addisons disease Flashcards

1
Q

what is addisons disease?

A
  • adrenal gland fails to produce adequate cortisol
  • opposite of cushings where too much cortisol is made

3 types:
primary - failure of adrenal glands to produce cortisol and aldosterone

secondary- failure of pituitary gland to produce ACTH leading to cortisol deficiency

tertiary - failure of hypothalamus to secrete CRH

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2
Q

primary vs secondary addisons signs

A

primary
- hyperpigmentation
- hypotension
- hyponatremia and hyperalkemia

secondary
- no hyperpigmentation or hyperalkaemia bc aldosterone is unaffected

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3
Q

addisons symptoms

A

generalised fatigue
weight loss and loss of apetite
hypoglycemia
salt cravings - aldosterone deficiency

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4
Q

addisons investigations

A

serum cortisol - <5 (low)

ACTH stimulation - no inc in cortisol - primary

insulin tolerance test- secondary / tertiary

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5
Q

what effects does low aldosterone levels have on Na + K levels

A
  • lowers Na levels
  • increases K levels
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6
Q

procedure on insulin tolerance test

A

induces hypoglycaemia which should cause the pituitary to make ACTH
this will in turn cause the adrenal glands to make more cortisol

if the pituitary isn’t functioning properly, it will not release this

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7
Q

gold standard for measuring adrenal insufficiency

A

short synacthen test

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8
Q

initial test for primary adrenal insufficiency - addisons

A

9am serum cortisol level, as cortisol levels are highest in the morning and a low value would indicate adrenal insufficiency.

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9
Q

What general advice should be given with regards to steroids and intercurrent illness?

A

double steroid dose

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10
Q

infectious cause of addinsons disease

A

TB

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11
Q

Aetiology of primary adrenal insufficiency (2)

A
  • Developed world: Autoimmune adrenal destruction (21-hydroxylase present in 60-90% of people)
  • Developing world: TB (+ sarcoidosis)
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12
Q

Complications of adrenal insufficiency (2)

A
  • Addisonian crisis (experiences by 40% of patients)
  • Cushing’s syndrome
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13
Q

Diagnosis of adrenal insufficiency (4)

A
  • First line: 8-9am cortisol
  • Gold standard: ACTH stimulation test (short Synacthen test)

RESULTS
- Low cortisol, high ACTH, poor response to synacthen = Primary adrenal insufficiency
- Low cortisol, low/normal ACTH, poor response to synacthen = Secondary adrenal insufficiency OR hypopituitarism

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14
Q

Other investigations for adrenal insufficiency (4)

A
  • U+E to test for hyponatraemia and hyperkalaemia
  • Aldosterone:renin ratio - aldosterone low renin high
  • Adrenal CT or MRI
  • Test bloods for 21-hydrolase adrenal antibodies
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15
Q

Other causes of adrenal insufficiency (2)

A
  • Adrenal metastasis (lung, liver, breast)
  • Adrenal haemorrhage (eg: meningococcal septicaemia)
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16
Q

Risk factors for adrenal insufficiency (3)

A
  • Female
  • Adrenocortical antibodies
  • Other autoimmune disease
17
Q

Signs of adrenal crisis (5)

A
  • Hyponatraemia
  • Hyperkalaemia
  • Profound fatigue
  • Dehydration
  • Vascular collapse (low BP)
18
Q

Signs of adrenal insufficiency (5)

A
  • Bronze hyperpigmented skin, particularly in palms (only in Addison’s)
  • Postural hypotension
  • Hypoglycaemia
  • Change in body hair distribution - Loss of pubic hair in women
  • Associated autoimmune condition
18
Q

Symptoms of adrenal insufficiency (4)

A
  • Weight loss
  • Nausea and vomiting
  • Lethargy and generalised weakness
  • Salt cravings
19
Q

Tell me about Primary adrenal insufficiency/Addison’s disease (3)

A
  • Pathology is at the adrenal glands
  • Decreased production of adrenocortical hormones (cortisol and aldosterone)
  • High ACTH, low adrenocortical hormones
20
Q

Tell me about Secondary adrenal insufficiency (4)

A
  • Pathology is in the pituitary
  • Inadequate ACTH released from pituitary
  • Leading to low release of adrenocortical hormones from the adrenal gland
  • Low ACTH, low adrenocortical hormones
21
Q

Treatment for Adrenal insufficiency (3)

A
  • Hydrocortisone - glucocorticoid to replace cortisol
  • Fludrocortisone - mineralocorticioid to replace aldosterone if necessary
  • Double the dose of hydrocortisone in trauma/infection
22
Q

Treatment of Addisonian/adrenal crisis (2)

A
  • Immediate 100mg hydrocortisone
  • IV solve + dextrose (if hypoglycaemia)
  • Without cortisol, you will die from adrenal crisis if you have an infection
23
Q

Why do patients with primary adrenal sufficiency present with bronzed skin?

A

High ACTH stimulates melanocytes, resulting in hyperpigmentation

24
Q

sick day rules

A

carry a steroid card and wearing a medical alert bracelet

25
Q

screening

A

osteoporosis with continued steoid use

26
Q

management of Addisons crisis

A
  • aggressive fluid resuscitation
  • administration of IV/IM steroids STAT
  • glucose administration if hypoglycaemia is present
27
Q

sudden stop or reduction in steroid treatment

A

can lead to life threatening adrenal crisis

catagorised by:
- hyponatraemia
- hyperalkaemia
- hypoglycaemia

28
Q

most appropriate first line for adrenal crisis

A

IV hydrocortisone
(NOT WITH FLUDROCORTISONE)

29
Q

normal 9am cortisol level

30
Q

if patient on hydrocortisine and fludrocortisone and illness where you need to double the dose - do you double both

A

no you would only need to double hydrocortisine

31
Q

concerning state not responding to fluids - treatment

A

IV hydrocortisone 100mg

32
Q

how common is autoimmune cause

A

IN DEVELOPED COUNTRIES - 80-90%

33
Q

autoantibody name

A

21-hydroxylase