Adrenal insufficiency resident survival guide: Difference between revisions
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==Do's== | ==Do's== | ||
* | <ref>https://www.elsevier.es/index.php?p=revista&pRevista=pdf-simple&pii=S2173509314700698</ref> <ref name="BornsteinAllolio2016">{{cite journal|last1=Bornstein|first1=Stefan R.|last2=Allolio|first2=Bruno|last3=Arlt|first3=Wiebke|last4=Barthel|first4=Andreas|last5=Don-Wauchope|first5=Andrew|last6=Hammer|first6=Gary D.|last7=Husebye|first7=Eystein S.|last8=Merke|first8=Deborah P.|last9=Murad|first9=M. Hassan|last10=Stratakis|first10=Constantine A.|last11=Torpy|first11=David J.|title=Diagnosis and Treatment of Primary Adrenal Insufficiency: An Endocrine Society Clinical Practice Guideline|journal=The Journal of Clinical Endocrinology & Metabolism|volume=101|issue=2|year=2016|pages=364–389|issn=0021-972X|doi=10.1210/jc.2015-1710}}</ref> | ||
*In diagnosis of [[Adrenal insufficiency]] plasma [[cortisol]] to be measured between 8:00-9:00AM , after the early morning peak which happens between 6:00-8:00AM. | |||
*[[Hydrocortisone]] (preferred glucocorticoid) to be given in two or three divided doses to mimic circadian rhythm. | |||
*[[Glucocorticoid]] dose to be titrated based on symptom improvement. Least possible dose of [[glucocorticoid]] has to be used. | |||
*[[Mineralocorticoid]] dose to be titrated based on symptom improvement (salt craving, postural hypotension, edema) and electrolytes. | |||
*After adjusting the dose follow up to be continued annually. | |||
*Patients to be educated to self increase the dose of [[glucocorticoid]] in the presence of other illnesses like fever, wounds. | |||
*Patients to be educated to carry steroid emergency and medical alert identification in the event of [[adrenal crisis]] for early detection and treatment. | |||
*Patients to be educated on carrying and injecting [[glucocorticoid]] in case of an emergency. | |||
==Don'ts== | ==Don'ts== | ||
Revision as of 21:56, 17 January 2021
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:
Overview
Causes
Life Threatening Causes
Life-threatening causes include conditions that may result in death or permanent disability within 24 hours if left untreated.
Common Causes
- Primary adrenal insufficiency: Autoimmune adrenalitis
- Central adrenal insufficiency: Chronic glucocorticoid use.
Less common causes:
- Infections:
- Tuberculosis
- Fungal infections(histoplasma)
- Cytomegalovirus
- HIV
- Adrenal hemorrhage
- X-linked adrenoleukodystrophy
- Trauma
- Metastasis [2] [3]
Diagnosis
Shown below is an algorithm summarizing the diagnosis of [[adrenal insufficiency]]. [3] [4]
| Adrenal Insufficiency suspected | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Serum basal cortisol | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| <5 µg/dL | 5-18 µg/dL | >18 µg/dL | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Confirms Adrenal Insufficiency | Dynamic tests | Rules out Adrenal Insufficiency | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Primary Adrenal Insufficiency suspected | Secondary Adrenal Insufficiency suspected | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| ACTH stimulation test | ACTH stimulation test | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Serum cortisol <18 µg/dL | Serum cortisol >18µg/dL | Serum cortisol <18 µg/dL | Serum cortisol 18-23µg/dL | Serum cortisol >23 µg/dL | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Confirms Adrenal Insufficiency | Rules out Adrenal Insufficiency | Confirms Adrenal Insufficiency | Indeterminate | Rules out Adrenal Insufficiency | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Insulin hypoglycemic test | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Serum cortisol <18µg/dL | Serum cortisol >18µg/dL | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Confirms Adrenal Insufficiency | Rules out Adrenal Insufficiency | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Treatment
Shown below is an algorithm summarizing the treatment of adrenal insufficiency. [3] [5][6]
| Primary adrenal insufficiency | Secondary adrenal insufficiency | ||||||||||||||||||||||||||||||||||||||
| Lifelong Glucocorticoid and Mineralocorticoid replacement therapy | Lifelong Glucocorticoid replacement therapy | ||||||||||||||||||||||||||||||||||||||
| Mineralocorticoid replacement therapy: 9 α-Fludrocortisone 0.05-0.2 mg/day PO single dose in the morning | |||||||||||||||||||||||||||||||||||||||
| Glucocorticoid replacement therapy: 1. Hydrocortisone 15-25mg PO in two or three divided doses 2. Cortisone acetate 20-25mg PO single dose in the morning | |||||||||||||||||||||||||||||||||||||||
Do's
- In diagnosis of Adrenal insufficiency plasma cortisol to be measured between 8:00-9:00AM , after the early morning peak which happens between 6:00-8:00AM.
- Hydrocortisone (preferred glucocorticoid) to be given in two or three divided doses to mimic circadian rhythm.
- Glucocorticoid dose to be titrated based on symptom improvement. Least possible dose of glucocorticoid has to be used.
- Mineralocorticoid dose to be titrated based on symptom improvement (salt craving, postural hypotension, edema) and electrolytes.
- After adjusting the dose follow up to be continued annually.
- Patients to be educated to self increase the dose of glucocorticoid in the presence of other illnesses like fever, wounds.
- Patients to be educated to carry steroid emergency and medical alert identification in the event of adrenal crisis for early detection and treatment.
- Patients to be educated on carrying and injecting glucocorticoid in case of an emergency.
Don'ts
- The content in this section is in bullet points.
References
- ↑ https://www.ncbi.nlm.nih.gov/books/NBK499968/
- ↑ Feingold KR, Anawalt B, Boyce A, Chrousos G, de Herder WW, Dungan K; et al. (2000). "Endotext". PMID 25905309.
- ↑ 3.0 3.1 3.2 3.3 Bornstein, Stefan R.; Allolio, Bruno; Arlt, Wiebke; Barthel, Andreas; Don-Wauchope, Andrew; Hammer, Gary D.; Husebye, Eystein S.; Merke, Deborah P.; Murad, M. Hassan; Stratakis, Constantine A.; Torpy, David J. (2016). "Diagnosis and Treatment of Primary Adrenal Insufficiency: An Endocrine Society Clinical Practice Guideline". The Journal of Clinical Endocrinology & Metabolism. 101 (2): 364–389. doi:10.1210/jc.2015-1710. ISSN 0021-972X.
- ↑ https://www.elsevier.es/index.php?p=revista&pRevista=pdf-simple&pii=S2173509314700698
- ↑ Oprea, Alina; Bonnet, Nicolas C. G.; Pollé, Olivier; Lysy, Philippe A. (2019). "Novel insights into glucocorticoid replacement therapy for pediatric and adult adrenal insufficiency". Therapeutic Advances in Endocrinology and Metabolism. 10: 204201881882129. doi:10.1177/2042018818821294. ISSN 2042-0188.
- ↑ https://www.elsevier.es/index.php?p=revista&pRevista=pdf-simple&pii=S2173509314700698
- ↑ https://www.elsevier.es/index.php?p=revista&pRevista=pdf-simple&pii=S2173509314700698