Addison's

Question 1

Definition

Answer 1

Primary adrenal insufficiency
Destruction of the adrenal cortex
Decreased production of cortisol, aldosterone and DHEAS

Question 2

Causes

Answer 2

Autoimmunity
TB
Adrenal metastases->lung, breast, renal
Lymphoma
HIV
Hemorrhage->Waterhouse-Frederichsen
Antiphospholipid syndrome
Congenital

Drugs that inhibit cortisol production (Etomidate, mitotane, aminoglutethimide, ketoconazole, suramin, and metyrapone )
ACute withdrawal of exogenous steroids

Question 3

Symptoms

Answer 3

Tanned
Thin
Lethargy
Weakness

Depression, psychosis, low self esteem

GI: NVD, abdominal pain

Postural hypotension
Vitilogo

Question 4

Investigations

Answer 4

1st tests to order
serum electrolytes->low sodium, +potassium
blood urea->elevated
FBC->anemia, eosinophilia
morning serum cortisol->low

Tests to consider
high dose (250 micrograms) ACTH stimulation test
serum ACTH->cortisol low
plasma renin activity->elevated
plasma aldosterone->suppressed
plasma dehydroepiandrosterone (DHEA)
plasma DHEA sulphate (DHEAS)
adrenal antibodies
adrenal CT or MRI->normal or atrophic
insulin hypoglycaemia test
overnight single-dose metyrapone test

Question 5

Ongoing management

Answer 5

stable and/or after treatment of acute episode

1st line: glucocorticoid plus mineralocorticoid->hydrocortisone + fludrocortisone
adjunct: temporary switch to stress dosing of glucocorticoid
women with decreased libido
adjunct: androgen replacement->DHEA

Question 6

Advise in steroid use

Answer 6

Avoid abrupt withdrawal
All physicians must know
Steroid card
Wear medical bracelet
Add 10mg hydrocortisone before strenuous activity
Double doe if febrile illness, injury or stress
Have syringe with steroid

Question 7

F/U

Answer 7

Yearly
BP, UEC
Watch for autoimmune disease (pernicious anemia)

Question 8

Management of Addisonian crisis

Answer 8

ABC
IV access
Bloods for cortisol and ACTH
Hydrocortisone sodium succinate IV
IV fluids NS
Monitor blood glucose
Blood, urine, sputum for culture

Ongoing:
Glucose IV if hypo
IVF, correct UEC balance
Hydrocortisone
Change to oral if good condition
Fludrocortisone
Search for underlying cause

Question 9

Precipitating factors in addisonian crisis

Answer 9

Infection, trauma, surgery