Addison's Disease Flashcards by amo x

What is another term for Addison’s disease?

Autoimmune adrenalitis

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What is Addison’s disease?

It is defined as a condition in which there is autoimmune destruction of the adrenal glands, resulting in reduced cortisol and aldosterone secretion

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What antibodies are produced in Addison’s disease?

Anti-21 hydroxylase autoantibodies

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What is the most common cause of adrenal insufficiency?

Addison’s disease

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What are the nine clincial features of Addison’s disease?

Fatigue

Nausea & Vomiting

Muscle Weakness

Hyperpigmentation

Vitiligo

Salt Craving

Weight Loss

Hypotension

Syncope

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In most cases where does hyperpigmentation present in Addison’s disease?

Palmar Creases

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What is vitiligo?

It is characterised by pale white patches appearing on the skin

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In exams, how does Addison’s disease tend to present?

The clinical features can be non-specific, it is important to look at the blood for hyponatraemia and hyperkalaemia

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What are the four investigations used to diagnsoe Addison’s disease?

Blood Tests

Arterial Blood Gas (ABG)

ACTH Stimulation Test

MRI Scan

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What are the seven blood test results indicative of Addison’s disease?

Decreased Sodium Levels

Increased Potassium Levels

Increased Calcium Levels

Decreased Glucose Levels

Decreased Cortisol Levels

Increased ACTH Levels

21-Hydroxylase Antibodies

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When is serum cortisol conducted to investigate Addison’s disease?

It is conducted in primary care, where the ACTH stimulation test is not readily available

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When should serum cortisol levels be measured?

Morning

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What serum cortisol level excludes Addison’s disease?

> 500

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What serum cortisol level indicates Addison’s disease? What investigation should be conducted to confirm a diagnosis?

< 500

ACTH stimulation test

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What ABG feature indicates Addison’s disease?

Metabolic acidosis

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What is another term for the ACTH stimulation test?

Short Synacthen test

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What is the gold standard investigation of Addison’s disease?

ACTH stimulation test

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What is the ACTH stimulation test?

It involves the patient’s initial cortisol and ACTH levels being measured – ideally in the morning

We then inject the patients with IM tetracostartin, which is synthetic ACTH

Following administration, the cortisol levels are remeasured at 30 and 60 minutes

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What is a normal ACTH stimulation test result? Explain this

Increased cortisol levels at 30 - 60 minutes - usually to > 450

The synthetic ACTH administration will stimulate production of cortisol levels

What ACTH stimulation test result indicates Addison’s disease? Explain this

Decreased cortisol levels at 30 and 60 minutes

The synthetic ACTH administration will fail to stimulate the production of cortisol levels

How is the ACTH stimulation test used to differentiate between Addison’s disease and other causes of adrenal insufficiency?

Plasma ACTH levels

What plasma ACTH levels in the ACTH stimulation test indicate Addison’s disease? Explain

Increased plasma ACTH levels

This is due to the fact that Addison’s disease is a primary cause of hypoadrenalism, and therefore ACTH levels are elevated to stimulate cortisol production

What plasma ACTH level in the ACTH stimualtion test indicates secondary adrenal insufficiency? Explain this

Decreased plasma ACTH levels

This is due to the fact that pituatary dysfunction results in inadequate ACTH levels stimualting the adrenal glands

How are MRI scans used to investigate Addison’s disease?

They are used to exclude other causes of adrenal insufficiency, such as adrenal tumours, haemorrhage or structural pathology

What are the two pharmacological management options of Addison's disease?

Hydrocortisone Fludrocortisone

When is hydrocortisone used to manage Addison's disease?

It is the first line management option, alongside fludrocortisone

How is hydrocortisone used to manage Addison's disease?

It is used to replace glucocorticoids – cortisol

How do we administer hydrocortisone - in terms of dosage?

In most cases, individuals require 20 – 30 mg of hydrocortisone daily, which is administered in two divided doses per day - morning and evening

What hydrocortisone dose is greater - morning or evening? Why?

The morning dose is usually greater than the evening dose This is to mimic the normal 24 hour fluctuation of cortisol levels

What should all Addison's disease patients be administered to treat adrenal crisis?

Hydrocortisone injections with needles and syringes

When is fludrocortisone used to manage Addison's disease?

It is the first line management of Addison’s disease, alongside hydrocortisone

How is fludrocortisone used to manage Addison's disease?

It is used to replace mineralocorticoids – aldosterone

How do we administer fludrocortisone - in terms of dosage?

In most cases, individuals require 50 – 300 mg of fludrocortisone daily, which is adjusted according to their clinical status, U&Es and plasma renin level

What should all Addison's disease patients wear at all times? Why?

MedicAlert bracelets and steroid cards This is to allow emergency services to quickly identify their steroid dependency

How is pharmacological management adjusted in Addison's disease when individuals are ill?

We advise them that their glucocorticoid dose should be doubled, with the fludrocortisone dose remaining the same This is to match the normal steroid response

How is pharmacological management adjusted in Addison’s disease when individuals are ill - with vomiting?

They should administer IM corticosteroids until the vomiting stops

What is a complication of Addison's disease?

Addisonian Crisis

What is addisonian crisis?

It is defined as a life threatening deterioration of Addison’s disease, in which there is significantly reduced steroid levels

What are the four causes of addisonian crisis?

Sepsis Surgery Adrenal Haemorrhage (Waterhouse-Friderichsen Syndrome) Steroid Withdrawal

What are the four clinical features associated with Addisonian crisis?

Confusion Severe Weakness Delirium Hypotension

What are the three management options of addisonian crisis?

IM/IV 100mg Hydrocortisone 6 Hrly Until Stable IL Normal Saline Infused 30 – 60 Minutes Dextrose Infusion If Hypoglycaemia

What is primary adrenal insufficiency?

It is defined as adrenal gland dysfunction leading to direct reduced cortisol and aldosterone levels

What are the eight other causes of primary adrenal insufficiency?

Tuberculosis HIV Meningococcal Sepicaemia Renal Cancer Lung Cancer Breast Cancer Antiphospholipid Syndrome Postadrenalectomy

What is another term for meningococcal septicaemia?

Waterhouse-Friderichsen syndrome

What is secondary adrenal insufficiency?

It is a result of pituatary gland dysfunction resulting in inadequate ACTH stimulating the adrenal glands This results in reduced cortisol levels ONLY

What are the three causes of secondary adrenal insufficiency?

Pituatary Adenoma Sheehan's Syndrome Steroids

What clincial feature differentiates between primary and secondary adrenal insufficiency?

Hyperpigmentation It is only present in primary adrenal insufficiency