Editing Adrenal insufficiency (section)

== '''Classification''' ==

=== '''Primary (Addison disease)''' ===

** '''Aetiology'''
*** Congenital adrenal dysgenesis/hypoplasia
*** Defective steroidogenesis
*** Adrenal destruction
**** Autoimmune
**** Infectious
***** TB
***** Fungal
***** Viral
**** Malignant
**** Haemorrhage (Waterhouse-Friderichsen syndrome)
***** Occurs in setting of septicaemia caused by meningococcal or other organisms
***** More common in children and asplenic patients

=== '''Secondary''' ===

** ACTH deficiency
** '''Aetiology'''
*** Generally from pharmacologic steroid withdrawal
**** Occurs in patients receiving >20mg of prednisolone (or equivalent) daily for >5 days, or those receiving  low supra-physiologic doses for >3 weeks
**** Rate of recovery varies according to the curation and severity of previous glucocorticoid excess, and may need supplementation for several years
*** Surgical cure of Cushing syndrome
*** Pan-hypopituitarism caused by neoplastic or infiltrative disease
*** Granulomatous disease
*** Pituitary haemorrhage or infarction
**** Can occur in the setting of severe post-partum haemorrhage (Sheehan syndrome)
*** Chronic high-dose opioids
**** Occurs in up to 30% of high-dose long-term opioid users
**** Cessation of opioids results in reversion to normal
**** Glucocorticoids seems to improve symptoms (energy, mood) and it is therefore probably prudent to treat with glucocorticoids, if weaning opioids is impossible

=== '''Adrenal insufficiency in the critically ill''' ===

** Acute reversible dysfunction of the HPA axis with sepsis or SIRS
** Maybe occurs due to reduced responsiveness of target tissues to glucocorticoids or adrenal ACTH resistance