Adrenal insufficiency acute

Unfortunately steroids merely suppress the inflammation while the underlying cause of the disease remains. Another serious concern about steroids is that of toxicity. The abmpt withdrawal of glucocorticoid steroids results in acute adrenal insufficiency. Long term use may induce osteoporosis, peptidic ulcers, the retention of fluid, or an increased susceptibiUty to infections. Because of these problems, steroids are rarely the first line of treatment for any inflammatory condition, and their use in rheumatoid arthritis begins after more conservative therapies have failed. 

Potassium is contraindicated in patients who are at risk for experiencing hyperkalemia, such as those with renal failure, oliguria, or azotemia (file presence of nitrogen-containing compounds in the blood), anuria, severe hemolytic reactions, untreated Addison s disease (see Chap. 50), acute dehydration, heat cramps, and any form of hyperkalemia Potassium is used cautiously in patients with renal impairment or adrenal insufficiency, heart disease, metabolic acidosis, or prolonged or severe diarrhea. Concurrent use of potassium with... 

Describe the pharmacologic management of patients with acute and chronic adrenal insufficiency. 

Bilateral adrenal hemorrhage or infarction—usually due to anticoagulant therapy, coagulopathy, thromboembolic disease, or meningococcal infection. Causes acute adrenal insufficiency. 

Clinical Presentation and Diagnosis of Acute Adrenal Insufficiency (Adrenal Crisis)1,3,4 ... 

Evaluate patients presenting with the typical clinical manifestations for chronic or acute adrenal insufficiency. 

In patients presenting with acute adrenal crisis who have not been diagnosed previously with adrenal insufficiency, immediate treatment with injectable hydrocortisone and intravenous saline and dextrose solutions should be initiated prior to confirmation of the diagnosis because of the life-threatening nature of this condition. Determine and correct the underlying cause of the acute adrenal crisis (e.g., infection). 

The goals of treatment for adrenal insufficiency are to limit morbidity and mortality, return the patient to a normal functional state, and prevent episodes of acute adrenal insufficiency. 

Acute adrenal insufficiency (also known as adrenal crisis or Addisonian crisis) represents a true endocrine emergency. 

Adrenal hemorrhage - A6rena hemorrhage with resultant acute adrenal insufficiency has occurred. 

Autoimmune polyglandular syndrome-Chron c autoimmune thyroiditis may occur in association with other autoimmune disorders. Treat patients with concomitant adrenal insufficiency with replacement glucocorticoids prior to initiation of treatment. Failure to do so may precipitate an acute adrenal crisis when thyroid hormone therapy is initiated. Patients with diabetes mellitus may require upward adjustments of their antidiabetic therapeutic regimens. Nontoxic diffuse goiter or nodular thyroid disease Use caution when administering levothyroxine to patients with nontoxic diffuse goiter or nodular thyroid disease in order to prevent precipitation of thyrotoxicosis. If the serum TSH is already suppressed, do not administer levothyroxine. 

Hydrocortisone is a relatively short-acting agent. For replacement therapy in adrenal insufficiency it is administered orally and in combination with fludrocortisone. Hydrocortisone sodium succinate is a water-soluble derivative which can be used parenter-ally in emergencies such as acute bronchospasm and hypersensitivity reactions like anaphylactic shock. 

IV.a.1.9. Adrenal suppression. It results from inhibition of pituitary ACTH secretion, and some suppression of the normal adrenal response to stress may persist for years after stopping therapy. Rapid withdrawal of corticosteroid therapy can therefore precipitate dangerous acute adrenal insufficiency ( Addisonian crisis , with hypotension, vomiting, coma and ultimately death), and for this reason steroid treatment should always be reduced gradually, sometimes over many months, according to the dose and duration of therapy. 

In patients with longstanding hypothyroidism and those with ischemic heart disease, rapid correction of hypothyroidism may precipitate angina, cardiac arrhythmias, or other adverse effects. For these patients, replacement therapy should be started at low initial doses, followed by slow titration to full replacement as tolerated over several months. If hypothyroidism and some degree of adrenal insufficiency coexist, an appropriate adjustment of the corticosteroid replacement must be initiated prior to thyroid hormone replacement therapy. This prevents acute adrenocortical insufficiency that could otherwise arise from a thyroid hormone-induced increase in the metabolic clearance rate of adrenocortical hormones. 

