Addison's Disease Flashcards
1
Q
Adrenal Insufficiency Types
A
- Primary insufficiency (Addison’s)- inability of the adrenal glands to produce sufficient steroid hormones, most common cause is autoimmune
- Secondary insufficiency- inadequate pituitary or hypothalamic stimulation of the adrenal glands
2
Q
Adrenal Insufficiency Epidemiology
A
Primary insufficiency is relatively rare
Secondary insufficiency is more common as there are lots of factors that can lead to the suppression of the hypothalamic-pituitary axis (most common is exogenous steroid use)
3
Q
Adrenal Insufficiency Aetiology
A
- Addisons is used to describe primary adrenal insufficiency which can have many causes
- TB in developing world
- Autoimmune adrenal destruction is most common cause in Western Europe
- Autoimmune adrenal destruction is isolated in 40% of cases and part of autoimmune polyendocrinopathy syndrome in 60%
- Exogenous steroids is most common cause of secondary insufficiency
4
Q
Congenital Adrenal Hyperplasia Pathogenesis
A
- Genetic mutation leads to impaired production of cortisol
- Body recognises reduced cortisol and tries to stimulate adrenal glands further
- However no cortisol can be produced so androgens and sometime aldosterone are produced in large quantities but still no cortisol
- Virilisation occurs
- Most common cause of childhood adrenal insufficiency
5
Q
Adrenal Insufficiency In Critically Ill Patients
A
- Increasingly more reported
- CIRCI (critical illness related corticosteroid insufficiency)
- Conditions where adrenal insufficiency may occur include
- Sepsis, severe pneumonia, ARD…
- Should suspect if hypotension does not improve
6
Q
Adrenal Insufficiency Presentation
A
- Symptoms are often mild and nonspecific
- Presentation depends on rapidity of loss of adrenal function
Acute Presentation
- May be as a crisis precipitated by infection, surgery or trauma
- Presents with hypotension, hypovolaemic shock, acute abdominal pain, low-grade fever and vomiting
- Sudden onset e.g. WF, presents with collapse and shock
Chronic Presentation
- Symptoms develop insidiously and may be mild
- Fatigue
- Anorexia
- Nausea
- Vomiting
- Weight loss, cravings for salt, dizziness, hypotension GI upset
- Hyperpigmentation (buccal mucosa, lips, palmar creases, scars, pressure areas e.g. knuckles and knees
- Hypotension, postural hypotension
Giving levothyroxine can use up cortisol and symptoms can get worse in those with coexisting Addisons and hypothyroidism
7
Q
Adrenal Insufficiency Ix
A
- In early stages investigations can be normal
- Hyponatraemia, hyperkalaemia, hypercalcaemia (rarer)
- FBC may show mild anaemia, eosinophilia, lymphocytosis
- LFTs
- Cortisol (blood tests should be taken between 8 and 9am when levels are highest
- ACTH
- Renin and aldosterone for indication of mineralocorticoid activity
- Synacthen test confirm diagnosis (administer ACTH monitor cortisol)
8
Q
Adrenal Insufficiency Associated Diseases
A
- Most cases are autoimmune in origin, comorbidity with other autoimmune diseases common
- Thyroid, DM, pernicious anaemia, vitiligo, premature ovarian failure
9
Q
Adrenal Insufficiency Management
A
- Education
- Glucocorticoid replacement with hydrocortisone is mainstay, highest dose in morning
- Increase glucocorticoid during minor illness
- Do not replace thyroid before glucocorticoid
- Mineralocorticoid replacement with fludrocortisone
- Ongoing monitoring annually to ascertain symptoms
- Screen annually for other autoimmune conditions (TFTs, glucose, HbA1c, FBC, B12, coeliac)
10
Q
Adrenal Crisis
A
- Fatigue, nausea malaise
- Progressing to hypotension and hypovolaemia
- Urgent admission
- Immediate hydrocortisone IV
- Rehydration with saline
- Continuous cardiac and electrolyte monitoring
- Treat underlying disorders
- Can be caused when long term steroids are stopped, hypothalamic-pituitary axis has been suppressed
- Can be caused by infection
11
Q
Adrenal Insufficiency Complications
A
- Adrenal crisis
- Reduced quality of life
- Osteoporosis (usually not a risk but some people require regular high doses)
