Adrenal insufficiency

Introduction

Adrenal insufficiency arises when the adrenal gland is destroyed by disease, or atrophies following pituitary failure or chronic corticosteroid use or abuse.
In these situations, the amount of cortisol produced from the adrenal gland is insufficient to meet the body’s needs during periods of physical and psychological stress or severe illness.
The condition is associated with severe fluid and electrolyte imbalance and results in acute circulatory collapse.

Causes of adrenal insufficiency

  1. The causes of adrenal insufficiency include the following:
  2. Sudden cessation of prolonged corticosteroid use or abuse.
  3. Stress (e.g. infection, severe trauma, surgery, and dental procedures) in a patient with undiagnosed adrenal insufficiency or patients on prolonged corticosteroid treatment.
  4. Pituitary failure
  5. Auto-immune disease of the adrenal gland (Addison’s disease)
  6. Severe infections affecting the adrenal gland (e.g. meningococcus, tuberculosis, HIV)
  7. Congenital adrenal hyperplasia in children

Symptoms of adrenal insufficiency

The symptoms of adrenal insufficiency include the following:

  1. Nausea
  2. Vomiting
  3. Weakness
  4. Collapse
  5. Abdominal pain
  6. Diarrhoea

Signs of adrenal insufficiency

Known signs of adrenal insufficiency include the following:

  1. Dehydration
  2. Low or unrecordable blood pressure
  3. Darkening of oral mucosa, gums, skin, palms and soles in some individuals
  4. Evidence of corticosteroid abuse e.g. skin bleaching, Cushingoid appearance
  5. Ambiguous genitalia, short stature and failure to thrive in children
  6. Variable states of consciousness

Investigations

  • FBC (may show anaemia and eosinophilia)
  • Blood urea and electrolytes (may show high potassium)
  • Blood glucose (may be low)
  • Plasma cortisol (low)
  • Blood film for malaria parasites, if indicated
  • Urine and blood cultures, if indicated

Treatment for adrenal insufficiency

Treatment objectives

The following are the treatment objectives of adrenal insufficiency:

  1. To correct the fluid and electrolyte imbalance
  2. To correct hypoglycaemia
  3. To replace corticosteroids
  4. To identify cause and treat any precipitating factor

Non-pharmacological treatment

  • None

Pharmacological treatment

A. Acute treatment

1st Line Treatment
Evidence Rating: [B]
Intravenous fluid replacement
Adults:

  • 0.9% Sodium Chloride in 5% Glucose (Dextrose Saline), IV, 1 litre 4-6 hourly, until condition is stable

Children:
0.45% Sodium Chloride in 5% Glucose, IV, according to total requirement

And

Hydrocortisone, IV:
Adults

  • 200 mg stat. followed by 100 mg 6 hourly until condition is stable

Children

  • 6-12 years; 100 mg 6 hourly
  • 1-5 years; 50 mg 6 hourly
  • <1 year; 25 mg 6 hourly

Note

The IV hydrocortisone therapy may be required for several days.
Do not rush to change to maintenance therapy.
When the patient’s condition is stable (i.e. normal BP, cessation of vomiting etc.) go on to maintenance therapy.

B. Adjunct treatment in acute cases

  • Treat infection (e.g. malaria, pneumonia, UTI) or stress-inducing condition, if present or suspected, with appropriate medication.

C. Maintenance – for patients not previously on corticosteriods

1st Line Treatment
Evidence Rating: [A]
Prednisolone, oral, life-long
Adults: 5 mg morning and 2.5 mg evening each day
Children: 70 micrograms/kg 12 hourly
2nd Line Treatment
Evidence Rating: [A]
Hydrocortisone, oral, life-long
Adults

  • 10-20 mg morning and 5-10 mg evening each day
  • Children: 280 micrograms/kg 12 hourly

D. Maintenance – For patients on long term corticosteroid therapy who go into adrenocortical crisis (e.g. asthma, nephrotic syndrome)

Adults and Children

  • Restart the previous doses of oral corticosteroids given for the condition.

E. Maintenance – For patients who abuse corticosteroids

Adults

  • Restart oral corticosteroids, or replace topical corticosteroids with oral corticosteroids

Prednisolone, oral,

  • 20-40 mg daily
  • Gradually taper off the dose over several months (e.g. reducing by 2.5 mg per month) and eventually discontinue.

Caution

  • Long-term corticosteroid therapy requires specialist supervision. Healthcare practitioners should inform patients of the following:
  • Patients on corticosteroids should report to a hospital if they become ill and should tell their doctor, dentist, nurse or pharmacist that they are on corticosteroids
  • Patients should not stop treatment if they become ill, have an infection or are undergoing a dental procedure. Rather a doubling of the regular doses of corticosteroids is needed
  • Revert to hydrocortisone, IV for even minor surgical procedures including labour and delivery
  • The dose of corticosteroids must be reduced gradually if treatment has been for longer than 3 weeks and is to be stopped
  • Discourage the abuse of oral or topical corticosteroids

Referral Criteria

All patients suspected to have adrenal insufficiency should be for referred, after resuscitation, to a regional or teaching hospital assessment and long-term management.