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Adrenal insufficiency
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- 1What are the causes of primary adrenal failure?1) Addison's disease (80% in UK; autoimmune adrenalitis)
2) TB (most common worldwide)
3) Adrenal metastasis
4) Lymphoma
5) Opportunistic infections in HIV
6) Adrenal haemmorhage (Waterhouse-Friederichson syndrome)
7) Late onset congenital hyperplasia - 2What are the causes of secondary adrenal failure? How does the presentation differ to that of primary adrenal insufficiency?1) Iatrogenic - long term steroid use leads to suppression of the HPA axis, only revealed on cessation of the steroids
2) Hypothalamic-pituitary disease - rare
No hyperpigmentation (as ACTH is low) and no impact on mineralocorticoid production - 3How does primary adrenal insufficiency present?Mood: depression, psychosis
GI: Nausea/vomiting/abdominal pain (ALWAYS suspect Addison's in unexplained nausea and vomiting)
Pigmented palmar creases & buccal mucosa
Postural hypotension
Vitiligo (often sign of autoimmunity) - 4How does an Addison's crisis present?1) Shock
2) Metabolic alkalosis
3) Hyponatremia and hyperkalemia - 5What blood tests should be done when investigating adrenal insufficiency?1) Low sodium, high potassium
2) Hypoglycaemia
3) Uraemia
4) Hypercalcaemia
5) Eosinophilia
6) Anaemia - 6What tests are done to diagnose adrenal insufficiency and find the cause?1) Synacthen - measure cortisol, give tetracosactide 250 mcg IM, measure cortisol at +30 mins. If cortisol is >550 nmol/L, Addison's is excluded
2) 9am ACTH - to confirm primary adrenal failure
3) 21 hydroxylase adrenal antibodies (present in 80% of autoimmune disease)
4) Plasma renin and aldosterone - assess mineralocorticoid status
AXR/CXR - any signs of TB? If no autoantibodies found, can also perform adrenal CT, TB tests, histoplasma tests, and metastatic disease - 7How is Addison's disease managed?1) ~15-25mg hydrocortisone daily in 2-3 doses, i.e. 10mg on waking, 5mg lunchtime - avoid giving late at night due to problems sleeping
2) 50-200mcg fludrocortisone daily to correct postural hypertension and electrolyte imbalance, adjust both on clinical grounds. - 8If there is poor response clinical response to treatment to Addison's, what should be done next?Check for associated coeliac disease i.e. thyroid and coeliac serology
- 9How much extra hydrocortisone should be taken before strenuous activity/exercise?5-10mg hydrocortisone
- 10How should medication doses change in illness, severe stress or injury?Doube dosage
- 11If a patient is vomiting, how can they self-manage?100mg injection
- 12What does follow up with Addison's patients entail?Yearly BP and U&E checks - also watch for autoimmune disease (e.g. pernicious anaemia)
- 13How is an Addisonian crisis managed?Always start treatment before waiting for lab results if clinical diagnosis has been made
1) Blood tests for U&Es, glucose, cortisol and ACTH. May have high K+ and low Na+, ECG and calcium gluconate if necessary
2) Hydrocortisone 100mg IM stat
3) 0.9% saline 500ml bolus to correct hypotension and electrolytes, repeat as necessary
4) Blood, urine and sputum culture and antibiotics as necessary - 14How is Addison's crisis treatment continued?1) Monitor hypoglycaemia and give glucose as necessary
2) Give hydrocortisone 100 mg/8h IM as necessary
3) Change to oral steroids after 72 hours if the patient is well enough
4) Consider fludrocortisone - 15What are the precipitating factors in Addison's crisis?1) Infection
2) Trauma
3) Surgery
4) Missed medication
Remember that bilateral adrenal haemorrhage is an important cause (i.e. meningococcemia)
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- Met3B (Endocrinology) Karteikarten am Adrenal insufficiency, erstellt von Anna Hogarth am 07/03/2020.
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