Diabetes, Thyroid, Adrenal, Pituitary, Steroid, Calcium and other Hormonal disorders | Dr Arpan Bhattacharyya » Adrenal and Steroid

Orations

admin — Thu, 11 Jun 2009 09:43:05 +0000

International

1. Fibronectin in BAL fluid and plasma in Tuberculosis – World Conference of Lung Health, IUATLD, Italy, 1990.

2. Autosomal dominant hypocalcaemia: treatment with vitamin D can cause renal damage even at low normal serum calcium levels. Clinical case meeting (Society of Endocrinilogy) at Royal College of Physician(London), Feb.1998.

3. A novel complication of treatment of Addison’s disease. RCP postgraduate meeting in Diabetes and Endocrinology, Manchester, May,1998.

4. A young woman with fluctuating hypo- and hyperthyroidism. North West Endocrine Society meeting, Manchester, Dec,1998.

5. Addison’s disease and its varied presentation. Lancashire canter for medical studies, Preston, Feb. 1999.

6. Graves’ disease in pregnancy complicated by sensitivity reaction to both Carbimazole and Propylthiouracil. Society for Endocrinology conference, Bournemouth, Apr.1999.

7. Prevalence of genetic Haemochromatosis in patients with raised Alanine Aminotransferase. Northwest Association of Physician meeting (Manchester Medical Society presntation), Preston, Apr.1999.

8. Radioiodine for hyperthyroidism: A patient satisfaction survey. North West Endocrine Society meeting, Liverpool, may, 1999.

9. Obstetric difficulties due to thyroid disease. Clinical Practice day, Society for Endocrinology, Manchester, Oct, 1999.

10. Glucose tolerance test and drug induced Diabetes. International Diabetes update, Bangalore, Nov.2001.

11. Early Insulin therapy in type 2 Diabetes Mellitus. Workshop NNDU Singapore 2004.

National

1. Lipid alternation in Primary Hypothyroidism with effect on treatment -Endocrine Society of India Conference, Chandigarh, 1991

2. Plasma and urine osmolarity in Primary hypothyroidism Endocrine Society of India Conference, Bombay, India, 1993

3. Beta cell preservation in type 2 Diabetes Mellitus. ESICON 2002, Calcutta, Dec 2002.

4. Hospital management of Daibetes Meliitus. Madurai, April, 2002.

5. Syndrome X and complications of Diabetes Mellitus. Nagpur, February, 2003.

6. Prandial glucose regulation. Regional Diabetes Update, Kochin, 2003

7. Diabetes Management in Hospital setting , PGIMER, Chandigarh, Sep 2004

Regional

1. Pregnancy and thyroid dysfunction. Bangalore Society of Obstetrics and Gynaecology, Dec. 2001.

2. Postprandial Glucose Control. Which, When, How, Why? Karnataka chapter APICON, 2002, Hubli.

3. Newer oral agents in the treatment of type 2 Diabetes Mellitus, Ranbaxy Diabetes update, Bangalore, Sept. 2001.

4. Proponent for debate “HRT is a must for all postmenopausal women, unless contraindicated” KAPICON 2003, Mysore.

5. Opponent for debate “Early Insulin therapy in type 2 Diabetes” KIMC, Mangalore, Dec 2003.

6. Proponent for debate – Secretagogues vs Insulin in treatenmnt of early type 2 Diabetes. RSSDI 2004.

7. Hospital management of Diabetes Mellitus – API meeting Bellary, Aug 2004.

8. In patient manage,ment of Diabetes – Quotyam Diabetes Club meet – 2005

Patient Education

1. Diabetes and Diet, Diabetes Club, Bangalore 2002.

2. Diabetes for the elderly – Rotary Club, Indiranagar 2004.

3. Osteoporosis – Infosys, Bangalore 2004.

4. Diabetic complication – Diabetes Club, Bangalore 2004

Research Activities

admin — Thu, 11 Jun 2009 09:08:43 +0000

1. Collaborative Atorvastatin in Diabetes Mellitus, North Manchester General Hospital – Co-Investigator – 1996

2. Cross-over comparison of Viagra TM and Placebo for the treatment of pain in diabetic polyneuropathy in adult males A 1481016 , Hope Hospital, Manchester – Co-Investigator – 2000

3. A double blind comparison of Viagra and placebo: 148-1040 Study in Diabetic Foot Ulcers – Hope Hospital, Manchester – Co-Investigator – 2000

4. Glimepiride vs Metformin in children with type 2 Diabetes as monotherapy in Paediatric subjects with type 2 Diabetes Mellitus: A single blind comparison study. HOE490/4038. 2003-4. – Pr Investigator, Manipal Hospital, Bangalore.

