Adrenal Insufficiency

Question 1

What is primary vs secondary adrenal insufficiency

Answer 1

Primary: lack of cortisol and aldosterone production caused by autoimmune disorders or HPA axis suppression
Secondary: issue stems from pituitary or hypothalamus

Question 2

What is the primary cause of primary vs secondary adrenal insufficiency

Answer 2

Primary: Autoimmune adrenalitis
Secondary: dysfunction of the hypothalamic-pituitary portion of the HPA axis

Question 3

S/s of glucocorticoid insufficiency

Answer 3

• Fatigue, anorexia, myalgias, orthostasis
• Normochromic anemia, lymphocytosis, eosinophilia
• Increase in TSH, hypoglycemia, hyponatremia
• Low Na+ is characteristic of primary adrenal insufficiency

Question 4

S/s of mineralocorticoid deficiency

Answer 4

Dizziness or orthostatic hypotension
Salt craving
Increase in serum creatinine
Hyperkalemia

Question 5

S/s of androgen deficiency

Answer 5

Fatigue, dry itchy skin, decreased libido, loss of axillary and pubic hair

Question 6

What are distinguishing skin features in primary vs secondary adrenal insufficiency

Answer 6

Hyperpigmentation
•Primary adrenal insufficiency
Alabaster colored pale skin
•Secondary adrenal insufficiency

Question 7

What is an adrenal crisis

Answer 7

Acute adrenal insufficiency typically caused by infection, surgery, or suppressed glucocorticoid activation

Question 8

S/s of adrenal crisis

Answer 8

Postural hypotension — hypovolemic shock
Abd pain, nausea, vomiting
Comatose, obtunded, lethargic

Question 9

Adrenal crisis diagnostics ACTH stimulation test

Answer 9

Cosynotropin administered and cortisol levels are checked 0, 30 , and 60 mins after
•Cortisol level <450-500 nmol/L consider adrenal insufficiency

Question 10

Adrenal Crisis diagnostics : Insulin tolerance test

Answer 10

•Insulin injection to induce hypoglycemia
•Regular insulin of 0.1 units/kg IV
•Glucose, Cortisol & GH checked at 0, 30, 60 , and 120 minutes
•Cortisol level >550 nmol/L normal
•Requires clinical monitoring
•Contraindicated if Hx of CAD, CVA, or seizure disord

Question 11

Primary Adrenal insufficiency treatment

Answer 11

Mineralcorticoid and glucocorticoid replacement
Hydrocortisone and fludrocortisone
Monitor sodium, potassium, and renin

Question 12

Secondary adrenal insufficiency treatment plan

Answer 12

Glucocorticoid replacement only

Question 13

When is androgen replacement indicated

Answer 13

Lack of energy despite replacement

Question 14

Medical managment of admitted adrenal insufficiency and crisis

Answer 14

Admission: double typical dose of steroids
Crisis: crystalloid infusion, glucocorticoid IV (100mg IVB then 200mg daily)