Secondary Adrenal Insufficiency

Symptoms and signs are similar to those of Addison disease Symptoms and Signs Addison disease is an insidious, usually progressive hypofunctioning of the adrenal cortex. It causes various symptoms, including hypotension and hyperpigmentation, and can lead to adrenal crisis... read more and include fatigue, weakness, weight loss, nausea, vomiting, and diarrhea. Differentiating clinical or general laboratory features include the absence of hyperpigmentation and relatively normal electrolyte and BUN (blood urea nitrogen) levels; hyponatremia, if it occurs, is usually dilutional.

Patients with panhypopituitarism have depressed thyroid and gonadal function and hypoglycemia Hypoglycemia Hypoglycemia, or low plasma glucose level can result in sympathetic nervous system stimulation and central nervous system dysfunction. In patients with diabetes who take insulin or antihyperglycemic... read more . Coma may supervene when symptomatic secondary adrenal insufficiency occurs. Adrenal crisis is especially likely if a patient is treated for a single endocrine gland problem, particularly with thyroxine, without hydrocortisone replacement.

Tests to differentiate primary and secondary adrenal insufficiency are discussed under Addison disease Diagnosis Addison disease is an insidious, usually progressive hypofunctioning of the adrenal cortex. It causes various symptoms, including hypotension and hyperpigmentation, and can lead to adrenal crisis... read more . Patients with confirmed secondary adrenal insufficiency (see table ) should have CT or MRI of the brain to rule out a pituitary tumor or pituitary atrophy.

Adequacy of the hypothalamic-pituitary-adrenal axis Overview of the Endocrine System The endocrine system coordinates functioning between different organs through hormones, which are chemicals released into the bloodstream from specific types of cells within endocrine (ductless)... read more during tapering or after stopping long-term corticosteroid treatment can be determined by injecting cosyntropin 250 mcg IV or IM. After 30 minutes, serum cortisol should be > 20 mcg/dL (> 552 nmol/L); specific levels vary somewhat depending on the laboratory assay in use. An insulin stress test to induce hypoglycemia and a rise in cortisol is the standard for testing integrity of the hypothalamic-pituitary-adrenal axis in many centers but careful monitoring is required to avoid severe prolonged hypoglycemia.

The corticotropin-releasing hormone (CRH) test can be used to distinguish between hypothalamic and pituitary causes but is rarely used in clinical practice. After administration of CRH 100 mcg (or 1 mcg/kg) IV, the normal response is a rise of plasma ACTH of 30 to 40 pg/mL (6.6 to 8.8 pmol/L); patients with pituitary failure do not respond, whereas those with hypothalamic disease usually do.

Glucocorticoid replacement is similar to that described for Addison disease Treatment Addison disease is an insidious, usually progressive hypofunctioning of the adrenal cortex. It causes various symptoms, including hypotension and hyperpigmentation, and can lead to adrenal crisis... read more . Each case varies regarding the type and degree of specific hormone deficiencies. Normally, cortisol is secreted maximally in the early morning and minimally at night. Thus, hydrocortisone (identical to cortisol) is given in 2 or 3 divided doses with a typical total daily dose of 15 to 20 mg. One regimen gives half the total in the morning, and the remaining half split between lunchtime and early evening (eg, 10 mg, 5 mg, 5 mg). Others give two-thirds in the morning and one-third in the evening. Doses immediately before bed should generally be avoided because they may cause insomnia. Alternatively, prednisone or prednisolone 4 to 5 mg orally in the morning and possibly an additional 2.5 mg orally in the evening may be used. During acute febrile illness or after trauma, patients receiving corticosteroids for nonendocrine disorders may require supplemental doses to augment their endogenous hydrocortisone production.

Fludrocortisone is not required because the intact adrenals produce aldosterone.

In panhypopituitarism, other pituitary deficiencies Selective Pituitary Hormone Deficiencies Selective deficiencies of pituitary hormones may represent an early stage in the development of more generalized hypopituitarism. Patients must be observed for signs of other pituitary hormone... read more should be treated appropriately.