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Home , Adrenal insufficiency

-Pituitary-Adrenal Axis Adrenal Insufficiency: (physical, Current Practice 2012 psychological) Hypothalamus - CRH or + Lawrence S. Kirschner, MD, PhD Pituitary - Professor of Medicine ACTH: Major direct regulator Division of , Diabetes, and Metabolism of secretion The Ohio State University’s Wexner Medical Center + Adrenals Cortisol, , Androgens

Overview Actions of cortisol

• A very brief review of adrenal function

• What is adrenal insufficiency?

• Adrenal insufficiency in the outpatient setting

• Adrenal insufficiency during critical illness

• Therapy for adrenal insufficiency

1 What is Adrenal insufficiency? • Actions of Aldosterone – Promotes sodium/water retention • When discussing adrenal insufficiency – Promotes potassium excretion (Addison disease), we are almost always – May be involved in tissue remodeling talking about (cortisol) ((ge.g. in the heart) insufficiency

• Actions of adrenal androgens • However, other adrenal hormones can also – Responsible for initiation of puberty be affected in primary adrenal failure • Secondary sex characteristics in women

Adrenal Insufficiency Clinical Addison disease (Addison disease)

Image courtesy of Wellcome Images http://images.wellcome. ac.uk/

2 Clinical Features of Chronic Features of Acute Adrenocortical Insufficiency Adrenocortical Insufficiency () • •Weakness, fatigue 100% • 100% • Weakness (prox. muscle), •Anorexia 100% confusion • 92% • , , abdominal pain •Hypotension 88% • , •Nausea, abdominal pain 56% • Hyperthermia •Salt craving 19% • ?? • Hypoglycemia »more common in children and women TREAT FIRST, AND DIAGNOSE LATER!!

Hyperpigmentation, Adrenal Crisis toxic appearance Addison disease • Acute loss of adrenal function – Acute loss of adrenals • Surgery • Hemorrhage/thrombosis – Acute loss of pituitary function – Acute loss of replacement

OR • Acute stress in the setting of compensated

Hyperpigmentation, including chronic adrenal failure Images courtesy of knuckles and palmar creases Wellcome Images – Precipitating event (e.g., like DKA) http://images.wellcome.ac.uk/

3 Normal Adrenal Function Secondary Adrenal Insufficiency • Primary Hypothalamus – Hypothalamus  CRH – Destruction of Pituitary glands  CRH Pituitary • Secondary  ACTH – Pituitary  ACTH – Inadequate ACTH Adrenals – NO increased Adrenals pigment Cortisol Aldosterone – Fewer electrolyte imbalances Cortisol Aldosterone (regulated by Renin/Angiotension system)

Primary Adrenal Insufficiency Causes of adrenal failure • Primary Hypothalamus – Adrenal gland • Like CS, iatrogenic causes are probably most common  CRH – Destruction of Pituitary glands • Inherited forms of adrenal failure – Typically presenting early in life (<1 yr) • CAH, especially salt-wasters (steroid biosynthesis defect) Adrenals • Other rare genetic diseases (lipoid CAH, AHC) – Typically presenting in childhood, and dx should be “obvious” • AAA Cortisol Aldosterone – Alacrima, Achalasia, Adrenal failure • Autoimmune Polyendocrine Syndrome (APS), Type I (APECED) – Ectodermal dysplasia, mucocutaneous candidiasis

4 Causes of adrenal failure Causes of adrenal failure

• Like CS, iatrogenic causes are probably most • Like CS, iatrogenic causes are probably most common common

