Adrenal insufficiency
Clinical features:
- weight loss, hyponatraemia, hypotension → shock, hypoglycemia, hypercalcemia.
- anorexia, nausea, vomiting, diarrhea, muscle cramps
- vitiligo etc
Investigations:
- Treatment should not be delayed to wait for results in patients with suspected acute adrenal crisis.
- A random blood sample for serum cortisol plasma ACTH (on ice)
- If the patient’s clinical condition permits, it may be appropriate to spend 30 minutes performing a short ACTH stimulation test.
| Investigation | Finding/justification |
| Assessment of glucocorticoids | |
Plasma cortisol level
|
|
| SST |
|
| ACTH |
|
| Assessment of mineralocorticoids | |
| S electrolytes |
|
| Plasma renin & aldosterone in supine position |
|
| Assessment of adrenal androgens | |
|
|
| To establish cause of primary (Addison’s disease): elevated ACTH | |
| Adrenal autoantibodies to 21-hydroxylase |
|
| CT or MRI of abdomen (adrenal protocol) |
|
| Plain X-ray, USG of abdomen |
|
| HIV serology | |
Patient with evidence of autoimmune adrenal failure
|
Screening for organ-specific autoimmune diseases
|
| Test for secondary adrenocortical insufficiency | |
| Box 20.51 | |
Management
Glucocorticoid replacement
- oral hydrocortisone (cortisol) 15–20 mg daily in divided doses
- 10 mg on waking and 5 mg at around 1500 hrs.
- These are physiological replacement
- Excess weight gain → over-replacement
- persistent lethargy or hyperpigmentation → inadequate dose or lack of absorption.
Mineralocorticoid replacement
- Fludrocortisone: dose of 0.05–0.15 mg daily,
- Follow up: blood pressure, plasma electrolytes, plasma renin.
- Indicated for primary adrenal insufficiency, not for secondary adrenal insufficiency.
Androgen replacement
- DHEAS (50 mg/day): women with primary insufficiency with symptoms of reduced libido and fatigue
- side-effects such as acne and hirsutism.