Adrenal Insufficiency

• Adrenal insufficiency


  Where the adrenal glands do not produce enough steroid hormones, particularly cortisol and aldosterone
• Addison's disease


  Specifically when the adrenal glands have been damaged, resulting in reduced cortisol and aldosterone secretion
• Primary adrenal insufficiency


  Caused by damage to the adrenal glands
• Secondary adrenal insufficiency


  Caused by inadequate ACTH and lack of stimulation of the adrenal glands, resulting from loss or damage to the pituitary gland
• Causes of secondary adrenal insufficiency

  • Tumours (e.g., pituitary adenomas)
  • Surgery to the pituitary
  • Radiotherapy
  • Sheehan's syndrome
  • Trauma
• Tertiary adrenal insufficiency


  Caused by inadequate corticotropin-releasing hormone release by the hypothalamus, usually due to long-term oral steroid use
• Symptoms of adrenal insufficiency

  • Fatigue
  • Muscle weakness
  • Muscle cramps
  • Dizziness and fainting
  • Thirst and craving salt
  • Weight loss
  • Abdominal pain
  • Depression
  • Reduced libido
• Signs of adrenal insufficiency

  • Bronze hyperpigmentation of the skin, particularly in creases
  • Hypotension (particularly postural hypotension)
• Bronze hyperpigmentation


  Caused by excessive ACTH stimulating melanocytes to produce melanin, mainly affecting skin creases, scars, lips and buccal mucosa
• If you see a patient in an OSCE exam who may have adrenal insufficiency, check for a medical alert bracelet worn to alert medical services that they are steroid-dependent if they become unconscious
• Biochemical findings in adrenal insufficiency

  • Hyponatraemia (low sodium)
  • Hyperkalaemia (high potassium)
  • Hypoglycaemia (low glucose)
  • Raised creatinine and urea due to dehydration
  • Hypercalcaemia (high calcium)
• ACTH


  High in primary adrenal insufficiency, low in secondary adrenal insufficiency
• CT or MRI of the adrenal glands can be helpful if suspecting structural pathology, but are not routinely required
• MRI of the pituitary gives further information about pituitary pathology
• Hydrocortisone


  Used to replace cortisol
• Fludrocortisone


  Used to replace aldosterone
• Patients are given a steroid card, ID tag and emergency letter to alert emergency services that they depend on steroids for life
• Doses are doubled during an acute illness to match the normal steroid response to illness
• Patients and close contacts are taught to give intramuscular hydrocortisone in an emergency
• Adrenal crisis


  Acute presentation of severe adrenal insufficiency, where the absence of steroid hormones leads to a life-threatening emergency
• Management of adrenal crisis

  1. ABCDE approach to initial assessment and arrange transfer to hospital

  2. Intramuscular or intravenous hydrocortisone

  3. Intravenous fluids

  4. Correct hypoglycaemia

  5. Careful monitoring of electrolytes and fluid balance