Dr. Andy

Reflections on medicine and biology among other things

Saturday, December 03, 2005

Adrenal insufficiency

As shown in the figure on the right, the adrenal gland produces cortisol in response to ACTH (Adrenocorticotropin hormone) produced by the pituitary.

Cortisol is the bodies very own corticosteroid, doing things like supporting blood pressure and suppressing inflammation. Prednisone and dexamethasone are other corticosteroids given pharmacologically. If you don't make your own cortisol, you die unless you get replacement therapy. Tuberculosis is the most common cause of adrenal insufficiency (i.e. cortisol deficiency) worldwide, but autoimmune attack on the adrenal gland is the most common cause in the US. In these cases adrenal insufficiency usually develops slowly, giving the body a chance to adapt. In overwhelming infection, for example, the adrenal can be deprived of blood supply, infarct and cortisol production can be lost suddenly, leading to death unless someone recognizes what is going on and gives replacment therapy.

More rarely, the pituitary or hypothalamus can fail, leading to no ACTH and no cortisol, even though the adrenal is working normally. These are termend secondary (pituitary) and tertiary (hypothalamus) adrenal insufficiency. To distinguish between primary and higher order adrenal insufficiency, endocrinologists do something called an ACTH stimulation test where they inject ACTH and look for a rise in cortisol (endocrinologists love doing tests to either stimulate or suppress secretion of hormones). There are both regular and low-dose ACTH stim tests, but until now, I didn't know why. According to an article in the JAMA (no free text):
The choice of the 250-µg dose is based solely on the fact that ACTH comes in 250-µg vials. However, with this dose, ACTH reaches plasma levels that are approximately 1000 times the values observed in maximally stressed healthy individuals, thereby potentially causing a falsely normal cortisol response by an adrenal gland that is in fact partially impaired
Glad to see they were thinking when they came up with the original test! Hence the development of "low-dose" ACTH stim testss which use just 1ug, a more physiologic dose.

As an allergist, my biggest concern is secondary adrenal insufficiency caused by prolonged use of steroid medications like prednisone. Sometimes even high doses of inhaled steroids can lead to adrenal suppression (patients are on so much steroid medicine the adrenal stops making your own).

Note the steroids discussed here are distinct from the steroids used by most pro athletes.

This "patient page," which accompanies the JAMA article gives more info on adrenal insufficiency


At 1:03 PM, Blogger Joan said...

It's shocking to me how little is known about diagnosing and treating adrenal insufficiency, especially since it often accompanies auto-immune hypothyroidism, and treatment with thyroid hormones is contraindicated until the adrenals are healed.

I'm glad to see someone is following up on this. My endo consistently denied I had any problems with my adrenals, since I passed my stim test with flying colors. Now I know why. Thanks.

At 1:53 AM, Anonymous Carol said...

There seems to be differing opinions on whether to use a drug such as cortef versus a naturalistic approach to replace the adrenal hormones. Is there a real reason for one over the other?
Is Adrenal insufficiency and Addisons Disease the same?
Would appreciate any comments.

At 10:54 PM, Anonymous Jayne said...

This 'reasoning' behind the decision for the ACTH doseage in the stim test is a joke. But I'm not surprised. Addison's is a disease process that's overlooked - many people have to go to hell and back before they're diagnosed and that's if they're lucky. My friend never made it. Guess that stomach flu was more serious than her doctor thought. Even in the ER, doctors rarely know what Addison's is. This is all so stupid in this day and age. Physicians, educate yourselves so you recognise that zebra when it walks in!

At 11:34 PM, Anonymous C. Andreasen said...

Please, anyone who even thinks they are suffering from
adrenal fatique, get a copy of "Safe Uses of Cortisol" by
William Jeffries, published by Charles C Thomas.

At 6:07 PM, Anonymous Anonymous said...

My son has just been diagnosed as having adrenal insufficiency, to wit, insufficient cortisol. His E/D doc wants him to take Cortef twice a day. My head is swimming. We've fought for a diagnosis and now I am wondering if the treatment is worse than the disease.

At 6:35 PM, Anonymous Paula said...

I have a 16 year old daughter that always had irregular periods (1 every 4 - 6 months) and sweated more than we thought normal.

She also has/had asthma.

