Introduction
The human body consists of two adrenal glands, present in a way that one adrenal gland is situated above one kidney. Adrenal glands produce three essential hormones needed for the human body's basic functions.
What Is Adrenal Insufficiency?
When the adrenal glands cannot produce enough cortisol or aldosterone hormones, adrenal insufficiency results, it is a life-threatening disorder that affects people of all age groups and does not have a gender preference. Depending on the cause of the reduced adrenal hormone production, adrenal insufficiency is classified into three types:
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Primary Adrenal Insufficiency: Also called Addison's disease, it occurs due to damage or dysfunction of the adrenal gland, resulting in reduced cortisol and aldosterone production. In the case of primary adrenal insufficiency or Addison's disease, hyperpigmentation results in dark skin and bluish-black discoloration of the mouth, nipples, vagina, rectum, or scrotum. These characteristic features help in distinguishing between primary and secondary adrenal insufficiency.
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Secondary Adrenal Insufficiency: In this type of adrenal insufficiency, there is a problem with the ACTH secretion by the pituitary gland. As a result of reduced ACTH production, the adrenal hormone level is also affected.
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Tertiary Adrenal Insufficiency: In the case of tertiary adrenal insufficiency, there is a problem with the hypothalamus that stimulates the pituitary gland to produce ACTH hormone, which, in turn, is responsible for the synthesis and release of adrenal hormones like cortisol and aldosterone.
What Are the Causes of Adrenal Insufficiency?
Primary adrenal insufficiency results from the immune system mistakenly attacking healthy adrenal glands. Other contributing factors include:
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Fungal infections.
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Tuberculosis affects the adrenals.
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Inherited disorders of endocrine glands.
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Cancer.
What Is Adrenocorticotropic hormone (ACTH) Deficiency?
A deficiency in adrenocorticotropic hormone (ACTH) can lead to adrenal insufficiency, affecting the stress response of the body. The primary treatment involves hormone replacement therapy to supplement the inadequate production of cortisol. Continuous monitoring and adjustments in medication are crucial to maintaining optimal hormone levels. Individuals with ACTH deficiency often face symptoms such as fatigue and weakness, necessitating close medical management to achieve a balanced and healthy lifestyle.
What Causes Secondary Adrenal Insufficiency?
Secondary adrenal insufficiency is caused by insufficient production of adrenocorticotropic hormone. This can occur due to the following reasons:
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Long-term corticosteroid use, such as for rheumatoid arthritis or asthma, can lead to secondary adrenal insufficiency. This occurs when the adrenal glands do not respond to ACTH, causing metabolic stress.
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Reduced blood flow to the pituitary gland.
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Tumors of the pituitary gland.
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Surgical removal of the pituitary gland.
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Radiation therapy to the pituitary gland.
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Panhypopituitarism due to infection, trauma, granulomas, etc.
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Failure to produce adrenocorticotropic hormone.
What Are the Symptoms of Secondary Adrenal Insufficiency?
Symptoms of almost all types of adrenal insufficiency are similar. However, it differs from one person to another. The following are the symptoms of secondary adrenal insufficiency:
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Tiredness.
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Weakness.
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Feeling dizzy.
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Loss of weight.
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Appetite loss.
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Dehydration.
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Nausea and vomiting.
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Hypoglycemia (low blood sugar level).
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Muscle ache.
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Diarrhea.
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Hypotension (reduced blood pressure).
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Irregular or no menstruation.
The below symptoms are seen in severe, untreated cases:
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Severe fatigue.
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Severe abdominal pain.
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Renal failure.
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Dangerously low levels of blood pressure.
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Shock.
How Is Secondary Adrenal Insufficiency Diagnosed?
The diagnosis of secondary adrenal insufficiency includes:
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Serum Cortisol Level: Cortisol level in the blood is measured by this test. A reduction in the level of serum cortisol denotes adrenal insufficiency.
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Serum Adrenocorticotropic Hormone: The level of adrenocorticotropic hormone in the blood is an essential indicator of adrenal insufficiency caused by secondary and tertiary means. In both the above cases of adrenal insufficiency, there is a decreased level of ACTH in the blood.
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Prolonged ACTH Stimulation Test: Secondary and tertiary adrenal insufficiency is diagnosed with the help of this test. In this test, one milligram of Cosyntropin is given intramuscularly, followed by the measurement of cortisol levels at different hour intervals, say, 1, 6, 12, and 24, for 24 hours. In the case of secondary and tertiary forms of adrenal insufficiency, there is an increase in cortisol levels even after a day, that is, 24 hours. In Addison's disease, cortisol levels rise only for the first hour, and there is not much of a difference after the one hour.
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Imaging Tests: Imaging tests like CT (computerized tomography) scans and MRI (magnetic resonance imaging) scans are used to determine the size and presence of any abnormality in the pituitary gland.
What Is the Treatment for Secondary Adrenal Insufficiency?
Glucocorticoid treatment is the only available treatment in case of secondary adrenal insufficiency. In the case of secondary adrenal insufficiency caused due to panhypopituitarism, treatment is required for other associated pituitary deficiencies. Depending on which hormone is deficient, glucocorticoids are recommended in people with cortisol deficiency; Hydrocortisone or Prednisone is recommended.
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Hydrocortisone: A maximum dose of 15 to 30 mg (milligrams) of Hydrocortisone should be given in two to three doses. It can be given in one of two ways:
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Of the total dose, half should be given as a morning dose, and the remaining should be split and given in the afternoon and evening.
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Two-thirds of the dose can be given in the morning and the remaining one-third in the evening.
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Prednisone: 4 to 5 mg of Prednisone is given orally in the morning, followed by 2.5 mg in the evening.
Note: Corticosteroids are not usually prescribed before going to bed because they can bring about difficulty in sleeping.
What Are the Complications of Adrenal Insufficiency?
A critical complication of acute adrenal insufficiency is the Addisonian crisis, which can occur during periods of stress such as fever, surgery, or dehydration. Suddenly stopping or reducing steroid intake can also trigger this crisis. Prompt medical treatment is essential, as untreated cases can result in severe outcomes such as shock, seizures, and coma.
What Are the Dietary Choices for People With Addison’s Disease?
Addison's disease diet requires careful choices. Individuals with Addison's must regulate sodium intake to manage low blood pressure and salt loss. Also, one needs to maintain a balanced diet with sufficient protein and nutrition. Regular consultations with healthcare professionals or dieticians are essential to create personalized diet plans for the specific needs of those with Addison's disease.
Conclusion:
Adrenal insufficiency, due to hormonal imbalance and reduced ACTH hormone production from the adrenal gland, exhibits symptoms similar to Addison's disease. Determining the cause of adrenal insufficiency helps in making the treatment plan. Secondary adrenal insufficiency is a condition that can be best managed with the help of corticosteroid treatment.
