Adrenal Insufficiency¶
Griffin Bullock
Background¶
- Differential: Primary (Adrenals) vs Secondary (Pituitary):
- Exogenous steroid use (>10mg for >3wks) undergoing severe physiologic stress or sudden discontinuation of steroid
- Autoimmune adrenal insufficiency (Addison’s)
- 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
- Lab Abnormalities: hyponatremia, hyperkalemia, hypoglycemia
Evaluation¶
- Inpt Setting
- Draw AM cortisol and ACTH (ideally 8am) 0.25mg cosyntropin cortisol 1h after
- Cortisol level ≥18-20 rules out primary adrenal insufficiency (and most secondary)
- Draw AM cortisol and ACTH (ideally 8am) 0.25mg cosyntropin cortisol 1h after
- Outpt Setting
- Draw AM cortisol level for screening (>15 rules typically rules out adrenal insufficiency)
- ACTH stimulation for confirmation
Management¶
- Consult endocrine if ACTH stimulation test is abnormal
- Outpt: physiologic replacement doses usually with hydrocortisone (dosed 8am and ~2-4pm to mimic physiology). Can be dosed based on BSA or estimation based on weight. Ranges from ~20-40mg total daily (ex. 15mg AM, 10mg PM). Pt to increase if acute illness.
- Adrenal crisis (if concerned, treat first, test later)
- BMP, glucose monitoring, ACTH level, serum cortisol
- Fluid resuscitation: NS or D5NS. Do not use hypotonic saline.
- Hydrocortisone 100mg x1 followed by 50mg q8h