A meta-analysis of 10 randomized placebo-controlled trials found that dehydroepiandrosterone DHEA supplementation resulted in small improvements in health-related quality of life and depression in women with adrenal insufficiency. Symptoms of adrenal insufficiency; low to normal plasma adrenocorticotropic hormone levels indicate over-replacement.
Dosage may need to increase to 0. Blood pressure; serum sodium and potassium levels; plasma renin activity in the upper normal range. Available as an over-the-counter supplement; can improve mood and quality of life in women. Patients should be counseled about the need for stress-dose glucocorticoids for illnesses and before surgical procedures because destruction of the adrenal glands prevents an adequate physiologic response to stress.
In our practice, we use a stress-dose strategy for outpatient procedures e. This involves a dose of glucocorticoids three times the maintenance dose the day of the procedure and two days after i.
For minor illnesses such as influenza or viral gastroenteritis, the patient can take three times the steroid dose during the illness and resume normal dosing after resolution of symptoms. Patients should also have an injectable form of glucocorticoid intramuscular dexamethasone available in cases of nausea, vomiting, or other situations when oral intake is not possible. Mineralocorticoid replacement generally does not need to be changed for illness or procedures.
However, the dose may need to be adjusted in the summer months when there is salt loss from excessive perspiration. Thyroid hormone therapy in persons with undiagnosed Addison disease may precipitate an adrenal crisis because the thyroid hormone increases the hepatic clearance of cortisol. In addition, patients with a new diagnosis can have a reversible increase in thyroid-stimulating hormone levels because glucocorticoids inhibit secretion. In individuals with type 1 diabetes mellitus, unexplained hypoglycemia and decreasing insulin requirements may be the initial signs of Addison disease.
Patients with Addison disease should be treated in conjunction with an endocrinologist and be monitored on a regular basis for appropriate hormone therapy Table 3. Glucocorticoid doses should be titrated to the lowest tolerated dose that controls symptoms to minimize the adverse effects of excess glucocorticoid. It is important to instruct patients to learn the proper guidelines for stress dosing of glucocorticoids, to have an injectable form of glucocorticoid available, and to wear an adrenal insufficiency medical alert identification.
Autoimmune thyroid disease Hashimoto disease or Graves disease 8 , 28 — Thyroid-stimulating hormone, thyroid peroxidase antibody, and thyroid-stimulating immunoglobulin levels. Celiac disease Type 1 diabetes mellitus 8 , 28 — 30 , Hypoparathyroidism 8 , 28 — 30 , Primary ovarian insufficiency Pernicious anemia 8 , 28 , Complete blood count, vitamin B 12 level, and parietal cell antibody level. Primary gonadal failure testes NOTE : Data compiled from multiple studies across different populations.
Information from references 8 , and 28 through Data Sources : Articles were searched using the PubMed and Cochrane databases, and obtained from the Essential Evidence Plus summary provided by the journal editors. The search terms included Addison disease, autoimmune primary adrenal insufficiency, cosyntropin stimulation testing, glucocorticoid treatment, mineralocorticoid treatment, DHEA treatment, and the immunology of Addison disease.
Articles with abstracts that were published in English within the past five years were the primary focus; older literature on the signs, symptoms, and diagnosis of Addison disease were cited as appropriate. Search dates: December and October Already a member or subscriber?
Log in. Interested in AAFP membership? Learn more. Reprints are not available from the authors. Immunologic endocrine disorders. J Allergy Clin Immunol. Autoimmune adrenal insufficiency and autoimmune polyendocrine syndromes: autoantibodies, autoantigens, and their applicability in diagnosis and disease prediction [published correction appears in Endocr Rev. Endocr Rev. Autoimmune polyendocrine syndromes. N Engl J Med. Adrenal cortex and steroid hydroxylase autoantibodies in children with organ-specific autoimmune diseases: markers of high progression to clinical Addison's disease.
J Clin Endocrinol Metab. Adrenal cortex and steroid hydroxylase autoantibodies in adult patients with organ-specific autoimmune diseases: markers of low progression to clinical Addison's disease. Estimated risk for developing auto-immune Addison's disease in patients with adrenal cortex autoantibodies. Clin Endocrinol Oxf. Clinical, immunological, and genetic features of autoimmune primary adrenal insufficiency: observations from a Norwegian registry.
Burke CW. Adrenocortical insufficiency. Clin Endocrinol Metab. Delayed diagnosis of adrenal insufficiency is common: a cross-sectional study in patients. Am J Med Sci. Hemodynamic changes in acute adrenal insufficiency. Intensive Care Med. Diagnosis of adrenal insufficiency: evaluation of the corticotropin-releasing hormone test and basal serum cortisol in comparison to the insulin tolerance test in patients with hypothalamic-pituitary-adrenal disease.
The natural history of adrenal function in autoimmune patients with adrenal autoantibodies. J Endocrinol. Adrenocorticotropin stimulation test: effects of basal cortisol level, time of day, and suggested new sensitive low dose test. Rapid adrenocorticotropic hormone test in practice.
Retrospective review. Am J Med. Arlt W, Allolio B. Adrenal insufficiency. Crown A, Lightman S. Why is the management of glucocorticoid deficiency still controversial: a review of the literature. Influence of hydrocortisone dosage scheme on health-related quality of life in patients with adrenal insufficiency. Inadequacies of glucocorticoid replacement and improvements by physiological circadian therapy. Eur J Endocrinol. The ACTH test may not be accurate in people who have had secondary adrenal insufficiency for a shorter time because their adrenal glands have not yet shrunk and can still respond to ACTH.
A health care professional will give you an IV injection of the hormone insulin , which lowers your levels of blood glucose. The dose is high enough to cause hypoglycemia, which occurs when your blood glucose level drops too low. Hypoglycemia causes physical stress, which normally triggers the pituitary to make more ACTH.
A health care professional will draw your blood at the beginning of the test and again every half hour during the next 2 hours. The ITT is the most reliable test to diagnose secondary adrenal insufficiency. This test can also tell secondary from tertiary adrenal insufficiency. A health care professional will give you an IV injection of CRH and take samples of your blood before and 30, 60, 90, and minutes after the injection to measure ACTH levels.
This result shows secondary adrenal insufficiency. A slow rise in ACTH levels suggests tertiary adrenal insufficiency. Once doctors diagnosis and identify the type of adrenal insufficiency, they may use blood and imaging tests to find the exact cause.
If Addison's disease is suspected, blood tests will be carried out to measure the levels of sodium, potassium and cortisol in your body. A low sodium, high potassium or low cortisol level may indicate Addison's disease. You may need to see a hospital hormone specialist endocrinologist for your blood to be tested for the following:.
If cortisol in your blood is low or your symptoms strongly suggest Addison's disease, you'll need to have a synacthen stimulation test to confirm the diagnosis. Your GP may refer you to an endocrinology unit a unit that specialises in the study of hormones for the test.
How urgent the referral is will depend on how severe your symptoms are. Synacthen is a man-made synthetic copy of the adrenocorticotrophic hormone ACTH. ACTH is naturally produced by the pituitary gland a pea-sized gland below the brain to encourage the adrenal glands to release cortisol and aldosterone.
When synacthen is given, the adrenal glands should respond in the same way as they would to ACTH by releasing cortisol and other steroid hormones into the blood. A blood sample will be taken and tested for cortisol before an injection of synacthen is given into your arm. Further blood samples will be taken to measure cortisol after 30 minutes and after 60 minutes. If the ACTH level is high but the cortisol and aldosterone levels are low, it's usually confirmation of Addison's disease.
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