Adrenal Insufficiency Overview

Adrenal Insufficiency

• Adrenal insufficiency is a condition where the adrenal glands don't produce enough cortisol and aldosterone.
• Three types exist: primary, secondary, and tertiary.
• It is a common issue.
• The Endocrine Society has created new guidelines for effective management.

Primary Adrenal Insufficiency

• Caused by dysfunction of the adrenal glands.
• Common causes include autoimmune disease, congenital adrenal hyperplasia, and tuberculosis.
• Symptoms: weakness, fatigue, anorexia, weight loss, hyperpigmentation, nausea, vomiting, hypotension, and hyperkalemia.
• Hyperpigmentation arises from melanocyte-stimulating hormone in ACTH.
• High ACTH and low cortisol levels are observed.
• Diagnosis confirmed by ACTH and cortisol levels (not random cortisol).
• Treatment involves replacing cortisol and aldosterone.
• In a homeless patient with symptoms, primary adrenal insufficiency is a likely diagnosis.

Secondary Adrenal Insufficiency

• Caused by insufficient ACTH production from the pituitary gland.
• Common causes include long-term steroid use and pituitary surgery.
• Symptoms: weakness, fatigue, anorexia, weight loss, nausea, vomiting, hypotension, and hyperkalemia.
• Low ACTH and low cortisol levels are observed.
• Treatment usually involves replacing cortisol, potentially aldosterone as well.

Tertiary Adrenal Insufficiency

• Caused by insufficient corticotropin-releasing hormone from the hypothalamus.
• Common causes include traumatic brain injury, meningitis, and stroke.
• Symptoms: weakness, fatigue, anorexia, weight loss, nausea, vomiting, hypotension, and hyperkalemia.
• Low ACTH and low cortisol levels are observed.
• Treatment usually involves replacing cortisol, potentially aldosterone as well.

Management of Adrenal Insufficiency

• Patient education and medical alert (bracelet/necklace) are essential.
• Dosage adjustments are needed based on illness or procedures.
• Over-prescription of steroids is a concern, so monitoring for Cushingoid features and adjusting dosage is crucial.
• A cortisol stimulation test differentiates between primary, secondary, and tertiary.
• Treatment: cortisol and aldosterone (primary), cortisol (possibly aldosterone) in secondary and tertiary.
• Tapering steroid medication is crucial to prevent flares, especially for those on steroids for more than three weeks. Use of pre-filled packs (short-term) and slow, gradual tapers (long-term) are recommended.
• Patients should understand the risks of adrenal suppression.

Cortisol Replacement

• Hydrocortisone (10-20mg morning, 0-10mg evening) is preferred.
• Prednisone (5-7.5mg daily) can be used.
• Dosage adjustment is often needed (patients may be overmedicated).
• Patients with primary adrenal insufficiency need injectable steroids (Solucortef) for emergencies.
• Significant events (surgery, illness, trauma) require doubling the dose.

Aldosterone Replacement

• Fludrocortisone is the only recommended medication.
• Dose is individualized based on patient needs.
• Initiate with a low dose and increase as needed to address symptoms like hypotension, hyperkalemia, and fluid retention.

Considerations for Tapering Steroids

• Gradual tapering is needed for patients on steroids more than three weeks.
• Guidelines for short-term and long-term tapering are provided (pre-filled packs and slow, gradual tapers).
• Patients need to understand potential risks of adrenal suppression during tapering.

Key Takeaways

• Adrenal insufficiency is a complex, treatable condition.
• Understanding different types and their management is critical.
• Early diagnosis and treatment prevent complications.
• Patient education and self-management are essential.

Adrenal Insufficiency Diagnosis and Treatment

• Cortisol Levels: Target mid-range levels (10-15) to avoid insufficiency or excess symptoms
• Adrenal Stimulation Test: After hydrocortisone, test adrenal function, even if cortisol is in the mid-range.
• Emergency Management: Suspected adrenal insufficiency needs immediate IV dexamethasone. It does not interfere with cortisol stimulation testing.
• Dexamethasone Coverage: IV dexamethasone during testing ensures patient safety.
• Hydration: D5 normal saline for hydration.
• Hydrocortisone Replacement: Following the stimulation test, initiate hydrocortisone at 100 mg every 8 hours.
• ACTH Levels: High ACTH indicates primary, low ACTH suggests secondary/tertiary.
• Treatment Strategies: Primary needs cortisol and aldosterone, secondary/tertiary primarily cortisol.
• Dosage Calculation: Cortisol dosage based on body surface area (formula provided).
• Emergency Guidelines: Initially cover with dexamethasone, then do stimulation testing, adjust cortisol replacement with hydrocortisone 100mg every 8 hours and use D5 normal saline.