Addison's disease Flashcards
1
Q
What is Addison’s disease?
A
- Addison’s disease, also known as primary adrenal insufficiency and hypocortisolism, is a long-term endocrine disorder in which the adrenal glands do not produce enough steroid hormones
- Destruction of the adrenal cortex leasd to glucocorticoid (cortisol) and mineralocorticoid (aldosterone) insufficiency
- Signs are volatile and inconsistent
- It maye be diagnosed as anorexia nervosa or viral infection in error (but K is decreased in the former and raised in Addison’s)
2
Q
Describe the pathway involved in adrenal function
A
3
Q
What are the causes of primary adrenocortical insufficiency?
A
- Autoimmunity (80% of the cause in UK)
- TB (commonest cause worldwide)
- Adrenal metastases
- Lymphoma
- Opportunistic infections in HIV
- Adrenal haemorrhage
- Waterhouse - Friderichsen syndrome
- Antiphospholipid syndrome
- Congenital (late onset congenital adrenal hyperplasia)
4
Q
What is the commonest cause of secondary adrenocortical insufficiency?
A
- Chronic steroid use
- It suppresses the pituitary-adrenal axis
- This only becomes apparent when steroids are withdrawn
5
Q
What are the other rarer causes of secondary adrenocortical insufficiency?
A
- Hypothalamic-pituitary disease leading to decreased ACTH production
- Mineralocortioid production remains intact
- And there is no hyperpigmentation as ACTH production is decreased
6
Q
What are the symptoms od Addison’s disease?
A
- Tanned
- pigmented palmar creases &buccal mucosa
- Lean
- Tired
- Tearful
- Weak
- Anorexic
- Dizzy
- Faint
- Flu like myalgias and arthralgias
- Changes in mood
- depression
- psychosis
- GI
- nausea/vomiting
- unexplained abdominal pain
- diarrhoea/constipation
- Postural hypotension
- Vitiligo
7
Q
What are the signs of critical deterioration in Addison’s disease?
A
- Shock
- Low BP
- Tachycardia
- High temperature
- Coma
8
Q
What tests should be done to diagnose Addison’s disease?
A
- Sodium and potassium (low and high respectively)
- Low glucose
- Ureamia
- Hypercalcaemia
- Eosinophilia
- Anaemia
9
Q
What is the diagnostic test for Addison’s disease?
A
- SynACTHen test - Short ACTH stimulation test
- Check plasma cortisol before and half an hour after giving the patient synacthen IM
- In healthy individuals, the cortisol level should increase
- In Addison’s disease, both the cortisol and aldosterone levels are low, and the cortisol will not rise during the stimulation test
- ACTH test
- In Addisons ACTH is abnormally high at 9am and low in secondary causes of Addisons
- 21 Hydroxylase adrenal autoantibodies (+ve in autoimmune diseases in 80%)
- Plasma renin and aldosterone to assess mineralocorticoid status
10
Q
What imaging tests should you carry out for Addison’s disease?
A
- AXR/CXR
- For signs of TB or past TB
- Adrenal CT
- For TB
- Histoplasma
- Metastatic disease
11
Q
What is the treatment for Addison’s disease?
A
- Replace steroids
- HYDROCORTISONE DAILY
- Give mineralocorticoids to correct postural hypotension
- FLUDROCORTISONE DAILY
- If there is a poor response then consider an associated autoimmune disease (check thyroid or do coeliac serology)
12
Q
What advice should be given for steroid use?
A
- Avoid giving steroids late as it may cause insomnia
- Avoid stopping steroids abrubtly
- Wear steroid bracelet declaring steroid use
- Add 5-10mg hydrocortisone to daily intake before strenuous activity or exercise
- Follow up yearly (BP and U&Es)
- Watch for autoimmune diseases (pernicious anaemia)
- Give out syringes and show the patient how to inject IM if they are vomiting and cannot take oral steroids
13
Q
What advise should be given to patients for exogenous steroid use?
A
- Replacement steroids are vital in those taing long term steroids when acutely unwell
- Adrenal insufficiency will develop with deadly hypovolaemic shock if additional steroids are not given
- Warn against abruptly stopping steriods
- Emphasise that prescribing doctors must know about steroid use –> give them a steroid card
14
Q
What is Addisonian crisis?
A
- It is a medical emergency and potentially life-threatening situation requiring immediate emergency treatment.
- It is a constellation of symptoms that indicate severe adrenal insufficiency caused by insufficient levels of the hormone cortisol.
15
Q
What are the signs and symptoms of Addisonian crisis?
A
- Shock
- Raised HR
- Vasoconstriction
- Postural hypotension
- Oligouria
- Weakness
- Confused
- Comatose
