Disease Description (Causes and Symptoms)
- Definition: A condition caused by decreased secretion of glucocorticoids (mainly cortisol) and mineralocorticoids (aldosterone) secreted by the adrenal cortex. It is classified as primary (damage to the adrenal glands themselves) or secondary (insufficient ACTH from the pituitary gland/hypothalamus).
- Pathophysiology summary:
- Primary (e.g., autoimmune disease, tuberculosis, metastatic cancer, hemorrhage, etc.) → decreased cortisol, aldosterone, and androgens; increased ACTH (causing skin hyperpigmentation).
- Secondary (e.g., suppression after long-term steroid use, pituitary lesions) → mainly decreased cortisol; aldosterone is usually preserved, so electrolyte abnormalities and hyperpigmentation are less pronounced.
- Major causes (examples): Autoimmune adrenalitis, tuberculosis, adrenal hemorrhage, metastatic cancer, fungal infection, congenital adrenal hyperplasia and metabolic diseases (e.g., adrenoleukodystrophy), discontinuation of long-term steroid use, and pituitary lesions.
- Typical symptoms:
- Chronic form: Chronic fatigue and malaise, weight loss, loss of appetite, nausea, vomiting and abdominal pain, hypotension and dizziness, hypoglycemia, decreased body hair (especially in women), skin hyperpigmentation (primary form), and preference for salty foods.
- Acute (adrenal crisis): Severe dehydration, hypotensive shock, decreased consciousness, high fever, electrolyte abnormalities (hyponatremia and hyperkalemia), and severe vomiting and abdominal pain — an emergency.
Treatment
- General principles: Replace deficient hormones, treat the underlying cause, and respond immediately to emergencies (adrenal crisis).
- Chronic treatment (outpatient)
- Glucocorticoid replacement: The standard is hydrocortisone (cortisol) 15–25 mg/day divided between the morning and afternoon (e.g., 10 mg in the morning, 5 mg at noon, and 5–10 mg in the afternoon). Adjust according to the patient’s condition.
- Mineralocorticoid (needed in primary adrenal insufficiency): Fludrocortisone 0.05–0.2 mg/day (adjust according to blood pressure, electrolytes, and renin levels).
- Alternative medications: Prednisone or dexamethasone may be used (however, dexamethasone has no aldosterone effect).
- Adrenal crisis (emergency)
- Immediately administer IV hydrocortisone 100 mg as a bolus, followed by a continuous infusion of 200 mg/24h, or repeat administration of 50–100 mg q6–8h.
- Correct hemodynamics and electrolytes with large amounts of normal saline (including glucose if necessary); administer glucose in cases of hypoglycemia.
- Identify and treat the cause (e.g., antibiotics in cases of infection).
- Treatment of underlying diseases: If tuberculosis is present, use combination anti-tuberculosis therapy (in this case, the corticosteroid dose may need to be adjusted according to drug interactions); treat tumors, hemorrhage, infections, etc.
- Education on dose escalation during stress: During febrile illness, surgery, trauma, severe diarrhea, vomiting, etc., take 2–3 times the usual dose (as directed by a doctor) or use an emergency injection if needed.
- Monitoring and management of adverse effects:
- Blood pressure, weight, electrolytes (sodium and potassium), blood glucose, and bone density (risk of osteoporosis due to long-term steroid use).
- With long-term high-dose use: Risks such as infection, osteoporosis, weight gain, hyperglycemia, and gastrointestinal bleeding.
- Education and preventive measures:
- Abruptly stopping steroid medication is dangerous (especially after long-term use) — taper gradually according to a doctor’s instructions.
- An emergency steroid injection (self-injection or injection by a caregiver) and mandatory emergency identification (medical alert bracelet, sticker, or card) are recommended.
Outpatient Visit Checklist (Including Preparation Items and Example Questions)
- Items to prepare (bring to medical examination and testing)
- A list of all medications and supplements currently being taken (including doses and administration times)
- Recent blood test results (electrolytes, blood glucose, cortisol and ACTH levels, RENIN/ALD, etc.) and the dates of testing
- Copies or summaries of previous imaging (abdominal CT, brain MRI)
- Past medical history (tuberculosis, tumors, coexisting autoimmune diseases, brain surgery, long-term steroid use)
- A symptom diary (when symptoms began, frequency, aggravating factors, weight changes, symptoms of hypotension, etc.)
- Emergency steroid injection or medical alert information, if available
- Questions to organize in advance for the doctor at the outpatient visit (examples)
- Accurately write down the steroids currently being taken and the times they are taken
- Record whether there have been any recent fainting or hypotension episodes, or any instances of being unable to take medication due to vomiting
- Whether there are plans for surgery, treatment, or pregnancy
Examples of General Questions to Ask the Doctor
- Could you tell me what is causing this disease (whether it is primary or secondary)?
- On what basis did you determine the appropriate dose of the steroid currently prescribed? What are the side effects?
- How should I increase my medication dose during stressful situations such as fever, severe diarrhea, or surgery?
- What should I do immediately in an emergency (vomiting or fainting), such as using an emergency injection or visiting the emergency room?
Examples of Disease-Specific Questions
- Do I need a mineralocorticoid (fludrocortisone) in my case? If so, what are the dose and monitoring methods?
- What tests should I have, and how often, to manage the risks of osteoporosis and infection with long-term use? Also, what are the recommendations for vaccines (e.g., pneumococcal and influenza vaccines)?
(If necessary, additional tests such as an ACTH stimulation test, blood ACTH/cortisol measurement, abdominal CT, or brain MRI may be performed to classify the cause and determine the treatment direction.)