P1: SBT
0521779407-02 CUNY1086/Karliner 0 521 77940 7 June 7, 2007 19:18
Adrenal Insufficiency 69➣Infiltrative
➣Trauma (head injury)
➣Exogenous/endogenous glucocorticoid excess, progestational
agents (eg, medroxyprogesterone), following successful surgical
cure of endogenous Cushing’s syndrome
management
What to Do First
■Acute AI:
➣Give dexamethasone (Decadron) IV, can change to hydrocorti-
sone after Cosyntropin testing is complete; note that DEX does
not cross-react in the assay for cortisol
➣Normal saline for volume expansion
➣Do Cosyntropin stimulation test simultaneously with dexam-
ethasone
➣Search for precipitating factors: infection
■Chronic AI:
➣Establish diagnosis, causeGeneral Measures
■Distinguish clinical syndromes of chronic vs. acute AI
■Assess for a priori evidence of primary vs. secondary AI
■Assess level of physiologic stress: cortisol requirements increase 10-
fold with severe stress (e.g., ICU illness)
■Medical alert bracelet, patient education
specific therapy
■Acute AI: hydrocortisone (=cortisol)
■Chronic AI: hydrocortisone (=cortisol), higher doses required dur-
ing stress; fludrocortisone PRN in primary AISide Effects & Contraindications
■Cortisol:
➣Side effects: weight gain, Cushingoid features, metabolic alkalo-
sis, osteoporosis
➣Contraindications: none
■Fludrocortisone
➣Side effects: hypokalemia, edema, hypertension
➣Contraindications: hypokalemia, hypertension
follow-up
■Assess clinical response, weight, skin pigmentation
■Follow blood pressure, orthostatic vital signs, serum electrolytes