• Inherited forms of adrenal failure • Inherited forms of adrenal failure – Typically presenting early in life (<1 yr) – Typically presenting early in life (<1 yr) • CAH, especially salt-wasters (steroid biosynthesis • CAH, especially salt-wasters (steroid biosynthesis defect) defect) • Other rare genetic diseases (lipoid CAH, AHC) • Other rare genetic diseases (lipoid CAH, AHC) – Typically presenting in childhood, and dx – Typically presenting in childhood, and dx should be “obvious” should be “obvious” • AAA • AAA – Alacrima, Achalasia, Adrenal failure – Alacrima, Achalasia, Adrenal failure • Autoimmune Polyendocrine Syndrome (APS), • Autoimmune Polyendocrine Syndrome (APS), Type I (APECED) Type I (APECED) – Ectodermal dysplasia, mucocutaneous – Ectodermal dysplasia, mucocutaneous candidiasis candidiasis

Causes of adrenal failure • Presenting later in life • Like CS, iatrogenic causes are probably most – Autoimmune Polyendocrine Syndrome common (APS), Type II • Type I DM, disease • Inherited forms of adrenal failure – Typically presenting early in life (<1 yr) • May occur as sole autoimmune feature • CAH, especially salt-wasters (steroid biosynthesis (although rare) defect) – Adrenal hemorrhage • Other rare genetic diseases (lipoid CAH, AHC) – Typically presenting in childhood, and dx • Resulting from should be “obvious” – HIV, other viral diseases • AAA – Adrenalectomy – Alacrima, Achalasia, Adrenal failure • Autoimmune Polyendocrine Syndrome (APS), Type I (APECED) • Note that non-classical CAH rarely causes – Ectodermal dysplasia, mucocutaneous candidiasis adrenal insufficiency

5 Adrenal hemorrhage!

Pre-bleed Post-bleed

Secondary adrenal failure Diagnosis of Adrenal Insufficiency in the Outpatient setting: Static Testing • Pituitary malfunction • A GOOD HISTORY IS ESSENTIAL! – Tumor destroying normal cells – History of steroid use, including nasal or injected steroids (e.g., – Autoimmune back injections) • May be quite specific for loss of ACTH-producing cells • 8 AM cortisol (probably NOT reliable in – Infiltrative diseases of pituitary hospitalized patients)

• Histiocytosis X Strongly Very unlikely suggestive • Normal range • Metastatic disease 0 37 18 25 8am Cortisol (ug/dl)

6 Diagnosis of Adrenal Insufficiency in the Outpatient setting: Static Testing - 2 Adrenal Insufficiency: • ACTH measurements – Generally not helpful, particularly low Current Practice 2012 values – Elevated values may suggest primary Adrenal Insufficiencyyg in the right clinical setting Rami N. Khayat, MD Associate Professor • “Suggestive” findings: Pulmonary, Critical Care, and Sleep Medicine – , hyperchloremia, The Ohio State University’s Wexner Medical Center acidosis, hypercalcemia, azotemia, /hyperkalemia and fasting hypoglycemia

Diagnosis of Adrenal Insufficiency: Adrenal Insufficiency during Critical ACTH stim test Illness

• Give IV/IM bolus of 250 mcg ACTH, measure blood at 0, 30, 60 min • Adrenal function during critical illness Cortisol ug/dl • Relative adrenal insufficiency • Normal response is for cortisol to reach >18 20 • Overvi ew of C orti cost eroid th erapy i n th e mcg/dl 10 ICU • Caveat :ACTH stim test • Conclusions will be “normal” in early pituitary failure. Once adrenal atrophy sets in, test becomes subnormal 03060

7 Acute Adrenal Function in Critical Illness • Adrenal Gland Death Acute critical illness Recovery • Synthetic inhibition

• Drugs • Cytokines Sub-acute; chronic critical • Etomidate llness • » • Destruction Maladaptive Adaptive • Pre-existing • Acute responses responses • Autoimmune • Hemorrhage • • Infection • HIV • CMV Impaired Adrenal Decreased • TB • Fungal immune function Inflammatory • response response

The Adrenal Response to Prolonged Adrenal Function in Critical Illness Critical Illness •  Hepatic metabolism of cortisol • Rifampin • • Phenobarbital • Glucorticoid Resistance

J Clin End Met. 1995;80:1238.

