
Cushing’s Syndrome
  • Rare disorder
  • How often will it present in the primary care setting?
slide19
Many people complain of weight gain and bruising but few have Cushing’s
  • Even astute clinicians should screen for glucocorticoid excess
screening tests
Screening Tests
  • 24 hour urine cortisol
  • 1 mg dex test
  • 11 p.m. salivary cortisol
slide21

24 Hour Urine Cortisol

  • Inconvenient but most sensitive
  • May need to do more than one unless results are 2-3x normal
  • Occasional false positives
diurnal variation of cortisol
Diurnal Variation of Cortisol

Pre-Dex

Cortisol

Post-Dex

Time

1 mg dex test
1 mg Dex Test
  • 1 mg dexamethasone at 11 p.m. and measure 8 a.m. cortisol the next day
  • Healthy subjects will have cortisol <2 µg/dl
slide24

1 mg Dex Test

  • false positives

- dilantin

- obesity

- estrogen

- stress

- depression

slide25

A 30 y.o. woman has gained 20 pounds over the last six months. She has also noted leg swelling and her blood pressure is harder to control. She takes HCTZ and a BCP.B/P 140/100, BMI 35, bruises on legs, buffalo hump, pale pink striae.

slide26
She has read about Cushing’s syndrome and is worried about a pituitary tumor
  • Potassium 3.8, A1C 5.6%, CBC nl
slide27
She takes 1 mg of dex at 11 p.m. and an 8 a.m. cortisol the next day is 10 µg/dl.
  • Does she have Cushing’s?
slide29

A 40 y.o. man has poorly controlled hypertension. His weight has increased by 50 lb in the last year. He has bright purple striae and significant muscle weakness. A 1 mg DST shows a cortisol of 20 so screening test is positive.

slide30
To rule out a false positive do confirmatory test
  • He collects a 24 hour UFC and the value is 350 µg/dl (<50)
  • Test is positive – he has Cushing’s
  • Now what?
slide31
When cortisol excess is confirmed draw

ACTH ACTH 

Pituitary tumor Adrenal tumor

Ectopic

slide32

Glucocorticoid Excess

Screening Test

Normal

Abnormal

Confirm Test

Stop

Abnormal

Normal

Get ACTH

Stop

Undetectable

Elevated

Adrenal

Pituitary

Ectopic

Do DST to differentiate

slide33

ACTH

Cortisol

ACTH

Cortisol

ACTH

Cortisol

Adrenal

Tumor

Ectopic

Production

Pituitary

Hyperfunction

Urinary free cortisol

baseline

2 mg

8 mg

ACTH

300 µg

180

40

989 µg

991

990

undet.

4034 µg

4000

3989

slide34

A 41 y.o. collapsed on the golf course in August. For 6 months he has been tired with intermittent nausea, abdominal pain and deterioration of his golf game. In the ER his BP was 60/- with a pulse of 130. He has a deep tan, pigmented buccal mucosa, a small thyroid and a normal neuro exam.

in the er
In The ER
  • Sodium 125
  • Potassium 6.4
  • Chloride 98
  • CO2 18
  • Creatinine 1.4
  • Glucose 75
features of primary ai
Features of Primary AI
  • Hyperpigmentation
  • Fatigue and weakness
  • Hypotension
  • Postural dizziness
  • Abdominal pain
  • Weight loss
causes of primary adrenal insufficiency
Causes of Primary Adrenal Insufficiency
  • Autoimmune
  • Adrenal hemorrhage
  • Granulomatous disease
slide43
Cortrosyn stimulation test

- Measure plasma cortisol before and 1 hour after IM injection of 250 µgACTH (cortrosyn)

slide45
After cortrosyn stimulation test begin steroid replacement.
  • Little practical reason to start dexamethasone before cortrosyn.
slide46
After the cortrosyn test the IV saline is continued and you give the 100 mg of hydrocortisone. One hour later the lab calls with the cortisol results.
  • Basal cortisol 0.1 µg/dl
  • Stimulated cortisol 0.1 µg/dl
slide47
What if the results were
  • Basal cortisol 9 µg/dl
  • Stimulated cortisol 25 µg/dl
classical glucocorticoid equivalents

