Adrenal Insufficiency Flashcards
What is adrenal insufficiency?
Destruction of the Adrenal leading to lack of:
Cortisol
Aldosterone
DHEAS
What may result from decreased cortisol?
Hypoglycemia
Confusion
Weakness
Fatigue
What may result from decreased aldosterone?
Hyponatremia & Hyperkalemia Dehydration Hypotension Salt craving Weakness Abdominal pain, nausea, decreased appetite
What may result from decreased adrenal androgens?
Decreased DHEAS –> Fatigue
What are common symptoms of adrenal insufficiency?
Salt cravings Fatigue Muscle weaknesss Dizzyness Nausea, Vomiting, Abdominal pain “Sense of impending doom, feeling down” Weight loss
What some signs of AI?
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
T or F: Autoimmune destruction of the adrenals
is the most common cause of 1o AI
True
What are some causes of 1o AI?
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:
What is the pathophysiology of Type Polyglandular Autoimmune Syndrome?
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
What is Polyglandular Autoimmune Syndrome Type 2 and what diseases are caused?
Linked to HLA (and others) that have complex and multifactorial genetics that results to:
- Addison’s (100%)
- Autoimmune thyroid disease
- Type 1 Diabetes
What is the most common cause of secondary adrenal insufficiency?
Steroid withdrawal
What are some uncommon causes of adrenal insufficiency?
pituitary tumor, hypothalamic disease, panhypopituitarism, pituitary surgery, isolated ACTH deficiency, hypophysitis (autoimmune, immune checkpoint inhibitor),
What can cause relative AI?
Sepsis –> Circulating cytokines can inhibit CRH and ACTH leading to inadequate cortisol response
What may Immune Checkpoint Inhibitors cause?
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
True or False: 1o AI is more common than 2o AI?
False: 2o is
What is the best diagnosiuc test for AI?
Best test is ACTH stimulation test (Cosyntropin test)
What is a ACTH stimulation test?
- baseline cortisol measured
- 250 micrograms of ACTH IV pushed
- 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
What is the gold standard test for AI?
Cosyntropin Test (ACTH Stimulation Test)
What is recommended if Cosyntropin Test (ACTH Stimulation Test) is not availble?
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
How to distinguish 1o AI from 2o AI?
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
Why is K+ levels normal in 2o AI?
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.
What the symptoms of adrenal crisis?
Weight Loss
Fatigue
Weakness
Severe Hypotension
Abdominal Symptoms
Fever
What is the treatment for adrenal crisis?
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
Why a clinician may want to administer dexamethasone instead of hydrocortisone>
Hydrocortisone is more potent than dexamethasone, however, dexamethasone will not interfere with the Cosyntropin test if a diagnosis is not yet made.
What are some long-term management components for AI?
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
What are some long-term management considerations for AI?
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
True or False: 24 hour urinary free cortisol is more accurate than serum cortisol
True: Serum cortisol could be normal or elevated in Cushing’s syndrome
