Addison’s vs. Cushing’s
The adrenal glands are key organs that play a key role in the formation of steroid hormones. Examples of these hormones includes cortisol and aldosterone which can impact several organ systems, the immune system, the metabolism, and importantly electrolyte balance.
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For this reason, disease states that can 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 represents either the under production 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 to patients with Addison’s.
Signs and Symptoms of Addison’s
Generally endogenous steroids can be thought of as hormones that are released in the body under times of stress – sometimes thought of as the “fight or flight” response. Steroids act to 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 patients with Addison’s.
Signs and symptoms of Addison’s disease includes reduced blood pressure, blood sugar, salt retention, and water retention. A key physical manifestation which will require monitoring is weight loss as patients will have reduced water retention. These patients may often present with intolerance to cold with symptoms of dizziness, dehydration, cravings for salt, muscle aches and fatigue. Patients may also exhibit signs of reduced sex steroid production causing hair loss (alopecia), slow and irregular menstrual cycles, and decreased sexual appetite. Addison’s patients may also exhibit strange pigmentation on their skin sometimes regarded as a “bronze pigment” on the hands a face.
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Clinical Manifestations of Addison’s Disease
Hyponatremia (Serum Na+ < 135 mEq/L) is a very common and potentially serious manifestation to evaluate in patients with Addison’s. Patients with Addison’s experience hyponatremia as a result of increased excretion of sodium and water from the body. In addition, patients are at increased risk of retaining excess potassium leading to hyperkalemia (K+ > 5 mEq/L). Hyperkalemia can cause arrythmia in these patients which can precipitate into other serious conditions. These patients are also at increased risk of hypoglycemia and hypotension. Eosinophilia (eosinophil count > 500/mm3) is a possible manifestation in patients with adrenal insufficiency but not an accurate predictor for diagnosis of Addison’s.
Pharmacology of Addison’s Disease
As Addison’s disease is caused primarily by the underproduction of steroids, adding steroids is the key treatment for these patients. There are several steroids that can be administered to these patients including prednisone and hydrocortisone – with dosages that may vary based on the patient’s response. Patients 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 patients potentially need to be put on steroids chronically following their diagnosis. It is important to recognize that chronic steroid replacement can be dangerous when these patients abruptly discontinue their treatment. This can trigger a serious condition called Addisonian crisis from acute adrenal insufficiency. Patients with this condition may present with severe hypotension which can be fatal. Therefore, patients 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. Patients experiencing Addisonian crisis should be restarted on steroid therapy as soon as possible. The hypotension should be treated with fluids either saline or D5W.
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Nursing Interventions for Addison’s Disease
There are several important monitoring parameters to keep in mind when treating Addison’s patients. 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 patients experiencing acute adrenal insufficiency. Other vitals such as heart rate and blood pressure should be evaluated for these patients. Blood sugar changes may be among the most important factors to monitor for. Patients should be counseled on the signs and symptoms of hypoglycemia and treated appropriately.
Patients with adrenal insufficiency may exhibit psychological changes as well – potentially indicating depression screening. A PHQ-9 screen may be advised for patients presenting with significant mood changes.
Other interventions may include 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.
Test Your Knowledge
1. Addison’s Disease is:
- Increased secretion of cortisol
- Increased secretion of aldosterone and cortisol
- Decreased secretion of cortisol
- Decreased secretion of aldosterone and cortisol
2. A patient with Addison’s Disease is being discharged home on Prednisone. Which of the following statements by the patient warrants you to re-educate the patient?
- “I will notify the doctor if I become sick or experience extra stress.”
- “I will take this medication as needed when symptoms present.”
- “I will take this medication at the same time every day.”
- “My son has bought me a Medic-Alert bracelet.”
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 patients 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 patients with small cell lung cancer may be at increased risk of developing Cushing’s. Most patients 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
Patients 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. Patients may also have excessive hair production – particularly on the face, neck, chest, abdomen, and thighs. These patients 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
Clinical Manifestations of Cushing’s Syndrome
Multiple changes to vital signs may be observed in these patients – particularly hypertension (systolic > 140 mmHg). Patients with elevated blood pressure may require therapeutic intervention to reduce cardiovascular risks. Other key manifestations includes hyperglycemia, hypernatremia, and immune system suppression.
The goal when treating Cushing’s syndrome is to attack the underlying cause whether it be exogenous or endogenous. A key exogenous factor to be aware of is steroid overuse – therefore the key treatment is to taper these patients off steroids slowly. Patients who may be prone to this event include those with chronic inflammatory conditions for example patients with rheumatoid arthritis.
Cushing’s patients 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 patient may be deprived of after the procedure.
Pharmacology of Cushing’s Syndrome
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 patients involve controlling cortisol production. Ketoconazole, metyrapone, and intravenous etomidate may be used to decrease the production of cortisol in these patients. 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.
Nursing Interventions of Cushing’s Syndrome
There are several important monitoring interventions that will be required in patients 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 patients 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. Patients with high blood sugar should be provided with insulin to correct the 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 patients may be on medications with interactions.
Patients 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 which requires a referral to an optometrist.
Test Your Knowledge
3. Which of the following patients are at risk for developing Cushing’s Syndrome?
- A patient with a tumor on the pituitary gland, which is causing too much ACTH to be secreted
- A patient taking glucocorticoids for several weeks
- A patient with a tuberculosis infection
- A patient who is post-opt from an adrenalectomy
Addison’s and Cushing’s are very rare yet life threatening diseases that can drastically impair a patient’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.