NEWSLETTER
APPROACH TO PATIENTS WITH ADRENAL DISORDERS
Dr. Ali Jawa, Consultant Endocrinologist, King Edward University Hospital
ADRENAL INSUFFICIENCY (ADDISONS DISEASE)
The normal adrenal response to acute illness or stress is an
increase in production of cortisol, which has important
protective effects. Unfortunately, this needed increase may
be lacking in some persons because of exogenous use of
corticosteroids that suppress native cortisol production, or
dysfunction in the hypothalamic-pituitary-adrenal (HPA) axis
seen in some cases of severe illness.
Native cortisol production is enzymatically inhibited by the anesthetic agent etomidate and the antifungal medication ketoconazole. Exogenous use of corticosteroids can suppress the HPA axis with as little as 7.5 mg of prednisone/prednisolone or 0.75 mg of dexamethasone daily for more than three weeks. This suppression may last for months after the exogenous steroid is stopped.
The clinical factors that manifest in adrenal insufficiency are somewhat nonspecific and may easily be missed. Classic features of Addisonian crisis include nausea, vomiting, diarrhea, abdominal pain, and delirium. Physical examination findings of adrenal hypofunction include postural hypotension, tachycardia, and fever. Increased skin pigmentation may occur with longstanding adrenal insufficiency. Of the laboratory findings seen with inadequate adrenal function, hypoglycemia and eosinophilia are important to remember, because they are less likely to occur in other disease states. Hyponatremia and hyperkalemia typically occur but may be masked by fluid and electrolyte replacement.
Referral guidelines: When to send to an endocrinologist
- Patients with history of repeated courses of steroids should be regarded with suspicion for secondary adrenal insufficiency.
- Consider in association with other autoimmune disease, e.g. thyroiditis, Hashimoto's, pernicious anemia, other endocrine disease.
- Also in association with previous TB, HIV.
- Symptoms of weight loss, muscle fatigue, weakness, postural hypotension and in particular nausea, vomiting, unexplained anemia or fever.
- Unexplained dizziness on standing and/or Unexplained Orthostatic hypotension.
- Unexplained skin hyper-pigmentation.
- Any cortisol level <3 mg/dL is suspicious for adrenal insufficiency.
- Unexplained Hyponatremia
PRIMARY HYPERALDOSTERONISM (CONN'S SYNDROME)
Conn's syndrome is a disease of the adrenal glands involving excess production of aldosterone. The excess secretion of the hormone aldosterone into the blood is from an abnormal adrenal gland or glands. Two types of abnormalities are seen: a benign tumor of one adrenal, called an adenoma or a general enlargement of both adrenals, called hyperplasia. Conn's syndrome is important because it is a potentially curable cause of hypertension.
Hypertension is the main, and often the only, symptom. Other symptoms may include hypokalemia, fatigue, muscle weakness, polyuria and nocturia. Since its symptoms are non specific, Conn's syndrome should be suspected in all patients with high blood pressure.
Referral guidelines: When to send to an endocrinologist
- Unexplained hypokalemia
- Moderate to severe hypertension (>160/110mmHg) or difficult to control with medication.
- Family member with an endocrine tumor.
