Addison's Disease (& Primary Adrenal Insufficiency)

Question 1

Addison’s disease

Answer 1

• Main cause of primary adrenal insufficiency
• autoimmune adrenalitis

Question 2

Main causes of primary adrenal insufficiency

Answer 2

1. autoimmune (addisons)
2. trauma
3. infections (TB)
4. invasions (neoplastic, sarcoid)

Question 3

Main causes secondary adrenal insufficiency

Answer 3

1. pituitary disorders (tumours, sheehan)
2. chronic opiate use
3. isolated ACTH deficiency

Question 4

Main cause (99%) of adrenal insufficiency

Answer 4

long-term glucocorticoid use

Question 4

Main causes of tertiary adrenal insufficiency

Answer 4

• long term glucocorticoid use
• directly after treating Cushings disease

Question 5

Pathophysiology of Addison’s (& adrenal insufficiency)

Answer 5

• destruction or inactivation of adrenal layers
• cortisol deficiency
• aldosterone deficiency
• adrenal androgen deficiency

Question 6

Functions of cortisol

Answer 6

• maintain gluose homeostasis
• immune function
• regulate stress response

Question 7

Signs of cortisol deficiency

Answer 7

• hypoglycaemia
• increased infections
• impaired stress response

Question 8

Functions of aldosterone

Answer 8

• regulates Na+ and K+ balance via kidneys

Question 9

Signs of aldosterone deficiency

Answer 9

• hyponatraemia
• hyperkalaemia
• volume depletion
• orthostatic hypotension

Question 10

Functions of adrenal androgens

Answer 10

• Maintenance of secondary sexual characteristics

Question 11

Signs of adrenal androgen deficiency

Answer 11

(more prominent in women, as males have testes producing testosterone)
- reduced body hair
- reduced libido

Question 12

Main consequence of lost negative feedback from adrenal glands in Addison’s (& primary adrenal insufficiency)

Answer 12

• increased ACTH levels from pituitary
• increased melanocyte-stimulating hormone
• ** hyperpigmentation of the skin**

Question 12

Clinical features of Addisonian crisis

Answer 12

• hypotension
• hypovolaemic shock
• acute abdominal pain
• fever
• vomiting
• collapse
• hyperkalaemia

Question 13

Symptoms of chronic adrenal insufficiency

Answer 13

• fatigue and weakness
• anorexia and weight loss
• nausea and vomiting
• ‘salt craving’
• diarrhoea and constipation
• syncope and dizziness
• irritable, confused

Question 14

Signs of chronic adrenal insufficiency

Answer 14

• hyperpigmentation
• hypotension
• hypoglycaemia
• hyponatraemia
• loss of body hair

Question 15

Investigating Addison’s disease

Answer 15

Bloods:
- decreased Na+, increased K+
- decreased glucose
- increased ACTH
- adrenal antibodies (anti-21 hydroxylase)

ABG:
- normal gap metabolic acidosis

short synacthen test:
- no increase in cortisol (after giving ACTH)
- indicates primary insufficiency

Question 17

Short synacthen test

Answer 17

• used to differentiate primary & secondary adrenal insufficiency
• measure cortisol levels then give ACTH
• remeasure cortisol after 30mins
• normal = rise in cortisol

Question 19

Managing acute adrenal/addisonian crisis

Answer 19

• ABCDE
• aggressive IV fluids
• IM or IV hydrocortisone

Question 20

Long-term management of primary adrenal insufficiency

Answer 20

combination of hydrocortisone & fludracortisone
patient education crucial