1. Adrenal Insufficiency UNC Internal Medicine Morning Report June 28, 2010 Edward L. Barnes, MD

2. Adrenal Insufficiency Primary Adrenal Insufficiency is also known as Addison’s Disease in honor of Dr. Thomas Addison Primary Adrenal Insufficiency is also known as Addison’s Disease in honor of Dr. Thomas Addison Born in April 1793, at Long Benton, Newcastle-upon-Tyne and died on June 29 1860, at 15 Wellington Villas, Brighton Born in April 1793, at Long Benton, Newcastle-upon-Tyne and died on June 29 1860, at 15 Wellington Villas, Brighton Dr. Addison is also credited with the discovery of Pernicious Anemia Dr. Addison is also credited with the discovery of Pernicious Anemia

3. Introduction Adrenocorticotropic Hormone (ACTH) is the major factor in the secretion of cortisol and androgenic steroids by the adrenal cortex Adrenocorticotropic Hormone (ACTH) is the major factor in the secretion of cortisol and androgenic steroids by the adrenal cortex ACTH secretion is regulated as a balance between the stimulatory effects of CRH (mediated by the CNS) and the negative feedback mediated by circulating levels of glucocorticoids ACTH secretion is regulated as a balance between the stimulatory effects of CRH (mediated by the CNS) and the negative feedback mediated by circulating levels of glucocorticoids

4. Adrenal Insufficiency Arises when cortisol levels are not sufficient to meet the needs of the body Arises when cortisol levels are not sufficient to meet the needs of the body Cortisol aids in maintaining vascular tone, hepatic gluconeogenesis, and in maintaining glycogen Cortisol aids in maintaining vascular tone, hepatic gluconeogenesis, and in maintaining glycogen Inadequate cortisol in times of stress can lead to hypotension, shock, and hypoglycemia Inadequate cortisol in times of stress can lead to hypotension, shock, and hypoglycemia

5. Adrenal Insufficiency Mineralocorticoid deficiency typically leads to renal wasting of sodium, retention of potassium, and reduced intravascular volume Mineralocorticoid deficiency typically leads to renal wasting of sodium, retention of potassium, and reduced intravascular volume

6. Primary Adrenal Insufficiency Most commonly is of an autoimmune etiology, resulting from chronic destruction of the adrenal cortex Most commonly is of an autoimmune etiology, resulting from chronic destruction of the adrenal cortex Typical histologic feature is lymphocytic infiltration Typical histologic feature is lymphocytic infiltration Antibodies to adrenal cortical antigens are present early in the disease process Antibodies to adrenal cortical antigens are present early in the disease process Patients with autoimmune adrenal disease are more likely to have polyglandular autoimmune systems causing deficiency of other endocrine glands Patients with autoimmune adrenal disease are more likely to have polyglandular autoimmune systems causing deficiency of other endocrine glands

7. Primary Adrenal Insufficiency Several Other Mechanisms Exist: Several Other Mechanisms Exist: Bilateral adrenal hemorrhage Bilateral adrenal hemorrhage Infection: Tuberculosis, CMV, Histoplasmosis Infection: Tuberculosis, CMV, Histoplasmosis Metastatic Disease Metastatic Disease Deposition Diseases: Hemochromatosis, Amyloidosis, Sarcoidosis Deposition Diseases: Hemochromatosis, Amyloidosis, Sarcoidosis Drug Induced: Ketoconazole, Etomidate, Rifampin, Anticonvulsants Drug Induced: Ketoconazole, Etomidate, Rifampin, Anticonvulsants Congenital Adrenal Hyperplasias Congenital Adrenal Hyperplasias

8. Secondary Adrenal Insufficiency Caused by pituitary failure of ACTH secretion Caused by pituitary failure of ACTH secretion Etiologies include: Etiologies include: any cause of primary or secondary hypopituitarism any cause of primary or secondary hypopituitarism Exogenous Glucocorticoid Therapy Exogenous Glucocorticoid Therapy Megestrol, which has some glucocorticoid therapy Megestrol, which has some glucocorticoid therapy

9. Clinical Presentation Acute adrenal insufficiency (Adrenal Crisis) should be expected in any patient acute, unexplained volume depletion and shock Acute adrenal insufficiency (Adrenal Crisis) should be expected in any patient acute, unexplained volume depletion and shock Hyperkalemia, acidosis, and hypoglycemia may also be accompanying Hyperkalemia, acidosis, and hypoglycemia may also be accompanying

