Definition

[1]
Adrenal Insufficiency is a disorder where the adrenal glands are unable to produce enough cortisol and in some cases aldosterone is depleted as well. Primary Adrenal Insufficiency is called Addison's Disease.

Incidence

[2]
[3]
0.8 per 100 000 people (Addison's Disease)

Age

30-39 (Addison's Disease)

Gender

About 10 times more likely in females (Addison's Disease)

Aetiology

[4]

Risk Factors

[5]

Signs and Symptoms

[6]

Pathophysiology

[7]
Addison's Disease results from destruction of the adrenal gland leading to reduces cortisol and aldosterone production. Cortisol is the body's stress hormone and with out it the body is unable to respond correctly to stresses such as infection. Reduced aldosterone leads to increased sodium excretion which causes hypotension. While sodium is excreted, potassium is retained. Due to reduced negative feedback, people with Addison's disease have elevated circulating ACTH and renin.

In secondary adrenal insufficiency there is a problem with signalling to the adrenal glands which means that the adrenal glands do not produce hormones even though it is capable. In some cases there is a problem with the Hypothalamus or Anterior Pituitary so that there is reduced ACTH release. The most common cause of secondary adrenal insufficiency is use of exogenous glucocorticoids which acts on the body's negative feedback system but when the medication is stopped the adrenal glands are unable to respond immediately. It is therefore important to reduce doses before totally withdrawing from glucocorticoids.

Investigations

[8]

Bloods

Imaging

  • Head MRI - if pituitary tumour is suspected

Diagnosis

[9]
Diagnosis is difficult because the symptoms are non-specific. Inability to respond to ACTH stimulation makes Addison's Disease very likely.

Differentials to rule out

Treatment

[10]
[11]

Non-Pharmacological

  • Fluid resuscitation

Pharmacological

  • Cortisol replacement
  • Aldosterone replacement

Surgical

  • Tumour resection (with chemotherapy and radiotherapy)

Management

[12]
Patients should be evaluated yearly to ensure that the cortisol and aldosterone supplements are sufficient. Patient's must also be made aware that they need to increase the dose of cortisol in a stress situation such as active infection, trauma or surgery.

Complications

[13]

Prognosis

[14]
Prognosis is good if treatment is adhered to, which it usually is because of the uncomfortable symptoms associated with adrenal insufficiency.

See Also

BMJ Best Practice - Addison's Disease
Oxford Handbook of Clinical Medicine - 9th Edition p 218
  1. ^ Oxford Handbook of Clinical Medicine - 9th Edition p 218
  2. ^ Oxford Handbook of Clinical Medicine - 9th Edition p 218
  3. ^ Dynamed -Adrenal insufficiency in adults
  4. ^ Dynamed -Adrenal insufficiency in adults
  5. ^ http://bestpractice.bmj.com.ezp.lib.unimelb.edu.au/best-practice/monograph/56.html
  6. ^ http://bestpractice.bmj.com.ezp.lib.unimelb.edu.au/best-practice/monograph/56.html
  7. ^ http://bestpractice.bmj.com.ezp.lib.unimelb.edu.au/best-practice/monograph/56.html
  8. ^ http://bestpractice.bmj.com.ezp.lib.unimelb.edu.au/best-practice/monograph/56.html
  9. ^ http://bestpractice.bmj.com.ezp.lib.unimelb.edu.au/best-practice/monograph/56.html
  10. ^ Oxford Handbook of Clinical Medicine - 9th Edition p 218
  11. ^ http://bestpractice.bmj.com.ezp.lib.unimelb.edu.au/best-practice/monograph/56.html
  12. ^ http://bestpractice.bmj.com.ezp.lib.unimelb.edu.au/best-practice/monograph/56.html
  13. ^ http://bestpractice.bmj.com.ezp.lib.unimelb.edu.au/best-practice/monograph/56.html
  14. ^ http://bestpractice.bmj.com.ezp.lib.unimelb.edu.au/best-practice/monograph/56.html