Adrenal Insufficiency

By Peter Galvin, MD

The adrenal glands, which sit atop of both kidneys, produce the hormone cortisol, which regulates blood glucose, blood pressure, stress response, immune function, and other metabolic functions, and aldosterone, which regulates blood sodium and potassium levels and helps maintain blood pressure and volume. The adrenals are vital to the correct functioning of multiple body systems, and when they fail it is called adrenal insufficiency. Individuals with adrenal insufficiency often have fatigue, nausea, vomiting, abdominal pain, muscle or joint pain, anorexia, and weight loss. Some may also have darkening of their skin color, a sudden drop in blood pressure when they stand up from a sitting or lying position (orthostasis), and salt cravings. Severe adrenal insufficiency can cause low blood pressure, shock, low sodium levels (hyponatremia), confusion, lethargy, and, rarely, death if untreated.

Glucocorticoid-induced adrenal insufficiency is the most common cause of adrenal insufficiency. Most patients with this condition have taken steroid (i.e. prednisone) doses that are higher than what the body normally produces, which suppresses normal production of cortisol from the adrenal glands. Glucocorticoid-induced adrenal insufficiency may occur when people taking high-dose steroids over a long period drastically reduce their dose or suddenly stop taking the steroids completely. This is why anyone who has taken high-dose steroids for a significant period of time must reduce their dosage gradually, often over a period of six months or longer.

Less common causes of adrenal insufficiency are primary adrenal insufficiency, which affects four to 221 per million individuals, and secondary adrenal insufficiency, which affects 140 to 279 per million individuals. Primary adrenal insufficiency most commonly occurs when the immune system produces antibodies that damage or destroy the adrenal glands (Addison disease). Secondary adrenal insufficiency occurs when the pituitary gland in the brain does not produce enough corticotropin, a hormone that stimulates the adrenals to produce cortisol. Causes of secondary disease include pituitary gland tumors, hemorrhage, inflammation, surgery or radiation involving the pituitary gland, or medications such as opiates that decrease corticotropin levels.

Adrenal insufficiency is diagnosed using an early morning blood test for cortisol levels (cortisol levels are highest in the morning and decrease during the day). Low levels of another hormone called dehydroepiandrosterone sulfate (DHEAS) support the diagnosis. Early morning levels of corticotropin can help determine if the condition is primary or secondary. Treatment involves the use of steroids – hydrocortisone, 15 to 25 mg daily, or prednisone, 3 to 5 mg daily. Those with primary (Addison) disease should also take fludrocortisone. If the condition is glucocorticoid-induced, then, as mentioned above, the steroids should be restarted and gradually tapered so that the adrenals can regain normal cortisol production.

The adrenals normally release increased levels of cortisol during times of stress such as fever, surgery, critical illness, acute trauma, substantial blood loss, labor and vaginal delivery, and severe emotional distress. However, those with adrenal insufficiency cannot produce the extra cortisol and are therefore at risk of developing adrenal crisis during these situations. Therefore, these patients must have their steroid doses increased in times of stress and should be instructed on the use of an emergency steroid injection kit to prevent adrenal crisis.

For more information go to the website of the Endocrine Society at www.endocrine.org

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