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Home , Adrenal cortex, Zona fasciculata, Zona glomerulosa

CHAPTER 8

Adrenal Gland

Devra K. Dang, PharmD, BCPS, CDE, FNAP | Trinh Pham, PharmD, BCOP | Jennifer J. Lee, PharmD, BCPS, CDE

LEARNING OBJECTIVES KEY TERMS AND DEFINITIONS After completing this chapter, you should be able to ACTH (adrenocorticotropic ) — a hormone produced 1. Identify the hormones produced by the adrenal glands by the that stimulates 2. Describe the functions of and in the body the to produce glucocorticoids, mineralocorticoids, 3. Recognize the signs and symptoms of adrenal insuffi ciency and . PART 4. Describe the pharmacological treatment of patients with acute and chronic adrenal Addison ’ s disease— a disorder insuffi ciency in which the adrenal glands do not produce enough hormones. 3 5. Recognize the signs and symptoms of Cushing ’ s syndrome and the result of too Adenoma— a benign much (noncancerous) tumor of glandular 6. Describe the pharmacologic and nonpharmacologic management of patients with origin. Cushing ’ s syndrome Adrenal insuffi ciency — a term 7. List management strategies for administration of and mineralocorti- referring to a defi ciency in the levels of adrenal hormones. coid therapy to avoid development of adrenal disorders — the hormone produced by the adrenal glands that regulates the balance of , he adrenal glands are an integral part of the , secreting water, and concentrations in the body. T hormones that act throughout the body to regulate functions and promote Corticotropin-releasing . In addition to the neurotransmitters epinephrine and norepineph- hormone (CRH) — a hormone rine, the secreted by the adrenal glands are vital to a wide released by the that variety of physiological processes. Pharmacologic agents that resemble the regulates the release of ACTH from the pituitary gland. adrenal hormones in chemistry and action are important in the treatment of — any of the many conditions. steroid hormones made by the cortex of the . Cortisol — the primary glucocorticoid produced by the adrenal cortex upon stimulation by ACTH. Cushing ’ s syndrome— a hormonal disorder caused by prolonged exposure of the body to a concentration of cortisol that is higher than what the body normally requires. Endogenous— produced or synthesized from within an organism. Exogenous— originating from outside an organism.

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Glucocorticoid— a steroid CASE STUDY hormone that has anti-infl ammatory and immunosuppressive properties. Adrenal Insuffi ciency Hypercortisolism— excess Mrs. Smith is a 30-year-old woman who presents to the emergency department with amount of circulating cortisol. complaints of fatigue, muscle weakness, anorexia, and dizziness for the last few days. Hypocortisolism— insuffi cient She also states that she has a bad cold, has been coughing, and had a fever of 101 ° F. amounts of circulating cortisol. She has a history of autoimmune disease and has been treated for it with prednisone — a steroid 10 mg daily and hydroxychloroquine 400 mg daily for the last 5 years. hormone that affects fl uid and Her vital signs are 108/64 and pulse 96 lying down, blood pressure balance in the body. 80/45 and pulse 110 sitting, respiration rate of 26, and temperature of 99.8 ° F. Labora- Steroidogenesis— the synthesis tory data show a low serum sodium and blood glucose (sugar) level along with high of (glucocorticoids and mineralocorticoids). and potassium levels.

Physiology of the Adrenal Glands

The adrenal glands are small triangular-shaped organs located on top of both kid- neys (Figure 8-1). It consists of two main regions: the adrenal cortex, which makes up the outer region of the adrenal gland, and the , which makes up the inner region of the adrenal gland. The inner medulla is responsible for secret- ing the hormones epinephrine and norepinephrine (also known as and noradrenaline, respectively). These hormones are involved in the activities of the sympathetic nervous system, which regulates the body ’ s responses to stress (e.g., the fi ght-or-fl ight response). See Chapter 3 for a more detailed discussion of epineph- rine and norepinephrine. The outer adrenal cortex secretes three major classes of hormones: glucocorticoids , mineralocorticoids, and androgens (male sex hormone, e.g., ). 1 These three major classes of hormones control many important functions in the body. This chapter focuses on the actions and pharmacologic uses of glucocorticoids and mineralocorticoids. The adrenal glands work interactively with the hypothalamus and pituitary gland, and this is referred to as the hypothalamic-pituitary-adrenal-axis. The hypothalamus releases corticotropin - releasing hormone (CRH) , which in turn stimulates the pituitary gland to release adrenocorticotropic hormone (ACTH) . The adrenal cortex is made up of three distinct zones: the outer , the middle , and the inner . When stimulated by ACTH, these zones produce and release min- eralocorticoids (from the zona glomerulosa), glucocorticoids (from the zona fasciculata), and androgens (from the zona reticularis).1 Cortisol is the primary glucocorticoid and its main functions are to regulate blood glu- cose concentrations, maintain normal blood pressure, promote protein and lipid (fat) break- down while preventing protein synthesis, and regulate infl ammation. Cortisol also affects wound healing and normal immune activity. Aldosterone is the primary mineralocorticoid and is responsible for maintaining the balance of sodium (salt), potassium, and water in the body. Adrenal androgens control sexual maturation during childhood and . Disorders of the adrenal cortex may result in decreased production of glucocor- ticoids or mineralocorticoids. This is known as hypocortisolism or adrenal insuffi - ciency . When the adrenal cortex produces too much cortisol, hypercortisolism results. This can lead to the development of a condition called Cushing ’ s syndrome. These are the two most common disorders of the adrenal glands and will be discussed in detail later in this chapter.

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