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ADRENAL INSUFFICIENCY

Written by Nabeel Salim

Last Reviewed: February 2019

Review Due: February 2020

DEFINITION

'a clinical syndrome caused by an inadequate production of adrenal hormones'

 

AETIOLOGY

Primary (Addison's Disease)

Autoimmune (most common cause in the UK)

Tuberculosis (most common worldwide)

 

Secondary

Long Term Exogenous Steroid Use

Hypothalamic-Pituitary Disease

 

SIGNS AND SYMPTOMS

  • Anorexia

  • Mylagia/Arthralgia

  • Fatigue

  • Hyperpigmentation of Palmar Creases and Buccal Mucosa

  • Dizziness

  • Depression/Psychosis

  • Nausea and Vomiting

  • Abdominal Pain

  • Diarrhoea and Constipation

  • Postural Hypotension

 

PATHOPHYSIOLOGY

In the UK, the leading cause of Addison's Disease (primary adrenal insufficiency) is autoimmune destruction of the adrenal cortex, resulting in impaired production of adrenocortical hormones, including cortisol and aldosterone. Worldwide, Adrenal TB is a more common cause of Addison's Disease.

 

Secondary adrenal insufficiencies are characterised by inadequate production of Adrenocorticotropic Hormone (ACTH) by the anterior pituitary. This can occur in patients on long term steroid therapy, where the adrenal axis becomes suppressed and fails to produce adequate levels of cortisol.

 

Investigations

Routine Bloods

U&Es: Hyponatraemia, Hyperkalaemia and Uraemia

FBC: Eosinophilia, Anaemia

Glucose: Low

 

Cortisol: Low

ACTH: High in Primary, Normal/Low in Secondary

 

Short Synacthen Test

This is the gold standard diagnostic test for Addison's Disease and involves measuring plasma cortisol levels before and 30 minutes after the administration of synthetic ACTH (250mcg IM). A normal response would see a large increase in cortisol levels at 30 minutes, however this would not be the case in patients with Addison's Disease

 

TREATMENT

Patients with adrenal insufficiency require (usually lifelong) replacement therapy.

Glucocorticoid Replacement: Hydrocortisone

Mineralocorticoid Replacement: Fludrocortisone

 

Patients taking long-term steroids must be counselled on the risks associated with this. They may also require other medication, such as bisphosphonates for bone protection. Patients should also be advised to:

  1. Carry identification indicating they take long-term steroids

  2. Double their normal steroid dose in case of febrile illness or stress

  3. Administer IM hydrocortisone if vomiting illness prevents oral intake

  4. Never abruptly stop taking their steroids

  5. Advise all their doctors/dentists/surgeons that they take regular steroids

 

Acute Adrenal Crisis

All patients presenting with an acute crisis (also known as an Addisonian Crisis) should have bloods taken for ACTH and cortisol. They should receive IV fluid resuscitation (to correct volume depletion), IV dextrose (to correct hypoglycaemia) and steroid replacement (to correct the lack of circulating glucocorticoid)

EPIDEMIOLOGY

Addison's Disease is rare, with an approximate incidence of 0.6 per 100,000 and a prevalence of 4-11 per 100,000.

 
 

REFERENCES