adrenal suppression craig s. miller, dmd, ms

Adrenal Insufficiency Craig S. Miller, DMD, MS ENDOCRINE DISEASE: comes in many forms. Simplistically, there are disorders that cause over- or under-production hormones for the affected gland.  Pituitarism (HYPO-, HYPER)  Diabetes mellitus, insipidus  Thyroidism (HYPO-, HYPER)  Adrenalism (HYPO-, HYPER)  Parathyroidism (HYPO-, HYPER)  Renal disease (erythropoetin)  Ovaries, testes (gonadal-related hormones) The pituitary gland is the master regulator of most endocrine glands. It receives signals from the hypothalamus and sends signals to the target (endocrine) organ by secreting hormones. These in effect modulate the production of the target glandular organ. Adrenal Gland  This powerpoint presentation focuses primarily on normal adrenal cortical function and hypofunction.  The adrenal gland secretes several hormones from either the adrenal cortex or adrenal medulla (see Box 15-1 in the text). Adrenal Cortex (located around the medulla)  The adrenal cortex consists of 3 zones (zona glomerulosa [ZG], zona fasciculata [ZF] and zona reticularis [ZR]) which secrete gluocorticoids, mineralocorticoids and androgens.  Cholesterol is the precursor molecule for these hormones. Pheochromocytoma Adapted from Fig. 16-22 page 507 of Anatomy & Physiology 5 th ed Thibodeau GA, Patton KT Main secretory product Aldosterone Cortisol Androgens Epinephrine Norepinephri ne Action Regulates salt and water balance by affecting renal distal tubules Anti-inflammatory, decrease bone formation, decrease muscle mass, increase blood glucose, increase glomerular filtration, modulate emotions Sexual maturation Increase cardiac output Increase arterial pressure, increase peripheral resistance Regulation Secretion of cortisol is regulation by ACTH (on right) and circadian rhythm (see below). “Biological Clock” normal pattern Normal secretion rate of cortisol over a 24-hour period is approximately 20 mg Regulation Secretion of aldosterone is less dependent of the pituitary gland. It is regulated by angiotensin II which receives signals primarily from salt and water balance and blood pressure sensors in the kidney. Biological Effects of Cortisol  Breakdown of protein  Suppress ACTH synthesis  Anti-inflammatory  blocks endothelial cell expression of I/ECAM  Enzyme induction  Hematopoeisis  Fat deposition  Enhances appetite  Maintain muscular work  Reduction of eosinophils  Gluconeogenesis  Liver glycogen deposition  Uric acid excretion  Water excretion  Growth inhibition  Elevation of blood glucose [...]... IS AT RISK FOR AN ADRENAL CRISIS? General Rule: Patients taking steroids are safer to treat than patients who have primary adrenal insufficiency (Addison’s Disease)  Adrenal crisis in a patient with secondary adrenal suppression is rare and tends not to be as severe   Only 4 cases of Adrenal Crisis in dental literature  All related to extractions/surgery bleeding and primary adrenal insufficiency... patient adrenal suppression? If so, can he produce cortisol when you stress them during a dental procedure? If they can’t produce enough cortisol during stress an ADRENAL CRISIS could occur (see next slide) How do you know? What guidelines are advised? Adrenal Crisis  Cause: severe glucocorticoid deficiency with or without mineralocorticoid deficiency due to stress (surgery, infection and inability of adrenal. .. hr 18-36 18-36 4 0.75 0 0 18-36 36-54 0.6 0 36-54 Cortisone 30 mg daily = prednisone 7.5 mg daily Taking steroids on an alternate-day regimen causes less adrenal suppression than daily dosing Topical Steroid Ointments (Generally do not cause adrenal suppression Exception ultra-high potency drugs used for long periods over large areas of the body, especially if occlusive dressing are used)     Ultra-high... Generally do not cause adrenal suppression The vast majority of patients treated with conventional doses of inhaled steroids have no clinically relevant systemic steroid effects  Daily doses above 1000 to 1500 mg/day (in four divided doses) of beclomethasone dipropionate or budesonide in adults (depending on body mass) generally are considered to be the cutoff point, indicating adrenal suppression is probable...  “Evidence indicates that the vast majority of patients with adrenal insufficiency can receive routine dental treatment without the need for supplemental glucocorticoids Individuals at risk for adrenal crisis are those who undergo stressful surgical procedures and have no or extremely low adrenal function because of primary or secondary adrenal insufficiency.” Dental Management text 6th Ed Guidelines... medication? What type of steroids they take? How potent is the steroid? How long have they taken it? Do they have adrenal suppression because of their medication?  To accurately determine if they are suppressed, you may need to order an cortisol stimulation test to determine their degree of suppression and ability to respond to stress Therapeutic Uses of Steroids        Arthritis Rheumatic carditis... a physical threat (eg., lion, tiger or bear), you have the necessary sugar in your bloodstream to run away ADRENAL DISEASE  TYPES  HYPOFUNCTION (see next slide)  HYPERFUNCTION Example on right shows enlarged adrenal gland (top) compared to normal (bottom) This condition causes many problems, but most do not pose a great risk to the practice of dentistry on these patients  BENIGN TUMOR: Adenoma... Kentucky 2-3 million, one can expect about 2 cases developing per year  Adrenal insufficiency attributed to all causes occurs in about 4060 persons per million  Thus, a dental practice serving 2000 adults can expect to encounter about 40-50 patients who chronically use steroids or have potential adrenal abnormalities Causes Primary Adrenal Insufficiency Autoimmune disease  Tuberculosis  Hemorrhage... hypofunction These are not discussed in this presentation Types of Adrenal Insufficiency (Hypofunction) ** Primary - glucocorticoid & mineralocorticoid deficiency due to destruction or atrophy of the gland Also known as Addison’s Disease  Secondary – due to reduced pituitary function - Cushing’s syndrome (due to prolonged steroid use) ** Adrenal Crisis ** Indicates greater risk of adverse event Epidemiology... Tuberculosis  Hemorrhage  Neoplasia  Infection (Fungal, TB, HIV, CMV)  Sepsis  Hemochromatosis  Drugs  Adrenalectomy  Addison’s Disease Features: anorexia, weakness, weight loss, nausea, salt craving hyperpigmentation of frictional surfaces and mucosa hypotension, hyponatremia, hypovolemia, Primary Adrenal Insufficiency (Addison’s Disease)  Labs: hyponatremia, hyperkalemia, elevated BUN, low serum . carditis  Renal disease  Collagen diseases  Allergic diseases  Bronchial asthma  Organ transplant  Ocular disease  Skin disease  GI disease  Malignancies  Diseases of liver  Sarcoidosis  Thrombocytopenia . Cortisol pushes glucose into the bloodstream, whereas insulin works to store glucose in fat cells and muscle. Cortisol is released during stress which releases glucose into the bloodstream so. CMV)  Sepsis  Hemochromatosis  Drugs  Adrenalectomy Addison s Disease Features: anorexia, weakness, weight loss, nausea, salt craving hyperpigmentation of frictional surfaces and mucosa hypotension,