Adrenal insufficiency

Abstract

Glucocorticoids have an important role in the metabolic regulation, in the cardiovascular, immune, and nervous systems, and in the adaptive response to stress. The adrenal insufficiency can be caused by a primary disease of the adrenal (low concentration of cortisol and high ACTH levels) or secondary to the hypothalamic-pituitary dysfunction (low cortisol and ACTH levels). Chronic glucocorticoid deficiency leads to insidious and unspecific symptoms (weakness, fadigue, gastrintestinal symptoms, anorexia, loss of weight). In the presence of mineralocorticoid deficiency clinical findings are also associated to hypotension, syncope, dehydration and circulatory shock, with hiponatremia and hiperkalemia. Management consists of cortisol replacement (hydrocortisone PO, 12-15 mg/m2 cortisone acetate PO, 25mg/day or prednisone PO, 5-10 mg/day) for secondary adrenal insufficiency and cortisol and mineralocorticoid replacement (9a fluorohydrocortisone PO, 0.1mg/dia) for primary cause of adrenal insufficiency. Infections, traumas and surgeries can precipitate an acute crisis, Addisonian crisis, a life- threatening situation if not treated. Treatment consists of replacing intravascular volume with sodium chloride (0.9% NaCl 2L/h) and glucocorticoid (100 mg IV of hydrocortisone every 6 hours). Addisonian crisis is frequently associated with infection, therefore this diagnosis must be confirmed and properly treated with antibiotics.