Hypoaldosteronism

Question 1

Another name to Addison’s disease

Answer 1

Adrenal insufficiency

Question 2

Pathophysiology in Primary adrenal insufficiency

Answer 2

Damage to adrenal gland -> reduction in cortisol and aldosterone

Question 3

Pathophysiology of central (secondary) adrenal insufficiency

Answer 3

* secondary = due to problems with the pituitary gland or hypothalamus

Result: inadequate secretion of CRH or ACTH

Question 4

Can exogenous steroid use result in adrenal insufficiency?

Answer 4

• Yes - it can result in secondary adrenal insufficiency
• If the patient is on long-term steroids -> CRH or ACTH suppression

(due to negative feedback loss)

*even if the steroids are withdrawn patient may still not be able to stimulate their adrenal glands

Question 5

Features of Adrenal Insufficiency

Answer 5

• Fatigue
• Nausea
• Bronze hyperpigmentation to skin
• Cramps
• Abdominal pain
• Poor weight gain / weight loss
• Developmental delay or poor academic performance

Question 6

What is Addisonian Crisis?

Answer 6

aka adrenal crisis

• acute presentation of severe Addison

*often the first presentation

Question 7

Cause of Addisonian crisis (2)

Answer 7

Can be the first presentation

Caused by:

• Sudden withdrawal of long term steroids
• Triggered by infection, trauma or other acute illness in someone with established Addisons

Question 8

Features of Addisonian Crisis

Answer 8

• Reduced consciousness and hypotension
• Weakness, nausea, vomiting, abdominal pain
• Seizures
• Hypoglycaemia, hyponatraemia, hyperkalaemia
• Patients can be very unwell

Question 9

Treatment of Addisonian Crisis

Answer 9

• Intensive monitoring of U&Es and glucose
• Parenteral steroids (IV hydrocortisone)
• IV fluid resuscitation
• Correction of hypoglycaemia
• Treat infection is suspected

Question 10

Blood tests result in Addison’s

Answer 10

Addisons = primary adrenal insufficiency (due to adrenal glands)

Addisons

• Low cortisol
• High ACTH
• Low aldosterone
• High renin

Question 11

Blood test results due to secondary adrenal insufficiency

Answer 11

Secondary: brain (hypothalamus, pituitary) or long-term steroids

• Low cortisol
• Low ACTH
• Normal aldosterone
• Normal renin

Question 12

Treatment of Addison’s disease

Answer 12

• Replacement steroids titrated to clinical sign, symptoms and electrolytes
  
  • Hydrocortisone is used to replace cortisol (the glucocorticoid)
  • Fludrocortisone is used to replace aldosterone (the mineralocorticoid) where required
• Growth and development should be monitored closely
• Patients are given a steroid card and emergency ID tag to alert emergency services if needed
• Doses should not be missed (they are essential to life)
• Should have an individual care plan for the event of an illness

Question 13

(2) types of steroids used in Rx of Adrenal Insufficiency

Answer 13

• Hydrocortisone is used to replace cortisol (the glucocorticoid)
• Fludrocortisone is used to replace aldosterone (the mineralocorticoid) where required

*dose cannot be missed = essential to life

Question 14

Do we increase dose of steroids if a patient has a minor cough/cold (no fever)?

Answer 14

No

(if fever - then we need to)

Question 15

What type of illness do we need to increase steroids in? (in patient with adrenal insufficiency)

Answer 15

Fever (over 38 C) or / and vomiting, diarrhoea

There is an increased demand for the steroids to deal with an illness -> may develop hypoglycaemia

Question 16

What does patient with adrenal insufficiency, need to have in case of an illness?

Answer 16

Individual care plan

Question 17

What is included in the ‘individual care plan’?

Answer 17

Individual care plan - in case of the illness and increased demands for steroids

• increased dose and given more regularly until the illness has completely resolved
• Blood sugar needs to be monitored closely and they need to eat foods containing carbohydrates regularly
• If they have diarrhoea or vomiting, they will need an IM injection of steroid at home and likely required admission for IV steroids