Addison's/ Adrenal insufficiency Week 6 Flashcards Preview

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Flashcards in Addison's/ Adrenal insufficiency Week 6 Deck (20)

problem in adrenal insufficiency/ Addison's

(Addison's is the most common cause of PRIMARY adrenal insufficiency) decreased secretion of steroids- cortisol (glucocorticoid) aldosterone (mineralcorticoid) and androgen


why does primary adrenal insufficiency happen?

90% autoimmune, body attacks adrenal cortex (associated w/ other autoimmune stuff- type 1 DM, autoimmune thyroid dx, pernicious anemia and ovarian failure) other rarer causes- hemorrhage/ traumatic injury, cancer, adrenal gland TB


s/s of adrenal insufficiency- remember low "steroid"

S sodium/ sugar both low (salt cravings reported)
T tired/fatigue/weak
E electrolyte imbalance- potassium, calcium (increase)
R reproductive changes- women have irregular menses/ loss of body hair, men have erectile dysfunction
O lOw BP- risk for vascular collapse/ shock
I increased pigmentation/ hyperpigmentation (common at buccal mucosa, also at pressure points, recent scars, or skin creases)
D diarrhea/ nausea/ anorexia, depression


Addisonian crisis aka adrenal gland crisis s/s

vomiting/ diarrhea
abdominal pain
profound weakness
severe hypoglycemia
hypovolemic shock


Addisonian crisis tx

need urgent management- (fatal if left untreated, can make official dx later- start treatment if suspected) Give dexamethasone initially (4 mg IV) while the basal cortisol measurement and the cosyntropin stimulation test are performed; empiric treatment with IV hydrocortisone (100 mg IV q8h, with rapid tapering) can then be initiated. Also need D5NS to correct volume depletion, dehydration, and hypoglycemia. Should be in the ICU


long term tx for adrenal insufficiency

All patients with chronic adrenal insufficiency require replacement with glucocorticoids (aka cortisol) and occasionally with mineralocorticoids (aka aldosterone). Hydrocortisone is frequently used in primary adrenal insufficiency because it has some mineralocorticoid activity. The usual dosage of hydrocortisone is 10 to 15 mg every morning and 5 to 10 mg in the afternoon. When prednisone is used, typical doses are 2.5 to 5 mg daily. If additional mineralocorticoid effect is necessary for persistent hyperkalemia and/or orthostatic hypotension, fludrocortisone 0.05 to 0.2 mg once a day may be added (cortisol replacement= prednisone or hydrocortisone) (aldosterone replacement= Fludrocortisone aka Florinef).


Autoimmune adrenalitis

aka Addison's- most common cause of primary adrenal insufficiency


Autoimmune adrenalitis is associated with ?

increased levels of 21-hydroxylase antibodies


most common cause of central (secondary/tertiary) adrenal insufficiency is

withdrawal of glucocorticoids after long-term use


primary adrenal insufficency mainly from?



common presenting sign of adrenal insufficiency ?

weight loss


classic laboratory abnormalities found with adrenal insufficiency

hyponatremia and hyperkalemia.


hyperkalemia is due to ?

mineralocorticoid deficiency (aldosterone)


hyponatremia occurs mainly due to ?

glucocorticoid deficiency (cortisol) It is the result of elevated vasopressin values with free water retention, shift of extracellular sodium into cells, and decreased delivery of filtrate to the diluting segments of the nephron due to decreased glomerular filtration rate


calcium usually?
glucose usually?

Mild to moderate hypercalcemia
Fasting blood glucose is usually low-normal (if pt also has type 1 DM, hypoglycemia prob more severe)


How is adrenal insufficiency usually diagnosed?

In the outpatient setting, a low morning cortisol value (< 3 μg/dL) is sufficient to diagnose adrenal insufficiency, and a high morning cortisol value (> 20 μg/dL) excludes the diagnosis.


In most instances, a dynamic test called what is also performed?

cosyntropin stimulation test- determines whether the adrenals are able to respond to maximal stimulation by synthetic ACTH


How is the cosyntropin test performed?

by collecting a specimen for measurement of a baseline serum cortisol level, administration of 250 μg of cosyntropin (brand name Cortrosyn, Synacthen) IV or IM, and then collecting specimens for serum cortisol measurement 30 and 60 minutes later. An abnormal result is defined as a stimulated cortisol level at either 30 or 60 minutes of less than 18 to 20 μg/dL (< 450-500 nmol/L). can be done at any time of day. If pt is receiving glucocorticoid therapy, the dose should be withheld (12 hours for hydrocortisone, 24 hours for prednisone) before the test is performed to avoid detection of synthetic glucocorticoids in the cortisol assay


Other dynamic testing includes

the insulin tolerance test, metyrapone test, glucagon stimulation test, and CRH stimulation test


What testing can be used to distinguish primary from central adrenal insufficiency?

In primary adrenal insufficiency, ACTH is elevated, whereas ACTH is “abnormally normal” (i.e., not elevated in response to low cortisol) or frankly low in central adrenal insufficiency.