Disease states that alter the production from the adrenal glands can have serious implications towards the overall health of the human body. Addison’s disease and Cushing’s syndrome are important diseases that represent either the underproduction of endogenous steroids (Addison’s Disease) or the overproduction (Cushing’s).
Causes of Addison’s Disease
Addison’s disease can be caused by immune-mediated destruction of either: the adrenal or pituitary cells, cancer or infection of these cells, or physical trauma to the adrenal glands. Ultimately, the damage to these cells leads to the underproduction of steroids such as aldosterone or cortisol. As a result, the treatment for Addison’s can aid in remembering how the disease works as the treatment will require the addition of steroids for clients with Addison’s.
Signs and Symptoms of Addison’s Disease
Signs and symptoms of Addison’s disease include reduced blood pressure, blood sugar, salt retention, and water retention. A key physical manifestation that will require monitoring is weight loss as clients will have reduced water retention.
These clients may often present intolerance to the cold with symptoms of dizziness, dehydration, cravings for salt, muscle aches, and fatigue. They may also exhibit signs of reduced sex steroid production causing hair loss (alopecia), slow and irregular menstrual cycles, and decreased sexual appetite. Addison’s clients may also exhibit abnormal pigmentation on their skin sometimes regarded as a “bronze pigment” on the hands a face.
Generally, endogenous steroids can be thought of as hormones released in the body under stress – sometimes thought of as the “fight or flight” response. Steroids improve the chances of survival under critical situations by increasing blood sugar, blood pressure, and water retention. Key survival pathways become activated in response to steroid release from the adrenals – therefore, the chronic underproduction of these hormones will yield the opposite result in clients with Addison’s.
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Addison’s Disease Pathophysiology
Hyponatremia (Serum Na+ < 135 mEq/L) is a very common and potentially serious manifestation to evaluate in clients with Addison’s. Clients with Addison’s experience hyponatremia as a result of increased excretion of sodium and water from the body.
In addition, clients are at increased risk of retaining excess potassium leading to hyperkalemia (K+ > 5 mEq/L). Hyperkalemia can cause arrhythmia in these clients, precipitating other serious conditions. These clients are also at increased risk of hypoglycemia and hypotension.
Eosinophilia (eosinophil count > 500/mm3) is a possible manifestation in clients with adrenal insufficiency but is not an accurate predictor for diagnosis of Addison’s.
Addison’s Disease Treatment
As Addison’s disease is caused primarily by the underproduction of steroids, adding steroids is the key treatment for these clients. Several steroids can be administered to these clients, including prednisone and hydrocortisone, with dosages that may vary based on the client’s response. Clients with aldosterone deficiency may also receive fludrocortisone to be taken once daily.1
Steroid replacement is usually an acute treatment modality when used in other disease states. Addison’s clients may need to be chronically on steroids following their diagnosis. It is important to recognize that chronic steroid replacement can be dangerous when these clients abruptly discontinue their treatment.
This can trigger a serious condition called Addisonian crisis from acute adrenal insufficiency. Clients with this condition may present with severe hypotension, which can be fatal. Therefore, clients on chronic steroids should be carefully advised to never suddenly discontinue their regimen. If steroid withdrawal is necessary, they will need to be tapered off slowly.
Clients experiencing Addisonian crisis should be restarted on steroid therapy as soon as possible. The hypotension should be treated with fluids either saline or D5W.
Addison’s Disease Nursing Interventions
There are several important monitoring parameters to keep in mind when treating Addison’s clients. Daily weights may be advised to monitor for weight loss resulting from water loss. Weight monitoring, as well as serum electrolytes (sodium, potassium, and calcium), should be closely watched particularly in clients experiencing acute adrenal insufficiency.
Other vitals such as heart rate and blood pressure should be evaluated for these clients. Blood sugar changes may be among the most important factors to monitor for. Clients should be counseled on the signs and symptoms of hypoglycemia and treated appropriately.
Clients with adrenal insufficiency may also exhibit psychological changes, potentially indicating depression screening. A PHQ-9 screen may be advised for clients presenting with significant mood changes.
Other interventions may include the management of symptomatic changes such as hair loss or menstrual cycle changes. Specific treatments for these changes should be considered – while careful monitoring is performed to assess for changes in quality of life.
