Adrenal Insufficiency¶
Griffin Bullock
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¶
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Generalized weakness, lightheaded, abdominal pain, nausea, weight loss, fatigue
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Lab Abnormalities: hyponatremia, hyperkalemia, hypoglycemia
Evaluation¶
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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)
- Draw AM cortisol and ACTH (ideally 8am) -> 0.25mg cosyntropin -> cortisol 1 hour after
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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
Last update:
2022-06-20 11:22:06