10. Clinical Presentation Chronic insufficiency typically develops more insidiously Chronic insufficiency typically develops more insidiously Symptoms may include weakness, weight loss, nausea, vomiting, anorexia, and postural hypotension Symptoms may include weakness, weight loss, nausea, vomiting, anorexia, and postural hypotension Increased skin pigmentation can be seen with primary adrenal insufficiency secondary to melanocyte stimulating activity associated with ACTH Increased skin pigmentation can be seen with primary adrenal insufficiency secondary to melanocyte stimulating activity associated with ACTH Hyponatremia and Hyperkalemia may develop secondary to a lack of aldosterone Hyponatremia and Hyperkalemia may develop secondary to a lack of aldosterone

11. Clinical Presentation Secondary Adrenal Insufficiency may present with evidence of adrenal insufficiency as well as other evidence of hypopituitarism Secondary Adrenal Insufficiency may present with evidence of adrenal insufficiency as well as other evidence of hypopituitarism

12. Differential Diagnosis Acute Adrenal insufficiency Acute Adrenal insufficiency Various conditions can cause hypotension and or shock Various conditions can cause hypotension and or shock Chronic Adrenal Insufficiency Chronic Adrenal Insufficiency Chronic Starvation (anorexia nervosa) Chronic Starvation (anorexia nervosa) Gastrointestinal Disease secondary to inflammation or malignancy Gastrointestinal Disease secondary to inflammation or malignancy Other causes of hyperpigmentation including drug exposures Other causes of hyperpigmentation including drug exposures Other causes of fatigue and malaise Other causes of fatigue and malaise

13. Diagnostic Workup Baseline Cortisol and ACTH levels should be obtained in the early morning Baseline Cortisol and ACTH levels should be obtained in the early morning A morning cortisol level of <3  g/dL is virtually diagnostic A morning cortisol level of <3  g/dL is virtually diagnostic A level of <10  g/dL is highly suspicious A level of <10  g/dL is highly suspicious A level of >18  g/dL should rule out Adrenal Insufficiency except in the setting of a critically ill patient A level of >18  g/dL should rule out Adrenal Insufficiency except in the setting of a critically ill patient

14. Diagnostic Workup Cosyntropin Stimulation Test Cosyntropin Stimulation Test Measure morning cortisol level (pre-test level) Measure morning cortisol level (pre-test level) Administer 1  g dose Cosyntropin Administer 1  g dose Cosyntropin Measure a second cortisol level 1 hour after Cosyntropin administration Measure a second cortisol level 1 hour after Cosyntropin administration Normal response demonstrates a level of greater than 20  g/dL after cosyntropin Normal response demonstrates a level of greater than 20  g/dL after cosyntropin Patients with both primary and secondary adrenal insufficiency will not demonstrate appropriate response Patients with both primary and secondary adrenal insufficiency will not demonstrate appropriate response Patients with primary insufficiency will fail to respond to repeated administrations, however patients with secondary insufficiency may show an increased response to repeated testing/stimulation Patients with primary insufficiency will fail to respond to repeated administrations, however patients with secondary insufficiency may show an increased response to repeated testing/stimulation

15. Diagnostic Workup Further determination of primary vs. secondary adrenal insufficiency will be based upon ACTH level Further determination of primary vs. secondary adrenal insufficiency will be based upon ACTH level High ACTH level expected in primary insufficiency High ACTH level expected in primary insufficiency

16. Treatment: Acute Adrenal Insufficiency Treat Acute Adrenal Insufficiency with Hydrocortisone 50-100 mg IV q8 hrs Treat Acute Adrenal Insufficiency with Hydrocortisone 50-100 mg IV q8 hrs In addition, volume resuscitate with Normal Saline In addition, volume resuscitate with Normal Saline

17. Treatment: Chronic Adrenal Insufficiency Hydrocortisone 20-30 mg po daily Hydrocortisone 20-30 mg po daily Typically divide dose 2/3 in am, 1/3 in pm Typically divide dose 2/3 in am, 1/3 in pm May use Prednisone 5 mg po daily instead May use Prednisone 5 mg po daily instead Fludrocortisone 0.05-0.1 mg po qam Fludrocortisone 0.05-0.1 mg po qam Not necessary in patients with secondary adrenal insufficiency Not necessary in patients with secondary adrenal insufficiency Provide instruction for periods of acute illness or increased stress Provide instruction for periods of acute illness or increased stress

18. The End

19. References: 1. Pearce, JMS. Thomas Addison. J R Soc Med. 2004 June; 97(6): 297–300. 2. Ontjes, DA. Disorders of the Adrenal Cortex. Netter’s Internal Medicine, 2 nd ed. 2009; 321-4. 3. Adrenal Insufficiency. Little: Dental Management of the Medically Compromised Patient, 7th ed. 2007. 4. Oelkers, W. Adrenal Insufficiency. N Engl J Med. 1996 Oct 17;335(16):1206-12.