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LEARNING OBJECTIVES

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LEARNING OBJECTIVES

Upon completion of the chapter, the reader will be able to:

  1. Explain the regulation and physiologic roles of hormones produced by the adrenal glands.

  2. Recognize the clinical presentation of patients with adrenal insufficiency.

  3. Describe the pharmacologic management of patients with acute and chronic adrenal insufficiency.

  4. Recommend therapy monitoring parameters for patients with adrenal insufficiency.

  5. Recognize the clinical presentation of Cushing's syndrome and the physiologic consequences of cortisol excess.

  6. Describe the pharmacologic and nonpharmacologic management of patients with Cushing's syndrome.

  7. Recommend strategies to prevent the development of hypercortisolism and hypocortisolism.

  8. Recommend therapy monitoring parameters for patients with Cushing's syndrome.

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KEY CONCEPTS

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  • Image not available. Signs and symptoms of adrenal insufficiency reflect the disturbance of normal physiologic carbohydrate, fat, and protein homeostasis caused by inadequate cortisol production and inadequate cortisol action.

  • Image not available. Lifelong glucocorticoid replacement therapy may be necessary for patients with adrenal insufficiency, and mineralocorticoid replacement therapy is usually required for those with Addison's disease.

  • Image not available. During an acute adrenal crisis, the immediate treatment goals are to correct volume depletion, manage hypoglycemia, and provide glucocorticoid replacement.

  • Image not available. Patients with known adrenal insufficiency should be educated regarding the need for additional glucocorticoid replacement and prompt medical attention during periods of excessive physiologic stress.

  • Image not available. Patients with Cushing's syndrome caused by endogenous or exogenous glucocorticoid excess typically present with similar clinical manifestations.

  • Image not available. Surgical resection is considered the treatment of choice for Cushing's syndrome from endogenous causes if the tumor can be localized and if there are no contraindications.

  • Image not available. Pharmacotherapy is generally reserved for patients (1) in whom the ectopic adrenocorticotropic hormone–secreting tumor cannot be localized, (2) who are not surgical candidates, (3) who have failed surgery, (4) who have had a relapse after surgery, or (5) in whom adjunctive therapy is required to achieve complete remission.

  • Image not available. In drug-induced Cushing's syndrome, discontinuation of the offending agent is the best management option. However, abrupt withdrawal of the glucocorticoid can result in adrenal insufficiency or exacerbation of the underlying disease.

  • Image not available. Glucocorticoid dosages less than 7.5 mg/day of prednisone or its equivalent for less than 3 weeks generally would not be expected to lead to suppression of the hypothalamic–pituitary–adrenal axis.

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INTRODUCTION

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The adrenal glands are important in the synthesis and regulation of key human hormones. They play a crucial role in water and electrolyte homeostasis, as well as regulation of blood pressure, carbohydrate and fat metabolism, physiologic response to stress, and sexual development and differentiation. This chapter focuses on pharmacologic and nonpharmacologic management of the two most common conditions associated with adrenal gland dysfunction: glucocorticoid insufficiency (e.g., Addison's disease) and glucocorticoid excess (Cushing's syndrome). Other adrenal disorders such as congenital adrenal hyperplasia, pheochromocytoma, hypoaldosteronism, and hyperaldosteronism are beyond the scope of this chapter.

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PHYSIOLOGY, ANATOMY, AND BIOCHEMISTRY OF THE ADRENAL GLAND

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The adrenal gland is located on the upper segment of the kidney (Fig. 45–1). It consists of ...

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