The Cushing’s syndrome with Type Diabetes & Rheumatoid Arthritis

Question: Discuss about the Cushings Syndrome with Type Diabetes Rheumatoid Arthritis. Answer: Incidence Causes of the Cushings Syndrome Statistics indicate that out of every 1 million people, 13 of them are affected by the Cushings syndrome. It is however more common among women as compared to men. The condition mostly presents when a person is between 25 to 40 years of age (Wilson et al, 2014). The Cushings syndrome is caused by elevated levels of the cortisol hormone in the body. This hormone is produced by the adrenal glands in order to carry out various roles in the body. The functions of cortisol for instance includes; regulating blood pressure, ensuring the normal functioning of the cardiovascular system and further, it helps the body to respond to stress (Ding et al, 2013). Cortisol therefore controls protein and fat metabolism into energy but one develops the Cushings syndrome when the hormone levels go high. Another cause of the Cushings syndrome includes the excessive use of corticosteroids. Oral corticosteroids taken by individuals as medication in high doses particularly over a long period of time causes this condition (Graversen et al, 2012). Corticosteroids include prednisone which is used to treat rheumatoid arthritis, asthma among other inflammatory conditions; has similar effects as those of the cortisol hormone. Since these doses are higher than the amount of cortisol produced within the body, the Cushing syndrome occurs due to the side effects of excessive cortisol. Risk Factors The risk factors for the development of the Cushings Syndrome include exogenous use of corticosteroids as in the treatment of rheumatoid arthritis for Maureen Smith in the case study. As described above, prednisone is one of the major corticosteroids contributing to the Cushings syndrome, as a medication for rheumatoid arthritis (Ding et al, 2013). Another risk factor includes the presence of pituitary adenoma where the pituitary gland secretes excessive ACTH that consequently stimulates the secretion of excess cortisol by the adrenal glands (Wilson et al, 2014). This is common in women and is referred to as endogenous Cushings syndrome. Thirdly, the presence of a tumor that secretes ectopic ACTH in any organ that does not normally secrete ACTH will contribute to its excessive presence in the body and thus more cortisol production to lead to the Cushings Syndrome. Such organs could be the lungs, the thymus gland, thyroid and even the pancreas (Graversen et al, 2012). Adrenal adenoma which is a tumor that affects the adrenal cortex but not cancerous also contributes to the Cushings syndrome. This is because adrenal adenoma contributes to the production of cortisol without the control by the ACTH. However, adrenocortical carcinomas such as benign and/or nodular adrenal gland enlargement also result to the Cushing syndrome. Impact on Patient and Family Among the impacts the Cushings Syndrome on an individual and their families include the high treatment and management costs of the condition especially when it is associated with other complication like rheumatoid arthritis and diabetes. A better amount of finances which could be put to other individual and family use is diverted to settling bills for healthcare (Torio, 2013). Another impact is that the victim might likely not be able to report to their workplaces just like Maurine Smith might not feel adequate to work at the pizza restaurant. The families members including their children take up the role of caregiving in order ensure their family member is happy (Graversen et al, 2012). Patients who suffer from the Cushings syndrome can suffer depression and even anxiety. The families will also have difficulty taking care of the emotionally affected relative. Common Signs and Symptoms for the Cushings Syndrome Sign/Symptom Pathophysiology 1. Development of a buffalo hump. It is one of the commonest sign and symptom especially among women with the Cushings syndrome. A buffalo hump occurs at the upper back and it is caused by an accumulation of fats at this particular part of the body (Ding et al, 2013). The fats accumulate to form a fat pad at the upper back. 2. Reduced general body immunity where individuals are very susceptible to infections. The Cushings syndrome results in a decrease in the production of lymphocytes by the immune system. The body also has a suppressed formation of antibodies to fight off harmful microorganisms and/or organisms (Wilson et al, 2014). As a result, the patients are prone to a variety of diseases especially after a longer stay with the condition. 