5. Glycon Registry: Open labelled trial to see efficacy on glycaemic control, lipids with injection Glargine once daily in patients with type 1 and 2 Diabetes mellitus. 2003-4 Pr Investigator, Manipal Hospital, Bangalore.

6. An open labelled randomised, three treatment, three period, three sequence cross-over, relative bio-availability study of two formulations of Testosterone with one formulation of Restendol in hypogonadal subjects under fed condition. Pr Investigator Lotus Lab, 2004

7. A multicentric 12-week comparative study of twice-daily Novomix 30 + Pioglitazone versus Sulphonylurea + Pioglitazone. 2004, Pr Investigator, Manipal Hospital, Bangalore.

Underactive Adrenal or Hypocortisolism

admin — Thu, 28 May 2009 09:37:32 +0000

What are the causes of Low cortisol hormone??

The disease of low cortisol production can arise either because of destruction of adrenal gland itself (Addison’s disease or primary hypocortisolism) or due to malfunction of pituitary or hypothalamus (secondary hypocortisolism). Common causes of secondary adrenal insufficiency are tumors of the pituitary, head injury, radiotherapy and long standing steroid medication suppressing the axis.

The primary adrenal deficiency, also called Addison’s disease, is the result of infective or inflammatory or infiltrative processes involving the adrenal glands. The most common is the autoimmune destruction of the glands. This is followed by less commoner conditions like metastasis, amyloidosis, tuberculosis, opportunistic infection in AIDS/HIV, infarction, haemorrhage, adrenomyeloneuropathy, congenital adrenal hyperplasia etc.

What are the clinical features of Addison’s disease?

Symptoms are non-specific. Common presentations are loss of weight, loss of appetite, tiredness, hyper-pigmentation of the skin, dizziness and low BP, nausea, vomiting, decreased axillary and pubic hair and reduced libido in women. It could be associated with vitiligo i.e. patchy whitening of the skin. Blood test may show low sodium, high potassium, elevated urea, low hemoglobin.

What other problems could be associated with this?

This disease could be a part a cluster of autoimmune diseases called autoimmune polyglandular syndrome where other than low cortisol there is low level of thyroid, parathyroid and sex hormones. Type 1 diabetes could also be a part of it.

How do we confirm this?

There are several ways to confirm this problem. Low blood sodium, high blood potassium with elevated urea indirectly point to low cortisol. Finding low blood cortisol, which fails to increase after injection of synacthen is diagnostic of Addison’s disease. This test is called short synacthen test. Other tests that the doctor may want is adrenal CT scan

What is the treatment?

This problem of low cortisol is corrected by administration of the hormones in the tablet form. The most natural replacement is through tablet hydrocortisone, however prednisolone can be used for economic reason. The other hormone aldosterone is replaced by giving tablet fludrocortisone. The initiation of hydrocortisone requires monitoring. This monitoring can be done by observing for several parameters like weight, BP, blood sodium and potassium levels, blood cortisol levels in the form of cortisol day curve. One has to get admitted for a day for the last test. One more important thing to note is that this hydrocortisone tablet should be taken at particular time of the day i.e. on waking, at midday and at 5 pm. Compliance is very important here.

How to manage during an intercurrent illness?

The requirements of cortisol go up when a patient of cortisol deficiency undergoes a surgery or develops a severe illness like pneumonia. For moderate elective procedures or investigations e.g. Endoscopy or angiography, patients should receive a single dose of 100mg hydrocortisone before the procedure. For major surgery patient should take 20mg hydrocortisone orally or 100mg intrmuscular injection before surgery, and receive 100mg intrmuscular injection every sixth hourly for the first three days and then rapidly go back to pre surgery level. In case of pneumonia patients should receive 50-100mg intrmuscular injection every sixth hourly until completely cured.

Does management differ during pregnancy?

No. One can continue the same dose during the pregnancy. If the hyper emesis gravidarum i.e. the condition of excess vomiting in the first three months, ensues then intramuscular injection may be required. During labor 100mg of hydrocortisone is given by intramuscular injection every sixth hourly.

What are the implications of long-term steroid administration?

The steroid medications like prednisolone, betamethasone or dexamethasone are given for various medical conditions like asthma, rheumatoid arthritis and many connective tissue disorders like SLE for longer periods to achieve remission. If any of these are given for more than 3 weeks or if prednisolone or its equivalent is given at 40mg/day or more for less than 3 weeks or a short term therapy (< 3weeks) is given within one year of cessation of long term therapy (>3 weeks) or is given as a evening dose then the body fails produce its own cortisone when external therapy is withdrawn. Therefore in such situations the steroids should be withdrawn slowly. After the remission has been achieved these drugs are reduced to a dose of 7.5mg of prednisolone or equivalent per day and then further reduction is carried out more gradually over months. Ideal would be to start on hydrocortisone tablet and to do a test called short synacthen test to know whether the body has regained its capacity to produce cortisol on its own before finally stopping the drug.

