Adrenal Insufficiency and Crisis
Exam Pass Notes
Key Takeaways
- Addison's disease causes inadequate cortisol/aldosterone due to adrenal damage.
- Requires lifelong steroid replacement.
- Adrenal crisis is an acute, severe presentation of adrenal insufficiency requiring emergency treatment.
- Steroid doses often need to be increased for dental procedures and illness in Addison's patients.
- Recognise adrenal insufficiency symptoms. Be prepared to treat adrenal crisis with IM/IV hydrocortisone.
Overview
- Adrenal insufficiency is a condition where the adrenal glands do not produce enough steroid hormones like cortisol and aldosterone.
- This can lead to symptoms like fatigue, weakness, nausea, and low blood pressure.
- Adrenal crisis is a life-threatening complication of adrenal insufficiency. It is caused by a sudden need for extra steroids that the body cannot produce.
- Signs include confusion, vomiting, abdominal pain, and loss of consciousness.
- Dental procedures and infections can trigger adrenal crisis in people with adrenal insufficiency.
- Steroid doses may need to be adjusted before procedures.
Addison's Disease
- Addison's disease (primary adrenal insufficiency) is caused by damage to the adrenal cortex, which produces cortisol and aldosterone.
- Cortisol regulates blood sugar, metabolism, inflammation, and stress response.
- Aldosterone regulates fluid and electrolyte balance.
- In Addison's, low cortisol and aldosterone cause fatigue, nausea, low blood pressure, electrolyte imbalances.
- Treatment is lifelong steroid replacement.
Steroid Dose Modification for Dentistry
- Patients with Addison's may need increased glucocorticoid doses before dental procedures, as they cannot mount a natural cortisol stress response.
- Minor procedures: take usual morning dose and an extra dose 1 hour before appointment.
- Minor dental surgery: double next dose 1 hour before procedure and for 24 hours after.
- Major surgery like extractions should be done in hospital under IV/IM hydrocortisone.
Adrenal Crisis Signs
- Adrenal crisis causes acute adrenal insufficiency symptoms like confusion, abdominal pain, vomiting, hypotension, and loss of consciousness.
- It can be triggered by infection, trauma, surgery, or stress in someone with adrenal insufficiency. If untreated, it can be fatal.
- Unlikely to happen with routine dental treatment in someone not known to have adrenal insufficiency. Consider other diagnoses first.
Adrenal Crisis Management
- For patients with adrenal insufficiency, confirm steroid dosage and if they have emergency hydrocortisone injection kit.
- Adjust steroid dose before procedures as needed.
- If adrenal crisis occurs, maintain ABCs, call ambulance, consider giving IM/IV hydrocortisone 100mg if available or from patient's kit.
- Hospital treatment may include rehydration, further hydrocortisone, and managing underlying infection or other triggers.
Causes of Addison's Disease
- In the UK, autoimmune disease causes 70-90% of Addison's disease cases.
- Immune system attacks and damages adrenal cortex.
- Genetics play a role - higher risk if autoimmune conditions in patient or family members.
- Other causes include TB infection, adrenal haemorrhage, cancer spread to adrenals, surgical removal, inherited ALD.
Symptoms of Addison's Disease
- Early symptoms of Addison's like fatigue, salt craving can be vague. Gradually worsens over months/years.
- Can progress to low blood pressure, nausea, diarrhoea, abdominal pain, hyperpigmentation.
- Adrenal crisis causes acute and severe symptoms, may lead to shock, coma and death if untreated.
Living with Addison's Disease
- Treatment is lifelong corticosteroid medication, usually hydrocortisone plus fludrocortisone.
- Must take doses on time every day. Carry emergency injection kit. May need dose increases during illness/injury.
- Extractions/major surgery done in hospital under IV/IM hydrocortisone. Experienced patients can often advise on dose changes.