Alrehal danl lisoYelers

Hylerfunct Hyfuncton
(aslrenol ins«fficiency)
Hyfercortiso lism
Hyferalalostevonism (Allisoh elisease)
(Cushing yndone)
SA)

frimory Seconslary Rrimary

Seconlary
exo9enouS endogeuous (Conn Sydtoe)
Dexon use) •AcTH rom withiu inyolves involUes
defeteut from extra lestructiou of • Suppre ssiou
-
olreuel glenod aollenl glonod all regions of HPA - cXis of
AcTH
inalefeulet) adrel
(G-F. R)
Cortex • im
poiel in
Cortisol/Analregeu
Proluetieon
(F. R)
hormer l
Min erolocertco
(AlelosTeroue) il
(G)
 Cushing syelome
enalogenous over-proluc tion ( cortisoi)

AcTH -inalegen
ACTH -lefeleut let
^ACTH y Cause bilateroul AcTH (narmal)
alreual hyfexplasia

85 Askeual Problem
prtui tery Pro ble m wot pi tui tety Problen
(Ectopic-AcTH) benigh Tamoy Malignoavt Tmor
(pituitary Aolenomas)
ACTH excretel rom
(orenol Aolenama) (Aelrenal Carcinoma)

(TuMor) in any site f baly

enelo crihe Non- enelocriny

• Thy roial
.Smal cell Lung Caucer
fancrees
 Treetmeut o
Cushing oliseuse
wou-fhormacoloic
theropy
• Surgi cl ( Fist line / choi Ce for bot AcTH -oleped.inelepeuo)
Tronssphenoill: choice or ituitorry Aolenoma (cushing sense)
-. la PoYosC opiC Aolrenalectomy:
referrel or uni-lorteral Akeuel alenome
Radiothet apy (preferrek for tumors imvling of otuca
or Caverhous
-
siar)
Proviles Cliuiceel im (rouement (Ge%) witain
(3-5 years)
but TrisK (hypopiuifarism)

Pharmocologie heruy (c Secool

sterotalegenesis (uhibitofs
•MetGrofoue
.
Beto Con Zole
•Etomiolate
Osilo lrostat
Aslrenaly fkc Ayest
•
Mitoto
u
Ageut tayet
CYro heptiliae
• Pasiree tiale
Glucocor ticoial- Receftar Blo cKing Age
.Mifefristoue
 Me Tyrapone 1Be töconaZo le
ZG (AledosTetone)
Adreuol zG (Aosterone) X blocK
cortex
zF (Cortisol) X blocK Aolrenon! Cortex ZF (Cevtiso) X blocK
ZR (Anogen) LzRÇAuge) X
blocK

(Anedrogeule siale effect) ais 2

lao (Anti -analageuic effect) as
•inhibits |- p-hyAoxylase eazyme
(u- p.kyolroxy leuse euzyme) .inhibits
17-o- hyroylase eneyme
in hibition Cortisol syn. Auti -
uhelro 9euic effect
•Mytyrufoue Leaol to steroielgeuesis • Befocononzule •
beneficol in women
shuuts towarel anolrogens
aned Coau se aulrogeuie siole efRet •Wot beueical i men
Cause 3ynecom os tic
(ACne / hirsuts m) hyPogonadism

inhibi tiou Allo steron syn. most Common Side effet

BP-COuges -GIT- lis co
mfor t
Cause
Lwatriuresis ( wa-ex<ret Cause Dermatologic Teac tton
.severe hepatotoXicity
(due to heptic Trans awinase eue

WoTe: because of risK

heeel
of Sever hepertoto Xiet)
to monitoring (liver Funeten Test)
at Cbaseliue) Ro(lewesk by
(weekly)
heonitorin CALT)
in Corti'sol conc.
Sudaleu decrease •
frompts ComPensutory vise in AcTH
efectve in loweriny cortisal cohc.
after sSeverul uweess t Therapy
Cortiso| (Suollen)
ra
ACTH ( Compen tory)

Comcowitanly usel
Metgra poue Beto cohezole =
Synersistic effeet
(Anolrogenie eflect (Anti- Aueltogeuie e
ffect) (L cortisol, Siede etfect)
 Etomialate Osilolros tat
• is imilazo(e lervAtive similer to Preveuts Corttsel syThests
(KetoconoTole)taot inhibits(p-hydsylar by ihibition (ll-p. hydroxylouse)
and hve otuer mechou's s m

only cvailable in gor euterol fortmatatron- availa ble as erau

Ta b.
(Taße tab. X2, witu or w'
tacut oo)