Steroid Medications

admin — Thu, 28 May 2009 09:33:05 +0000

1) What is steroid?

Steroid is name of a hormone that comes form Adrenal glands mainly. There are different types of steroids in our body; they serve various types of metabolic function. Some of the steroids are life-saving, meaning without them we can not survive. Some of them suppress inflammation. Other steroids come form Testes and Ovaries; they are called sex-steroids. In addition to controlling metabolism they are important in sexual function.

2) What are their uses?

These drugs are used for various medical conditions in which the inflammatory response has to be controlled. In diseases like asthma these are given by tablet, injection or through inhaler. In certain other medical conditions like rheumatoid arthritis, SLE and other connective tissue disorders these are very helpful. These are the life saving medications in situations like adrenal insufficiency and severe allergic reactions.

3) What are different types of steroids?

There are different types of steroids. They are mainly classified on the basis of their potency. While hydrocortisone, commonly called as hysone or histone, is least potent; dexamethasone, commonly known as dexona, is the most potent. However most commonly used steroid is prednisolone which is intermediate in potency.

4) Are their any side effects to these drugs?

If one uses these drugs in excess then they create a variety of problems. The most dramatic of all is the Cushing’s syndrome in which patient manifests with florid signs of steroid excess. These drugs can cause increase in blood sugar leading to diabetes, increase BP, weaken the bones (osteoporosis), muscle weakness, ulcer in the tummy, raised pressure in the eyes (glaucoma), increased chance of infections etc. However if used judicially then they help in combating many ailments effectively. Also if a person is taking a steroid drug for a long time then it must be reduced slowly otherwise patient may develop crisis which could be life threatening.

5) Is there any difference between these steroids and steroids used by sports persons for performance enhancement?

Yes, there is a lot of difference between them. They are called anabolic-androgenic steroids. These are basically male sex related hormones; anabolic means body building and androgenic means masculine characteristics. In sports their use is illegal. They are used in the belief that they increase the muscle strength and hence performance. Although it may be true in short term they are deleterious to health if used on a long term basis.

6) What are the problems of its long term use?

In both men and women they can cause liver and kidney cancer, jaundice, increased blood pressure, bad cholesterol, mood swings etc. In men testicles may shrink, sperm production and fertility decreases, baldness increases. They are at increased risk of developing prostate cancer. The women develop excessive facial hair, male pattern bald ness, menstrual disturbances, and changes in genetalia. If children abuse these drugs then their overall growth will be stunted.

Cushing’s Syndrome

admin — Thu, 28 May 2009 09:29:34 +0000

The condition of cortisol excess is called Cushing’s syndrome. It can be due to excess secretion of cortisol either due to a problem in adrenal gland it self or due to excess secretion of ACTH, the Pituitary hormone that controls cortisol secretion. The latter situation can be either due to ACTH coming from pituitary or coming from some cancerous lesions, when it is called ectopic secretion of ACTH. The reason for the adrenal gland to produce excess of cortisol could be a tumor which is either benign or cancerous. However the most common reason being the condition called iatrogenic Cushing’s which is caused due excess intake of steroid drugs for some reason or other.

The patients suffering from this disorder may have following picture. They can have a round face, a buffalo hump (collection of fat in the back just below the neck), weakness of muscles resulting in difficulty in getting up from the sitting position, weakness of bone (osteoporosis) resulting in easy fractures, menstrual disturbances, thinning of the skin, raised blood pressure and high blood sugar. Many experience mood disturbances like depression. Loss of sexual drive can be another problem. Many become susceptible to infections.

When a person has clinical features suggestive of Cushing’s syndrome the clinician looks for evidence of increased cortisol production. He would order for measurement of blood cortisol at 8 am and midnight. If they are high then a tablet called dexamethasone will be given at 11pm and your blood will be tested next morning at 8 am for cortisol level. In normal persons there will be low level of cortisol in the next morning but if it is high then the suspicion of Cushing’s syndrome is strong. From here he proceeds to find out if this excess is coming from adrenals or from ACTH excess. Estimation of ACTH value, which is done only at a few centers in India, helps solve this problem. While in the former ACTH is undetectable in the latter it is high. If ACTH is found to be high then it could be of either pituitary source or of an ectopic source. A MRI scan of the pituitary or CT scan of abdomen or chest can reveal the culprit.

If the cause is in the pituitary then a surgery called Trans sphenoidal surgery is done to remove the tumor from the pituitary. It may be followed by radiotherapy in case of failure of surgery. If it is located in the adrenal then either one or both glands are removed. We have two options here. One is an open surgery second one is laparoscopic surgery. In the latter the advantage is that a small cut is needed and recovery is faster. However it is useful only if size is less than six cms. If it is more than six cms then probability that it could be cancerous lesion are high, whence open surgery is preferable. In either case one has to be on replacement of the hormones in appropriate dose later. If it is an ectopic source then an attempt is made to remove the source. But in case it is not possible then certain drugs like ketoconazole or metyrapone are given to suppress the cortisol production.

