Adrenal insufficiency

Question 1

What is adrenal insufficiency?

Answer 1

Adrenal glands do not produce enough steroid hormones- cortisol and aldosterone

Question 2

What is primary adrenal insufficiency?

Answer 2

Addison’s disease
- Adrenal glands have been damaged, resulting in reduction in the secretion of cortisol and aldosterone
Autoimmune is the most common cause

Question 3

What is secondary adrenal insufficiency?

Answer 3

Insufficient ACTH secretion due to loss or damage to the pituitary gland
- Surgery
- Infection
- loss of blood flow
- Sheeshan’s syndrome: massive blood loss during childbirth leads to pituitary gland necrosis

Question 4

What is tertiary adrenal insufficiency?

Answer 4

Inadequate CRH release by the hypothalamus
Usually due to sudden withdrawal of long term exogenous steroids

Question 5

Why should long term steroids be tapered slowly?

Answer 5

To allow time for the adrenal axis to regain normal function and adequately produce endogenous steroids

Question 6

What are the symptoms of adrenal insufficiency?

Answer 6

Fatigue
Nausea
Cramps
Abdominal pain
Reduced libido

Question 7

What are the signs of adrenal insufficiency?

Answer 7

Bronze hyperpigmentation to skin- ACTH stimulates melanocytes to produce melanin
Hypotension- postural especially

Question 8

What investigations are carried out?

Answer 8

• Hyponatraemia
• Hyperkalaemia
• Early morning cortisol
• Short syncathen test (test of choice)
• ACTH (high in primary, low in secondary)
• Adrenal antibodies (autoimmune)
• CT/MRI adrenals
• MRI pituitary

Question 9

What are normal levels for random cortisol?

Answer 9

> 450 nmol/l- not Addison’s
<450 nmol/l- adrenal status uncertain

Question 10

What is a short syncathen test?

Answer 10

ACTH stimulation test
Syncathen is synthetic ACTH
Syncathen will stimulate healthy adrenal glands to produce cortisol and levels will double
Failure of cortisol to rise indicated Addison’s disease

Question 11

What is the treatment of adrenal insufficiency?

Answer 11

Glucocorticoid (cortisol) replacement- hydrocortisone, prednisolone, dexamethasone

Mineralocorticoid (aldosterone) replacement- fludrocortisone

Question 12

What is Addisonian crisis?

Answer 12

Acute presentation of severe Addison’s where the absence of steroid hormones leads to a life threatening presentation

Question 13

What is the presentation of Addisonian crisis?

Answer 13

Reduced consciousness
Hypotension
Hypoglycaemia, hyponatraemia, hyperkalaemia
Patients very unwell

Question 14

What is the management of Addisonian crisis?

Answer 14

Intensive monitoring
Parenteral steroids (IV hydrocortisone stat then 100mg every 6 hours)
IV fluid resuscitation
Correct hypoglycaemia