Chronic adrenal insufficiency Treatment
Endocrinology / / August 12, 2017
treatment. patients with chronic insufficiency of the adrenal cortex must receive adequate nutrition, to observe hygiene regime.They should be protected from injury and infection.
Mild forms of adrenal chronic disease, when the patient feels quite well without any special treatment, demand still periodically replacement therapy, since even a small voltage (mild infection, trauma, and so on.) Can cause the patient to acute adrenal insufficiency.
Patients with chronic adrenal insufficiency prescribe a diet poor potassium salts, and are added to the normal amount of salt 5-10 g of sodium chloride per day.A further quantity of sodium chloride is provided in the form of powders or in solution: Natr.chlorat.10,0 + Natr.citrici 5,0 dissolve in 1 liter of water, add sugar to taste, fruit juice or jam.The patient should drink per day 0.5-1 liters of solution.It should be borne in mind that the introduction of an excess of salt can lead to the formation of edema.Along with sodium chloride, it is recommended in
hormone replacement treatment of chronic adrenal insufficiency has been made possible, when Hartman and others received the aqueous extract of the adrenal cortex with a hormonal activity, - Cortina.Currently cortin little used for the treatment of patients with chronic adrenal insufficiency, since the lack of an accurate representation of the composition of the drug, as well as a relatively small activity limit its use.If necessary for patients assigned cortin 2-3-6 ml 2-3 times a day intramuscularly.
for replacement therapy of chronic insufficiency of the adrenal cortex are primarily used cortisone and cortisol (hydrocortisone).These steroids have an advantage over synthetic analogs of glucocorticoid -. Prednisone, triamcinolone, dexamethasone, etc., as along with glikokortikoidnym effect they cause mild mineralocorticoid effect.
Under normal circumstances, to compensate for the deficit in the glucocorticoid enough 12.5-50 mg of cortisone or hydrocortisone 10-30 mg per day administered orally in equal doses for 2-3 hours.
Early treatment for the removal of existing metabolic disorders often require high doses of glucocorticoid, reaching up to 75-100 mg per day;subsequently the dose is gradually reduced.When physical or mental stress, in case of injury or infection joining glucocorticoid dose should be increased as compared with the usual 3-5 times.In such cases it may be necessary to intramuscular injection of cortisone acetate in a dose of 100-150 mg per day.When receiving glucocorticoid inside to reduce its irritant effect on the gastric mucosa it is recommended to take them with food.
In some patients treated with cortisone and cortisol are sometimes combined with the addition to the normal diet of salt is enough for them satisfactory compensation.
In the absence of cortisol and cortisone replacement therapy may be used synthetic analogs of glucocorticoid - prednisone or prednisolone at a daily dose of 5-15 mg orally.At the same time, as a rule, it is necessary simultaneously to introduce drugs mineralocorticoid action (various drugs deoxycorticosterone, ftorgidrokortizon).
Most patients receiving cortisone or cortisol to normalize blood pressure and eliminate orthostatic hypotension, also necessary to introduce mineralocorticoid drugs.
most widely used various drugs deoxycorticosterone.The oil solution deoxycorticosterone acetate (Doxil) at the start of treatment (is crisis) administered intramuscularly in an amount of 5.3 mg per day.In the future, under the control of the general condition of the patient at a daily dose of Doxa measuring blood pressure may be gradually increased until the systolic blood pressure did not reach the level of 100 mm Hg software.Art., and the diastolic pressure should not rise above 70 mm.After improving the dose Doxa is often possible to reduce up to 2.5-5 mg in one - two days.
prolonged release preparation - deoxycorticosterone-trimethyl-tsetat - administered intramuscularly as a saline suspension of 2.5 to 1 ml every 2-4 weeks?.
Currently rarely used implantation tablets crystalline deoxycorticosterone.Absorption of tablets deoxycorticosterone occurs at a certain rate, and replanting tablets must proceed from the individual needs of the patients in this preparation, the treatment of established oil solution Doxy.Number of deoxycorticosterone, absorbed from the tablets a day should be 75% of the required daily dose of Dox.
in recent years increasingly used a synthetic steroid with a great mineralocorticoid activity - ftorgidrokortizon.Ftorgidrokortizon appointed by mouth once a day for breakfast at a dose of 0.05-0.2 mg.
the treatment of glucocorticoid in combination with a mineralocorticoid patients do not require incremental introduction of salt.
some mineralocorticoid treatment without combining them with the glucocorticoid significantly less effective than combination therapy.
