Adrenal Insufficiency Flashcards
Adrenal insufficiency is when the adrenal glands don’t produce enough steroid hormones, particularly ____ and ____
cortisol and aldosterone
What is cortisol used for?
Helps regulate metabolism, blood pressure and body’s response to stress
What disease refers to damaged adrenal glands (primary adrenal insufficiency) resulting in reduced secretion of cortisol and aldosterone?
Addison’s disease
What is the most common cause of Addison’s disease in the developed world?
autoimmunity
What is the most common cause of adrenal insufficiency in the developing world?
TB
(also sarcoidosis)
What antibodies are present in Addison’s disease?
21-alpha-hydroxylase auto antibodies
What is Waterhouse-Friderichsen syndrome?
Adrenal insufficiency due to adrenal haemorrhage, often due to meningococcal meningitis
What causes secondary adrenal insufficiency?
Main cause is iatrogenic (steroids)
Also by adrenal metastasis (lungs, liver, breast) or adrenal haemorrhage
Inadequate ACTH stimulating the adrenal glands resulting in low levels of cortisol being released. Loss or damage of pituitary gland. HPA suppression.
What can damage the pituitary gland?
congenital underdevelopment (hypoplasia)
Surgery
Infection
Loss of blood flow
Radiotherapy
True or false: secondary adrenal insufficiency can cause hyperpigmentation
False - No ACTH to stimulate the melanocytes. Happens for primary adrenal insufficiency
Tertiary adrenal insufficiency is the result of inadequate ___ release by the _____
CRH, hypothalamus
What can cause tertiary adrenal insufficiency?
Long term (more than 3 weeks) oral steroids causing suppression of hypothalamus.
When the exogenous steroids are suddenly withdrawn, the hypothalamus doesn’t kick into action fast enough and endogenous steroids are not adequately produced.
What should be tapered slowly to allow time for the adrenal axis to regain normal function?
Long term steroids
What are features of adrenal insufficiency?
Lethargy
Weight loss
Postural hypotension (when stand up)
Vitiligo
Hyperpigmentation (primary)
Change in body hair
Abdominal pain
Vomiting
Hypoglycaemia
In babies also:
Poor feeding
Jaundice
Failure to thrive
What are features of adrenal insufficiency in older children?
Nausea and vomiting
Poor weight gain or weight loss
Reduced appetite (anorexia)
Abdominal pain
Muscle weakness
Muscle cramps
Developmental delay
Poor academic performance
Bronze hyperpigmentation to skin in Addison’s (high ACTH levels stimulating melanocytes)
What investigations are made for suspected adrenal insufficiency?
U&Es:
Hyponatraemia and hyperkalaemia
Blood glucose:
Hypoglycaemia
Test levels of:
Cortisol, ACTH, aldosterone and renin
Short synacthen Test (ACTH stimulation test)
CXR is TB suspected
What is the short synacthen test?
Used to confirm adrenal insufficiency
Done in morning, 9am as cortisol highest.
Involves giving synacthen (synthetic ACTH). Then blood cortisol measured at baseline, 30mins and 60 mins post administration.
The cortisol levels should at least double in response to synacthen. If not, indicates primary adrenal insufficiency.
How do you manage adrenal insufficiency?
Replacement steroid titrated to signs, symptoms and electrolytes.
Cortisol is replaced with the glucocorticoid hormone Hydrocortisone.
Aldosterone is replaced with the mineralocorticoid hormone Fludrocortisone.
Patients given steroid card and emergency ID tag
Why are patients given steroid card and emergency ID tag?
They are dependent on their steroids for life. Doses are increased during an acute illness to match normal steroid response to illness.
What is an adrenal crisis?
Also called Addisonian crisis, emergency that occurs due to severe deficiency of cortisol.
Often triggered by stress, illness, surgery, trauma or interruption of corticosteroid management, increasing the body’s demand for cortisol.
What are signs and symptoms of adrenal crisis?
Low blood pressure
Hyponatremia
Hyperkalaemia
Severe weakness
Fatigue
Nausea
Vomiting
Abdominal pain
Dehydration
Confusion
Loss of consciousness
