Adrenal Insufficiceny

Question 1

What is adrenal insufficiency?

Answer 1

clinical manifestation of hypocortisolism and hypoaldosteronism

Question 2

What is primary adrenal insufficiency?

Answer 2

adrenal pathology

Question 3

What is secondary adrenal insufficiency?

Answer 3

pituitary / hypothalamic insufficiency

Question 4

What are the causes for adrenal insufficiency?

Answer 4

1. TB (most common worldwide)
2. AI destruction (most common in the UK)
3. Meningococcal septicaemia (Waterhouse-Friderichsen syndrome)
4. Pituitary tumours, radiation or infiltration

Question 5

What is the presentation of primary adrenal insufficiency?

Answer 5

1. Lethargy
2. Anorexia
3. N+V
4. Weight loss
5. Salt craving
6. Pigmented skin
7. Hyponatraemia
8. Hyperkalaemia

Question 6

What is the presentation of secondary adrenal insufficiency?

Answer 6

1. Lethargy
2. Anorexia
3. N+V
4. Weight loss
5. Salt craving

Question 7

What is the presentation of an adrenal crisis?

Answer 7

1. Collapse
2. Shock
3. Hypotension
4. Pyrexia

Question 8

What is Waterhouse-Friderichsen syndrome?

Answer 8

adrenal haemorrhage induced by meningitis

Question 9

Why is there hyperpigmentation in primary adrenal insufficiency?

Answer 9

due to the lack of negative feedback on ACTH which drives high levels of the hormone.

Question 10

How is ACTH produced?

Answer 10

from the cleavage of POMC (MSH is a byproduct of this too)

Question 11

Why is there no hyperpigmentation in secondary adrenal insufficiency?

Answer 11

there is a pituitary dependent reduction in ACTH – this means less MSH so no hyperpigmentation

Question 12

What bloods are done for adrenal insuff?

Answer 12

• FBC, U+Es (Na and K)
• Glucose
• 9am serum cortisol <500 nmol/L

Question 13

What is the diagnostic test for adrenal insufficiency?

Answer 13

Short synACTHen test

Question 14

What other investigations may be done for adrenal insuff?

Answer 14

• Investigations for TB
• Adrenal imaging
• Pituitary imaging

Question 15

What is the process of the the short synACTHen test?

Answer 15

1. 250 ug IM synthetic ACTH
2. Check cortisol at 30 and 60mins
3. Cortisol <550nM = diagnostic

Question 16

What is the management of adrenal insuff?

Answer 16

1. Homrone replacement
2. sick day rules
3. management of underlying cause if app

Question 17

What hormone replacement is used?

Answer 17

1. Life long hydrocortisone +/- fludrocortisone

2. Consider DHEA replacement (androgens) in certain cases - to be decided by specialists

Question 18

What is fludrocortisone used?

Answer 18

an aldosterone agonist and so would only be needed if the cause is primary

Question 19

What is the acute management of adrenal insuf?

Answer 19

1. Hormone replacement
2. Resus
3. Rehydration
4. Continued maangement

Question 20

What hormone replacement is used acutely?

Answer 20

1. 100mg hydrocortisone IV / IM
2. 200mg HC /24h continuous infusion OR
3. 50mg every 6hours IV or IM

Question 21

What is the resusitation process?

Answer 21

1. 500ml fluid bolus of 0.9% NaCl over 15mins

2. Replace any deficits

Question 22

What rehydration is used acutely?

Answer 22

3-4L 0.9% NaCl in 24hours

Question 23

What continued management for adrenal insuff?

Answer 23

refer to endo for advice and LT management including sick day rules etc