What are the symptoms and treatment of adrenal insufficiency?

Symptoms and Treatment of Adrenal Insufficiency

Clinical Presentation of Adrenal Insufficiency

The key symptoms of adrenal insufficiency include fatigue, nausea, vomiting, abdominal pain, weight loss, hypotension, and in primary adrenal insufficiency, skin hyperpigmentation and salt craving. 1, 2

Common Symptoms

• Fatigue and weakness (50-95% of patients) 2
• Nausea and vomiting (20-62%) 2
• Anorexia and weight loss (43-73%) 2
• Abdominal pain or muscle cramps 1
• Postural hypotension 3
• Cognitive impairment (confusion in severe cases) 1

Distinguishing Features by Type

• Primary adrenal insufficiency:

  • Skin hyperpigmentation (especially in skin folds, scars, and mucous membranes) 2, 3
  • Salt craving 3
  • Electrolyte abnormalities (hyponatremia, hyperkalemia) 1

• Secondary adrenal insufficiency:

  • No hyperpigmentation 2
  • Generally normal electrolytes 4
  • May have other pituitary hormone deficiencies 2

Laboratory Findings

• Hyponatremia (low sodium)
• Hyperkalemia (high potassium) - primarily in primary adrenal insufficiency
• Hypoglycemia (especially in children)
• Mild hypercalcemia may occur 1
• Prerenal renal failure (elevated creatinine) 1

Diagnosis

Early diagnosis is crucial to prevent adrenal crisis. The diagnostic approach includes:

1. Morning cortisol and ACTH levels:

   • Primary adrenal insufficiency: Low cortisol (<5 μg/dL), high ACTH 2
   • Secondary adrenal insufficiency: Low cortisol, low or normal ACTH 2

2. Confirmatory testing:

   • Cosyntropin (Synacthen) stimulation test: Measure cortisol before and 60 minutes after 250 μg cosyntropin 2, 5
   • Insulin tolerance test (gold standard for secondary adrenal insufficiency) 5

Treatment of Adrenal Insufficiency

Maintenance Therapy

1. Glucocorticoid replacement:

   • Hydrocortisone 15-25 mg/day divided into 2-3 doses 4, 2
   • Alternative: Prednisone 3-5 mg daily 2

2. Mineralocorticoid replacement (for primary adrenal insufficiency only):

   • Fludrocortisone 0.05-0.3 mg daily 2
   • Monitor blood pressure and electrolytes 4

Stress Dosing Protocol

Patients must adjust their glucocorticoid dose during illness or stress:

• Minor illness/stress: Double or triple usual daily dose 4
• Moderate stress: Hydrocortisone 50-75 mg/day in divided doses 4
• Severe stress: Hydrocortisone 100 mg IV immediately, followed by 100-300 mg/day as continuous infusion or divided doses every 6 hours 1, 4

Management of Adrenal Crisis

Adrenal crisis is a life-threatening emergency requiring immediate treatment:

1. Immediate interventions:

   • Hydrocortisone 100 mg IV bolus immediately 1, 4
   • Followed by 100-300 mg/day as continuous infusion or divided doses every 6 hours 1
   • Rapid IV administration of isotonic saline (1 L over an hour), then 3-4 L over 24 hours 1
   • Treat precipitating conditions (infections, etc.) 1

2. Monitoring during crisis:

   • Hemodynamic parameters
   • Serum electrolytes
   • Blood glucose 4

3. Tapering: Parenteral glucocorticoids should be tapered over 1-3 days to oral maintenance therapy once the patient stabilizes 1

Prevention of Adrenal Crisis

1. Patient education is crucial:

   • Written instructions for emergency situations 4
   • Stress dosing protocols 4
   • Medical alert identification 3

2. Emergency kit:

   • Injectable hydrocortisone (100 mg) 2
   • Training for self-administration or administration by family members 3

3. Regular monitoring:

   • Annual consultation to assess replacement adequacy 1
   • Monitor weight, blood pressure, and electrolytes 4
   • Assess for symptoms of over or under-replacement 1

Common Pitfalls and Caveats

• Delayed diagnosis due to non-specific symptoms; maintain high index of suspicion 6
• Hyperpigmentation may be absent in recent-onset primary adrenal insufficiency or secondary adrenal insufficiency 6
• Electrolyte disturbances may be masked by vomiting, diarrhea, or parenteral fluid therapy 6
• Adrenal crisis can be fatal if untreated - don't delay treatment while waiting for confirmatory tests 5
• Glucocorticoid-induced adrenal insufficiency is common in patients who have recently tapered or discontinued supraphysiological doses of glucocorticoids 2

Proper diagnosis, treatment, and patient education are essential for managing adrenal insufficiency and preventing life-threatening adrenal crises.