Adrenal Insufficiency

Adrenal Insufficiency – Griffin Bullock

Background

  • Differential: Primary (Adrenals) vs Secondary (Pituitary):
    • Exogenous steroid use (>10 mg for >3wks) undergoing severe physiologic stress or sudden discontinuation of steroid
    • Critical Illness (not consensus)
    • Autoimmune Adrenal Insufficiency
    • Infection/Infiltration: tuberculosis, sarcoidosis, malignancy
    • Hemorrhage (Waterhouse-Friderichsen syndrome)
    • Pituitary mass/tumor, infarct, infiltration, surgery
    • Trauma

 

Presentation

  • Generalized weakness, lightheaded, abdominal pain, nausea, weight loss, fatigue
  • Symptoms are often vague and non-specific. More common in chronic disease
  • Lab Abnormalities: Hyponatremia, Hyperkalemia, Hypoglycemia
  • Shock (adrenal crisis) unresponsive to vasopressors, volume, or refractory

 

Evaluation

  • Inpatient Setting: ACTH stimulation test and ACTH lvl with baseline lab draw
  • High-dose stimulation 250 mcg: #cortisol 18-20 rules out primary, most secondary
  • Outpatient Setting: morning serum cortisol concentration (>15 mcg/dL wnl) for screening
    • ACTH stimulation for confirmation

 

Management

  • If concerned about adrenal crisis, treat and figure out testing later):
  • When to consult/refer to Endocrine:
    • If testing is abnormal
    • If clinical suspicion is high and testing is indeterminate
  • Adrenal Crisis:
    • BMP, glucose monitoring, ACTH level, serum cortisol/ACTH stimulation test
    • Fluid resuscitation: isotonic fluid (2-3 L). do not use hypotonic saline
    • Dexamethasone 4 mg immediately then q12h or other stress dose steroid
    • ACTH stimulation (confirmatory)
    • Consult Endocrine
    • Further workup of cause, mineralocorticoid replacement