Adrenal Medulla

admin — Thu, 28 May 2009 09:25:50 +0000

Adrenal medulla secretes the hormones epinephrine and nor-epinephrine. They are our flight or fight hormone. Remember exam days, we used to get so tensed! That is because excess Adrenaline. The most common problem of this part of the adrenal gland is the tumor called phaeochromocytoma, which secretes excess of these hormones.

The common features of this are high blood pressure that is difficult to control, episodic headache, sweating, flushing, faster heart beats and difficulty in breathing. If left untreated such patients suffer from heart failure, pulmonary edema or encephalopathy i.e. damage to brain.

Sometimes a crisis situation takes in these patients leading to very high blood pressures requiring admission to the hospital. These can be life-threatening conditions. Straining, exercise, surgery, pressure on the tummy, anesthesia, taking beta-blocker group of drugs only for blood pressure and certain other drugs, precipitate these.

The confirmation is done by testing a 24-hour urine sample for VMA, metanephrines and free catecholamines. Certain precautions are required before this test is performed.

How the Test is performed:

A 24-hour urine sample is needed. On waking up urinate in the morning and do not collect it. Your time starts now.
Collect all subsequent urine (in the special container) throughout the day and night
Keep it in a cool place during the collection period.
Next day at the same time urinate into the container. This completes your collection.
Cap the container& return it as instructed.

Following are to be avoided during the collection for three days prior to the test.

Foods: Coffee, bananas, chocolate, citrus fruits, and vanilla.

Drugs: Levodopa, lithium, aminophylline, clonidine, erythromycin, methyldopa, quinidine, tetracyclines, nitroglycerin, imipramine, phenothiazines, salicylates, metoclopramide, domperidone, hydralazine, decongestants.

After confirming the disease, next step is to do certain tests to localize the tumor and to know how far it has spread in the body. These include MRI scan, 123I- MIBG scan or venous sampling if the first two fail to demonstrate anything.

Treatment is the surgical removal of the tumor. But before the surgery is performed the blood pressure has to be controlled initially with a drug called phenoxybenzamine with addition of propranalol 48-72 hrs later. To assess the cure 24 hour urine is tested for free catecholamines after 2 weeks. If the tumor is cancerous then long term drugs as mentioned above are needed to control the BP. High dose 123I- MIBG, chemotherapy are required for those tumors which have spread in the body.

Control of Adrenal Gland

admin — Thu, 28 May 2009 09:18:54 +0000

Control of Secretion: Cortisol is secreted in response to a stimulating hormone called adrenocorticotropic hormone (ACTH) from the master gland ‘pituitary’ situated in the brain. ACTH is itself secreted under control of the hypothalamic peptide corticotropin-releasing hormone (CRH). Aldosterone is controlled by the body’s sodium, potassium and water concentrations.

Diseases resulting from abnormalities of this pituitary and adrenal axis either cause a deficiency status or excess status of the hormone cortisol.

Adrenal and Steroid

admin — Thu, 28 May 2009 09:15:37 +0000

The adrenal glands are triangular shaped hormone-producing glands situated on top of the kidneys. They measure about one-half inch in height and 3 inches in length. Structurally each gland consists of a medulla (the center of the gland), which is surrounded by the cortex.

The medulla is responsible for producing epinephrine and nor epinephrine (adrenaline). The adrenal cortex produces cortisol (glucocorticoid) and aldosterone. The adrenal cortex also makes sex hormones but this only becomes important if overproduction is present.

Adrenal Gland Functions

Adrenal Cortex produces Cortisol that regulates glucose, protein, and fat metabolism. It contributes towards the control of water and electrolyte concentrations. This hormone mainly increases the glucose concentration of the blood by causing the liver to produce more glucose. It causes protein and fat breakdown to ensure that more amino acids and triglycerides are available for conversion to glucose by liver. It tones down inflammatory process.

The hormone aldosterone acts on the kidney to cause increased reabsorption of sodium and water with increased excretion of potassium. This helps to maintain the proper balance of these important ions. It is the main hormone that controls the electrolytes and water along with a small contribution from cortisone.

The medullary hormones are mainly responsible for the maintenance of blood pressure, heart rate, and heart function. They are responsible for the fight or flight response seen during a stressful situation. They are called Adrenaline (epinephrine) and Nor-Adrenaline (nor epinephrine).

Adrenal gland also secretes certain amounts of Sex steroids in both men and women, this in addition to those produced by Testes and Ovaries. Certain steroid in this aspect like DHEA-S has some therapeutic consideration recently as women deficient in these can have distinct symptoms.