mineralocorticoid Overdose can lead to swelling, headaches, increased blood pressure, sometimes the development of heart failure.A more rare complication are arthralgia.In connection with hypokalemia may develop sudden muscle weakness, ascending paralysis, cardiac arrhythmia.In recognition of hypokalemia can provide great help electrocardiographic study, in which is revealed the reduction or distortion of the T wave and prolongation of the interval Q - T
mineralocorticoid treatment of complications of therapy consists in the abolition of drugs with mineralocorticoid effect, doubling the dose of cortisone, the limitation in foodsodium chloride, potassium chloride assignment 4-10 g per day in divided doses inside.In acute ascending paralysis development may require intravenous administration of potassium chloride - 0.5% solution in 5% glucose solution.Intravenous injection of potassium chloride only droplets: 500 ml infusion solution should last 1-2 hours if necessary drip of potassium chloride can be carried out 2-3 times a day..
To eliminate edema diuretics are appointed simultaneously with 4-10 grams of potassium chloride per day.
Treatment of acute adrenal insufficiency crisis
Treatment consists of replacement therapy with corticosteroids and other measures aimed at elimination of violations of water-salt balance, hypoglycemia and vascular insufficiency.
best drug for substitution treatment of acute crisis of adrenal insufficiency are water-soluble drugs Cortisol - Cortisol hemisuccinat or Cortisol phosphate.These preparations may be administered by intramuscular injection of 100 mg every 4-6 hours. In severe Stroke administered at the same dose intravenously with a solution of 5% glucose saline.
less advisable to use a water-soluble gidrohloristogo prednisolone 30 mg intramuscularly or intravenously, depending on the severity of the crisis.This drug does not have sufficient mineralocorticoid activity, and from the outset it is necessary to combine with mineralocorticoid - Doxa 5-10 mg 1-2 times a day.
In the absence of soluble drugs hydrocortisone or prednisolone in the beginning of treatment it is advisable to enter intravenously 10-20 ml Cortina simultaneously with intramuscular injection of cortisone acetate, the effect of which will manifest only after 3-4 hours. If cortin is the only available drug having glikokortikoidnym actionit should be administered intravenously or intramuscularly every 2-3 hours. The total daily amount can be reduced to 200 ml.Cortina Treatment should be combined with intramuscular injection of Dox (5-10 mg 1-2 times a day).
If no doctor available water-soluble drugs cortisol or prednisolone or Cortina treatment is cortisone acetate.Cortisone acetate administered intramuscularly in the dose of 100-150 mg and then 50 mg every 4-6 hours depending on the patient's condition.To each suction speed single dose cortisone acetate are preferably administered in different places in divided portions.
the treatment of crisis with large doses of hydrocortisone or cortisone, in most cases mineralocorticoid activity of these drugs is sufficient to restore the water-salt balance.However, if in the next few hours after initiation of treatment with cortisone or cortisol in combination with the introduction of fluid and salt effects of dehydration and do not decrease blood pressure remains low, it is advisable to introduce the Dox (5-10 mg 1-2 times a day).It is recommended on the first day of treatment crisis administered per day to 30-40 mg of Dox.However, the appointment of such large doses of Dox increases the risk associated with its overdose.
Simultaneously with the start of replacement therapy with corticosteroids should start drip of 5% glucose solution to saline.During the day the patient should receive from 2 to 3.5 liters of this solution was added with 50 ml of a 5% ascorbic acid.
When anacatharsis shown intravenous administration of hypertonic saline solution (Sol Natr chlor 10% -... 20.0).
To combat dehydration may also be used a blood transfusion.
To eliminate vascular insufficiency patients administered subcutaneously mezaton (Sol Mesatoni 1% -. 1,0) (0,1% -0,3-0,5 Sol Adrenalini hydrochl..), The adrenaline.In the appointment of adrenaline great care is needed, and it should be used only in extreme cases, the very sharp decrease in blood pressure as an initial pressure increase after administration of epinephrine may be followed by a sharp drop in its.Noradrenalin infusion can be administered intravenously (Sol Noradrenalini bitartarici 0,2%.): 2 ml of 0.2% norepinephrine dissolved in 1000 ml of 5% glucose and administered at a rate of 20 to 100 drops per one minute.
In all cases it is expedient to use camphor, caffeine kordiamina (intramuscularly, subcutaneously or intravenously), kardiazola.
