Adrenal Insufficiency

Question 1

What is adrenal insufficiency? Types?

Answer 1

When adrenal glands do not produce enough aldosterone or cortisol.

Types

• Primary (Addison’s disease -> high ACTH, low aldosterone and cortisol)
• Secondary (low ACTH, low aldosterone and cortisol)

Question 2

Symptoms of Addison’s disease

Answer 2

• Fatigue
• Nausea
• Cramps
• Abdominal pain
• Reduction in the patient’s libido
• Bronzed hyperpigmentation (due to ACTH activating melanocytes to produce melanin)
• Hypotension (due to a lack of aldosterone action on the body).

Question 3

What features? What investigations are carried out for adrenal insufficiency?

Answer 3

Features

• Hyponatremia
• Hyperkalaemia

Ix
- Short synacthen test
> Synthetic ACTH injected
> Cortisol rise observed
> Primary adrenal insufficiency –> cortisol won’t rise as the adrenal glands dont work
> Secondary adrenal insufficiency –> cortisol glands will rise as the adrenal glands do work

• Adrenal antibodies (adrenal cortex antibodies and 21 hydroxylase antibodies)
• CT/MRI of the adrenal glands if there is suspicion of an adrenal tumour, haemorrhage or any other structural pathologies.
• MRI of the pituitary gland
• Long synacthen test–> previously used to identify between primary adrenal insufficiency or adrenal atrophy due to a lack of ACTH stimulation (secondary adrenal insufficiency). If there is cortisol rise, then it indicates the latter.

Question 4

What is the management of adrenal insufficiency?

Answer 4

• Replacement of the titrated steroids
  > Cortisol –> glucocorticoids
  > Aldosterone –> Fludocortisone
• Steroid card and emergency ID tag is necessary
• Missed doses fatal –> require double the doses until baseline reached in acute attacks

Question 5

What is Addisonian crisis (Adrenal Crisis)?

Management?

Answer 5

Steroid levels drop sufficiently low to the point where patient is experiencing life threatening symptoms:

1) Reduced consciousness
2) Hypoglycaemic
3) Hyponatremic
4) Hyperkalaemic
5) Hypotensive
6) Very Unwell

Can be the patient’s first presentation of the Addison’s disease. Can also be triggered by other things e.g.trauma, infection, acute illness or lack of adherence to treatment plan.

Management

• Intensive monitoring
• Para-enteral steroids e.g. 1-100mg hydrocortisone IV stat and then 100mg Hydrocortisone every 6 hours
• Carefully monitor electrolyte levels and fluid levels.