Classical Glucocorticoid Equivalents

Daily Replacement Doses

5 mg Prednisone

20-25 mg Hydrocortisone

0.75 mg Dexamethasone

37.5 mg Cortisone acetate

more physiologic equivalents

More Physiologic Equivalents

Daily Replacement Doses

5 mg Prednisone

10-15 mg Hydrocortisone

0.75 mg Dexamethasone

treatment guidelines
Treatment Guidelines
  • Monitor therapy clinically and with electrolytes.
  • Can’t use ACTH or cortisol to monitor therapy.
  • Consider other autoimmune disease.
long term therapy
Long-Term Therapy
  • Hydrocortisone (10-15 mg/day)
  • Start with hydrocortisone and add florinef as needed.
  • Florinef (0.05-0.1 mg/day)
stress dose
Stress dose?
  • Pulling wisdom teeth
  • Colonoscopy
  • Endometrial biopsy
  • Flu with aches and pains
stress dose1
Stress dose?
  • CABG
  • Hip replacement
  • Final exams
  • Death in the family
slide55

A 45 y.o. woman with RA has been treated with 10 mg of prednisone for 3 years. She will undergo laparoscopic surgery in 2 days. Her surgeon wants you to write pre-op orders.

slide56
Pituitary adrenal axis is suppressed
  •  ACTH due to exogenous glucocorticoid
  • Stopping glucocorticoid and/or stress of surgery could lead to adrenal crisis
slide57

Peri-Operative Corticosteroid Coverage

  • Minor surgical stress- usual dose day of procedure
  • Moderate surgical stress- 50 mg HC day of procedure then resume usual dose

Ann Surg 219:416, 1994

slide58

Peri-Operative Corticosteroid Coverage

  • Major surgical stress- 100 mg HC on day of procedure- 50 mg HC on post-op day 1
  • Resume usual dose unless clinical condition deteriorates

Ann Surg 219:416, 1994

slide59
Avoid too much glucocorticoid
  • After a stress dose rapidly resume the replacement dose
  • Don’t use cortisol or ACTH to try to monitor therapy
slide60

A 60 y.o. man has taken 60 mg of prednisone daily for 6 months for anterior ischemic optic neuropathy. His ophthalmologist has seen no improvement and wants to stop the steroid.

slide61

The Dilemma

  • Stopping the drug will lead to secondary adrenal insufficiency
  • He has muscle weakness and weight gain and his T score is -2.9. The glucocorticoid needs to be stopped as rapidly as possible
taper option 1
January 1

January 15

January 30

February 1

February 15

March 1

60 mg

40 mg

20 mg

10 mg

5 mg

Off

TaperOption # 1
taper option 2
January 1

January 15

February 1

March 1

April 1

60 mg

60 mg q.o.d.

30 mg q.o.d.

10 mg q.o.d.

Off

TaperOption # 2
taper option 3
January 1

January 2

February 1

March 1

April 1

May 1

etc. until off

60 mg

10 mg

9 mg

8 mg

7 mg

6 mg

TaperOption # 3
questions to ask
Questions to Ask
  • What is the reason for the taper?
  • Is it to avoid recurrence of disease?
  • Is it to avoid adrenal crisis?
slide66

Effect of Dose of Hydrocortisone on Mortality

RR 95% CI p

0<HC<20 1.3 0.7-2.6 ns

20<HC<25 1.4 0.6-3.3 ns

25<HC<30 1.6 1.1-2.4 .014

HC>30 2.9 1.4-5.9 .003

JCEM 94:4216, 2009

slide67

Take Home Points

  • Remember glucocorticoid equivalencies
  • Use stress doses sparingly
  • When HPA axis is suppressed, taper slowly beginning at a maintenance dose
slide68
A 42 y.o. with a history of chronic back pain has severe fatigue and the lab pages you because his cortisol is 1.0 and his TSH is 1.4.
slide69

One of your patients takes 5 mg of prednisone daily after an organ transplant. She is having her wisdom teeth pulled tomorrow morning and calls to find out what to do about her prednisone since she will be NPO.