Adrenal insufficiency Signs + symptoms
Lethargy, weakness, anorexia,
nausea + vomiting, weight loss,
Definition failure to produce ‘salt-craving’
sufficient steroid from adrenals Hyperpigmentation (especially
Aetiology palmar creases)
Primary Vitiligo, loss of pubic hair in
Addison’s disease (80%) females, hypotension
autoimmune destruction of
the adrenal glands Addisonian crisis
Aetiology ‘MAIL’ Collapse, shock, pyrexia
o Metastases from breast, Aetiology
lung, renal cancer 1. Sepsis/surgery acute
o Autoimmune exacerbation
o Infections e.g. TB, CMV, 2. Adrenal haemorrhage
HIV 3. Steroid withdrawal
o Lymphomas
Idiopathic Mx
Post-adrenalectomy Hydrocortisone 100mg IV/IM
Secondary 1L normal saline over 30-60 mins
Prolonged prednisolone use w/ dextrose if hypoglycaemic
Pituitary adenoma Continue hydrocortisone for 6h
Sheehan’s syndrome until patient is stable
No Fludrocortisone is required
because high cortisol exerts weak
mineralocorticoid action
Oral replacement after 24h +
reduce to maintenance over 3-4
Ix days
Definite short Synacthen test
Plasma cortisol measured before +
30 mins after giving Synacthen
250μg IM
Adrenal autoantibodies such as Mx
anti-21 hydroxylase may also be Replace glucocorticoid +
demonstrated
mineralocorticoid
If ACTH stimulation unavailable
Hydrocortisone 2/3 divided
then (e.g. primary care) then
9:00am serum cortisol is useful: doses: 20-30mg/day majority
> 500nmol/L Addison’s unlikely morning dose
< 100 nmol/L abnormal Fludrocortisone
100-500 nmol/L ACTH test done Conservative = education-
don’t miss doses
Electrolyte abnormalities MedicAlert bracelets/steroid
High K+, low Na+, hypoglycaemia, cards
metabolic acidosis
Lethargy, weakness, anorexia,
nausea + vomiting, weight loss,
Definition failure to produce ‘salt-craving’
sufficient steroid from adrenals Hyperpigmentation (especially
Aetiology palmar creases)
Primary Vitiligo, loss of pubic hair in
Addison’s disease (80%) females, hypotension
autoimmune destruction of
the adrenal glands Addisonian crisis
Aetiology ‘MAIL’ Collapse, shock, pyrexia
o Metastases from breast, Aetiology
lung, renal cancer 1. Sepsis/surgery acute
o Autoimmune exacerbation
o Infections e.g. TB, CMV, 2. Adrenal haemorrhage
HIV 3. Steroid withdrawal
o Lymphomas
Idiopathic Mx
Post-adrenalectomy Hydrocortisone 100mg IV/IM
Secondary 1L normal saline over 30-60 mins
Prolonged prednisolone use w/ dextrose if hypoglycaemic
Pituitary adenoma Continue hydrocortisone for 6h
Sheehan’s syndrome until patient is stable
No Fludrocortisone is required
because high cortisol exerts weak
mineralocorticoid action
Oral replacement after 24h +
reduce to maintenance over 3-4
Ix days
Definite short Synacthen test
Plasma cortisol measured before +
30 mins after giving Synacthen
250μg IM
Adrenal autoantibodies such as Mx
anti-21 hydroxylase may also be Replace glucocorticoid +
demonstrated
mineralocorticoid
If ACTH stimulation unavailable
Hydrocortisone 2/3 divided
then (e.g. primary care) then
9:00am serum cortisol is useful: doses: 20-30mg/day majority
> 500nmol/L Addison’s unlikely morning dose
< 100 nmol/L abnormal Fludrocortisone
100-500 nmol/L ACTH test done Conservative = education-
don’t miss doses
Electrolyte abnormalities MedicAlert bracelets/steroid
High K+, low Na+, hypoglycaemia, cards
metabolic acidosis
