Addison's

Question 1

Issue

Answer 1

Autoimmune destruction of the adrenal glands –> low cortisol and aldosterone

Question 2

Features
- […], weakness, anorexia, nausea & vomiting, weight […], […]
- […] (60%)
- […] (especially palmar […])*, loss of […] […] in women, […]
- […]glycaemia
- […]natraemia and […]kalaemia
- […] Renin, […] aldosterone

Adrenal crisis: collapse, shock, pyrexia

Answer 2

Lethargy, loss, ‘salt-craving’
VITILIGO
- hyperpigmentation, creases, pubic hair in women, hypotension
- hypoglycaemia
- hyponatraemia and hyperkalaemia
- high Renin, low aldosterone
Adrenal crisis: collapse, shock, pyrexia

Question 3

Other causes (not auto-immune) for Addison’s (primary adrenal insufficiency)

Surgical […]
Trauma
Infections ([…]: more common in the developing world)
[…] 2ndary to menigococcal […] ([…]-[…] syndrome)
Infarction
Less common: neoplasm, […], […]

Answer 3

removal
Tuberculosis
Haemorrhage, septicaemia, Waterhouse-Friderichsen
sarcoidosis, amyloidosis

Question 4

Primary vs 2ndary adrenal insufficiecny

Answer 4

*Primary Addison’s is associated with hyperpigmentation whereas secondary adrenal insufficiency is not

Question 5

Investigations
[…] stimulation test (short […] test)

Plasma cortisol is measured […] and […] minutes after giving Synacthen […] IM.

2nd line - 9am serum cortisol
[…]-[…] nmol/l should prompt a ACTH stimulation test to be performed

Adrenal autoantibodies such as […] may also be demonstrated.

ABG - METABOLIC […]

Answer 5

ACTH, Synacthen

before, 30 250ug

100-500
anti-21-hydroxylase

ACIDOSIS

Question 6

Mx - primary adrenal insufficiency

Answer 6

1.PO hydrocortisone: usually given in 2 or 3 divided doses. Patients typically require 20-30 mg per day, with the majority given in the first half of the day
2. fludrocortisone

Question 7

Patient education

Answer 7

1. emphasise the importance of not missing glucocorticoid doses –> adrenal crisis
2. consider MedicAlert bracelets and steroid cards
3. patients should be provided with hydrocortisone for injection with needles and syringes to treat an adrenal crisis
4. Sick day rules

Question 8

Sick day rules

Answer 8

glucocorticoid dose should be doubled, with the fludrocortisone dose staying the same

Question 9

Addisonian crisis: causes

Answer 9

sepsis or surgery causing an acute exacerbation of chronic insufficiency (Addison’s, Hypopituitarism)

adrenal haemorrhage eg Waterhouse-Friderichsen syndrome (fulminant meningococcemia)

steroid withdrawal

Question 10

Addisonian crisis: mx

Answer 10

hydrocortisone 100 mg im or iv
1 litre normal saline infused over 30-60 mins or with dextrose if hypoglycaemic
continue hydrocortisone 6 hourly until the patient is stable. No fludrocortisone is required because high cortisol exerts weak mineralocorticoid action
oral replacement may begin after 24 hours and be reduced to maintenance over 3-4 days