Addison's/ Adrenal insufficiency Week 6

Question 1

problem in adrenal insufficiency/ Addison’s

Answer 1

(Addison’s is the most common cause of PRIMARY adrenal insufficiency) decreased secretion of steroids- cortisol (glucocorticoid) aldosterone (mineralcorticoid) and androgen

Question 2

why does primary adrenal insufficiency happen?

Answer 2

90% autoimmune, body attacks adrenal cortex (associated w/ other autoimmune stuff- type 1 DM, autoimmune thyroid dx, pernicious anemia and ovarian failure) other rarer causes- hemorrhage/ traumatic injury, cancer, adrenal gland TB

Question 3

s/s of adrenal insufficiency- remember low “steroid”

Answer 3

S sodium/ sugar both low (salt cravings reported)
T tired/fatigue/weak
E electrolyte imbalance- potassium, calcium (increase)
R reproductive changes- women have irregular menses/ loss of body hair, men have erectile dysfunction
O lOw BP- risk for vascular collapse/ shock
I increased pigmentation/ hyperpigmentation (common at buccal mucosa, also at pressure points, recent scars, or skin creases)
D diarrhea/ nausea/ anorexia, depression

Question 4

Addisonian crisis aka adrenal gland crisis s/s

Answer 4

vomiting/ diarrhea
abdominal pain
profound weakness
severe hypoglycemia
hypovolemic shock

Question 5

Addisonian crisis tx

Answer 5

need urgent management- (fatal if left untreated, can make official dx later- start treatment if suspected) Give dexamethasone initially (4 mg IV) while the basal cortisol measurement and the cosyntropin stimulation test are performed; empiric treatment with IV hydrocortisone (100 mg IV q8h, with rapid tapering) can then be initiated. Also need D5NS to correct volume depletion, dehydration, and hypoglycemia. Should be in the ICU

Question 6

long term tx for adrenal insufficiency

Answer 6

All patients with chronic adrenal insufficiency require replacement with glucocorticoids (aka cortisol) and occasionally with mineralocorticoids (aka aldosterone). Hydrocortisone is frequently used in primary adrenal insufficiency because it has some mineralocorticoid activity. The usual dosage of hydrocortisone is 10 to 15 mg every morning and 5 to 10 mg in the afternoon. When prednisone is used, typical doses are 2.5 to 5 mg daily. If additional mineralocorticoid effect is necessary for persistent hyperkalemia and/or orthostatic hypotension, fludrocortisone 0.05 to 0.2 mg once a day may be added (cortisol replacement= prednisone or hydrocortisone) (aldosterone replacement= Fludrocortisone aka Florinef).

Question 7

Autoimmune adrenalitis

Answer 7

aka Addison’s- most common cause of primary adrenal insufficiency

Question 8

Autoimmune adrenalitis is associated with ?

Answer 8

increased levels of 21-hydroxylase antibodies

Question 9

most common cause of central (secondary/tertiary) adrenal insufficiency is

Answer 9

withdrawal of glucocorticoids after long-term use

Question 10

primary adrenal insufficency mainly from?

Answer 10

autoimmune

Question 11

common presenting sign of adrenal insufficiency ?

Answer 11

weight loss

Question 12

classic laboratory abnormalities found with adrenal insufficiency

Answer 12

hyponatremia and hyperkalemia.

Question 13

hyperkalemia is due to ?

Answer 13

mineralocorticoid deficiency (aldosterone)

Question 14

hyponatremia occurs mainly due to ?

Answer 14

glucocorticoid deficiency (cortisol) It is the result of elevated vasopressin values with free water retention, shift of extracellular sodium into cells, and decreased delivery of filtrate to the diluting segments of the nephron due to decreased glomerular filtration rate

Question 15

calcium usually?

glucose usually?

Answer 15

Mild to moderate hypercalcemia

Fasting blood glucose is usually low-normal (if pt also has type 1 DM, hypoglycemia prob more severe)

Question 16

How is adrenal insufficiency usually diagnosed?

Answer 16

In the outpatient setting, a low morning cortisol value (< 3 μg/dL) is sufficient to diagnose adrenal insufficiency, and a high morning cortisol value (> 20 μg/dL) excludes the diagnosis.

Question 17

In most instances, a dynamic test called what is also performed?

Answer 17

cosyntropin stimulation test- determines whether the adrenals are able to respond to maximal stimulation by synthetic ACTH

Question 18

How is the cosyntropin test performed?

Answer 18

by collecting a specimen for measurement of a baseline serum cortisol level, administration of 250 μg of cosyntropin (brand name Cortrosyn, Synacthen) IV or IM, and then collecting specimens for serum cortisol measurement 30 and 60 minutes later. An abnormal result is defined as a stimulated cortisol level at either 30 or 60 minutes of less than 18 to 20 μg/dL (< 450-500 nmol/L). can be done at any time of day. If pt is receiving glucocorticoid therapy, the dose should be withheld (12 hours for hydrocortisone, 24 hours for prednisone) before the test is performed to avoid detection of synthetic glucocorticoids in the cortisol assay

Question 19

Other dynamic testing includes

Answer 19

the insulin tolerance test, metyrapone test, glucagon stimulation test, and CRH stimulation test

Question 20

What testing can be used to distinguish primary from central adrenal insufficiency?

Answer 20

In primary adrenal insufficiency, ACTH is elevated, whereas ACTH is “abnormally normal” (i.e., not elevated in response to low cortisol) or frankly low in central adrenal insufficiency.