Clinical approach to adrenal insufficiency in hospitalised patients

Abstract

Primary adrenal insufficiency (Addison's disease) refers to glucocorticoid deficiency resulting from adrenal gland disease. Central adrenal insufficiency is because of disorders of the pituitary gland (secondary) or the hypothalamus (tertiary). Long-term hypothalamic-pituitary-adrenal (HPA) axis suppression is commonly seen after chronic glucocorticoid therapy (iatrogenic). Transient HPA axis suppression is increasingly being reported in hospitalised patients with acute illness (relative adrenal insufficiency). This article extensively reviews various aetiologies and management of adrenal insufficiency.

58-Year-Old Woman With Progressive Nausea and Fatigue

“…1 This is most marked in areas of skin exposed to friction, such as palmar creases, knuckles, scars, and oral mucosa, and is augmented by sun exposure. [1][2][3] Concordantly, our patient noted it to be most prominent in her palmar creases, elbows, and an old scar on her face.…”

“…It can also be caused by drugs (busulfan, cyclophosphamide, zidovudine), systemic diseases (hemochromatosis, scleroderma), and ectopic corticotropin-producing tumors (small cell lung cancer). 2 Hyperpigmentation occurs in primary adrenal insufficiency because cortisol deficiency decreases negative feedback resulting in pituitary hypersecretion of corticotropin, which stimulates melanocyte receptors. 1 This is most marked in areas of skin exposed to friction, such as palmar creases, knuckles, scars, and oral mucosa, and is augmented by sun exposure.…”

“…Although the pathophysiology underlying adrenal crisis may be more attributable to mineralocorticoid deficiency, immediate replacement with fludrocortisone is not effective due to its slow onset of sodium-retaining effects. 2 Aggressive fluid resuscitation (initial rates of 1 L/h with continuous cardiac monitoring 1 ) and antibiotics to treat the underlying infection are important, but the patient continues to be in hypovolemic shock despite resuscitative attempts and will benefit the most from immediate treatment with glucocorticoids.…”

“…Failure to produce peak cortisol levels of greater than 18 mg/dL confirms primary adrenal insufficiency with an overall sensitivity and specificity of 96%. 1,2 If the results of corticotropin stimulation testing remain inconclusive and there is concern about secondary adrenal insufficiency, an insulin tolerance test can be performed by administering intravenous insulin to induce hypoglycemia. In normal persons, this test should stress the hypothalamic-pituitary-adrenal axis and cause an appropriate increase in the plasma cortisol level.…”

Renin‐Angiotensin‐Aldosterone System and Hypothalamic‐Pituitary‐Adrenal Axis in Hospitalized Newborn Foals

“…There is no reason to believe that adrenal gland insufficiency is limited to the zona fasciculata because the adrenocortical layers share circulation and innervation, and ACTH stimulates both the zona glomerulosa and the zona fasciculata . Therefore, systemic inflammation, cytokines, poor perfusion, and hypotension may affect both glucocorticoid and mineralocorticoid production . ACTH deficiency leading to severe hyponatremia and hypoaldosteronism in people further supports the importance of ACTH in mineralocorticoid secretion .…”