How do you treat Cushing’s disease?
Selective removal of pituitary adenoma. Bilateral adrenalectomy if source unlocatable, or re-occurence post-op (complication: Nelson’s syndrome - increased skin pigmentation due to increased ACTH from enlarging pituitary tumour as adrenalectomy removes negative feedback; responds to pituitary radiation).
How do you treat an adrenal adenoma or carcinoma?
Adrenalectomy cures adenomas but rarely cures cancer. Radiotherapy and adrenolytic drugs (mitotane) follow if carcinoma.
How do you treat ectopic ACTH?
Surgery if tumour is located and hasn’t spread. Metyrapone (blocks 11 beta-hydroxylase), ketoconazole and fluconazole decrease cortisol secretion pre-op or if awaiting effects of radiation.
Intubation and mifepristone and etomidate may be needed e.g. in severe ACTH-associated psychosis.
When should steroid treatment cards be issued?
- Oral/systemic - when prescribed for >3 weeks or receiving >4 short oral courses per year
- ICS
What is the treatment for Addison’s disease?
- Replace steroids: around 15-25mg hydrocortisone daily
- Mineralocorticoids to correct postural hypotension
- Advise wearing bracelet to declare steroid use
- Add 5-10mg hydrocortisone before strenuous activity/exercise
What is the management for Addisonian crisis?
- Bloods for cortisol and ACTH (tell lab it’s urgent)
- U+E’s
- Treat before results with hydrocortisone 100mg IV stat
- IV fluid bolus e.g. 500ml 0.9% saline to support BP
- Monitor blood glucose for hypoglycaemia
- Blood, urine, sputum for culture, then antibiotics if concern about infection
How do you treat Cushing’s syndrome?
- Iatrogenic: stop medications if possible
- Cushing’s disease: removal of pituitary adenoma
- Adrenal adenoma or carcinoma adrenalectomy: radiotherapy and adrenolytic drugs (mitotane) follow if carcinoma.
- Ectopic ACTH: surgery if tumour hasn’t spread. Metyrapone, ketoconazole and fluconazole decrease cortisol secretion pre-op.
