Adrenal Insufficiency

Question 1

What is Adrenal Insufficiency?

Answer 1

• Adrenal glands do not produce enough steroid hormones, particularly aldosterone and cortisol

Question 2

What are the causes of adrenal insufficiency?

*there is primary, secondary, tertiary

Answer 2

• Priary adrenal insufficiency (Addison’s disease)
  
  • Autoimmune (common in developed world)
  • TB (common worldwide)
  • Adrenal metastases
  • HIV
  • Lymphoma
  • adrenal haemorrhage
  • congenital adrenal hyperplasia
  • Waterhouse-Friderichsen syndrome
• Secondary
  
  • surgery - pituitary tumour removal
  • radiotherapy
  • Sheehan’s syndrome
• Tertiary
  
  • long term steroid use with sudden withdrawal

Question 4

What hromone release will be affected in Primary AI compared to secondary AI?

Answer 4

• Primary Adrenal Insufficiency
  
  • Cortisol
  • Aldosterone
• Secondary
  
  • Cortisol

*RAAS can still influence the adrenal glands

Question 5

What are the Sx for AI?

Answer 5

• Fatigue, joint and muscle pain
• Cramps
• Abdominal pain, N&V, D/C
• Decrease libido
• Depress, psychosis, confusion

Question 6

What signs would you see for AI?

Answer 6

• Hyperpigmentation to skin
• Postural hypotension

Question 7

How does abrupt steroid withdrawal causes AI?

Answer 7

1. Long term steroid use (more than 3weeks) cause suppresion of hypothalamus -pituitary-adrenal axis
2. Inadequate CRH release by hypothalamus
3. When steroids suddenly withdrawn, hypothalamus is not quick enough to respond and produce enough endogenous steroids

Question 9

Describe how you get hyperpigmentation in AI?

Answer 9

1. ACTH and a-MSH have same precussor which is POMC
2. Increase in ACTH willalso increase in MSH production
3. MSH stimulates melanocyte to produce melanin

Question 10

What Ix would you order for AI?

Answer 10

• Bloods
  
  • low Na
  • High K
  • Low glucose
• Short Synacthen Test
• Plasma cortisol
• Plasma ACTH
  
  • High: Primary
  • Low: Secondary or tertiary
• Adrenal autoantibodies
  
  • adrenal cortex antibodies
  • 21-hydroxylase antibodies
• Imaging
  
  • CT/MRI adrenal
  • MRI pituitary

Question 12

Describe the Synacthen test

*what is synacthen, when its performed, what other ix taken

Answer 12

• synthetic ACTH
• Performed in the morning
• plasma cortisol measured before and 30mins after
• Interpretatio of results
  
  • cortisol level less than double of baseline = primary AI

Question 13

How would your Mx AI?

Answer 13

• Replacement steroids
  
  • hydrocortisone - for cortisol
    
    • 15-25mg daily, 2-3 doses
    • 1st dose (higher dose) in morning
  • fludrocortisone - for aldosterone
    
    • 50-200mcg daily
• Steroid card
• Emergency ID tag

Question 14

What is Addisonian crisis?

Answer 14

Acute presentation of severe Addisons

Question 15

What are the clinical features of Addisonian Crisis?

Answer 15

• Reduce consciousness
• Hypotension
• Hypoglycaemia, Hyponatraemia, Hyperkalaemia

Question 16

What are the Sx of Addisonian crisis?

Answer 16

• Extreme fatigue
• Weight loss and decreased appetite
• Low blood pressure, even fainting
• Nausea, diarrhea or vomiting (gastrointestinal symptoms)

Question 17

How would you Mx Addisonian crisis?

Answer 17

• Intensive monitoring if unwell
• Parenteral steroids (i.e. IV hydrocortisone 100mg stat then 100mg every 6 hours)
• IV fluid resuscitation
• Correct hypoglycaemia
• Careful monitoring of electrolytes and fluid balance