Therapeutics of adrenal glands

Question 1

Primary adrenal insufficiency

Answer 1

Problem with the adrenal gland - low cortisol, aldosterone and DHEA

• Addison’s - structural problem with adrenal cortex
• autoimmune/infective/toxic drugs/haemorrhage

Question 2

Secondary adrenal insufficiency

Answer 2

Not problem with adrenals but with pituitary , adrenal glands is under-stimulated (does not get enough ACTH)

• pituitary tumour
• steroids
• low cortisol and DHEA, but does not lack aldosterone

Question 3

Management of adrenal insufficiency

Answer 3

Give hydrocortisone 2-3x/day to mimic the diurnal rhythm of cortisol secretion (15-25mg/day)

Question 4

Monitoring of adrenal insufficiency

Answer 4

Treatment monitored based on BP, weight change, energy levels and electrolytes

• over-replacement –> weight gain, hypertension, cushinoid, poor glycaemic control
• under-replacement –> fatigue, nausea, weight loss, adrenal crisis

Question 5

Addison (adrenal) crisis

Answer 5

• triggered by stress (surgery/trauma/infection) if not receiving appropriate glucocorticoid cover
• hypotension (shock), tachycardia, anorexia, n&v, hypoglycaemia, low Na and High K
• needs urgent treatment with IV hydrocortisone and fluids

Question 6

Sick day rules for adrenal insufficiency

Answer 6

Moderate illness
- fever, minor trauma, minor surgery
- double replacement dose, return to normal dose 24 hours after resolution
Severe illness
- increase dose to 50mg hydrocortisone IM or IV every 6 hours
- taper dose to normal by halving it each day