What are the common endocrinology etiologies of hypotension?

From the Guidelines

Adrenal insufficiency is the most common endocrinological cause of hypotension, and it should be treated with glucocorticoid replacement with hydrocortisone (15-25 mg daily in divided doses) and sometimes mineralocorticoid replacement with fludrocortisone (0.05-0.2 mg daily) 1.

Common Endocrinological Causes of Hypotension

• Adrenal insufficiency: whether primary (Addison's disease) or secondary, leads to cortisol deficiency and often aldosterone deficiency, resulting in decreased vascular tone, impaired sodium retention, and reduced cardiac output.
• Hypothyroidism: causes hypotension through decreased cardiac contractility and heart rate, requiring levothyroxine replacement (typically starting at 25-50 mcg daily in elderly or cardiac patients, titrating upward) 1.
• Hypopituitarism: affects multiple hormonal axes and requires specific hormone replacements based on deficiencies.

Diagnosis and Treatment

• Adrenal insufficiency diagnosis involves measuring morning cortisol and adrenocorticotropic hormone (ACTH) levels to distinguish between primary and secondary causes.
• Treatment of adrenal insufficiency involves glucocorticoid replacement with hydrocortisone and sometimes mineralocorticoid replacement with fludrocortisone.
• Hypothyroidism diagnosis involves measuring thyroid-stimulating hormone (TSH) and free thyroxine (FT4) levels to confirm the diagnosis.
• Treatment of hypothyroidism involves levothyroxine replacement, starting at a low dose and titrating upward.

Clinical Considerations

• Prompt recognition of endocrine causes of hypotension is essential, as they often present with other symptoms like fatigue, weight changes, and electrolyte abnormalities that help distinguish them from non-endocrine causes of hypotension.
• Endocrinology consult is recommended at admission for patients with known adrenal insufficiency and/or prior hypophysitis, and physiological replacement steroids should be continued at home dosing throughout the regimen 1.

From the Research

Common Endocrinology Etiology of Hypotension

• Adrenal insufficiency is a common endocrinology etiology of hypotension, which can be primary or secondary 2, 3, 4, 5.
• Primary adrenal insufficiency, also known as Addison's disease, is caused by the inability of the adrenal glands to produce cortisol and aldosterone 3, 4.
• Secondary adrenal insufficiency is caused by the inability of the pituitary gland to produce adrenocorticotrophic hormone (ACTH), which stimulates the adrenal glands to produce cortisol 2, 4, 5.
• Other endocrinology etiologies of hypotension include:
  • Isolated hypoaldosteronism, which is characterized by low blood sodium and high blood potassium levels 3.
  • Pseudohypoaldosteronism, which is characterized by resistance to aldosterone 3.
  • Pheochromocytoma, which is a rare tumor of the adrenal gland that can cause hypotension 3.
  • Diabetic dysautonomia, which is a complication of diabetes that can cause hypotension 3, 4.
• Glucocorticoid-induced adrenal insufficiency is another common etiology of hypotension, which occurs when the use of synthetic glucocorticoids suppresses the hypothalamic-pituitary-adrenal axis 6.

Clinical Features of Hypotension

• The clinical features of hypotension in adrenal insufficiency include:
  • Low blood pressure, either permanently or only in upright posture (orthostatic hypotension) 3.
  • Electrolyte imbalances, such as low blood sodium and high blood potassium levels 3, 4.
  • Shock, which is a life-threatening condition that occurs when the body is not getting enough blood flow 3, 5.
  • Hypoglycemia, which is a condition characterized by low blood sugar levels 4.

Diagnosis and Treatment

• The diagnosis of adrenal insufficiency is based on clinical features, laboratory tests, and imaging studies 2, 3, 4, 5.
• The treatment of adrenal insufficiency includes glucocorticoid replacement therapy, which involves the use of synthetic glucocorticoids to replace the missing hormones 2, 5, 6.
• The treatment of hypotension in adrenal insufficiency includes the use of fluids, electrolytes, and medications to increase blood pressure and improve circulation 3, 5.