Addison's Disease Flashcards
What is Addison’s?
Draw out the adrenal gland axis!
Adrenal insufficiency
Primary adrenocortical failure:
What type of endogenous steroids becomes low due to no synthesis? - 2
What is the main cause?
How may cancer cause this?
What infections could cause it?
What congenital disease could cause this?
Glucocorticoids (i.e. cortisol)
Mineralcorticoids (i.e. aldosterone)
Autoimmune - antibodies against adrenal cortex and/or 21-hydroxylase, en enzyme involved in steroid synthesis.
Due to mets from breast, kidney etc.
TB
CMV
HIV
Congenital adrenal hyperplasia
Secondary adrenocortical failure:
This is iatrogenic. Why does the withdrawal of glucocorticoid treatment lead to this?
What type of endogenous steroid becomes low due to no synthesis?
Long term use suppresses pituitary-adrenal axis
Glucocorticoids ONLY
Presentation:
IT IS VERY NON-SPECIFIC!!
General:
- Main complaint
- Psychiatric - 2
- Other symptoms or signs? - 2
- Why do they get postural hypotension?
Gi:
- 5 S+S
- What happens as a result of these symptoms? - 3
What are the 4 T’s?
TIRED ALL THE TIME (TATT)!!!
Depression
Psychosis
Malaise
Dizziness
Due to low BP (POSTURAL HYPOTENSION)- Cushing’s causes hypertension
Diarrhoea*****
Constipation
N&V
Abdo pain
Weight loss
Anorexia
Dehydration
Tanned, tired, toned and
UNEXPLAINED ABDO PAIN OR VOMITING - THINK OF ADDISON’S
Presentation:
MSK and derm:
- Why is there skin pigmentation especially in the mucosa, sun-exposed areas, creases and scars?
- What flu-like MSK symptom may they have?
Caused by -ve feedback of hormones on the pituitary, leading to raised ACTH production.
Myalgia
Arthralgias
Onset:
Insidious onset - what are the signs?
What may be an acute presentation?
TATT, anorexia and GI symptoms
An adrenal crisis
Investigations - Bloods:
U&E:
- How does reduced mineralocorticoids and dehydration affect Na and K levels?
- Why does urea increase?
- What may happen to calcium levels? - rare
Glucose - why do they become hypoglycaemic?
Increase Ca
Low Na
High K
Sodium-potassium pump not functioning properly - they usually transport sodium out and potassium out
Due to hypovolaemia - vomiting and diarrhoea - lose fluids
Due to the lack of cortisol - Under stressful conditions, cortisol provides the body with glucose by tapping into protein stores via gluconeogenesis in the liver. This energy can help an individual fight or flee a stressor. However, elevated cortisol over the long term consistently produces glucose, leading to increased blood sugar levels.
Diagnostic tests:
When could serum cortisol be measured when it’s usually at its peak, to show it is extremely low?
High dose ACTH stimulation test:
- What is another name for this? - S
- What is done?
- What would be the result for primary failure?
- What would be the result for early secondary failure?
- What would be the result for late secondary failure?
What does low serum ACTH show?
Morning (8-9 am) - SO a morning serum cortisol test is done first!
Synacthen Test
IM/IV tetracosactide (artificial ACTH) is given - baseline checked before, 30 and 60 minutes after
1* - small or no rise
2* early - Sharp rise due to extra boost by extra ACTH
2* later - Small rise - adrenals eventually atrophy without ACTH
Secondary cause - ACTH should be fine as pituitary gland should be working
Management - Corticosteroid replacement:
Hydrocortisone (gluco):
- How many times a day and why?
Prednisolone (gluco):
- How many times a day?
Fludrocortisone (mineral):
- What 2 things does this help with?
Why are the steroids not taken in the evening or before bed?
Twice - AM and late afternoon to follow circadian rhythm
Once in the morning
Corrects postural hypotension
Na and K imbalance
They can cause insomnia.
Other considerations:
What needs to be done to the dose if they are unwell (there is an infection, trauma or surgery)?
What route is used if they have D&V?
Why do they wear a bracelet declaring steroid use?
Why should you treat Addisons before any hypothyroidism?
Double the dose
Give them IM hydrocortisone - obviously coz they can’t use it orally
Wearing an Adrenal Insufficiency Steroid Dependent Alert Medical ID Bracelet helps you to ensure your medical condition is made known to attending paramedics and other medical professionals, allowing them to quickly assess and diagnose the situation, and therefore accurately and quickly provide you with the best.
Because as the metabolic demands increases, it uses up cortisol which is only going to make Addison’s
Congenital adrenal hyperplasia:
How does androgens (i.e. testosterone) get released?
Presentation:
Apart from Addisonian symptoms, what will hyperandrogenism cause?
A compensatory rise in ACTH occurs causing adrenal hyperplasia.
Ambiguous genitalia in females
Precocious puberty
Infertility - they get PCOS
