From the Guidelines
Adrenal insufficiency is a life-threatening condition that presents with signs and symptoms such as extreme fatigue, weight loss, decreased appetite, low blood pressure, dizziness, muscle weakness, nausea, vomiting, abdominal pain, salt cravings, and hyperpigmentation, and requires immediate medical attention to prevent morbidity and mortality. The diagnosis of adrenal insufficiency should be considered in all patients presenting with unexplained collapse, hypotension, vomiting, or diarrhea, and hyperpigmentation, hyponatremia, hyperkalemia, acidosis, and hypoglycemia increase clinical suspicion of primary adrenal insufficiency 1. Common signs of adrenal insufficiency include:
- Extreme fatigue
- Weight loss
- Decreased appetite
- Low blood pressure (especially upon standing, called orthostatic hypotension)
- Dizziness
- Muscle weakness
- Nausea
- Vomiting
- Abdominal pain
- Salt cravings
- Hyperpigmentation (darkening of the skin, particularly in skin folds, knuckles, and scars) Laboratory findings typically show low sodium, high potassium, low blood glucose, and elevated ACTH levels in primary adrenal insufficiency 1. Treatment involves hormone replacement with glucocorticoids (typically hydrocortisone 15-25 mg daily in divided doses) and sometimes mineralocorticoids (fludrocortisone 0.05-0.2 mg daily), and patients should carry emergency medication and wear medical identification to ensure proper treatment during illness or emergencies 1. In cases of suspected acute adrenal insufficiency, treatment should never be delayed by diagnostic procedures, and the diagnostic test for primary adrenal insufficiency should be paired measurement of serum cortisol and plasma ACTH 1. Patients with adrenal insufficiency are at risk of adrenal crisis, a life-threatening emergency that presents with severe hypotension, shock, confusion, and sometimes fever, and requires immediate treatment with intravenous hydrocortisone and fluid replacement 1. Education on stress dosing and a medical alert bracelet for adrenal insufficiency is essential to trigger stress-dose corticosteroids by emergency medical services, and endocrine consultation prior to surgery or any procedure for stress-dose planning is recommended 1.
From the Research
Signs and Symptoms of Adrenal Insufficiency
- The condition is characterized by inadequate glucocorticoid production due to destruction of the adrenal cortex or lack of adrenocorticotropic hormone stimulation 2
- Patients can present with an insidious onset of symptoms, or acutely in adrenal crisis, which requires prompt recognition and treatment 2
- Symptoms of adrenal insufficiency are non-specific, often overlooked or misdiagnosed, and are related to the lack of cortisol, adrenal androgen precursors, and aldosterone (especially in primary adrenal insufficiency) 3
- Chronic symptoms include fatigue, weight loss, and vulnerability to infection 4
Diagnosis and Treatment
- Diagnosis is based on measurement of the adrenal corticosteroid hormones, their regulatory peptide hormones, and stimulation tests 3
- The goal of therapy is to establish a hormone replacement regimen that closely mimics the physiological diurnal cortisol secretion pattern, tailored to the patient's daily needs 3
- Maintenance glucocorticoid replacement is usually given as a twice or thrice daily hydrocortisone preparation, and patients with primary adrenal insufficiency also require mineralocorticoid replacement 2
- Regular monitoring for features of under- and over-replacement is essential during follow-up, and patient education is a key feature of management of this condition 2
Complications and Management
- Adrenal crisis is a life-threatening complication of glucocorticoid and mineralocorticoid under-replacement, which may be prevented by educational programs towards the adrenal insufficient patient 5
- Patients with adrenal insufficiency are at risk of adrenal crisis, usually precipitated by major stress, such as severe infection or surgery, and early dose adjustments are required to cover the increased glucocorticoid demand in stress 6
- Careful and repeated education of patients and their partners is the best strategy to avoid this life-threatening emergency 6