Monitor patients switched from chronicsystemic corticosteroids to avoid acute adrenal insufficiency in response to stress... 

Substitution therapy for deficiency states acute or chronic adrenal insufficiency, congenital adrenal hyperplasia, and adrenal insufficiency secondary to pituitary insufficiency, nonendocrine disorders arthritis rheumatic carditis allergic, collagen, intestinal tract, liver, ocular, renal, shin diseases bronchial asthma cerebral edema malignancies PO 5-60 mg/day in divided doses. Intra-articular, Intralesional (acetate) 4-100 mg, repeated as needed. Intra-articular, Intralesional (sodium phosphate) 2-30 mg, repeated at 3-day to 3-week intervals, as needed. IM (acetate, sodium phosphate) 4-60 mg a day. 

Substitution therapy in deficiency states acute or chronic adrenai insufficiency, congenital adrenal hyperplasia, and adrenal insufficiency secondary to pituitary insufficiency nonendocrine disorders arthritis rheumatic carditis aiiergic, coiiagen, intestinai tract, liver, ocular, renal, shin diseases bronchiai asthma cerebrai edema maiignancies PO... 

Synthetic glucocorticoids are prednisolone, prednisone, methylprednisolone, dexamethasone, betamethasone and triamcinolone (Table 13.2). Hydrocortisone is available as either succinate or phosphate salts for oral and intravenous administration. It is the drug of choice when a rapid effect is required, e.g. acute adrenal insufficiency, or as peri-operative replacement therapy. Prednisolone can also be given intravenously. It has about 0.8 of the mineralocorticoid activity of hydrocortisone. Prednisone is a prodrug that is converted to prednisolone in the body. For chronic therapy, synthetic steroids without mineralocorticoid activity are preferred, such as dexamethasone, betamethasone or triamcinalone. Beclo-metasone passes membranes poorly and is more active topically than when given orally. It is used as an aerosol for chronic rhinitis and asthma, and topically in severe eczema. Fludrocortisone is a synthetic halogenated derivate of cortisol that is used for its mineralocorticoid effect. 

Chronic adrenocortical insufficiency is characterized by weakness, fatigue, weight loss, hypotension, hyperpigmentation, and inability to maintain the blood glucose level during fasting. In such individuals, minor noxious, traumatic, or infectious stimuli may produce acute adrenal insufficiency with circulatory shock and even death. 

Caution [C, /-] Contra Active varicella Infxn, serious Infxn except TB, fungal Infxns Disp Table VI-1 SE T Appetite, hyperglycemia, -i- K+, osteoporosis, nervousness, insomnia, steroid psychosis, adrenal suppression, fat redistribution, hypertension EMS Acute adrenal insufficiency can result w/ hypotension and shock if chronic steroids are abruptly stopped. Sxs can include abd pain, tach, confusion, hypotension, and chills. Support w/ IV fluids and steroid admin. GI perforation w/ chronic use. Can T Infxn risk and fracture risk from osteoporosis. Steroid psychosis can cause anxiety, agitation, euphoria, insomnia, mood swings, personality changes, depression, and memory loss usually at does of prednisone over 20 mg/d OD Acute hyperglycemia supportive care... 

Zwaan CM, Odink RJ, Delemarre-van de Waal HA, Dankert-Roelse JE, Bokma JA. Acute adrenal insufficiency after discontinuation of inhaled corticosteroid therapy. Lancet 1992 340(8830) 1289-90. 

Four boys 4—8 years old with symptomatic adrenal insufficiency had all used consistent high doses of fluticasone propionate 1000-1500 micrograms/day over extended periods (16 months to 5 years) (58). They presented with acute hypoglycemia secondary to iatrogenic adrenal suppression, with abnormal corticotropin tests, although none had Cushingoid features. 

Adrenal insufficiency can be associated with hypothyroidism (either by autoimmune destruction or due to hypophyseal disease) and carries the risk of acute Addisonian crisis if thyroid substitution precedes glucocorticoid therapy. The diagnostic problem presented by the fact that a few patients with central hypothyroidism have a moderately increased serum TSH should be kept in mind (62). 

An acute episode of adrenal insufficiency secondary to adrenal hemorrhage occurred in one patient receiving aldesleukin (5). 

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