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).
Another condition which can manifest as adrenal insufficiency is congenital adrenal hyperplasia.

Question 2

Explain the aetiology/risk factors of adrenal insufficiency.

Answer 2

The most common cause of Addison’s disease worldwide is TB, however, in the UK, the most common cause is autoimmune disease.

CAH is a congenital disorder and the most common cause is the loss of the 21-hydroxylase enzyme, meaning that there is lack of production of adrenocortical hormones.

Question 3

Summarise the epidemiology of adrenal insufficiency.

Answer 3

An epidemiological study of Addison’s disease carried out in Norway in 1999 showed a prevalence of 140 patients per million and a recorded mean incidence in the past decade of 0.62 per 100,000.
Screening studies indicate a worldwide incidence of classical 21-hydroxylase-deficient CAH as 1 in 13,000 to 1 in 54,000 live births.

Question 4

Recognise the presenting symptoms of adrenal insufficiency. Recognise the signs of adrenal insufficiency on physical examination.

Answer 4

Babies with the salt-wasting form of CAH typically presents a week after birth with severe hypotension, weight loss and inability to feed. This is a medical emergency and if the child is not treated, then it will die.
Addisons’s disease can be characterised by the following signs and symptoms:
Fatigue
Anorexia
Weight loss
Hyperpigmentation
Hypotension

Question 5

Identify appropriate investigations for adrenal insufficiency and interpret the results.

Answer 5

A short synACTHen test is the gold standard.

Question 6

Generate a management plan for adrenal insufficiency.

Answer 6

Fludrocortisone

Prednisolone

Question 7

Identify the possible complications of adrenal insufficiency and its management.

Answer 7

Secondary Cushing’s syndrome

Osteopenia/osteoporosis

Treatment-related hypertension

Question 8

Summarise the prognosis for patients with adrenal insufficiency.

Answer 8

Patients should receive replacement therapy for life. Adherence to treatment is high, since non-compliance results in uncomfortable symptoms. Furthermore, patients know that non-compliance is potentially life-threatening.