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Causes of Cushing’s Syndrome
Cushing’s syndrome can be thought of as the opposite of Addison’s as it represents the overproduction of endogenous steroids. It can be caused by external factors such as steroid overuse or overdose in clients on chronic steroids. Other causes may be the development of a tumor on the adrenal or pituitary gland leading to overstimulation and production of steroids.
Notably, clients with small cell lung cancer may be at increased risk of developing Cushing’s. Most clients with Cushing’s will have over secretion of ACTH as a result of a tumor on the pituitary gland.
Signs and Symptoms of Cushing’s Syndrome
The primary symptomatic change that will be observed in Cushing’s syndrome is weight gain. This is due in part to water retention as well as the steroids causing changing in fat distribution. “Moon face” is often regarded as a classic presentation in Cushing’s as well as a “buffalo hump” that develops on the back of the neck.2
Those with Cushing’s may also experience changes to the skin – in some cases stretch makes may form due to rapid weight gain as well as red cheeks. Clients may also have excessive hair production – particularly on the face, neck, chest, abdomen, and thighs.
These clients may have weakness and fatigue, as well as loss of muscle mass. Women with Cushing’s can have changes to their menstrual cycle and reduced fertility while both men and women can have changes to their libido.2
Cushing’s Syndrome Pathophysiology
Multiple changes to vital signs may be observed in these clients – particularly hypertension (systolic > 140 mmHg). Clients with elevated blood pressure may require therapeutic intervention to reduce cardiovascular risks. Other key manifestations include hyperglycemia, hypernatremia, and immune system suppression.
Cushing’s Syndrome Treatment
When treating Cushing’s syndrome, the goal is to attack the underlying cause, whether exogenous or endogenous. A key exogenous factor to be aware of is steroid overuse – therefore the key treatment is to slowly taper these clients off steroids. Clients who may be prone to this event include those with chronic inflammatory conditions for example clients with rheumatoid arthritis.
Cushing’s clients with endogenous factors such as a tumor on the pituitary or adrenal gland may need to be surgically removed. As a result, removal of endocrine glands may require supplementation of the affected hormones or steroids that the client may be deprived of after the procedure.
Medical treatment for Cushing’s is relatively limited when compared to Addison’s as key interventions involve treating the underlying cause. The primary treatment for these clients involve controlling cortisol production. Ketoconazole, metyrapone, and intravenous etomidate may be used to decrease the production of cortisol in these clients.
However, it is imperative to recognize that all these medications have several serious side effects, as well as potential for interactions and toxicity. Therefore, the use of these treatments are not preferred when surgical intervention is still an option.
Cushing’s Syndrome Nursing Interventions
Several important monitoring interventions will be required in clients with Cushing’s. Electrolyte changes are important to watch for such as serum sodium, potassium, and calcium. Daily weights may be advised to monitor for increased water and salt retention. Increases in weight by 1 lbs/day or 2-3 lbs in a few days may require pharmacologic intervention.
Cushing’s clients are at increased risk of experiencing hyperglycemia due to steroid production. Therefore, periodic blood glucose tests should help prevent elevated blood sugars and reduce risks associated with diabetes. Clients with high blood sugar should be provided with insulin to correct their blood sugar levels.
If they present with symptoms of diabetes, they may also need to be treated with oral antidiabetic medications. However, they should be initiated with caution especially since these clients may be on medications with interactions.
Clients with Cushing’s should be screened for bone weakness or osteoporosis as increased steroids can reduce bone mineral density – therefore requiring osteoporosis treatment such as calcium and vitamin D supplementation. Cushing’s victims may also be at an increased risk of developing a cataract, requiring a referral to an optometrist.
Conclusion of Addison’s vs Cushing’s
Addison’s and Cushing’s are very rare yet life threatening diseases that can drastically impair a client’s quality of life and potentially increase their risk of mortality. It is critical to understand these conditions as earlier treatment and detection can improve their chances of survival and reduce the risks associated with the condition. A clear understanding of these conditions will help as you prepare for the NCLEX® exam.
- Adrenal Insufficiency (Addison’s Disease): Disorders: Knowledge Base. Pituitary Network Association. https://pituitary.org/knowledge-base/disorders/adrenal-insuffieciency-addison-s-disease. Accessed October 13, 2019.
- Cushing’s Disease. Pituitary Network Association. https://pituitary.org/tag/cushing-s-disease. Accessed October 13, 2019.