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Hypertension
0/3
Mechanisms of Blood Pressure Regulation
07:36
Pathogenesis of Primary and Secondary Hypertension
41:56
End of Topic Quiz
00:20:00
Ischaemic Heart Disease
0/5
Atherosclerosis
14:37
Plaque Formation
06:06
Pathophysiology of Angina
09:44
Pathophysiology of Myocardial Infarction
11:49
End of Topic Quiz
00:20:00
Heart Failure Mechanisms
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Types of Heart Failure (Systolic vs. Diastolic)
09:06
Pathophysiological Changes in Heart Failure
07:56
Clinical Manifestations and Stages of Heart Failure
02:59
End of Topic Quiz
00:20:00
Alzheimer’s Disease
0/4
Pathogenesis of Alzheimer’s Disease
08:53
Genetic and Environmental Risk Factors
07:24
Clinical Stages and Symptoms
04:27
End of Topic Quiz
00:20:00
Parkinson’s Disease
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Pathogenesis of Parkinson’s Disease
13:53
Motor and Non-Motor Symptoms
31:18
Risk Factors and Progression
03:43
End of Topic Quiz
00:20:00
Pain Pathways and Analgesia
0/5
Types of Pain
11:47
Pathways of Nociception
08:14
Mechanisms of Pain Modulation
24:13
Pharmacological and Non-Pharmacological Pain Management
24:16
End of Topic Quiz
00:20:00
Diabetes Mellitus
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Types of Diabetes
05:58
Pathophysiology of Hyperglycaemia
06:15
Acute and Chronic Complications
17:05
Management Strategies
05:54
End of Topic Quiz
00:20:00
Thyroid Disorders
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Hypothyroidism
05:39
Hyperthyroidism
12:07
Pathophysiology of Thyroid Hormone Synthesis and Regulation
07:53
End of Topic Quiz
00:20:00
Cushing’s vs Addison’s Disease
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Cushing’s Disease
13:41
Addison’s Disease
11:58
Key Differences Between Cushing’s and Addison’s Disease
15:40
End of Topic Quiz
00:20:00
Cardiovascular & Endocrine Pathophysiology

Introduction

  • Cushing’s disease is a disorder characterised by increased adrenocorticotropic hormone (ACTH) production from the anterior pituitary gland, leading to excess cortisol release from the adrenal glands.
  • Often caused by a pituitary adenoma, it may also result from the excess production of corticotropin-releasing hormone (CRH) from the hypothalamus.
  • Cushing’s syndrome refers to the signs and symptoms associated with prolonged exposure to high cortisol levels, resulting from endogenous (like Cushing’s disease) or exogenous (like long-term corticosteroid use) causes.

Aetiology

Endogenous Cushing’s Syndrome:

  • Pituitary Adenoma: A benign tumour in the pituitary that secretes excessive ACTH, leading to increased cortisol production (Cushing’s disease).
  • Ectopic ACTH Secretion: Tumours elsewhere (e.g., lungs) secreting ACTH, causing Cushing’s syndrome.
  • Adrenal Tumours: Tumours in the adrenal glands, directly producing excess cortisol.

Exogenous Cushing’s Syndrome:

  • Long-Term Corticosteroid Use: Common cause from prolonged medication use (e.g., prednisone) for conditions like asthma or rheumatoid arthritis.

Epidemiology

  • Cushing’s disease is rare, typically presenting in the third and fourth decades of life.
  • The annual incidence of benign adrenal adenoma causing Cushing’s disease is 0.6 per million.

Pathophysiology

  • ACTH Action: Stimulates the adrenal cortex to produce cortisol; excessive ACTH (from a pituitary adenoma or ectopic source) leads to adrenal gland overstimulation and excess cortisol.
  • Cortisol Excess: Has wide-ranging effects on metabolism, immune function, and cardiovascular health; chronic cortisol excess disrupts these systems, leading to Cushing’s syndrome symptoms.

Symptoms

Physical Changes:

  • Weight gain (moon face, buffalo hump)
  • Thinning arms and legs, purple striae, easy bruising
  • Muscle weakness, thin, fragile skin
  • Increased facial/body hair (hirsutism in women)

Metabolic Disturbances:

  • High blood sugar, high blood pressure, dyslipidemia

Other Symptoms:

  • Menstrual irregularities, decreased fertility and libido
  • Osteoporosis, impaired wound healing, infections
  • Depression, anxiety, and cognitive issues

Diagnosis

  • Clinical Suspicion: Based on symptoms and medical history (e.g., corticosteroid use).
  • Laboratory Tests:
    • 24-hour urinary free cortisol, late-night salivary cortisol, low-dose dexamethasone suppression test, plasma ACTH
  • Imaging Studies:
    • MRI of the pituitary gland, CT scan of the abdomen
  • Inferior Petrosal Sinus Sampling: To confirm ACTH source in some cases.

Treatment

  • Goal: Normalise cortisol levels and alleviate symptoms.

Treatment Options:

  • Surgery:
    • Transsphenoidal surgery: First-line for most Cushing’s disease cases.
    • Adrenalectomy: Removal of adrenal glands if other methods are not viable.
  • Radiation Therapy: For residual tumour post-surgery.
  • Medical Therapy:
    • Centrally Acting Agents: Pasireotide and cabergoline
    • Adrenal Steroidogenesis Inhibitors: Ketoconazole, metyrapone, mitotane, osilodrostat
    • Glucocorticoid Receptor Antagonists: Mifepristone
  • Combination Therapy: Using multiple medications to enhance efficacy.

Prognosis

  • Surgical Remission: Possible in many patients after transsphenoidal surgery.
  • Recurrence: Not uncommon; requires lifelong monitoring.

Role of the Pharmacist

  • Medication Management: Educating patients on medication use, adherence, and side effects.
  • Medication Reconciliation: Identifying potential drug interactions.
  • Patient Counselling: Disease management, lifestyle changes, and monitoring.
  • Collaboration: Working with healthcare teams for optimal patient care.

Key Points

  • Understanding the Differences: Differentiate between Cushing’s disease (specific cause) and Cushing’s syndrome (general condition).
  • Pharmacological Treatment: Learn about the various treatments, mechanisms, and side effects.
  • Patient-Centered Care: Focus on education, adherence, and collaborative care.

References

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