ADRENAL INSUFFICIENCY

Question 1

Causes of adrenal insufficiency

Answer 1

Sudden cessation of prolonged corticosteroid use or abuse
Stress
Pituitary failure
Addison’s disease
Severe infections affecting the adrenal gland
Congenital adrenal hyperplasia in children

Question 2

Examples of stressful factors that can cause adrenal insufficiency

Answer 2

infection
severe trauma
surgery
dental procedures

Question 3

Severe infections that can infect the adrenal glands and cause adrenal insufficiency

Answer 3

HIV
Tuberculosis
Meningococcus

Question 4

Addison’s disease

Answer 4

Autoimmune destruction of the adrenal gland

Question 5

Stress will cause adrenal insufficency in these situations

Answer 5

in a patient with undiagnosed adrenal insufficiency
patients on prolonged corticosteroid treatment.

Question 6

Symptoms of adrenal insufficiency

Answer 6

Nausea
Vomiting
Weakness
Collapse
Abdominal pain
Diarrhoea

Question 7

Signs of adrenal insufficiency

Answer 7

Dehydration
Low or unrecordable blood pressure
Darkening of oral mucosa, gums, skin, palms and soles
Evidence of corticosteroid abuse
Variable states of consciousness

Question 8

Signs of adrenal insufficiency in children

Answer 8

Ambiguous genitalia
short stature
failure to thrive

Question 9

Signs that point to corticosteroid abuse

Answer 9

Skin bleaching
Cushingoid appearance

Question 10

Treatment objectives in adrenal insufficiency

Answer 10

To correct the fluid and electrolyte imbalance
To correct hypoglycaemia
To replace corticosteroids
To identify cause and treat any precipitating factor

Question 11

Acute treatment of adrenal insufficiency

Answer 11

Intravenous fluid replacement
Adults
0.9% Sodium Chloride in 5% Glucose (Dextrose Saline), IV, 1 litre 4-6 hourly, until condition is stable
Children
0.45% Sodium Chloride in 5% Glucose, IV, according to total fluid requirement

And

Hydrocortisone, IV,
Adults
200 mg stat. followed by 100 mg 6 hourly until condition is stable
Children
6-12 years; 100 mg 6 hourly
1-5 years; 50 mg 6 hourly
< 1 year; 25 mg 6 hourly

Question 12

How long should acute treatment be done for

Answer 12

Patient can be on IV hydrocortisone for several days
When the patient is stable (i.e, normal BP, cessation of vomiting), move on to maintenance treatment

Question 13

First line maintenance treatment of adrenal insufficiency for patients not previously on corticosteroids

Answer 13

Prednisolone, oral, life-long
Adults
5 mg morning and 2.5 mg evening each day
Children
70 micrograms/kg 12 hourly

Question 14

Second line maintenance treatment of adrenal insufficiency for patients not previously on corticosteroids

Answer 14

Hydrocortisone, oral, life-long
Adults
10-20 mg morning and 5-10 mg evening each day
Children
280 micrograms/kg 12 hourly

Question 15

Maintenance treatment of adrenal insufficiency for patients on long term corticosteroid therapy who go into adrenocortical crisis eg. asthma, nephrotic syndrome

Answer 15

Restart the previous doses of oral corticosteroids given for the condition.

Question 16

Maintenance treatment of adrenal insufficiency for patients who abuse corticosteroids

Answer 16

Restart oral corticosteroids, or replace topical corticosteroids with oral corticosteroids
Prednisolone, oral, 20-40 mg daily
Gradually taper off the dose over several months (e.g. reducing by 2.5 mg per month) and eventually discontinue

Question 17

The dose of corticosteroids must be reduced gradually if treatment has been for longer than ………….. and is to be stopped

Answer 17

3 weeks

Question 18

For patients on long term corticosteroid therapy who become ill,have an infection or undergoing a dental procedure, what should be done concerning their steroid dose

Answer 18

Double the regular dose of corticosteroid the patient takes

Question 19

For patients on corticosteroids undergoing minor surgical procedures including labour, delivery, etc, this should be done

Answer 19

Change the corticosteroid to IV Hydrocortisone