Adrenal insufficiency

Question 1

What is adrenal insufficiency?

Answer 1

Adrenal glands do not produce enough steroid hormones

Question 2

Adrenal insufficiency can be classified as…

Answer 2

Primary, secondary or tertiary

Question 3

Describe the pathophysiology of primary adrenal insufficiency

This is also known as…

What are the causes?

Answer 3

Pathology affecting the adrenal glands = adrenal glands do not produce enough cortisol

This is also known as Addison’s disease

Adrenal gland pathology:
- Most common cause is autoimmune

Question 4

Describe the pathophysiology of secondary adrenal insufficiency

What are the causes?

Answer 4

Pathology affecting the pituitary gland = pituitary not producing enough ACTH

Pituitary pathology:

• Trauma (e.g. surgery)
• Pituitary apoplexy
• Necrosis (Sheehan’s syndrome)

Question 5

Describe the pathophysiology of tertiary adrenal insufficiency

What are the causes?

Answer 5

Hypothalamus not producing enough CRH

Pathology affecting the hypothalamus:
- Sudden withdrawal of exogenous steroids

Question 6

What are the characteristic symptoms and signs of Addison’s disease?

Answer 6

Very non-specific symptoms:

• Nausea
• Abdominal pain
• Fatigue

Signs:

• Bronze hyperpigmentation of the skin (ACTH stimulates melanocytes to produce melanin)
• Hypotension (particularly postural hypotension)

Question 7

Describe the investigation of primary adrenal insufficiency

Answer 7

Short synacthen test

Question 8

Describe the management of adrenal insufficiency

Answer 8

Replacement steroids:

• Hydrocortisone
• Fludrocortisone

Question 8

How does the dose of exogenous steroids change for someone with adrenal insufficiency during times of stress, e.g. acute illness/surgery?

Answer 8

“Sick day rules” = double the dose

Question 9

Adrenal crisis is also known as…

Answer 9

Addisonian crisis

Question 11

What is an adrenal crisis?

What are the clinical features?

Answer 11

Acute, severe life-threatening presentation of Addison’s:

• Reduced consciousness
• Severe hypoglycaemia, hypotension, hyponatraemia and hyperkalaemia

Question 12

What are the triggers/causes of an Addisonian crisis?

Answer 12

• First presentation of unknown Addison’s
• Acute stress in a patient with known Addison’s, e.g. infection/trauma
• Suddenly stopping long term exogenous steroids