3. Round moon face Round moon face is caused by the deposition of fats within the mid-section, shoulders and upper back (March et al, 2014). The moon face is particularly caused by the deposition of excessive fast over an individual patients face. 4. Obesity around the trunk Truncal obesity occurs among Cushings syndrome patients as a result of the development of fat pads around the trunk (Gadelha et al, 2014). When the condition presents occurs along with diabetes, obesity increases because there is reduced break down of fats to glucose, leaving them to accumulate within the subcutaneous tissue as fat pads. 5. High blood Pressure This is occurs as the general response to the increased amount of cortisol levels in the body. However, the main factor that contributes to the high blood pressure among the Cushings syndromes patient is fluid retention (Ding et al, 2013). The patients suffer from water and sodium retention which bring about this particular hypertension. The narrowing of the arteries due to low density lipoproteins and plaques both of which result from poor diet also increase the blood pressure as their lumen narrow up. Common Classes of Drugs for the Cushings Syndrome Their Physiological Effect Cortisol-secretion inhibiting drugs This is a class of drugs used in treating the Cushings Syndrome, which mainly inhibit the secretion of the cortisol hormone by the adrenal glands. In particular, this class of drugs inhibits steroidogenesis in the body and thus lower the levels of cortisol present in blood. These drugs include Metyrapone, mitotane, ketoconazole and aminoglutethimide (Wilson et al, 2014). Ketoconazole is currently the most popular drug in the treatment of the Cushings disease. Even so, the other cortisol inhibiting drugs can also be administered alone and/or as combinations. Another significant cortisol suppressing drug used in the treatment of the Cushings syndrome is Mifepristone. This particular drug is the most appropriate for the treatment of people with Cushing disease who also have type 2 diabetes (Gonzalez et al, 2016). From the case study, it is clear that Maureen Smith has type 2 diabetes that resulted from the use of corticosteroids as medication from rheumatoid arthritis and her Cushings s yndrome. Mifepristone is also approved for use by individual patients suffering from glucose intolerance. The drug hinders the effect of the cortisol hormone on the tissues of a patient. It however has several side effects just like the rest of the above discussed cortisol inhibiting medications. These include vomiting, fatigue, headaches, nausea, edema, muscle aches, and low potassium levels in blood and high blood pressure (Gadelha et al, 2014). More serious side effects may also present and these include hepatic toxicity and/or neurological side effects. Adrenocorticotropic Hormone (ACTH) Suppressing drugs This class of drugs is the alternative medication to the cortisol inhibiting drugs described above, for the treatment of the Cushings syndrome. They are however not popular choices as standard medications for the treatment of this particular condition. These drugs specifically suppress the effect of the Adrenocorticotropic hormone on the adrenal gland to secrete cortisol according to Laws et al (2013). They therefore target to inhibit the ACTH effect on the adrenal glands rather than targeting the cortisol hormone (Gadelha et al, 2014). These drugs include for instance, cyproheptadine, cabergolin, vasopressin antagonists, valproic acid, and PPAR-gamma agonists among others. The latest medications under this class include pasireotide which also decreases the production of the Adrenocorticotropic hormone by a pituitary tumor. Pasireotide is usually administered in two injections two times a day. In cases where pituitary gland surgery is rendered unsuccessful, Pasireotide is the most re commended drug under this particular class. Even so, it has several side effects among them being nausea, headaches, diarrhea, high blood sugar, fatigue in the muscles and joints, and pain in the abdomen. Nursing Strategies The nursing care strategies for the Cushings syndrome with both rheumatoid arthritis and type 2 diabetes for Maurine Smith in the first 24 hours after admission mainly include: lowering the corticosteroid medication dosage and/or reducing cortisol levels in blood, managing the high blood sugar, decreasing risk to injuries and infections, increasing self-care ability, improving the integrity of the skin, improving ones body image and mental functioning. According to Wilson et al (2014), emergency nursing strategies and medication for patients suffering from Cushing syndrome must be based on the cause of this particular condition. In this particular case, it is clear that the main cause of the condition for Maureen Smith is the use of the corticosteroids doses in the treatment of rheumatoid arthritis which she acquired at the age of 14 years. The effect of her corticosteroid use also contributed to the development of type 2 diabetes. The nursing strategies therefore for her current lif e threatening acute Cushings syndrome will include stabilizing the sugar levels but majorly reduce the use of corticosteroid use within the first 24 hours of post-admission (Gadelha et al, 2014). Therefore, the nurse should start decreasing the dose of prednisone being given to Maureen as treatment for rheumatoid arthritis. Even so, the signs and symptoms of both diabetes