Adrenal Gland Disorders

Hormones of Adrenal Medulla

Secretes 2 hormones : 1. Epinephrine 2. Norepinephrine.

Secreted in response to stimulation by sympathetic nerve, particularly during stressful situations.

Hormones of Adrenal Cortex

1. Glucocorticoids (cortisol, corticosterone) 2. Mineralocorticoids (aldosterone, deoxycorticostero ne) 3. Sex steroids (mainly androgens)

Normal regulation of adrenal glucocorticoid secretion

Control of Aldosterone Secretion :

2 most significant regulators

1.

2.

Concentration of potassium ions in ECF Angiotensin II

GLUCOCORTICOIDS
The principal glucocorticoid is cortisol (hydrocortisone), which helps :
1. 2.

3.
4.

Maintain blood pressure & cardiovascular function Slow the immune system's inflammatory response Balance the effects of insulin in breaking down sugar for energy Regulate the metabolism of proteins, carbohydrates, and fats

...ACTION OF GLUCOCORTICOIDS

Cardiovascular/renal Glucocorticoids increase cardiac out put and peripheral vascular tone, regulate the expression of adrenergic receptors In excess, the may cause hypertension They affect water and electrolyte balance (sodium retention, hypokalemia, and hypertension, or increased GFR)

Immune system Anti-inflammatory action, immuno-

suppresion

Glucocorticoids inhibit phospholipase A2, impair the release of IL-1, antigen processing, antibody production and clearance. As a consequence, glucocorticoids are widely used as drugs to treat inflammatory conditions such as arthritis or dermatitis, and as adjunction therapy for conditions such as autoimmune diseases

In the liver: increased glycogen deposition; increased gluconeogenesis Muscle & Fat: inhibits glucose uptake & utilization; increased lipolysis FFA increased cholesterol & triglycerides; decreased HDL-cholesterol

increase blood glucose; protein & lipid catabolism

(ACUTE ADRENAL INSUFFICIENCY)

Adrenal Crisis

1.Acute Adrenal Insufficiency, usually precipitated by sepsis or surgical stress 2.Acute haemorrhagic destruction of both adrenal glands ( anticoagulant therapy / a coagulation disorder) 3.Rapid withdrawl of steroid from patients with adrenal atrophy owing to chronic steroid administration

Adrenal Insufficiency
Can be divided into 2 general categories :
1.

2.

Associated with primary inability of the adrenal to elaborated sufficient quantities of hormone Associated with a secondary failure due to inadequate ACTH formation or release

Adrenal Crisis

Dehydration, hypotension Nausea and vomiting Unexplained hypoglycemia Unexplained fever (severe/absent) Hyponatremia, hyperkalemia

Treatment
1.

2. 3.

4.

Repletion of circulating glucocorticoids and replacement of the sodium and water deficit Bolus IV 100mg Hydrocortisone / 6 h If the crisis is preceded by prolonged nausea, vomiting and dehydration, several liters of saline solution may be required in the first few hours. Vasoconstrictive agent (such as dopamine) may be indicated in extreme condition

Comparative steroid potencies

Name Hydrocortisone (Cortisol) Cortisone acetate Prednisone Prednisolone Methylprednisolone Glucocorticoid potency 1 0.8 4 4 5

Mineralocorticoid potency 1 0.8 0.25 0.25 <0.01

Duration of action (t1/2 in hours) 8 oral 8, i.m 18+ 16-36 16-36 18-40

Dexamethasone
Betamethasone Triamcinolone

30-40
25 5 8 puffs 4 x a day equals 14 mg oral

<0,01
<0,01 <0,01

36-54
36-54 Des-36

Beclometasone Fludrocortisone acetate Deoxycorticosterone acetate (DOCA) Aldosterone

prednisone once a day 15 0 0.3

200 20 200-1000

ADRENAL CORTISOL INSUFFICIENCY IN ACUTE ILL PATIENTS HPA axis is dramatically altered during critical illnesses such as trauma, surgery, sepsis and shock. inadequate cortisol production during critical illness can result in hypotension, reduced systemic vascular resistance, shock and death.

IN ACUTE ILL PATIENTS

Subnormal cortisol production has been termed functional or relative adrenal insufficiency.

The elevated cortisol levels that are observed are viewed as insufficient to control the inflammatory response and maintain blood pressure.

IN ACUTE ILL PATIENTS

Treatment with supplementary cortisol should be initiated promptly following the measurement of a random cortisol levels and/or performing a cosyntropin stimulation test. Treated : 50-75 mg of Hydrocortisone IV/6h as bolus or the same ammount as a continous infusion. Treatment can be terminated if the cortisol levels obtained at the outset are appropiately elevated.