Adrenal insufficiency

Question 1

what is a typical presentation for someone with adrenal insufficiency

Answer 1

‘unwell’ for few months, weight loss amenorrhoea, acutely unwell last 48hrs vomiting and diarrhoea

Question 2

what is typical examination findings of someone presenting with adrenal insufficiency

Answer 2

dark skin, dehydrated, hypotensive, hyponatraemia, hyperkalaemia

Question 3

what does adrenal insufficiency mean

Answer 3

inadequate adrenocortical function

Question 4

what does primary adrenal insufficiency refer to

Answer 4

adrenal insufficiency due to problem with adrenal gland itself

Question 5

what does secondary adrenal insufficiency refer to

Answer 5

adrenal insufficiency due to cause outwith adrenal gland

Question 6

what are the most common causes of primary adrenal insufficiency

Answer 6

Addison’s disease(most common), Congenital adrenal hyperplasia(CAH), adrenal TB/malignancy

Question 7

what are the most common causes of secondary adrenal insufficiency

Answer 7

lack of ACTH stimulation, iatrogenic(excess exogenous steroids), pituitary/hypothalamic disorders
(if hypothalamic can also be called tertiary adrenal insufficiency)

Question 8

what are the typical clinical features of Addison’s disease

Answer 8

anorexia, weight loss, fatigue/lethargy, dizziness, low BP, abdo pain, vomiting, diarrhoea, skin pigmentation(darker skin)

Question 9

what is the pathophysiology of Addison’s disease

Answer 9

autoimmune destruction of the adrenal cortex

autoimmune antibodies are positive in 70% cases

Question 10

what other disease is Addison’s disease associated with

Answer 10

other autoimmune diseases, such as T1DM, autoimmune thyroid disease, pernicious anaemia

Question 11

what biochemistry is seen in adrenal insufficiency

Answer 11

low Na, high K, increased ACTH levels, increased renin, decreased aldosterone, adrenal antibodies

Question 12

describe the test is used to check ACTH levels

Answer 12

synacthen test, measure plasma cortisol before and 30mins after IV ACTH
normal cortisol before would be >250nmol/l, after would be >550nmol/l
(if less adrenal insufficiency because ACTH should increase cortisol)

Question 13

what do ACTH levels rise in adrenal insufficiency

Answer 13

because no/less cortisol production, so no negative feedback to prevent ACTH production

Question 14

what replacement treatment is used to manage adrenal insufficiency

Answer 14

hydrocortisone as cortisol replacement and fludrocortisone as aldosterone replacement
(if suspected don’t wait until diagnosis)

Question 15

what non-pharmacological management is used for adrenal insufficiency

Answer 15

education, ‘sick day rules’, cannot stop suddenly taking meds, need to weak ID so people know they have condition

Question 16

what is the general basis for treatment of adrenal crisis

Answer 16

rapid rehydration, fluids(normal saline), IV hydrocortisone, drinking

Question 17

what is the most common cause of secondary adrenal insifficiency

Answer 17

exogenous steroid use, such as high dose prednisolone, dexamethasone, inhaled corticosteroid

Question 18

describe how exogenous steroid use ca cause secondary adrenal insufficiency

Answer 18

by inhibiting CRH and ACTH, so adrenal gland isn’t stimulated to produce cortisol

Question 19

what are the clinical differences between Addison’s disease and secondary adrenal insufficiency

Answer 19

skin pale due to no ACTH increase and aldosterone intact due to RAAS