Adrenal insufficiency

Question 1

In adrenal insufficiency, what are the 2 main hormones that aren’t produced enough?

Answer 1

Aldosterone and cortisol

Question 2

1) What is the specific condition where the adrenal glands have been damaged, resulting in a reduction in the secretion of cortisol and aldosterone?
2) What is the commonest cause of this condition?

Answer 2

1) Addison’s disease (Primary adrenal insufficiency)
2) Autoimmune

Question 3

1) Secondary adrenal insufficiency is a result of what pathology, and this results in low what?
2) What is the cause of this pathology?
3) Name a cause of this
4) What is Sheehan’s syndrome?

Answer 3

1) Inadequate ACTH stimulating the adrenal glands, resulting in low cortisol release
2) Pituitary loss or damage
3) Surgery to remove a pituitary tumour, infection, loss of blood flow or radiotherapy
4) Massive blood loss during childbirth which leads to pituitary gland necrosis

Question 4

1) Tertiary adrenal insufficiency is due to what?
2) What is this normally caused by?

Answer 4

1) Inadequate CRH release by the hypothalamus
2) patients being on long term oral steroids which causes suppression of the hypothalamus

Question 5

Name 2 symptoms of adrenal insufficiency

Answer 5

• Fatigue
• Nausea
• Cramps
• Abdominal pain
• Reduced libido

Question 6

Name a sign of adrenal insufficiency

Answer 6

• Bronze hyperpigmentation to skin (ACTH stimulates melanocytes to produce melanin)
• Hypotension

Question 7

Investigations (1)
1) What would happen to K+ and Na+ levels in adrenal insufficiency?
2) What would ACTH levels be in primary adrenal insufficiency?
3) What would ACTH levels be in secondary adrenal insufficiency?
4) Name another possible investigation

Answer 7

1) Hyperkalaemia, hyponatraemia
2) High (no negative feedback from cortisol)
3) Low (problem with ACTH production)
4) MRI pituitary, CT or MRI adrenals, adrenal autoantibodies, synacthen test (test of choice)

Question 8

Investigations (2) - synacthen test
1) What is synacthen?
2) Aften synacthen administration, blood cortisol is measured at baseline, 30 and 60 minutes after administration. What would be seen in a healthy patient, and a patient with primary adrenal insufficiency?
3) How can you differentiate from a primary and a secondary adrenal insufficiency?

Answer 8

1) Synthetic ACTH
2) Synthetic ACTH will stimulate healthy adrenal glands to produce cortisol and the cortisol level should at least double. A failure of cortisol to rise (less than double the baseline) indicates primary adrenal insufficiency (Addison’s disease)
3) ACTH concentration

Question 9

Treatment of adrenal insufficiency is with replacement steroids
1) What steroid is given for cortisol replacement?
2) What steroid is given for aldosterone replacement?

Answer 9

1) Hydrocortisone (typically 20-30mg daily, with the majority given in the 1st half of the day)
2) Fludrocortisone

Question 10

1) Addisonian crisis is the term used to describe an acute presentation of severe Addisons, name 2 ways it can present
2) Name 2 aspects of the management of this

Answer 10

1) Reduced consciousness, hypotension, hypoglycaemia, hyponatraemia, hyperkalemia
2) Intensive monitoring if unwell, parenteral steroids, IV fluid resuscitation and hydrocortisone 100mg (IM or IV), correct hypoglycemia (1L IV saline over 30-60mins), monitoring of electrolytes and fluid balance

Question 11

In the management of an intercurrent illness, what happens to the hydrocortisone (glucocorticoid) and the fludrocortisone dose?

Answer 11

Hydrocortisone doubles but fludrocortisone stays the same