Adrenocortical Insufficiency

Addison's Disease is the name given to primary adrenocortical insufficiency. It is autoimmune or ideopathic and causes a reduction in glucocorticoids cortisol and mineralcorticoids aldosterone. Secondary adrenalcortical insuffeciency will also cause a decrease in sex hormones and is itself caused by a decrease in adrenocortical hormone d/t pituitary tumor.

Etiology and Physiology
Addison's can be ideopathic or autoimmune. In either case there is a decrease in gluco and mineral corticoids, cortisol and aldosterone. In secondary there is glucocorticoids and sex hormones are deficient but mineralcorticoids rarely are. There can be other causes such as tuberculosis, MI, fungus and AIDS but these are rare.

Signs and Symptoms
Classic signs of Addisson's are progressive weakness, weight loss progressing to anorexia, fatigue and hypepigmentations (JFK). Those with secondary are not hyperpigmented due to low ACTH (secreted from the pituitary which is malfunctioning) which does not occur with primary (Addison's). Other signs and symptoms:

Labs An ACTH stimulation test will show no rise in cortisol levels if the cause is primary. If secondary the cortisol levels will rise meaning the adrenal glands work and the pituitary is at fault.
 * Hyponatremia, will also crave salt
 * Hyperkalemia
 * orthostatic hypotension
 * Nausea, vomiting, diarrhea.
 * Hyponatremia
 * Hyperkalemia
 * Hyperglycemia
 * Low cortisol levels
 * Low aldosterone levels in urine

Adissonian Crisis
This is a medical emergency caused by physical or psychological stress or trauma, stopping replacement therapy suddenly, removal of pituitary, post adrenal surgery. Patient will be hypotensive, tachycardiac. nausea and vomiting, fever, weakness and confusion. They will not respond to fluid replacement therapy or vasopressin (other vasoconstrictors).

Treatment requires systemic support to reduce symptoms, high volume D5NS to rehydrate and correct for electrolyte imbalances, and high do hydrocortisone replacement.

Treatment
If hospitalized assess for dehydration and electrolyte blance often, daily wieights, I&O. Patient should be kept in a quiet room with tempreture and light levels that are comfortable for them. Low stress environment as stress can cause a worsening of symptoms.

When therapy is done on an outpatient basis patient education is paramount:
 * Take as scheduled.
 * Need for lifelong replacement therapy.
 * Stress, physical or psychological, or illness may require a temporary dose increase. Minor problems usually require a doubling of the dose.
 * Signs and symptoms of overdose and insufficient supply.
 * Glucocorticoids are taken as a divided dose; 2/3 in the morning and 1/3 in the afternoon.
 * Mineralcorticoids are taken once daily in the AM.
 * The times for both match the normal distribution cycle in the body.
 * Medical alert device needed.