Adrenal Insufficiency

Griffin Bullock

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Background

• Differential: Primary (Adrenals) vs Secondary (Pituitary):
  • Exogenous steroid use (>10 mg for >3wks) undergoing severe physiologic stress or sudden discontinuation of steroid
  • Autoimmune adrenal insufficiency
  • Infection/Infiltration: tuberculosis, sarcoidosis, malignancy
  • Hemorrhage (Waterhouse-Friderichsen syndrome)
  • Pituitary mass/tumor, infarct, infiltration, surgery, trauma

Presentation

• Generalized weakness, lightheaded, abdominal pain, nausea, weight loss, fatigue

• Lab Abnormalities: hyponatremia, hyperkalemia, hypoglycemia

Evaluation

• Inpatient Setting

  • Draw AM cortisol and ACTH (ideally 8am) -> 0.25mg cosyntropin -> cortisol 1 hour after
    • Cortisol level ≥18-20 rules out primary adrenal insufficiency (and most secondary)

• Outpatient Setting

  • Draw AM cortisol level for screening (>15 rules typically rules out adrenal insufficiency)
  • ACTH stimulation for confirmation

Management

• Consult endocrine if ACTH stimulation test is abnormal
• Adrenal crisis (if concerned, treat first, test later)
  • BMP, glucose monitoring, ACTH level, serum cortisol
  • Fluid resuscitation: NS or D5NS. Do not use hypotonic saline
  • Hydrocortisone 100mg x1 followed by 50mg q8h

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Last update: 2022-06-20 11:22:06