8 Cortisol and Septic

Group % Basalbasal cortisol  maxmax mortalitymortality

Good 30% <34 >9 26%

Intermediate1 <34 <9 50% 67% “The fact that cortical hormone therapy exerts beneficial effects in so many conditions makes it rather likely that Intermediate2 >34 >9 the hormone is not a specific antidote in any one of these cases but raises shock resistance in general because a Poor 20% >34 <9 82%

condition of relative adrenal insufficiency exists in organisms exposed to non-specific damage.” Annane JAMA 2000; 283:1038-1045

Prognostic Value of Cortisol Levels and ACTH Cortisol Levels-Marker of Survival Response

Venkatesh and Cohen 2011 Annane, D. et al. JAMA 2000;283:1038-1045

9 Effect of Low Dose on Mortality in Patients with

Annane, D. et al. JAMA 2002;288:862-871

Steroids In Septic Shock Effect of Low Dose Hydrocortisone on Mortality in Patients with Septic Shock Catechlamine dependent septic shock (300)

ACTH Stim Test

76% Non-Respp()onders (229) 24% Responders (70) <9 ug/dl cortisol >9 ug/dl cortisol

Steroids Placebo Steroids Placebo

50 mg Hydrocortisone q6º 50 mg Hydrocortisone q6º 50 ug qd 50 ug Fludrocortisone qd

Annane, D. et al. JAMA 2002;288:862-871 Annane JAMA 2002; 288:862-871

10 Steroids In Septic Shock Approach to Suspected Adrenal Insufficiency < 25 ug/dL 25 ug/dL to 40 ug/dL > 40 ug/dL Non- Responders Mortality Responders ACTH stim test Steroids Placebo Steroids Placebo 28 Day 53%* 63% 61% 53% < 9 ug/dL > 9 ug/dL ICU 58%* 70% 67% 59% Hospital 61%* 72% 69% 59% 1 Year 68%* 77% 69% 71% Persistent hypotention Vasopressor 57%* 40% 50% 53% Therapeutic Trial Withdrawal Median Median Median Median (28 days) 7 10 9 7 Steroid Replacement Treatment

Annane JAMA 2002; 288:862-871

Effects of Corticosteroids on Mortality ICU Severe Sepsis and Septic Shock Concerns

• High mortality in the Control group • Use of Etomidate • Design and power • Severe refractory shock required for enrollment

Annane BMJ 2004;329:480

11 Hydrocortisone Therapy for Patients with Septic Shock Kaplan–Meier curves for survival at 28 days according to CORTICUS response to corticotropin test

Sprung et al NEJM 2008

Hydrocortisone Therapy for Patients with Septic Shock Hydrocortisone Therapy for Kaplan–Meier Curves for Survival at 28 Days Patients with Septic Shock Sprung et al NEJM 2008

Enrolment and Outcome Sprung et al NEJM 2008

12 Corticosteroids for ARDS Treatment and Intensive NEJM 2006 “ARDSNET” Insulin Therapy for Septic Shock in Adults

JAMA 2010;303:341-348

Corticosteroid Treatment and Intensive Insulin Therapy for Septic Shock in Adults Role of Steroids in Specific Conditions

Good Bad

• Meningitis Industrial strength • Typhoid fever pharmacologic does • SiSpinal cord dij injury • Pneumocystis Carinii Pneumonia • No evidence . Fibroproliferative ARDS? . Sepsis? JAMA 2010;303:341-348

13 Surviving Sepsis 2008 • We suggest that intravenous hydrocortisone be given only to adult septic shock patients Adrenal Insufficiency: after it has been confirmed that their blood Current Practice 2012 pressure is poorly responsive to fluid resuscitation and vasopressor therapy (grade 2C). • We suggest that the ACTH stimulation test not Lawrence S. Kirschner, MD, PhD be used to identify the subset of adults with Professor of Medicine septic shock who should receive Division of Endocrinology, Diabetes, and Metabolism hydrocortisone (grade 2B). The Ohio State University’s Wexner Medical Center • We suggest that patients with septic shock should not receive if hydrocortisone is available (grade 2B).

