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Endocrinology > Adrenal Insufficiency > Flashcards

Adrenal Insufficiency Flashcards

1
Q

What is adrenal insufficiency?

A

Destruction of the Adrenal leading to lack of:
Cortisol
Aldosterone
DHEAS

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2
Q

What may result from decreased cortisol?

A

Hypoglycemia
Confusion
Weakness
Fatigue

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3
Q

What may result from decreased aldosterone?

A 
Hyponatremia & Hyperkalemia
Dehydration
Hypotension
Salt craving
Weakness
Abdominal pain, nausea, decreased appetite
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4
Q

What may result from decreased adrenal androgens?

A

Decreased DHEAS –> Fatigue

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5
Q

What are common symptoms of adrenal insufficiency?

A 
Salt cravings 
Fatigue
Muscle weaknesss
Dizzyness
Nausea, Vomiting, Abdominal pain 
“Sense of impending doom, feeling down”
Weight loss
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6
Q

What some signs of AI?

A 
Postural drop in blood pressure
Postural increase in pulse
Weight loss
Abdominal tenderness
Muscle weakness

Specifoc to 1o AI:
Hyperpigmentation of gum lines, palmar creases, and scars
Vitiligo

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7
Q

T or F: Autoimmune destruction of the adrenals

is the most common cause of 1o AI

A

True

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8
Q

What are some causes of 1o AI?

A

Autoimmune:
Poly Glandular Autoimmune I and II

Infections:
TB, Fungal,Histoplasmosis, Coccidiomycosis, Cryptococcus
HIV, CMV, MAI, Toxoplasma
Syphilis

Metastatic Disease:
Lung, Breast, Stomach, Colon cancer, Lymphoma

Adrenal Hemorrhage:

Adrenal Trauma:
Bilateral Adrenalectomy

Drugs:
Inhibition of cortisol synthesis (Ketoconazole, Rifampin, Metyrapone, Aminoglutethimide)
Activation of cortisol metabolism (Barbiturates, Phenytoin)
Peripheral resistance to glucocorticoids (Mifepristone, Chlorpromazine, Imipramine)

Liver Disease:

Tissue Infiltration:

Familial Diseases:

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9
Q

What is the pathophysiology of Type Polyglandular Autoimmune Syndrome?

A

Single Gene, autosomal recessive

Absence of AIRE (a transcriptor factor in thymus) causes a failure to remove autoreactive T cells results to:
Hypoparathyroidism
Chronic Mucocutaneous Candidiasis
Adrenal Insufficiency

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10
Q

What is Polyglandular Autoimmune Syndrome Type 2 and what diseases are caused?

A

Linked to HLA (and others) that have complex and multifactorial genetics that results to:

  • Addison’s (100%)
  • Autoimmune thyroid disease
  • Type 1 Diabetes
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11
Q

What is the most common cause of secondary adrenal insufficiency?

A

Steroid withdrawal

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12
Q

What are some uncommon causes of adrenal insufficiency?

A

pituitary tumor, hypothalamic disease, panhypopituitarism, pituitary surgery, isolated ACTH deficiency, hypophysitis (autoimmune, immune checkpoint inhibitor),

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13
Q

What can cause relative AI?

A

Sepsis –> Circulating cytokines can inhibit CRH and ACTH leading to inadequate cortisol response

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14
Q

What may Immune Checkpoint Inhibitors cause?

A

Hypophysitis may occur as a result from immune-related adverse event (irAEs) in patients treated with immune checkpoint inhibitors for cancer. Some anterior pituitary hormones may recover; however, secondary adrenal insufficiency is usually permanent

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15
Q

True or False: 1o AI is more common than 2o AI?

A

False: 2o is

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16
Q

What is the best diagnosiuc test for AI?

A

Best test is ACTH stimulation test (Cosyntropin test)

17
Q

What is a ACTH stimulation test?

A
  1. baseline cortisol measured
  2. 250 micrograms of ACTH IV pushed
  3. cortisol measured after 1 hour
    - -> cortisol should double in normal (at least 500 nmol/L)

An abnormal response is indicative of
either primary or secondary adrenal insufficiency

18
Q

What is the gold standard test for AI?

A

Cosyntropin Test (ACTH Stimulation Test)

19
Q

What is recommended if Cosyntropin Test (ACTH Stimulation Test) is not availble?

A

Measure AM cortisol and ACTH level

–> AM cortisol less than 140nmol/L is suggestive of adrenal insufficiency

–> ACTH of greater than 2 fold the upper limit is consistent with Primary Adrenal insufficiency

20
Q

How to distinguish 1o AI from 2o AI?

A

Both will have an abnormal Cosyntropin test (low cortisol after 1 hour)

Primary (Addison’s Disease):
High ACTH, low cortisol
Low Na+, high K+, low glucose

Secondary:
Low ACTH, low cortisol
Low Na+, normal K+, low glucose

21
Q

Why is K+ levels normal in 2o AI?

A

In secondary adrenal insufficiency, glucocorticoid deficiency will be present but not mineralocorticoid deficiency as aldosterone release is under the influence of the renin angiotension system. For this reason, potassium levels remain normal.

22
Q

What the symptoms of adrenal crisis?

A

Weight Loss

Fatigue

Weakness

Severe Hypotension

Abdominal Symptoms

Fever

23
Q

What is the treatment for adrenal crisis?

A

IV hydration and IV steroids:

A) Hydrocortisone 100mg IV bolus then 50-100mg IV q6h
OR

B) Dexamethasone 4mg IV q6h may also be considered if planning to do the Cosyntropin test at the same time

24
Q

Why a clinician may want to administer dexamethasone instead of hydrocortisone>

A

Hydrocortisone is more potent than dexamethasone, however, dexamethasone will not interfere with the Cosyntropin test if a diagnosis is not yet made.

25
Q

What are some long-term management components for AI?

A

Glucocorticoids for both primary and secondary adrenal insufficiency:
A) Hydrocortisone (15-25mg) in two or three divided doses
OR
B) Cortisone acetate (20-35mg) in two or three divided doses
OR
C) Prednisone 5mg in AM and 2.5mg in PM

  • Mineralocorticoids for primary adrenal insufficiency*
  • -> Florinef 0.1mg PO OD
26
Q

What are some long-term management considerations for AI?

A

Medical Alert bracelet, patient education
Patient needs to double the glucocorticoids during minor illness
IV steroids for major illness/surgery/hospitalization
DHEA replacement is optional

27
Q

True or False: 24 hour urinary free cortisol is more accurate than serum cortisol

A

True: Serum cortisol could be normal or elevated in Cushing’s syndrome

Endocrinology (16 decks)

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