Insights: Adrenal Insufficiency

From Lewis S Blevins Jr,  MD – I define hypopituitarism as the partial or the complete deficiency of one or more anterior pituitary hormones. As a result of how this all works, patients can have a myriad of symptoms and signs ranging from mild fatigue or increased need for sleep to remarkable perturbations in physiology that can be life threatening and associated with disabling symptoms. Sometimes, the gravity of the situation is only apparent during some other disease process or following a stressful event or injury that requires a stress response being mounted to maintain homeostasis and survival.

One of the “diagnoses” that I see with regularity in my busy pituitary practice is that of partial central adrenal insufficiency as a consequence of pituitary tumor or some other disease process or therapeutic approaches to disorders of the pituitary gland.

There are a number of different tests used to establish whether a patient has adrenal insufficiency. I will not go into them here. Suffice it to say that, as with any condition, some patients will have mild, moderate, or severe ACTH and cortisol deficiency while others will prove to be normal. Truthfully, most of our patients with central adrenal insufficiency have a partial form of the disorder. They make some cortisol. Just not enough. And they do not have proper responses to stimulation tests.

Those patients with moderate to severe deficiency are easy. We treat them with replacement doses of steroids. Those with mild deficiency are, however, much more difficult to treat. Most of them feel fine with little to no symptoms and signs of adrenal insufficiency. They simply feel well enough and don’t want to bother with steroid replacement. I certainly can understand that. My concern, however, is that, though the majority of these patients do fine, even in the long run, without treatment, major physiologic stressors, such as injury or some other illness, may not be met with an appropriate cortisol stress response and lead to prolonged illness, when one might otherwise recover swiftly, or even hypotension and shock with a significant illness (flu, urinary tract infection, etc.) or bodily injury suffered during an accident. In fact, this is what we see In clinical practice. I have encountered several patients who seem to have had mild adrenal insufficiency, didn’t take their steroids, or maybe weren’t prescribed them by treating physicians, and then had a medical event that led to severe hypotension or adrenal crisis along with a multitude of symptoms of cortisol deficiency.

So. My “default” has always been to recommend treatment for those with mild central adrenocortical insufficiency. It is safe to take full replacement doses of steroids……doses that are meant for a normal body…in this setting. I believe that this approach also leads to a heightened awareness of the need to take extra steroids during stressful events. Furthermore, medication will usually be up-to-date and on hand when needed should illness strike or one suffer an unexpected injury.

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