Adrenal insufficiency Flashcards
What is adrenal insufficiency?
deficiency of adrenal cortical hormones (e.g. mineralocorticoids, glucocorticoids + androgens)
What is primary adrenal insufficiency? What is the most common cause in the UK? How about worldwide?
Addison’s disease
UK: AI
Worldwide: TB
What can cause secondary adrenal insufficiency?
Inadequate ACTH from Pituitary
Infiltration: Mets (lung), Lymphomas, Amyloidosis
Iatrogenic: Sudden cessation of long-term steroid therapy
Describe the epidemiology of Addisons disease
Rare
UK prevalence: 8,400
Often 30-50 yrs
F > M
List 6 symptoms seen in Addisons
Dizziness Weight loss + Anorexia D+V Abdominal pain Lethargy + Weakness Depression
How does Addisons present?
Acute: crisis precipitated by infection, surgery or trauma: hypotension, hypovolaemic shock, acute abdominal pain, low-grade fever + vomiting.
Chronic: symptoms develop insidiously, may be mild + non specific
List 4 signs of adrenal insufficiency
Postural hypotension
Increased pigmentation
Loss of body hair in women (androgen deficiency)
Associated AI condition (e.g. vitiligo)
How is adrenal insufficiency confirmed?
9 am Serum Cortisol
< 100 nmol/L is diagnostic
> 550 nmol/L makes adrenal insufficiency unlikely
Short Synacthen Test
IM 250 mg synthetic ACTH
Serum cortisol < 550 nmol/L at 30 mins indicates adrenal failure
How do you identify the level of defect in the hypothalomo-pituitary-adrenal axis?
ACTH HIGH in primary disease
ACTH LOW in secondary
Long Synacthen Test
1 mg synthetic ACTH administered
Measure serum cortisol at 0, 30, 60, 90 + 120 minutes
Measure again at 4, 6, 8, 12 + 24 hours
Primary: no increase after 6 hours
Secondary: Delayed normal response
How do you identify the cause of adrenal insufficiency?
Autoantibodies (against 21-hydroxylase)
Abdo CT or MRI: exclude infection, haemorrhage, or mets
CXR: exclude lung malignancy
TFTs: often have hypothyroidism
What investigations are performed in an addisonian crisis?
FBC: neutrophilia = infection U+Es: High urea, Low Na+, High K+ CRP (High in acute infection) Calcium (may be raised) Glucose LOW Blood cultures Urinalysis: MC+S (UTI may have triggered crisis) CXR: identify cause e.g. TB, carcinoma or precipitant e.g. infection
How is an addisonian crisis treated?
Rapid IV fluid rehydration
50 mL of 50% dextrose to correct hypoglycaemia
Calcium glucunate if appropriate
IV 100 mg HYDROCORTISONE bolus
Repeated 6 hourly hydrocortisone until BP is stable
Treat precipitating cause (e.g. abx for infection)
Monitor
How is chronic adrenal insufficiency treated?
Hydrocortisone 10/5/5mg or Prednisolone 3-4mg OD
Fludrocortisone 50-100mcg OD
Hydrocortisone dosage needs to be increased during times of acute illness or stress
What advice is given to patients with adrenal insufficiency?
Have a steroid warning card
Wear a medic-alert bracelet
Emphasise importance of not missing doses
Provide emergency hydrocortisone (IM) for injection with needles + syringes for adrenal crisis/ too unwell for PO meds
In simple term, describe management of adrenal insufficiency with intercurrent illness
Glucocorticoid dose should be doubled
Fludrocortisone dose stays the same
Give 2 complications of adrenal insufficiency
HYPERKALAEMIA
Death during Addisonian crisis
What is the prognosis in adrenal insufficiency?
Adrenal function rarely recovers
Normal life expectancy if treated
What is type 1 AI polyendocrine syndrome?
Autosomal recessive disorder caused by mutations in the AIRE gene. Consists of the following diseases:
Addison’s disease
Chronic mucocutaneous candidiasis
Hypoparathyroidism
What is type 2 AI polyendocrine syndrome?
AKA: Schmidt's Syndrome Addison's disease T1DM Hypothyroidism Hypogonadism
What 6 signs may be seen in an addisonian crisis?
Hypotensive shock Tachycardia Pale Cold Clammy Oliguria
How do you administer drugs for patients with concurrent hypothyroidism and adrenal insufficiency?
Hydrocortisone BEFORE thyroxine (to prevent precipitating an Addisonian crisis)
Giving thyroxine first can enhance cortisol clearance + precipitate an adrenal crisis (increases BMR leading to increased requirement of cortisol)
What bloods are usually seen in Addisons?
High K+
Low Na+
Metabolic acidosis (less H+ excretion)
What should be done if Addisonian crisis is suspected whilst awaiting blood results?
DONT wait for results before administering tx.
Take blood for random cortisol + treat immediately if appropriate
