What are adrenal glands?
Adrenal glands are located just above kidneys and form 3 types of steroid hormones- glucocorticoids (cortisol), mineralocorticoids (aldosterone) and adrenal androgens (DHEA/DHEAS). Cortisol enables the body to respond and adapt to the stresses of daily life. It also helps to maintain blood sugar levels and promote a healthy immune system. Aldosterone works to balance salt and water in the body.
What causes adrenal insufficiency?
Adrenal insufficiency, occurs when underactive adrenal glands do not produce enough of the hormone cortisol and, in some cases, the hormone aldosterone.
In most cases, adrenal insufficiency results from the destruction of the adrenal cortex, the outer layer of the adrenal glands. This disorder is known as primary adrenal insufficiency
or Addison’s disease and in India is commonly due to tuberculosis or autoimmunity (condition in which a patient’s immune system uses its antibodies to attack and destroy its own adrenal glands). Some less common causes of primary adrenal insufficiency include: adrenal tumors and other infections.
Secondary adrenal insufficiency
is a more common form of adrenal insufficiency and is due to a lack of adrenocorticotropin (ACTH). ACTH is a hormone secreted by the pituitary gland, which, in turn, stimulates the adrenal glands to produce cortisol, but not aldosterone. The lack of ACTH leads to a drop in the production of adrenal cortisol.
Taking high doses of steroids, such as prednisone for a long duration is usually the most frequent cause of secondary adrenal insufficiency. Other causes of secondary adrenal insufficiency are less frequent and include: pituitary tumors, history of pituitary surgery, radiation.
What are the symptoms?
- Weight loss
- Lack of appetite
- Abdominal pain
- Darkening of the skin
- Dizziness or lightheadedness upon standing
- Craving salty foods
- Muscle and joint pain
If the symptoms of adrenal insufficiency are left untreated, they may lead to severe nausea, vomiting, abdominal pain, and low blood pressure, known as an adrenal crisis. Adrenal crisis can also be precipitated by stressful events such as surgery, trauma, and infection. If an adrenal crisis is not treated, it can be fatal.
Diagnosis of Adrenal Insufficiency
- To measure cortisol response, your doctor may order a stimulation test with either of the following:
Synacthen (ACTH) test
Insulin tolerance test
- Usually done in the laboratory
- Total duration of one hour
- Done in Endocrinology outpatient department
- Total duration of two hours
If even after stimulation cortisol is low, it suggests adrenal insufficiency.
- High ACTH levels suggest primary adrenal insufficiency.
- Once it has been determined whether the adrenal insufficiency is primary or secondary, your doctor may order an imaging (radiology) test for either your adrenal glands (usually a CT scan) or your pituitary gland (usually an MRI scan).
Treatment of Adrenal Insufficiency
Treatment of adrenal insufficiency involves replacing the insufficient hormones.
Treatment usually starts with either hydrocortisone or prednisone, corticosteroids that are used as cortisol replacements. The medication is taken orally once or twice a day.
In primary adrenal insufficiency, fludrocortisone, a drug that replaces aldosterone, is also frequently needed.
Stress dose of steroids
- Hydrocortisone/prednisolone is required for maintainence of normal blood pressure and blood sugar. It is therefore necessary for life.
- Since adrenal insufficiency is life-threatening, patients should carry a medical alert card at all times.
- There is no side effect if the replacement is in the amount required by the body.
- The dose should not be missed for a single day.
Your body needs large amount of hydrocortisone/ prednisolone during times of physical stress.
- In case of mild illness like low grade fever (less than 100oF),nausea, throat or ear infection
• Double the dose of prednisolone/ hydrocortisone.
- In case of severe illness like fever more than 100oF, pneumonia, injury requiring stitches or broken bone
• Triple the dose of prednisolone/ hydrocortisone.
- In case of vomiting or unconsciousness, if the patient is unable to swallow the tablet
• Give IV hydrocortisone _______mg stat.
• Also consult your endocrinologist immediately.
- Patient should go back to the usual dose after recovery.