If it is impossible to exclude infection as the cause of crisis patients administered large doses of broad-spectrum antibiotics.If data are available for the aggravation of tuberculosis process prescribed streptomycin 1 g per day.
Throughout the crisis period, blood pressure was measured every 1/2 hour. It is necessary to re-determine the content of potassium in the blood sodium and blood hemoglobin.The hemoglobin content gives an indication of the degree of dehydration, and reduced hemoglobin indicating a decrease in the dehydration.
Because Stroke at high doses of corticosteroids are used, you should consider the possibility of complications related to the treatment, in particular when large doses of Doxa.Among other symptoms of overdose Doxa described above, due to acute swelling of the brain may develop unconscious at the time when the patient's general condition has improved.There are indications of the possibility of development of psychotic states in connection with an overdose of hydrocortisone or cortisone.
With the improvement of the general condition of patients with corticosteroid dose gradually reduced;It decreases the amount of fluid administered parenterally.Vasotonic are administered if indicated.
Patients should be long on strict bed rest.Nutrition should be a full, rich in proteins, carbohydrates and vitamins, mechanically gentle, with the restriction of potassium salts.If necessary
surgery in patients with chronic insufficiency of the adrenal cortex dose cortisone acetate should be increased up to 200-300 mg per day or more (100-150 mg per day of surgery and on the morning of 50-100 mg every 4-6 hours).In the presence of water-soluble drugs expedient cortisol or prednisolone administered during surgery their intravenous drip c5% glucose solution at a physiological solution (100 mg hydrocortisone-hemisuccinate gidrohloristogo or 30 mg of prednisolone);infusion of 5% glucose saline solution to continue after the operation to adjust the amount of liquid droplets injected to 2.3 liters per day.
In patients with severe impairment of the adrenal cortex significant increase in cortisone dose (150-200 mg per day), it is advisable even for small surgical interventions as tooth extraction.
When an emergency operation will require a comprehensive therapy is the treatment of acute crisis of adrenal insufficiency.
Reduced doses of corticosteroids in the postoperative period should be carried out very slowly.
During pregnancy, in the first three months, usually require higher doses of corticosteroid medications.In the future, the need for replacement therapy is often reduced.During childbirth, patients should be treated, as in the big surgery.
When combined with chronic adrenal insufficiency with hypertension or renal hypertension may experience difficulties related to the fact that when a sufficient replacement therapy may increase blood pressure to a level above normal.These patients need more care in prescribing drugs with mineralocorticoid activity.They are increasingly used synthetic versions of cortisol and cortisone (prednisone and prednisone), do not linger in the body of sodium and water.However, these activities are not always possible to avoid an undesirable increase in blood pressure.
- Physiology of the adrenal cortex
- Chronic adrenal insufficiency.Addison's disease
- Pregnancy in patients with chronic insufficiency of the adrenal cortex
- blood supply and innervation of the adrenal
- Clinical evaluation of laboratory studies of the functional state of the adrenal cortex
- Determination of corticosteroids and their metabolites in urine
- Diagnosis and differential diagnosis of chronic adrenal insufficiency
- Biological effectsadrenocortical hormones.The biological effect of glucocorticoid
- morphology of adrenal
- Additional adrenal
- biosynthesis and metabolism cortex hormones adrenal
- Biological effects of C19-steroids
presence of peptic ulcer in patients with chronic heart failureadrenal cortex is not a contraindication to the use of glucocorticoid doses needed to maintain eukortikoidnogo state.With the combination of chronic adrenal insufficiency with diabetes need to take into account the increased sensitivity of these patients to insulin.Insulin therapy should be conducted only on the background of sufficient glucocorticoid replacement therapy.
Care should be taken when appointing thyroid drugs in patients who have chronic insufficiency of the adrenal cortex is combined with hypothyroidism.Excess thyroid drugs can cause these patients acute adrenal insufficiency.
addition to substitution treatment, patients with chronic insufficiency of the adrenal cortex in need of etiological therapy.Usually it is very difficult with sufficient reliability to eliminate tuberculosis defeat.Therefore, in the absence of direct evidence of another origin of the disease, patients with chronic insufficiency of the adrenal cortex is almost regarded as suffering from tuberculosis of the adrenal glands.They should receive systematic TB treatment under the supervision of TB specialists - antibacterial therapy for existing schemes tuberculosis treatment and spa treatment.
patients with chronic insufficiency of the adrenal cortex is expedient to appoint ascorbic acid at a dose of 1-1.5 grams per day, but this treatment is complementary to the basic methods of treatment, without replacing them.