Surviving Sepsis 2008

• daily addition of oral fludrocortisone (50 µg) if hydrocortisone is not available and the steroid that is substituted has no significant activity. Fludrocortisone is considered optional if hydrocortisone is used (grade 2C). Treatment of • that clinicians wean the patient from steroid therapy Adrenal when vasopressors are no longer required (grade 2D).

• We recommend that doses of corticosteroids Insufficiency comparable to >300 mg hydrocortisone daily not be used in severe sepsis or septic shock for the purpose of treating septic shock (grade 1A).

• that corticosteroids not be administered for the treatment of sepsis in the absence of shock. (grade 1D).

14 Treatment of Adrenal Insufficiency: Treatment of Adrenal Glucocorticoid Replacement Insufficiency:

• Hydrocortisone • Replacement of mineralocorticoid – Metabolized to cortisol needed if primary adrenal failure – Approx 10-12 mg/m2 is replacement dose of HC • Florinef is synthetic – In most people, this is about 20-25 mg/day mineralocorticoid (fludrocortisone) • 5’9”, 155 lb patient. BSA = 1.85. Dose = 18-22 mg – Comes in only 1 size (100 mcg) • 6’, 300 lb patient. BSA = 2.63. Dose = 26-31 mg – Most patients need 1 tab/day, but may – Mimic the diurnal variation (2/3 steroid A.M.; 1/3 need to titrate to symptoms or evening) electrolytes • Evening dose given mid afternoon (e.g., 3pm) unless patient is night owl – In patients on high dose HC (>50 mg/day), enough MC activity so that – Can also be given as single AM dose if patient tolerates florinef not usually needed

Glucocorticoid equivalents Treatment of Adrenal Insufficiency: Androgens • Hydrocortisone: 20 mg • Anecdotal evidence suggests that • Cortisone acetate: 25 mg replacing DHEA(S) may help improve patient well-being, but randomized studies have all been NEGATIVE • PdiPrednisone 4 -5 mg • 5 mg • Patients may benefit from a trial of DHEA • Dexamethasone 0.75-1 mg 50 mg. – Synthetic steroids have longer half life, and – Patient feels better  great! may have increased incidence of side effects (e.g., , weight gain, immune – No better  stop. suppression)

15 Treatment of Adrenal Insufficiency: Recovery from critical Efficacy illness • There is no single lab test that will judge adequacy of replacement, so patient • Patients that are suspected of having symptomatology important adrenal insufficiency should have their • ACTH goals: steroids weaned once critical illness has – Generally, aim for AM ACTH 50-150 pg/ml resolved [normal 10-50] – Lower ACTH values generally indicate • Typically, patients can be weaned to overtreatment replacement level treatment at the time of – Renin goals: discharge – Normalized • Further evaluation and tapering can then – Note that it may be very difficult to control ACTH be done in the outpatient setting levels if patient has significant mineralocorticoid deficient

Recovery from Addison’s? Facilitating HPA recovery • Patients who fail an ACTH stim should be retested to verify • Use Hydrocortisone – Shorter biological half-life means axis can • Patients with Cushing Syndrome that are cured recover while patient on therapy by surgery will be insufficient until their axis – If patient tolerates, put on once daily recovers replacement of HC and wait – Requirement for steroids post-op is a good • Go for lowest dose that patient will tolerate sign – Retest by ACTH stim q3-4 months until recovery – Patients with Cushing syndrome can take 1-2 years to recover • Can also use (low dose or qod dosing) but usually doesn’t work as well • Patients on chronic steroids for many years may take many years to recover their axis

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