Brandon Fainstad, MD
Expert Review – Pending
Objectives
- Determine physiologic difference between primary, secondary & tertiary adrenal insufficiency
- Determine the appropriate indications for testing and how to interpret hormone levels for the diagnosis of adrenal insufficiency
- Identify the basic principles and initial exogenous hormone doing for the management of adrenal insufficiency
Teaching Instructions
Plan to spend at least 30-60 minutes preparing for this talk by using the Interactive Board for Learning/Preparing and clicking through the graphics animations to become familiar with the flow and content of the talk. This can be presented in two ways:
1. Project the “Interactive Board for Presentation”
or
2. Reproduce a drawing of the presentation on a whiteboard.
With either method, print out copies of the Learner’s Handout so learners can take notes as you expand on the pathophysiology and management. Begin with reviewing the objectives for the session. Advance through the initial animations to review the normal physiology of the HPA axis and RAA axis. Then proceed to a discussion on adrenal insufficiency. Start by asking the learners how AI is diagnosed (when to order and how to interpret cortisol levels). Then move through the three levels of adrenal insufficiency: 1. Primary – adrenal, 2. Secondary – pituitary and 3. Tertiary – hypothalamic. Click on the Primary, Secondary or Tertiary buttons to reveal etiology, testing to differentiate and treatment.
Printouts
Interactive Boards
For Learning
Use for self-directed learning and for preparing to present
For Teaching
Use for Presenting – there is less text and fewer pop-ups
Take Home Points
- Primary adrenal insufficiency is more commonly associated with adrenal crisis, in contrast with central (secondary and tertiary), because of the mineralocorticoid deficiency which results in hypovolemia.
- A morning (8 AM) cortisol of < 3 is very predictive of adrenal insufficiency and > 15 essentially rules it out. All other values require an ACTH stimulation test.
- Adrenal crisis is a syndrome of hypotension/shock with possible fever, abdominal pain, nausea, and fatigue. It is a medical crisis and should be treated with stress dose steroids while awaiting diagnostic confirmation.
References
Bancos, I et al. Diagnosis and management of adrenal insufficiency. Lancet Diabetes and Endocrinology. 2015; 3: 216-26.
Charmandari, E, Nicolaides, NC & Chrousos, GP. Adrenal Insufficiency. Lancet. 2014; 383: 2152-67.
Bastin, M, et al. Effects of Etomidate on Adrenal Suppression: A Review of Intubated Septic Patients. Hospital Pharmacy. 2014 Feb; 49(2): 177–183.
