Premier adrenal hypofunction or adrenal insufisience (Addison) comes from adrenal gland and signed by low mineralocorticoid secretion, glucocorticoid, and androgen. Secondary adrenal hypofunction is caused by pituitary secretein from corticotrophin and it is signed by low glycocorticoid secretion. Aldosterone (main corticoid) is always influenced.
Addison disease is relative, because it can occur in every age; young or old. Secondary adrenal hypofunction occurs when the patient suddenly stop using exogenous steroid after long-term therapy or if pituitary injured caused by tumor, infiltrative, or autoimmune proses. If adrenal hypofunction diagnosis is got early then the prognosis is better.
Adrenal crisis or Addisionian crisis is critical deficiency toward mineralocorticoid and glucocorticoid. It basically follows with stress, sepsis, trauma, surgery, or steroid therapy termination in chronically adrenal insufficiency. Because this is a medical emergency, adrenal crisis must be handle appropriately.
Adrenal Hypofunction Causes
Premier Adrenal Hypofunction
- Autoimmune proses while antibody that is circulating responds specifically toward adrenal gland
- Bilateral adrenalectomy
- Hemorrhagic in adrenal gland
- Infection from histoplasmosis and cytomegalovirus
Secondary Adrenal Hypofunction
- Long-term corticosteroid therapy stoppage
- Hypopituitarism cause corticotrophin secretion decrease
- Tumor surgery of gland that produce corticotrophin
- Crisis Adrenal
- Glucocorticoid storage is empty in adrenal hypofunction caused by trauma, surgery, or other physiology stress.
Sign and Symptoms
Primer Adrenal Hypofunction
- Vitiligo area (no pigmentation)
- Asthenia (constant fatigue) is main symptom, and it is usually looked while patient in stress
- Bronze skin color
- Salty foods addiction
- Darken stomach
- Stress tolerance decrease
- Hyper pigmentation in mucus membrane, especially buccal membrane
- Orthostatic hypotension
- Low body weight
Secondary Adrenal Hypofunction
Sign and symptoms of secondary hypofunction are like primer hypofunction sign and symptoms without hyper pigmentation because corticotrophin and hormone that stimulate melanocyte is in low level.
- Crisis Adrenal
- Coma and death
- Fatigue and weakness
- Corticotrophin stimulation test will show cortisol plasma respond toward corticotrophin. This test is given by intravenous for 6 to 8 hours, and it can used for distinguishing premier and secondary adrenal insufficiency.
- If the patient has premier adrenal insufficiency (Addison Disease), the cortisol and plasma in urine cannot increase normally in responding toward corticotrophin.
- If the patient has secondary adrenal insufficiency, corticotrophin repeating doses that is prescribed every day will show cortisol increase continuously till reach normal result. In secondary adrenal hypofunction, aldosterone is in normal level as well.
- Laboratory result shows adrenal insufficiency in patient; sometime it will like Addison disease:
- Cortisol plasma is decreasing low than 10 µl/dL in morning, and lower in evening.
- Decrease in natrium level
- Kalium, Calcium,, and blood urea nitrogen serum is increase
- Hematocrit, lymphocyte, and eosinophil is increase.
Adrenal Hypofunction Treatment
- Corticosteroid replacement for lifetime, usually with cortisone or hydrocortisone
- For Addison disease treatment with fludrocortisone oral is needed to prevent dehydration, hypotension, and electrolyte problem or hyponatremia and hyperkalemia condition
For Adrenal Crisis
- First of all, intravenous hydrocortisone 100 mg , followed by 50 to 100 mg intramuscular or diluted in dextrose or normal saline and it is given in intravenous infusion until the patient condition stabile; Hydrocortisone 300 mg per day and normal saline 3-5 L until patient still have acute stadium of adrenal crisis.
- If patient with adrenal crisis, monitor vital signs, especially hypotension status and other shock sign like low consiousness level and urine output. Assess the patient if there is hypokalemia during treatment.
Periodically assess blood glucose if patient has diabetes history because steroid replacement need insulin dose in balance.
- Note every intake and output of patient. While waiting mineralocorticoid work, make sure patient need adequate fluid if there is excessive fluid loss.
- If patient has other medical diagnosis like post operative condition, the patient will need additional steroid to reach recovery period.
- Suggest patient to be aware of adrenal crisis symptoms and teach him/her how to do self care after hospitalization.
- Schadule diet program to maintain natrium and calcium balance.
- If patient is prescribed steroid, monitor Cushingoid signs like fluid retention in face and eye. Assess the fluid and electrolyte balance, especially if patient is prescribed mineralocorticoid. Monitor body weight and hypertension to know the body fluid status.
- If patient just prescribed glucocorticoid, observe orthostatic hypotension or abnormal electrolyte that indicated mineralocorticoid therapy need.
How to avoid Adrenal Crisis
Adrenal hypofunction need corticoid therapy for lifetime. To help patient with this circumstance makes sure to teach patient about:
- Teach patient how to assess overdoses
- Tell patient that he / she needs additional doses depend on physical stress like cold or flu
- Teach patient how to inject hydrocortisone
- Remind patient that physical stress will need additional cortisone to prevent adrenal crisis
- Suggest patient to provide emergency kit for him / her like hydrocortisone injection
- Remind that infection, injury, or excessive sweat will worsen adrenal crisis
- Ask patient to bring medical id card to show that he / she use steroid.