• use is limiteo to po treut witu (n elicatel or

petieuT wita
(ACute ypex-coxtisolemia) Cushiug dises (Prtui tavy Adenomq)
emeryency Trectment Symp toms Persist afler surgery
Reluriug Retuiring -
in Preparatiou fer surgery Wot Caneliutes for surgery
)

wote: heel to refueut mouiforiuy of WoTe i Prior to use keel to

(cortso() t preveut Chypo- cortisolemia) O correcte (hyPokalema, hypom e ghesemin)
3ECG, obtaineel at Cbaseliue) anak aoen
(one weeK
Po
ater testmeut) to mouitor
ssible CQT-ro
longaten)
Sile effeot Siole effect
O injecton site foin O QT- Prolongo tion Cneed monctoY wita EcG)
hypoteusion hy Po
Corti So lism
Myoctohus 3h ealoehe
se loetion twauseel
6) asec /Uomiting
 Adreno ly tic Ageuts CiTo tene )
•
Mittene: is cyto toxie lruy
. euzymes sys.
Il-deoxy cortiso{ (Comvert t cortisel by eu eym)
inhibits (I|-hylroxyla tio) o
ontry
leoxy Corti cosfero to alolosterene by

-|- (cauvert
Cortrso |

Alelosteroue

.
Similar to CKelo ConaTole), Toußes (weeK to onta) t give etfects
Sustainel Cortisol Suppressiou in mast ati ent; auel moy
rug is contua tion i up to Cone - Persist affer
Tuird) of foliets
resultiug iu GATro pay) of alrenal Corte (L size of cells )
minimol efect acute thera
ZG X affecteal iu py

Dama9e
Alveul CorteX zF X legeuerertes in okg-Term tuerrpy
Cels
LeR X legenerates cells

Siguificon T siole cffect Commen sile effe ct otuer sile

tfeet
• •
prolou9 eel bleeliuy
Nauseu /Or arrheoy tmes
.
GIT (at loses 7 2 3/oday) Hyler-cholesterolemie
Weurologic •
CNS effeets
, (reversible)
( so muoleace LeThary)
 Ageuts toret WT
Cytrokef ooline fosireotle
Somortos talin
-Drag (won.sSIRA)
analoy ACTH
cortisol

-Anti-cholinersc JAch
(for Cushig
sere) (for aulults wita Cushing liseorse
)
whom pitui tary suYzeYy
Wheu hot option
Sursty not Curotive
Siole effect Stale
•
Seloton
etfect
• Weight gaun O QT- prolongoion
(fwt) sinus broly Carolia
8) hegoate transaminoy
sesAST
ALT

cholelitaiasis
hyfoslycemia
6)wusea
o
Diarthe

Gluco CortiCoiel-
IRece(tor blo cHing agent (Mifefri's
Progesteroue- RA
toe)
Gluco
J cortisol in ssue
Corttcoiel-RA TAcTH , Tenelogeuous Cortisal in
. wibits lexame lhasone sugressiou
bleo

hecl to monifor (Sferoid secrettn)

wit all druy türrapy (except mifepriste)
FOA-approvesl for tresct eulogenous
Cushiny sykdoue wita
ex glucose auwo
Dmc fe-e)
ino|eronuCe Poor respoh re To Surgery
of not elwglble to sveyet)
Common Sisle-effect
a
highly eftf ectve in reversiny
6 euolo me Trion! hy perplasi
periPheral eelema
.hyPer corti seli s n

.
hyfekoewmi'e (UK)
hyPer lycemi
Wypec teusiou

Ar taralgi weight gain (fwt)

, heoelach, wauseay
5 Fatig ue
 Hyler olslosteronism

(PA)
(talos terone Secretion) SA)

Seconlorr 9
fumeny
Cohn Synlrome)
C
ause of SA
Causes PA
O
bilateal alrenol hyPerplasi e Most
(ommo4 by extrea oclrenl faefor
(Ex: Renin - Angiotensin sys-)
Builateroil alreuol hyferplosto4
Adreuol cortex Carcinome ta sim intose (TK)
5) Reni
freghen cy
resousive adr eho Corti Cal
aeleo mor
(4> Menses
6 Familial hyperalelo steronis m
(FH) (5) orel Cotreceptves
TyleCi) 9lucocorti coil 6j Cirrhosis
3-orms o(FH)4 less HF
Tele): Aleuomo or hyferplors:aCommon
(9euetic) |(Rere) 8) renal artery ste hosi's
LTyPe (3):
OBartter syulrome
 Clini col Rresentatioh of Hyfer alslosteronisn

Complain
Signs
() Muscle wealß
nesS O Teta ny
Parestuesias
O Poralysi's
3 heaolache /fatigue hyfertensio4
folydysia
5 nocturnet Polyuria nocturnot folyuril

