Adrenal Insufficiency

Question 1

What is adrenal insufficiency?

Answer 1

Inadequate production of steroid hormones by the adrenal glands (cortisol and aldosterone)

Question 2

What is Addison’s Disease?

Answer 2

Damage to the adrenal glands, resulting in a reduction of cortisol and aldosterone secretion

Question 3

What is Addison’s also called?

Answer 3

Primary Adrenal Insufficiency

Question 4

What is the most common cause of Addison’s Disease?

Answer 4

Autoimmune adrenal destruction

Question 5

What is secondary adrenal insufficiency caused by?

Answer 5

Inadequate ACTH to stimulate the adrenals

Question 6

What can cause secondary adrenal insufficiency?

Answer 6

Damage to the pituitary:

• Surgery
• Infection
• Radiotherapy
• Blood loss

Question 7

What is Sheehan’s Syndrome?

Answer 7

1. Massive blood loss during childbirth

2. Pituitary gland necrosis

Question 8

What causes tertiary adrenal insufficiency?

Answer 8

Inadequate CRH:

• Long term oral steroids (3 weeks +)

Question 9

Why do long term oral steroids cause adrenal insufficiency?

Answer 9

Addisonian Crisis

1. Exogenous steroids suppress the hypothalamus
2. Steroids are withdrawn
3. Hypothalamus does not respond fast enough to drop in steroid levels

Question 10

How should steroid treatments be stopped?

Answer 10

Tapered slowly to allow time for adrenal axis to regain function

Question 11

What are the symptoms of adrenal insufficiency?

Answer 11

FRANC

Fatigue
Reduced libido
Abdo pain
Nausea
Cramps

Question 12

What signs are there in adrenal insufficiency?

Answer 12

• Bronze hyperpigmentation (ACTH stimulates melanocytes to produce melanin)
• Hypotension (postural)

Question 13

What electrolyte disturbances are there in adrenal insufficiency?

Answer 13

Hyponatraemia (may be the only presenting feature)

Hyperkalaemia

Question 14

What is the first line test to diagnose Addison’s?

Answer 14

Short synacthen test

Question 15

What is the short synacthen test?

Answer 15

1. Give synacthen (synthetic ACTH)
2. Measure cortisol at baseline, 30 mins, and 60 mins
3. Cortisol should at least double with normal adrenals

Question 16

What does a short synacthen test diagnose and what result shows it?

Answer 16

Primary Adrenal Insufficiency (Addison’s)

Cortisol doesn’t double

Question 17

When should a short synacthen test be performed?

Answer 17

In the morning

Question 18

What antibodies are tested for autoimmune destruction of the adrenals?

Answer 18

• Adrenal cortex antibodies

- 21-hydroxylase antibodies

Question 19

What is the mainstay of adrenal insufficiency treatment?

Answer 19

Steroid replacement, titrated to suit signs, symptoms and electrolytes

Question 20

What medication replaces cortisol with adrenal insufficiency?

Answer 20

Hydrocortisone (glucocorticoid)

Question 21

What medication replaces aldosterone in adrenal insufficiency?

Answer 21

Fludrocortisone (a mineralocorticoid)

Question 22

What do patients with adrenal insufficiency have to carry?

Answer 22

• Steroid card

- Emergency tag to let emergency services know they’re dependent on steroids

Question 23

What should you do to steroid doses in adrenal insufficiency when they’re acutely unwell?

Answer 23

Double the doses to match physiological

Question 24

What is Addisonian crisis/adrenal crisis?

Answer 24

Acute adrenal insufficiency:

- absence of steroids is a threat to life

Question 25

How does adrenal crisis present?

Answer 25

• Reduced consciousness and acutely unwell
• Hypotension
• Hypoglycaemia, Hyponatraemia
• Hyperkalaemia

Question 26

When might adrenal crisis be expected?

Answer 26

• First presentation (undiagnosed)
• Suddenly stopping a long term steroid
• Infection or Acute illness
• Trauma

Question 27

How should Addisonian crisis be treated?

Answer 27

• Intensive monitoring (Fluid chart, electrolytes, NEWS2)
• Parenteral steroids (IV Hydro, 100mg stat then 6 hourly)
• IV fluids
• Correct hypoglycaemia