Adrenal Insufficiency

Question 1

What is adrenal insufficiency?

Answer 1

Have decreased cortisol +/- decreased aldosterone

Question 2

What are the common etiologies of ACTH-independent adrenal insufficiency?

Answer 2

ACTH-independent = not a pituitary issue

ADDISON
1. Autoimmune – antibodies vs the adrenal enzymes
2. Drugs - injury to the adrenal and drugs that increase the metabolism cortisol
3. Destruction of adrenal gland
4. Infectious - TB HIV
5. Skin changes (1ary only)
6. Orthostatic dizziness (1ary only)
7. Na down - hyponatremia

Familial ACTH-resistance

Question 3

What are common etiologies of ACTH-dependant adrenal insufficiency?

Answer 3

not a problem with the adrenal gland
- pituitary or brain issue

1. tumour in the pituitary or brain
2. rads to neck or brain
3. iatrogenic - abrupt stopping of steroid medication
4. treatment for Cushing’s syndrome
5. pituitary hemorrhage or infarction

Question 4

Adrenal insufficiency: explain the patho for s/s related to decreased androgen?

Answer 4

impacts libido and hair growth

Question 5

What is an adrenal crisis? s/s

Answer 5

life-threatening, medical emergency
shock like s/s
fever, DLOC, unstable, hypotension

Question 6

how would you treat an adrenal crisis?

Answer 6

5 S’s management
- Steroids - for the decreased cortisol
- Salt - tx the dehydration, give fluids
- Sugar - tx the hypoglycemia
- Supportive care
- Search for etiology

Question 7

What tests would you order to diagnose adrenal insufficiency and in what order?

Answer 7

1. serum cortisol (low)
2. serum ACTH (interpret in the context of serum cortisol – cortisol low and ACTH high ➔ primary cause; cortisol low and ACTH low ➔ suggests secondary cause)
3. Cosyntropin/ACTH stimulation test (cortisol rise suggests secondary/tertiary cause, NOT adrenal issue)
4. if thinking primary - serum aldosterone (low), serum renin (high), serum DHEA (low)
5. imaging to visualize potential tumours

Question 8

How would you treat and advice a patient with adrenal insufficiency?

Answer 8

1. glucocorticoid replacement (short-acting hydrocortisone) ➔ therapy for life
2. mineralocorticoid replacement (fludrocortisone) ➔ only for a primary where the adrenal is not functioning
3. PT education on diet (higher salt and good hydration)
4. androgen replacement for females if needed
5. Pt education about stress dosing to mimic real cortisol levels
6. medical alert bracelet

Question 9

why do we need to do steroid tapering?

Answer 9

Needs to be done because exogenous steroids suppress the hypo-pituitary-adrenal axis and overtime the adrenal is atrophied due to the suppression

so need to give time to the adrenals to bounce back

Question 10

what s/s do you see in both primary and secondary adrenal insufficiency?

Answer 10

Weakness and fatigue
Nausea and vomiting
Myalgias
Hypoglycemia
Hypotension
Abdo pain

Question 11

what s/s are unique to 1ary/ACTH independent causes of adrenal insufficiency?

Answer 11

hyperpigmentation
salt craving - hyponatremia
orthostatic hypertension
decreased libido, menses irregularities, and loss of axillary pubic hair

Question 12

what s/s are unique to 2ary/ACTH dependent causes of adrenal insufficiency?

Answer 12

visual disturbances/abnormalities
headaches