Laboratory Fihadings

AIJosterone to Renin Ratio (ARR) or PAC

()3o
PRA
ng/di (33e fu

On'y (PAC) I5 "g/d! (42o fmol/)

other Coboretory Fiakiugs

>
Hyfer-nortremie (^wa I42)
sufpresseal reuin actuty
O
6
Hyfo-Kolemler (UK)
O elevete flosma alelostero he O
va
Sele tel bicar bouette HyPo- megnesemia (lm9)

,
(Tolelo sterone tNa /water , K
Lmg )

Diagno sis
.
Ii tal liugnosis ) screening by ARR
. onfirmertory
test t excluele (ouls e positiues ARR) (ARR) +ve
O oral wa -loaing test
Salike infus'on test
O Fludro Cortisone sufPressien test (FST)
coptoAril Challeuge test
 retnent of Hyleralelosteronis m (Amay)

(Won-gharmancalagic Theraly Frst.

First-liuen

• Surgicoul

La paroscopic resec Tio4 ;

or Trecest (Alaloste rone proaluciny Alenoma)
e fate
to Permanent Cures in upto
of
(leol

Pharmacologic Ther py r secensl - liaes

Allosteroue Receftor Antagonist ChoiCe for

(bilateral aalrenol hyper plersia
•
SPironolactoue (won selecfve)

•EPlere noue( Selectue)

foTassium sparing Diureic

less effectve thon
•Amilorile (Spi ronolecone)

Aslsfttionol op Tions
al of tuese
lack
ACEI outcome ata in PA)
•CCI3
Diuretcs (Chior Tholilone)

Trea tineut ot HyPerolelosteronism (seconekony)

Control or Correctou of extron aalreuol stimalatten o alolosteone

SPiYOnolactone (unti etolory is lalentRie)
 SPironolac tone Eplerenone

Won- sele c
fUe •
SelecUe

high
•Preventg negoative ettect of ofinity for odolostetone rector
.
Low affinity for yAnolroeh-R
alolostrone- R
etvaton progeste rene-R

Siale effect siele effect

O
Menstrual iregularites ewer sex steroiel-lepenoleat
byneconasti
effects tuou Sironalectohe
3 GTolisComfor t
im potean ce

5) Byler-Kalemi e
(Jalolosteroue, K)
 ALison isecse
(Alseuol insutficiency)
secmary
Primoary
2G (hermal aalosterenc)
-zG X(aldosteone)
Aolreuet Cortex 42F X( cortisel) Alreul CorferzF X
(eortise)

LzRxudtogen) LeR Xauogens)

• inwolwes .
lestruction of lnvolwes SupPression of
-
all resions of aoreual cortex HPA caxis

LCRH
Compensatory manerkH Suppressiou Ceause
\ACTH LACTH

Cuuses
COAuses
O
Autoimmune olystunc fiou
Cor ficosteolol
Cin odeveloPest countries)
eXogencus use Lmirtoazaine
Megestrol
Pregestiy
T13 Meroxy-Progesterone

(inolevelo fing Counfie)

inhibit erisol syh.

(Keto Eonarzole)
BMelcotou
accelerote (orlsol metobd's.
•Phenytoia
-Pheuobarbitul
. rifampiu
 o Adlison liseose
Treatnen t
Corticosteroials
(IX2)
• Choice og ent tyalrocortsen Short t/2
Multialse
Cor
isone acetote regimeu
(IX)
•Alternertve ogeut ((realisoloue) Single alos

(Taiedosterone
MineraloCorfico iols repla cemeut (only gor Primary di'seere)
LXI
• FlualroCortisone acetarte (oroty)
c
|M =) e very 3-4 weeks )

Deexy- Coricosterone fri-methylacetote ( Pareaterally)

JOTe: treortmeut o (se Conelary l'sease) is simiter to (Primary liseare)

excelt, inerol Cor f Coils relacement ( for primary culy)

Diagho sis Alolison disease

fcortsol18 (( notma)
mulation test
O O
short Cosyutro fin sti 9ive yes Pou e Cabnotmoar) -) Aelodi'so

insuliu hyfo lycemia test

netyro foue test
3)
CRH- stmulationtest
 ACute Alrenal insufficiency
Crisis aY A
ololisoniau Cri sis)

True enolocrin e emergecy

cliicoal etures
volu me lepletou

Ccaases of Alkeuol crisis

O HPA-c Xis Suppressiou (most Common)

STress ful situotious

Traumo

5) nfectons

Treatment o
Arenal crisis

Corticosteroil
. 9luco Cor ttcoil
HylroCortisoe ( Choice due to Comb in
eel actvity Mineralo cartcorl

9iveu Pareuteralty olloWel by orol hyelo Cori sone (if peutieuts is stobl)

Fluil replacemet
blol pressure
:
Ror |V-olertrose (7%5) in normal saliue sol.
lex Trose CZ25) water
i

for hyo lycemio

:
9 (U-

. for hyPex Kalemia:

Flulroo Corfisoue