Addison’s disease/primary adrenal insufficiency or hypoadrenalism is a disorder of the adrenal glands. It is characterized by insufficient levels of cortisol and aldosterone. Secondary adrenal insufficiency can occur in case of pituitary pathology. It produces low levels of ACTH and hence patients have low cortisol and aldosterone levels.
Medications:
Acute Addisonian crisis
- Collect blood sample for random serum cortisol, ACTH, random blood sugar, blood urea nitrogen, serum electrolytes, complete blood count before administering medicines.
- Start inj. Primacort (Hydrocortisone 100 mg) i.v. every 6 hours.
- Add i.v. Sodium chloride 0.9% – 1 litre over 30 minutes, followed by 2 to 3 litres over next 24 hours. Avoid this step if there are signs of fluid overload.
- Add tab. Floricot (Fludrocortisone 0.1 mg) 1 tablet once a day.
- For hypoglycemia – give i.v. 25% Dextrose 100 ml over 30 minutes, followed by 10% dextrose 1 litre i.v. over 12 hours with regular blood glucose monitoring.
Once patient improves and tolerates oral fluids, start the maintenance treatment as below
- Tab. Omnacortil 5 (Prednisolone 5 mg) 1 tablet with breakfast. Titrate the dose to a maximum of 60 mg per day.
- Add tab. Floricot (Fludrocortisone 0.1 mg) 1 tablet with breakfast. Titrate the dose to a maximum of 0.2 mg per day.
- Adjust dose of Prednisolone and Fludrocortisone, according to serum electrolytes, blood glucose, blood pressure and plasma renin.
Investigations:
- Complete blood count – to rule out low RBC count and anaemia
- Serum cortisol at 8 am – levels will be lower than normal in Addison’s disease (normal range is 10- 20 mcg/dl)
- Plasma ACTH – low levels suggests secondary adrenal insufficiency i.e pituitary disease and high levels suggest primary adrenal insufficiency.
- Renal function test – to rule out kidney failure
- Serum electrolytes – low sodium, high potassium is associated with Addison’s disease.
- Random blood glucose – can be low in patients with Addison’s disease.
- Adrenal autoantibodies – may be positive if there is autoimmune damage to adrenal glands.
- X ray chest and abdomen – may find primary lung focus in case of secondary adrenal tuberculosis, and adrenal calcification in Addison’s disease.
- CT scan of adrenals – to evaluate possibility of adrenal tumour or metastases.
Referral:
Consider referral to endocrinologist if patient fails to respond or presents with additional complications.