Adrenal insufficiency (patient information)

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 * Associate Editor(s)-In-Chief: Jinhui Wu, M.D.

Overview
Adrenal insufficiency is a hormonal disorder that occurs when the adrenal glands do not produce enough of certain hormones. Adrenal insufficiency can be primary or secondary. Usual causes of adrenal insufficiency are genetic defects of adrenal gland, underactive parathyroid glands, pernicious anemia, chronic active hepatitis, diabetes and cancer. Symptoms include chronic, worsening fatigue, muscle weakness, loss of appetite, weight loss, nausea and vomiting, diarrhea and hypotension. ACTH stimulation test and CRH stimulation test are main tests for the diagnosis of adrenal insufficiency. Treatments involve replacing or substituting the hormones that the adrenal glands are not making, such as hydrocortisone, prednisone, dexamethasone or fludrocortisone acetate. Addisonian crisis is fatal, the preventive measures are very important for patients with adrenal insufficiency when stress happens.

What are the symptoms of Adrenal insufficiency?
The symptoms of adrenal insufficiency usually begin gradually. Usual symptoms include:
 * Chronic, worsening fatigue
 * Muscle weakness
 * Loss of appetite
 * Weight loss
 * Nausea and vomiting
 * Diarrhea
 * Hypotension
 * Hypoglycemia
 * Headache

Other health problems may also cause these symptoms. Only a doctor can tell for sure. A person with any of these symptoms should tell the doctor so that the problems can be diagnosed and treated as early as possible.

Who is at highest risk?

 * Genetic defects of adrenal gland
 * Underactive parathyroid glands
 * Pernicious anemia
 * Chronic fungal infections
 * Chronic active hepatitis
 * Diabetes
 * Vitiligo
 * Tuberculosis
 * Amyloidosis
 * AIDS-associated infections
 * Cancer
 * Surgical removal of the pituitary gland or hypothalamus

Diagnosis

 * ACTH stimulation test: The ACTH stimulation test is the most common test for patients who are suspected of diagnosing adrenal insufficiency. During this test, before and after being injected ACTH, the patient is detected with the level of blood cortisol and urine cortisol. In normal person, after an ACTH injection, it may show a rise in blood and urine cortisol levels. Patients with causes of adrenal insufficiency have little or no increase in cortisol levels.
 * CRH stimulation test: This test can differ the primary and secondary adrenal insufficiency. In this test, the patient is injected synthetic CRH and measured blood cortisol before and 30, 60, 90, and 120 minutes after the injection. The leval of blood cortisol in people with primary adrenal insufficiency such as Addison’s disease, demonatrates high levels of ACTH but no cortisol. For the patients with secondary adrenal insufficiency, they appear absent or delayed ACTH.
 * Abdominal x-ray test: An x-ray image of abdomine allows the doctor to check the shape and size of the adrenal glands.
 * Abdominal ultrasound: This is an painless test which uses sound waves to create a picture of the internal organs. It can help doctor reveal any signs in adrenal glands.
 * Cranial CT and MRI: These imaging tests can confirm the size and shape of pituitary gland and hypothalamus and show the organs near them. It is useful for the diagnosis of secondary adrenal insufficiency. CT scan produce a series of x-ray pictures giving cross-sectional images. A magnetic resonance imaging (MRI) scan may show a three-dimensional image of this region.

When to seek urgent medical care?
The urgent, severe worsening symptoms adrenal insufficiency is called an addisonian crisis or acute adrenal insufficiency. It is fetal and needs urgent medical care. If you experience either of the following symptoms, seeking urgent medical care as soon as possible:
 * Sudden, penetrating pain in the lower back, abdomen, or legs
 * Severe vomiting and diarrhea
 * Dehydration
 * Hypotension
 * Loss of consciousness

Treatment options

 * General therapy: Treatments of adrenal insufficiency involve replacing or substituting the hormones that the adrenal glands are not making. For example, cortisol can be replaced with a synthetic glucocorticoid such as hydrocortisone, prednisone, or dexamethasone. Aldosterone can be replaced with oral doses of fludrocortisone acetate. Before treatment starts, ask your health care team about possible side effects and how treatment may change your normal activities. The doses of each medication are adjusted to meet the needs of the individual under the doctor's direction.
 * Therapy of addisonian crisis: For an addisonian crisis, standard therapy is needed as soon as possible. It involves intravenous injections of glucocorticoids and large volumes of intravenous saline solution with dextrose. This treatment usually brings rapid improvement.

Diseases with similar symptoms

 * Riehl's melanosis
 * Hepatic cirrhosis
 * Hemochromatosis
 * Acanthosis nigricans

Where to find medical care for Adrenal insufficiency?
Directions to Hospitals Treating adrenal insufficiency

Prevention of Adrenal insufficiency
Acute adrenal insufficiency is fatal. When patients with adrenal insufficiency experience the following stress, they must be very careful.
 * Surgery: People who are not currently taking glucocorticoids but who have taken long-term glucocorticoids in the past year, and people with chronic adrenal insufficiency should tell their doctor before surgery. These patients must be treated with intravenous glucocorticoids and saline before surgery and continues until the patient is fully awake after surgery and able to take medication by mouth.
 * Illness: Patients with adrenal insufficiency should know the essentiality of increasing medication during such periods of stress. During illness, oral dosing of glucocorticoid needs to be adjusted to mimic the normal response of the adrenal glands on the body. When significant fever or injury happen, the patients may require triple oral dosing. Once recovery from the stress event, doses can be returned to maintenance levels. Be careful, when the conditions of severe infections, vomiting, or diarrhea occur, these signs suggest the possibility of addisonian crisis.
 * Pregnancy: If nausea and vomiting in early pregnant woman with adrenal insufficiency interfere with taking medication by mouth, injections of the hormone may be necessary. During delivery, treatment is similar to that of people needing surgery.

What to expect (Outlook/Prognosis)?
The prognosis of adrenal insufficiency depends on:
 * Whether the patient has received hormone replacement or not.
 * When stress happens on the patients with adrenal insufficiency, whether the treatment protocols are adjusted or not.