When she turned 16 her pediatrician suggested an OB/GYN. The OB/GYN put her on estro-step birth control pills.

In 16 days she gained 12 lbs.

Had a huge decrease in energy level and just overall felt like crap.

She stopped taking the pills but continued to gain over 30 lbs in 7 weeks.

Endo did testing and told us her thyroid was more than twice the size it should be and she has thyroid antibodies. He put her on .137 synthroid.

The blood work also showed an elevated cotisol level but the endo did not seem concerned about it.

Pediatrician repeated blood work and the cortisol came back lower than normal???

She then went to the endo/diabetes department at childrens in pittsburgh.

They did blood work again and said her 17oh progesterone was high and gave her an acth stim test.

We've not yet received the results from it.

She continues to feel awful with low energy.

She plays tennis everyday and has started having like a sugar crash with shaking and dizziness after about an hour of playing.

Anyone have any thoughts on where to go from here? Recommend a doctor?


At 8:12 PM, Anonymous Anonymous said...

I do have some thoughts for your daughter. She could have LOCAH or late-onset congenital adrenal hyperplasia. It is also known as non-classical 21 OHP CAH. She can be medicated and find relief within a few months if this is in fact the diagnosis. It is not a difficult thing to live with once you have a correct diagnosis. If the ACTH stim test comes back indicating an abnormal level, I would highly suggest getting a genetic test done for NC21OHP CAH. That is the only way to confirm or rule out the diagnosis. It is a very easily missed condition that is actually hypothesized to happen in 1 in 100 births in varying degrees. Often it is misdiagnosed as poly-cystic ovarian syndrome due to the increased androgens. Best of luck.

At 3:34 AM, Anonymous Anonymous said...

Discovered your site whilst surfing, thank you. I have Hashimoto's and although am on Levothyroxine, still suffer from disabling fatigue and other symptoms. My doc arranged for me to have a short Synacthen Test & the results are: Cortisol: normal basal level with subnormal response. The pathologist diagnosed 'Possible Stress - possible depletion of stores with chronic stress.' Sigh - My doc said he didn't want to give me steroids because he might not be doing me any favours. Great. So do I now have to struggle through the rest of my life with no energy and feeling so ill? Any advice most welcome.

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At 8:00 AM, Anonymous Anonymous said...

husband has been treated with prednisone off and on over last two years for crohn's. since going off pred afew months ago has been having bad panic attacks along with other related symtons. will his doctor think i am nuts if i suggest he test his adrenal glands? anonymous

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i cant tolerate my stress very well.please tell me what should i do? i get nervous very easily n i drink less water.

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At 12:02 PM, Blogger christina b said...

my son who is three and a half has been diagnosed with having adrenal insufficiency what is this? he has been taking prednisilone on a reg basis since he was 10 months on steroid inhalers i have also found out my uncle has addisons could this be hareditory. i have no info on this what so ever. what is is and is this condition serious?

At 2:30 PM, Anonymous Anonymous said...

Please see an integrative doctor. They know how to treat adrenal insufficiency. Alternatively, order the test yourself through directlabs.com. I used the Neuroscience neuroadrenal profile. It's awsome and accurate. I took it twice with similar results. Do the Dr. Wilson protocol adrenalfatigue.org) for treatmentof low cortisol levels. I also take rhodiola with the protocol.

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My doc said he didn't want to give me steroids because he might not be doing me any favours. Great. So do I now have to struggle through the rest of my life with no energy and feeling so ill? Any advice most welcome.

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At 8:54 AM, Anonymous Anonymous said...

I've been on pred for an autoimmune disease for 2 yrs. developed Cushings from it - got down to 2.5 mg on a very slow taper but got increased in the hospital after an asthma attack. Started a quick taper from there and ended up collapsing/fainting from what they said was adrenal insufficiency.... At 20 mg pred... Which was more than I had been on in months. Tapering slowly again now - at 12.5/15 mg alternating days and getting very lightheaded but BP is normal so drs do not think its the taper. Needless to say, i'm a bit scared of a repeat collapse that came out of nowhere. I was actually having a goid day.... Hppy, great mood - and it just hit me out of nowhere. Any signs of trouble to be aware of? I know with tapering, there are going to be problems - just don't know what are significant warnings!

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