You are here: Urology Textbook > Adrenal glands > Adrenal insufficiency

Symptoms and Treatment of Adrenal Insufficiency and Addisonian Crisis

Definition

Adrenal insufficiency is hypocortisolism due to dysfunction of the adrenal cortex, hypophysis, or hypothalamus with a potentially fatal outcome (Arlt et al., 2003).

Epidemiology

Prevalence 1/40.000, Mortality 0,3–1/100.000.

Etiology

• Diseases of the adrenals (Morbus Addison): after (bilateral) adrenalectomy, autoimmune disease, tuberculosis, adrenal metastases, sepsis. Medications: ketoconazole, mitotane, suramin. Rare causes are sarcoidosis, infections such as histoplasmosis, blastomycosis, or AIDS.
• Diseases of hypophysis and hypothalamus:
  • Acute withdrawal from steroids (discontinuation of medication, adrenalectomy).
  • Pituitary and hypothalamic diseases: Tumors, sarcoidosis, tuberculosis, radiation, and infarcts.
  • Sheehan syndrome: ischemic necrosis of the hypophysis due to heavy postpartum bleeding and shock.

Signs and Symptoms

• Acute adrenal crisis: clinical deterioration, fever, vomiting, abdominal pain, hypotension, lethargy. Synonyms: Addisonian crisis.
• Chronic adrenal insufficiency: fatigue, weight loss, nausea and vomiting, hyperpigmentation of the skin and mucous membranes, abdominal discomfort, diarrhea, salt starvation, and hypotension.

Diagnosis of Adrenal Insufficiency

• Laboratory tests: hyponatremia, hyperkalemia, hypoglycemia. Urine cortisol decreased, serum cortisol decreased, and serum ACTH increased or decreased depending on the cause. Test for autoantibodies against the adrenal cortex.
• ACTH test: inadequate increase in serum cortisol 60 min after administration of ACTH (0.25 mg i.v.).
• CRH test: inadequate increase of ACTH and cortisol after administration of CRH (1 μg/kgKG i.v.).
• Imaging: MRI or CT of the head or abdomen, depending on the suspected diagnosis.

Treatment of Adrenal Insufficiency

Emergency Treatment of Addisonian Crisis:

• Rapid infusion of 0.9% NaCl (2–3 l).
• 100 mg of hydrocortisone is administered i.v. as a bolus, followed by a continuous infusion of another 100 mg over 24 hours.
• Treat hyponatremia.
• After stabilizing the patient, a short ACTH test is necessary to confirm the diagnosis.

Perioperative Substitution Therapy after Bilateral Adrenalectomy:

• OP day: 100 mg of hydrocortisone is administered i.v. as a bolus with begin of anesthesia, followed by a continuous infusion of another 100 mg over 24 hours.
• Day 1–3: hydrocortisone 100 mg/24 h i.v.
• Day 4: hydrocortisone 20-20-10 mg p.o.
• Following days: after uncomplicated surgery, reduce by 10 mg/d until the maintenance dose (hydrocortisone 20-10-0 mg/d) is reached. If hydrocortisone is below 50 mg/d, fludrocortisone 0.1 mg/d is additionally necessary.
• Control of blood pressure, electrolytes, and renin activity.

Substitution Therapy for Chronic Adrenal Insufficiency:

• Hydrocortisone 20-10-0 mg/d
• Fludrocortisone 0.1 mg/d
• An increase in dosage is vital in case of infections or surgery.
• Control of blood pressure, electrolytes and renin activity.
• A steroid emergency card should be given to all patients with primary adrenal insufficiency and those who are on a long-term oral steroid.

References

Arlt und Allolio 2003 ARLT, W. ; ALLOLIO, B.: Adrenal insufficiency.
In: Lancet
361 (2003), Nr. 9372, S. 1881–93

  Deutsche Version: Akute Addison Krise und Therapie der Nebenniereninsuffizienz

Urology-Textbook.com – Choose the Ad-Free, Professional Resource

This website is designed for physicians and medical professionals. It presents diseases of the genital organs through detailed text and images. Some content may not be suitable for children or sensitive readers. Many illustrations are available exclusively to Steady members. Are you a physician and interested in supporting this project? Join Steady to unlock full access to all images and enjoy an ad-free experience. Try it free for 7 days—no obligation.