What special problems can occur with adrenal insufficiency?

During illness, oral dosing of glucocorticoid may be adjusted to mimic the normal response of the adrenal glands to this stress on the body. Significant fever or injury may require triple oral dosing. Once recovery from the stress event is achieved, dosing is then returned to maintenance levels. People with adrenal insufficiency should know how to increase medication during such periods of stress. Immediate medical attention is needed if severe infections, vomiting, or diarrhea occur. These conditions can precipitate an Addisonian crisis.

What are the symptoms of adrenal insufficiency?

The symptoms of adrenal insufficiency usually begin gradually. The most common symptoms are

•chronic, worsening fatigue
•muscle weakness
•loss of appetite
•weight loss

Other symptoms can include

•nausea
•vomiting
•diarrhea
•low blood pressure that falls further when standing, causing dizziness or fainting
•irritability and depression
•a craving for salty foods due to salt loss
•hypoglycemia, or low blood glucose
•headache
•sweating
•in women, irregular or absent menstrual periods

Hyperpigmentation, or darkening of the skin, can occur in Addison’s disease but not in secondary adrenal insufficiency. This darkening is most visible on scars; skin folds; pressure points such as the elbows, knees, knuckles, and toes; lips; and mucous membranes such as the lining of the cheek.

Because the symptoms progress slowly, they are often ignored until a stressful event like an illness or accident causes them to worsen. Sudden, severe worsening of symptoms is called an Addisonian crisis, or acute adrenal insufficiency. In most cases, symptoms of adrenal insufficiency become serious enough that people seek medical treatment before a crisis occurs. However, sometimes symptoms first appear during an Addisonian crisis.

Symptoms of an Addisonian or “adrenal” crisis include

•sudden, penetrating pain in the lower back, abdomen, or legs
•severe vomiting and diarrhea
•dehydration
•low blood pressure
•loss of consciousness

If not treated, an Addisonian crisis can be fatal.

What do adrenal hormones do?

Cortisol belongs to a class of hormones called glucocorticoids, which affect almost every organ and tissue in the body. Cortisol’s most important job is to help the body respond to stress. Among its many vital tasks, cortisol helps

•maintain blood pressure and cardiovascular function
•slow the immune system’s inflammatory response
•maintain levels of glucose—a form of sugar used for energy—in the blood
•regulate the metabolism of proteins, carbohydrates, and fats

The amount of cortisol produced by the adrenals is precisely balanced. Like many other hormones, cortisol is regulated by the brain’s hypothalamus and the pituitary gland. First, the hypothalamus releases a “trigger” hormone called corticotropin-releasing hormone (CRH) that signals the pituitary gland. The pituitary responds by sending out ACTH, which in turn stimulates the adrenal glands. The adrenal glands respond by producing cortisol. Completing the cycle, cortisol then signals back to both the pituitary and hypothalamus to decrease these trigger hormones.

What is adrenal insufficiency?

Adrenal insufficiency is an endocrine—or hormonal—disorder that occurs when the adrenal glands do not produce enough of certain hormones. The adrenal glands are located just above the kidneys. Adrenal insufficiency can be primary or secondary.

Primary adrenal insufficiency, also called Addison’s disease, occurs when the adrenal glands are damaged and cannot produce enough of the hormone cortisol and often the hormone aldosterone. Addison’s disease affects one to four of every 100,000 people, in all age groups and both sexes.1

Secondary adrenal insufficiency occurs when the pituitary gland—a bean-sized organ in the brain—fails to produce enough adrenocorticotropin (ACTH), a hormone that stimulates the adrenal glands to produce cortisol. If ACTH output is too low, cortisol production drops. Eventually, the adrenal glands can shrink due to lack of ACTH stimulation. Secondary adrenal insufficiency is much more common than Addison’s disease.