Physiology of an adrenal crisis?

[NDPitch]

Can any med students currently studying this material refresh my memory on this topic? Been a while since the year of physio we took in school.

I have a couple patients on long term steroid therapy, and in school we were taught guidelines on giving supplemental steroids to patients that are likely suppressed from taking steroids for long periods of time, and will be undergoing a stressful procedure such as some oral surgery or endodontic therapy.

At a high level it makes sense, they’re not producing their own cortisol. But what happens physiologically when cortisol is needed?

Stress happens, they can’t produce their own cortisol, and then what? What physiological response leads to the crisis. What should happen? What CAN’T happen as a result because the adrenal gland isn’t functioning normally from long term steroid use?

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[ChymeofPassion]

Can any med students currently studying this material refresh my memory on this topic? Been a while since the year of physio we took in school.

I have a couple patients on long term steroid therapy, and in school we were taught guidelines on giving supplemental steroids to patients that are likely suppressed from taking steroids for long periods of time, and will be undergoing a stressful procedure such as some oral surgery or endodontic therapy.

At a high level it makes sense, they’re not producing their own cortisol. But what happens physiologically when cortisol is needed?

Stress happens, they can’t produce their own cortisol, and then what? What physiological response leads to the crisis. What should happen? What CAN’T happen as a result because the adrenal gland isn’t functioning normally from long term steroid use?

Cortisol effects: A BIG FIB

An increased appetite
Increased blood pressure
Increased Insulin Resistance
Increased Gluconeogensis

Decreased Fibroblasts
Decreased Immuno
Decreased Bone Formation.

The major problems with primary adrenal insufficiency/crisis with a lack of cortisol is a hypotensive crisis and autoimmunity.

 

[mvenus929]

One of the primary reasons for the adrenal crisis is that glucocorticoids are needed in the adrenal gland to synthesize epinephrine (exogenous glucocorticoids don't have a high enough concentration in the adrenal gland to do this). So when the body is going through a stress, it has a harder time compensating due to lack of sufficient cortisol to do all the things above, and then they bottom out because they can't make epinephrine as an emergency back-up.

Also, different steroids have different potency, so if the patient is on high dose prednisone, they may be getting stress dosing for routine stress (i.e. flu, vomiting, etc). Surgery usually requires higher stress dosing, but some patients are on those doses as well.

 

[Professional Student]

I am not an attending like the poster above, but beyond steroids being needed for catecholamine synthesis (I was unaware of this), cortisol also increases transcription of sympathetic receptors that traffic to the cell membrane. So not only does hypocortisolism lead to decreased catecholamine synthesis (according to above at least) but also leads to a limited ability to respond to that signaling.

 

[Styrene]

Cortisol also increases catecholamine response through cortisol-mediated down-regulation of catechol-o-methyltransferases. This is one of the reasons there is a fast response to IV corticosteroids during hypotensive crisis in the setting of hypoadrenalism.