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