type 2 and the long term rheumatoid arthritis should remain under close monitoring. On the other hand the medical team including the nurse should use non-corticosteroid drugs for the management of the rheumatoid arthritis. There is need to slowly taper off the corticosteroid drugs in order to allow the patients body to return to its normal cortisol production mechanism (March et al, 2014). It is clear that the patient is severely hyperglycemic due to her diabetes type 2 condition. The first nursing strategy in this case should include rehydration by the use of intravenous saline. The patient can then be put on insu lin doses in measures of 0.3-0.4 units/kilogram of her body weight every day (Siu, 2015). The insulin doses can be given as bolus or basal. For instance, insulin glargine and insulin determir combination are the best options for both basal and/or bolus therapy. This intervention will help in lowering blood sugar levels from the current 14.0 mmol/L to the required levels, especially below 7.2 mmol/L (Emdin et al, 2015). Other urgent nursing strategies within the first 24 hours include administering adequate diet with lesser carbohydrates particularly for diabetic patients. Edema can be reduced by providing a diet with low levels of carbohydrate and Sodium. However, the diet should include higher amounts of vitamins and proteins in order to reduce some serious symptoms (Siu, 2015). The nurse should monitor the glucose and cortisol levels from the samples taken at intervals in order to administer the right medication. The patient should be encouraged to rest and relax within a quiet en vironment provided by the facility if she stabilizes within the first 24 hours of post admission. The nurse should ensure that they help the patient in changing position in order to prevent injury and promote the integrity of the skin. Acute conditions of both type 2 diabetes and the Cushings syndrome affect patients emotionally and therefore a need for nurses to improve the patients thought process (Emdin et al, 2015). The nurse should encourage both family and the patient to express their feelings and/or concerns openly. The patient will particularly be counseled on coping with mood swings,irritable nature and depression in order to fasten their healing process according to Chew et al, (2015). Even so, the main focus of all nursing strategies includes the monitoring and managing of complications that come along with the Cushings Syndrome. References Chew, B. H., Vos, R., Heijmans, M., Metzendorf, M. I., Scholten, R. J., Rutten, G. E. (2015). "Psychological interventions for diabetes?related distress in adults with type 2 diabetes mellitus".Cochrane Database of Systematic Reviews.1 Ding, Dale; Robert M. Starke; Jason P. Sheehan (2013). "Treatment paradigms for pituitary adenomas: defining the roles of radiosurgery and radiation therapy".J Neurooncol.117: 445457. Emdin, CA; Rahimi, K; Neal, B; Callender, T; Perkovic, V; Patel, A (10 February 2015). "Blood pressure lowering in type 2 diabetes: a systematic review and meta-analysis.".JAMA.313(6): 60315. Gadelha, Mnica R.; Leonardo Vieira Neto (2014). "Efficacy of medical treatment in Cushing's disease: a systematic review".Clinical Endocrinology.80: 112. Gonzalez, J.S., Tanenbaum, M.L, Commissariat P.V. (2016). "Psychosocial factors in medication adherence and diabetes self-management: implications for research and practice".American Psychologist.71: 539551. Graversen, D; Vestergaard, P; Stochholm, K; Gravholt, CH; Jrgensen, JO (April 2012). "Mortality in Cushing's syndrome: a systematic review and meta-analysis.".European journal of internal medicine.23(3): 27882. Laws Jr., E.R., Ezzat, S., Asa, S.L., Rio, L.M., Michel, L. Knutzen, R. (2013).Pituitary Disorders: Diagnosis and Management. United Kingdom: Wiley-blackwell. p.xiv.ISBN978-0-470-67201-3. March, L; Smith, EU; Hoy, DG; Cross, MJ; Sanchez-Riera, L; Blyth, F; Buchbinder, R; Vos, T; Woolf, AD (June 2014). "Burden of disability due to musculoskeletal (MSK) disorders.".Best practice research. Clinical rheumatology.28(3): 35366 Seida, Jennifer C.; Mitri, Joanna; Colmers, Isabelle N.; Majumdar, Sumit R.; Davidson, Mayer B.; Edwards, Alun L.; Hanley, David A.; Pittas, Anastassios G.; Tjosvold, Lisa; Johnson, Jeffrey A. (Oct 2014)."Effect of Vitamin D3 Supplementation on Improving Glucose Homeostasis and Preventing Diabetes: A Systematic Review and Meta-Analysis".The Journal of Clinical Endocrinology Metabolism.99(10): 35513560. Siu, AL (27 October 2015). "Screening for Abnormal Blood Glucose and Type 2 Diabetes Mellitus: U.S. Preventive Services Task Force Recommendation Statement.".Annals of Internal Medicine.163: 8618. Torio, Celeste (August 2013)."National Inpatient Hospital Costs: The Most Expensive Conditions by Payer, 2011".HCUP. Wilson, P.J.; Williams, J.R.; Smee, R.I. (2014). "Cushing's disease: A single centre's experience using the linear accelerator (LINAC) for stereotactic radiosurgery and fractionated stereotactic radiotherapy".Journal of Clinical Neuroscience.21(1): 100106.