Adrenal Insufficiency

Question 1

Terminology: Addisonian crisis

Answer 1

Acute adrenal crisis in patients with primary adrenal insufficiency (Addisonian’s disease)

Question 2

Terminology: Adrenal crisis

Answer 2

Any acute cortisol deficiency severe enough to cause life-threatening symptoms, regardless of the underlying cause.

Question 3

Precipitants of adrenal crisis

Answer 3

• Sudden withdrawal of exogenous steroids**
• Infections**
• Infarction
• Surgery
• Missed medications

Question 4

Clues to suspect adrenal insufficiency

Answer 4

• Does the patient look cushingnoid? AND is hypotensive?
• ASK for use of exogenous steroids
• History of pituitary surgery/tumour/radiation (hypopituitarism)
• History of autoimmune endocrine disorder (autoimmune adrenalitis)
• Hypotension with only partial response to fluid challenge
• HYPONATREMIA
• HYPOGLYCEMIA
• HYPOTENSION
• HyperK+ only in primary adrenal crisis

Question 5

Classical triad of adrenal insufficiency

Answer 5

Hypotension
Hyponatremia
Hypoglycaemia

Question 6

How does exogenous steroid use cause secondary adrenal insufficiency?

Answer 6

Exogenous glucocorticoid use
-> negative feedback
-> decrease in ACTH production
-> decrease in endogenous cortisol from the adrenal glands
-> adrenal atrophy

WHEN there is sudden withdrawal of exogenous steroid use
-> adrenal gland cannot produce cortisol immediately
-> adrenal crisis

*aldosterone unaffected as the portion of the adrenal cortex producing aldosterone remains unaffected

Question 7

In emergency setting: how to confirm cortisol deficiency?

Answer 7

1. Low random cortisol
   - if <100nmol/L and patient is hypotensive = highy likely adrenal insufficiency
2. Serum ACTH - send on ICE in EDTA tube
   - determines primary adrenal vs pituitary failure
3. Urine Na

NOTE: DO NOT NEED LAB RESULTS to start management in ED settings

Question 8

How to determine between primary vs secondary adrenal insufficiency?

Answer 8

1. Look for hyperpigmentation of lips, tongue, nail folds
2. Check serum ACTH

Question 9

ACUTE MANAGEMENT of adrenal crisis

Answer 9

DO NOT WAIT FOR LABS. Treat based on clinical suspicion

1. Stabilization & immediate Investigations
   a. Assess volume status - low or “normal”
   - Fluid replacement + Correction of Hypoglycemia: IV dextrose-saline infusion

b. STAT cortisol and ACTH, urine Na
c. Check potassium & ECG

2. Definitive Management
   ○ 100mg IV Hydrocortisone BOLUS STAT
   ○ Followed by 50mg IV Hydrocortisone q6h

• No need for mineralocorticoid acutely because Hydrocortisone (high dose) has mineralocorticoid effect
• Only when subsequently lowering of hydrocortisone dose + transition from IV to PO (loss of mineralocorticoid effect) –> then add Fludrocortisone

3. Investigate and Treat underlying cause

Question 10

Post-acute management (different from long term mx)

Answer 10

1. Taper hydrocortisone dose downwards over next 72h if stable
2. When able to take orally, switch to PO hydrocortisone
   - Stress replacement dose: 20mg morning + 10mg noon + 10mg evening
3. Counsel to stop TCM/exogenous steroids