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Adrenal Insufficiency

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Title: Adrenal Insufficiency


1
Adrenal Insufficiency
  • UNC Internal Medicine Morning Report
  • June 28, 2010
  • Edward L. Barnes, MD

2
Adrenal Insufficiency
  • Primary Adrenal Insufficiency is also known as
    Addisons Disease in honor of Dr. Thomas Addison
  • Born in April 1793, at Long Benton,
    Newcastle-upon-Tyne and died on June 29 1860, at
    15 Wellington Villas, Brighton
  • Dr. Addison is also credited with the discovery
    of Pernicious Anemia

3
Introduction
  • Adrenocorticotropic Hormone (ACTH) is the major
    factor in the secretion of cortisol and
    androgenic steroids by the adrenal cortex
  • ACTH secretion is regulated as a balance between
    the stimulatory effects of CRH (mediated by the
    CNS) and the negative feedback mediated by
    circulating levels of glucocorticoids

4
Adrenal Insufficiency
  • Arises when cortisol levels are not sufficient to
    meet the needs of the body
  • Cortisol aids in maintaining vascular tone,
    hepatic gluconeogenesis, and in maintaining
    glycogen
  • Inadequate cortisol in times of stress can lead
    to hypotension, shock, and hypoglycemia

5
Adrenal Insufficiency
  • Mineralocorticoid deficiency typically leads to
    renal wasting of sodium, retention of potassium,
    and reduced intravascular volume

6
Primary Adrenal Insufficiency
  • Most commonly is of an autoimmune etiology,
    resulting from chronic destruction of the adrenal
    cortex
  • Typical histologic feature is lymphocytic
    infiltration
  • Antibodies to adrenal cortical antigens are
    present early in the disease process
  • Patients with autoimmune adrenal disease are more
    likely to have polyglandular autoimmune systems
    causing deficiency of other endocrine glands

7
Primary Adrenal Insufficiency
  • Several Other Mechanisms Exist
  • Bilateral adrenal hemorrhage
  • Infection Tuberculosis, CMV, Histoplasmosis
  • Metastatic Disease
  • Deposition Diseases Hemochromatosis,
    Amyloidosis, Sarcoidosis
  • Drug Induced Ketoconazole, Etomidate, Rifampin,
    Anticonvulsants
  • Congenital Adrenal Hyperplasias

8
Secondary Adrenal Insufficiency
  • Caused by pituitary failure of ACTH secretion
  • Etiologies include
  • any cause of primary or secondary
    hypopituitarism
  • Exogenous Glucocorticoid Therapy
  • Megestrol, which has some glucocorticoid therapy

9
Clinical Presentation
  • Acute adrenal insufficiency (Adrenal Crisis)
    should be expected in any patient acute,
    unexplained volume depletion and shock
  • Hyperkalemia, acidosis, and hypoglycemia may also
    be accompanying

10
Clinical Presentation
  • Chronic insufficiency typically develops more
    insidiously
  • Symptoms may include weakness, weight loss,
    nausea, vomiting, anorexia, and postural
    hypotension
  • Increased skin pigmentation can be seen with
    primary adrenal insufficiency secondary to
    melanocyte stimulating activity associated with
    ACTH
  • Hyponatremia and Hyperkalemia may develop
    secondary to a lack of aldosterone

11
Clinical Presentation
  • Secondary Adrenal Insufficiency may present with
    evidence of adrenal insufficiency as well as
    other evidence of hypopituitarism

12
Differential Diagnosis
  • Acute Adrenal insufficiency
  • Various conditions can cause hypotension and or
    shock
  • Chronic Adrenal Insufficiency
  • Chronic Starvation (anorexia nervosa)
  • Gastrointestinal Disease secondary to
    inflammation or malignancy
  • Other causes of hyperpigmentation including drug
    exposures
  • Other causes of fatigue and malaise

13
Diagnostic Workup
  • Baseline Cortisol and ACTH levels should be
    obtained in the early morning
  • A morning cortisol level of lt3 mg/dL is virtually
    diagnostic
  • A level of lt10 mg/dL is highly suspicious
  • A level of gt18 mg/dL should rule out Adrenal
    Insufficiency except in the setting of a
    critically ill patient

14
Diagnostic Workup
  • Cosyntropin Stimulation Test
  • Measure morning cortisol level (pre-test level)
  • Administer 1 mg dose Cosyntropin
  • Measure a second cortisol level 1 hour after
    Cosyntropin administration
  • Normal response demonstrates a level of greater
    than 20 mg/dL after cosyntropin
  • Patients with both primary and secondary adrenal
    insufficiency will not demonstrate appropriate
    response
  • Patients with primary insufficiency will fail to
    respond to repeated administrations, however
    patients with secondary insufficiency may show an
    increased response to repeated testing/stimulation

15
Diagnostic Workup
  • Further determination of primary vs. secondary
    adrenal insufficiency will be based upon ACTH
    level
  • High ACTH level expected in primary insufficiency

16
Treatment Acute Adrenal Insufficiency
  • Treat Acute Adrenal Insufficiency with
    Hydrocortisone 50-100 mg IV q8 hrs
  • In addition, volume resuscitate with Normal Saline

17
Treatment Chronic Adrenal Insufficiency
  • Hydrocortisone 20-30 mg po daily
  • Typically divide dose 2/3 in am, 1/3 in pm
  • May use Prednisone 5 mg po daily instead
  • Fludrocortisone 0.05-0.1 mg po qam
  • Not necessary in patients with secondary adrenal
    insufficiency
  • Provide instruction for periods of acute illness
    or increased stress

18
The End
19
References
  • 1. Pearce, JMS. Thomas Addison. J R Soc Med. 2004
    June 97(6) 297300.
  • 2. Ontjes, DA. Disorders of the Adrenal Cortex.
    Netters Internal Medicine, 2nd ed. 2009 321-4.
  • 3. Adrenal Insufficiency. Little Dental
    Management of the Medically Compromised Patient,
    7th ed. 2007.
  • 4. Oelkers, W. Adrenal Insufficiency. N Engl J
    Med. 1996 Oct 17335(16)1206-12.
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