Adrenal insufficiency Flashcards
What is adrenal insufficiency?
deficiency of adrenal cortical hormones (e.g. mineralocorticoids, glucocorticoids + androgens)
What is primary adrenal insufficiency? What is the most common cause in the UK? How about worldwide?
Addison’s disease
UK: AI
Worldwide: TB
What can cause secondary adrenal insufficiency?
Inadequate ACTH from Pituitary
Infiltration: Mets (lung), Lymphomas, Amyloidosis
Iatrogenic: Sudden cessation of long-term steroid therapy
Describe the epidemiology of Addisons disease
Rare
UK prevalence: 8,400
Often 30-50 yrs
F > M
List 6 symptoms seen in Addisons
Dizziness Weight loss + Anorexia D+V Abdominal pain Lethargy + Weakness Depression
How does Addisons present?
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
List 4 signs of adrenal insufficiency
Postural hypotension
Increased pigmentation
Loss of body hair in women (androgen deficiency)
Associated AI condition (e.g. vitiligo)
How is adrenal insufficiency confirmed?
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
How do you identify the level of defect in the hypothalomo-pituitary-adrenal axis?
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
How do you identify the cause of adrenal insufficiency?
Autoantibodies (against 21-hydroxylase)
Abdo CT or MRI: exclude infection, haemorrhage, or mets
CXR: exclude lung malignancy
TFTs: often have hypothyroidism
What investigations are performed in an addisonian crisis?
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
How is an addisonian crisis treated?
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
How is chronic adrenal insufficiency treated?
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
What advice is given to patients with adrenal insufficiency?
Have a steroid warning card
Wear a medic-alert bracelet
Emergency hydrocortisone on hand
Give 2 complications of adrenal insufficiency
HYPERKALAEMIA
Death during Addisonian crisis