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Adrenal Insufficiency

Adrenal Insufficiency. UNC Internal Medicine Morning Report June 28, 2010 Edward L. Barnes, MD. Adrenal Insufficiency. Primary Adrenal Insufficiency is also known as Addison’s Disease in honor of Dr. Thomas Addison

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Adrenal Insufficiency

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  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 Addison’s 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 <3 mg/dL is virtually diagnostic • A level of <10 mg/dL is highly suspicious • A level of >18 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): 297–300. 2. Ontjes, DA. Disorders of the Adrenal Cortex. Netter’s 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 17;335(16):1206-12.

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