Adrenal Insufficiency
- epidemiology
- signs and symptoms
- diagnosis
- pathophysiology
- causes and risk factors
- treatments
- course
- patient education
- community resources
- references
Worst is adrenal crisis.
Epidemiology
Signs, Symptoms
History
- weight loss
- fatigue (G)
- anorexia (G)
- nausea, vomiting, abdominal pain (G,M)
- arthralgias, myalgias
Physical Exam
- hypotension
- auricular calcification
- increased skin pigmentation, especially of pressure areas, freckles, oral mucosa (ACTH breakdown pigments)
Lab Investigations
- hyponatremia and salt craving (M)
- hyperkalemia (mild)
- hypercalcemia
- mild acidosis
- hypoglycemia
mental health concerns
pubic hair loss in women due to loss of androgens
Diagnosis
Adrenal insufficiency becomes clinically manifest when more than 90% of the adrenal cortex is lost.
AM cortisol (8-9 AM): cortisol levels are highest in morning, and the test is standardized as such. Greater than 270 is strong evidence that adrenal insufficiency is not present; below 100 is strong evidence that insuffiency is present.
ACTH stimulation tests can be done with serum cortisol measured 30 minutes after injection, but can be false negative in 10-15% of patients. 250 mcg is of ACTH is administered.
An insulin stress test should cause hypoglycemia and a spike in both plasma cortisol and serum growth hormone within 1-2 hours.
Pathophysiology
- Inadequate cortisol despite high ACTH levels
Congenital adrenal hyperplasia
- inadequate cortisol desipte high ACTH
- give synthetic GC to inhibit ACTH
Causes and Risk Factors
Primary adrenal insufficiency:
- autoimmune activity (most common; can be part of a polyglandular autoimmune syndrome)
- Addison's disease
- metastatic malignancy or lymphoma
- infarction or hemorrhage (can see bilaterally in pregnancy)
- infections: TB ,CMV, fungi
- infiltrative disorders: sarcoidosis, amyloidosis, hemochromatosis
- trauma, surgery
- drugs: ketoconazole, mitotane, aminoglutethimide, etomidate, cyproterone, rifampin, dilantin
- congenital adrenal hyperplasia, adrenoleukodystrophy, familiy glucocorticoid deficiency
Secondary, ACTH deficiency, can be caused by:
- chronic glucocorticoid therapy
- hypopituitarism (ie pituitary tumour)
Treatments
Hydrocortisone is the active hormone and the preferred treatment, as it has a shorter half-life. It is given BID, with a greater dose in the AM. Correct dosing can be assessed by measuring urinary free cortisol and the day curve.
Other options include prednisone, cortisone acetate, or dexamathasone.
Fludrocortisone is a synthetic mineralocorticoid given as well to people with primary insufficiency.
Stress dosing is needed for infections, illnesses, etc. Double the dose for three days and then reevaluate.
Patients should also have medic alert bracelets letting them know
Emergency kits are also necessary for if patients can't keep their PO cortisol down - an injectable amount...
Course
Patient Education
Community Resources