Adrenal insufficiency

Question 1

Define adrenal insufficiency.

Answer 1

Addison’s disease, or primary adrenal insufficiency, is a disorder that affects the adrenal glands, causing decreased production of adrenocortical hormones (cortisol, aldosterone, and dehydroepiandrosterone).

Question 2

Explain the aetiology/risk factors of adrenal insufficiency. Summarise the epidemiology of adrenal insufficiency.

Answer 2

TB is the most common cause worldwide, but in the UK, the most common cause is autoimmune disease.
Less common causes are infections (e.g. Pseudomonas aeruginosa or meningococcus) or drugs (e.g. warfarin).

Question 3

Recognise the presenting symptoms of adrenal insufficiency.

Answer 3

Fatigue
Anorexia
Weight loss
Hyperpigmentation

Question 4

Recognise the signs of adrenal insufficiency on physical examination.

Answer 4

Hypotension (can be Addisonian crisis).
Nausea
Vomiting

Question 5

Identify appropriate investigations for adrenal insufficiency and interpret the results.

Answer 5

Serum electrolytes - hyponatraemia, hyperkalaemia, can rarely be hypercalcaemia
Blood urea
FBC - anaemia is present in 40% of patients.
Morning serum cortisol - cortisol should be high in the morning.

Question 6

Generate a management plan for adrenal insufficiency.

Answer 6

ACUTE
IV Hydrocortisone 50-100mg for 1-3 days

STABLE
Hydrocortisone: 15-30 mg/day orally given in 2 divided doses with two-thirds of the total dose given in the morning (around 8 a.m.) and one third in the afternoon (noon to 4 p.m.)
OR
Prednisolone: 2.5 to 5 mg orally once daily

AND

Fludrocortisone: 0.1 to 0.2 mg orally once daily

Question 7

Identify the possible complications of adrenal insufficiency and its management.

Answer 7

Hyperkalaemia: Give calcium gluconate, bolus IV insulin and 20% dextrose, 100ml.
Secondary Cushings’ syndrome: due to over-replacement of steroids.
Osteoporosis due to long term use of steroids.
Hypertension due to excessive mineralocorticoid replacement.

Question 8

Summarise the prognosis for patients with adrenal insufficiency.

Answer 8

Patients are generally ok once they start treatment and stay on life-long replacement.
Adherence is high since non-adherence results in uncomfortable symptoms.