Adrenal insufficiency Flashcards

1
Q

What is adrenal insufficiency?

A

deficiency of adrenal cortical hormones (e.g. mineralocorticoids, glucocorticoids + androgens)

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2
Q

What is primary adrenal insufficiency? What is the most common cause in the UK? How about worldwide?

A

Addison’s disease
UK: AI
Worldwide: TB

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3
Q

What can cause secondary adrenal insufficiency?

A

Inadequate ACTH from Pituitary
Infiltration: Mets (lung), Lymphomas, Amyloidosis
Iatrogenic: Sudden cessation of long-term steroid therapy

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4
Q

Describe the epidemiology of Addisons disease

A

Rare
UK prevalence: 8,400
Often 30-50 yrs
F > M

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5
Q

List 6 symptoms seen in Addisons

A
Dizziness 
Weight loss + Anorexia   
D+V
Abdominal pain 
Lethargy + Weakness  
Depression
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6
Q

How does Addisons present?

A

Acute: crisis precipitated by infection, surgery or trauma: hypotension, hypovolaemic shock, acute abdominal pain, low-grade fever + vomiting.
Chronic: symptoms develop insidiously, may be mild + non specific

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7
Q

List 4 signs of adrenal insufficiency

A

Postural hypotension
Increased pigmentation
Loss of body hair in women (androgen deficiency)
Associated AI condition (e.g. vitiligo)

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8
Q

How is adrenal insufficiency confirmed?

A

9 am Serum Cortisol
< 100 nmol/L is diagnostic
> 550 nmol/L makes adrenal insufficiency unlikely
Short Synacthen Test
IM 250 mg synthetic ACTH
Serum cortisol < 550 nmol/L at 30 mins indicates adrenal failure

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9
Q

How do you identify the level of defect in the hypothalomo-pituitary-adrenal axis?

A

ACTH HIGH in primary disease
ACTH LOW in secondary

Long Synacthen Test
1 mg synthetic ACTH administered
Measure serum cortisol at 0, 30, 60, 90 + 120 minutes
Measure again at 4, 6, 8, 12 + 24 hours
Primary: no increase after 6 hours
Secondary: Delayed normal response

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10
Q

How do you identify the cause of adrenal insufficiency?

A

Autoantibodies (against 21-hydroxylase)
Abdo CT or MRI: exclude infection, haemorrhage, or mets
CXR: exclude lung malignancy
TFTs: often have hypothyroidism

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11
Q

What investigations are performed in an addisonian crisis?

A
FBC: neutrophilia = infection
U+Es: High urea, Low Na+, High K+
CRP (High in acute infection)
Calcium (may be raised) 
Glucose LOW
Blood cultures  
Urinalysis: MC+S  (UTI may have triggered crisis)
CXR: identify cause e.g. TB, carcinoma or precipitant e.g. infection
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12
Q

How is an addisonian crisis treated?

A

Rapid IV fluid rehydration
50 mL of 50% dextrose to correct hypoglycaemia
Calcium glucunate if appropriate
IV 100 mg hydrocortisone bolus
Repeated 6 hourly hydrocortisone until BP is stable
Treat precipitating cause (e.g. abx for infection)
Monitor

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13
Q

How is chronic adrenal insufficiency treated?

A

Hydrocortisone 10/5/5mg or Prednisolone 3-4mg OD
Fludrocortisone 50-100mcg OD
Hydrocortisone dosage needs to be increased during times of acute illness or stress

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14
Q

What advice is given to patients with adrenal insufficiency?

A

Have a steroid warning card
Wear a medic-alert bracelet
Emergency hydrocortisone on hand

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15
Q

Give 2 complications of adrenal insufficiency

A

HYPERKALAEMIA

Death during Addisonian crisis

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16
Q

What is the prognosis in adrenal insufficiency?

A

Adrenal function rarely recovers

Normal life expectancy if treated

17
Q

What is type 1 AI polyendocrine syndrome?

A

Autosomal recessive disorder caused by mutations in the AIRE gene. Consists of the following diseases:
Addison’s disease
Chronic mucocutaneous candidiasis
Hypoparathyroidism

18
Q

What is type 2 AI polyendocrine syndrome?

A
AKA: Schmidt's Syndrome 
Addison's disease  
T1DM  
Hypothyroidism 
Hypogonadism
19
Q

What 6 signs may be seen in an addisonian crisis?

A
Hypotensive shock 
Tachycardia 
Pale  
Cold  
Clammy  
Oliguria
20
Q

How do you administer drugs for patients with concurrent hypothyroidism and adrenal insufficiency?

A

Hydrocortisone BEFORE thyroxine (to prevent precipitating an Addisonian crisis)
Giving thyroxine first can enhance cortisol clearance + precipitate an adrenal crisis (increases BMR leading to increased requirement of cortisol)

21
Q

What bloods are usually seen in Addisons?

A

High K+
Low Na+
Metabolic acidosis (less H+ excretion)

22
Q

What should be done if Addisonian crisis is suspected whilst awaiting blood results?

A

DONT wait for results before administering tx.

Take blood for random cortisol + treat immediately if appropriate