Adrenal Insufficiency

Adrenal Insufficiency Overview:

Adrenal insufficiency occurs when the adrenal glands don't produce enough of the hormones cortisol and aldosterone. These glands are very important for regulating the stress response, blood sugar, and blood pressure. When they are not produced in adequate amounts, a wide range of symptoms can result, ranging from fatigue and depression, to myalgia and skin pigmentation.

There are two main types of adrenal insufficiencies, primary and secondary. The difference lies in the source of the problem. With primary adrenal insufficiency, the adrenal gland itself is damaged (also known as Addison's disease). Secondary adrenal insufficiency involves HPA axis dysfunction. This can involve iatrogenic causes like drugs, or pituitary dysfunctions.

 

Aetiology:

+ Primary Adrenal Insufficiency

Primary adrenal insufficiency is caused by a destruction of the adrenal gland (Addisons disease). It can also occur as resulting a surgical removal of adrenal glands, TB, HIV, or metasteses.

Congenital adrenal hyperplasia is an inherited enzymatic deficiency that presents in childhood with primary adrenal insufficiency.

The symptoms associated with primary adrenal insufficiency revolve around a deficiency in mineralcorticoids and glucocorticoids.

Glucocorticoids

Due to a lack of glucocorticoids, sufferers of Addison's disease have a poor tolerance to stress.

Mineralcorticoids

Mineralcorticoid deficiencies lead to a loss of sodium and water through the kidneys. This can then lead to potassium buildup in the blood. It can cause hypoglycemia, lethargy, fevers, digestive system discomfort, weight loss, and general weakness.

ACTH

Elevated ACTH often results in hyperpigmentation of the skin.

+ Secondary Adrenal Insufficiency

See Cushing's syndrome.

Secondary adrenal insuficiency is the most common form of adrenal insuficiency. It's the result of a disorder involving the HPA system, and is most commonly iatrogenic.

Diagnosis relies on histroy of corticosteroid use, of finding cushings syndrome symptoms on physical examination.

 

Diagnostic Differences For Adrenal Insufficiency:

CRH ACTH Cortisol
Primary Adrenal Insufficiency High High Low
Secondary (Pituitary Disease) High Low Low
Secondary (Hypothalamic Disease) Low Low Low
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Symptoms

Fatigue

Weakness

Depression

Dizziness

Fainting

Dizziness

Weight loss

Psychosis

Arthralgia

Myalgia

Anorexia

Tachycardia

Postural BP Drop

Fever

Reduced Skin Turgor

Pigmentation (Secondary)

Skin Crease Pallor

Vitiligo

Hyperglycemia

Hirsutism

Hypertension

Osteoporosis

Muscle Weakness

 

Diagnostic Findings

  • Decreased cortisol levels
  • Elevated plasma ACTH levels
  • X-rays may show adrenal calcification
  • In order to diagnose primary adrenal insufficiency, an inability for the adrenal glands to respond to ACTH must be demonstrated. 
  • Secondary adrenal insufficiency is diagnosed by investigating history of corticosteroid use, or looking for cushingoid features. 
 

Therapeutic Aims:

1. Support The Adrenal Glands

Adrenal tonics are mainly used alongside catelcholamine precursers to ensure they are functioning adequately.

2. Decrease The Detrimental Effects of Stress on the Adrenal Glands.

Chronic or extreme stress further exacerbates adrenal deficiency. By ammeliorating the stress response the adrenals have a better chance of recovery.

3. Minimise the Physiological Effects of Stress on the Nervous System.

Herbs targeting the HPA axis are of particular relevance. The goal is to turn on the parasympathetic nervous system.

4. Support the Immune System if Required.

Adrenal deficiency often leads to secondary infections as a result of weakened immunity. Address any possible infection, or autoimmunity.

  • Immunomodulators (Echinaceae, Astragalus, Andrographis)
  • Immune Stimulants
 

Differential Diagnosis:

Chronic fatigue syndrome, fibromyalgia, anxiety, depression, cancer, hypothyroidism.

 

Considerations/Comorbidities:

Increased cortisol levels can decrease the immune response (especially NK cell cytotoxicity) by as much as 50% [2]. Once cortisol levels have become depleted and adrenal insufficiency is reached, the immune system can respond with rebound immunological hyperactivity post cortisol drop off, leading to autoimmune conditions [3]. 

 

Herbs For Adrenal Insufficiency:

  • Glycyrhiza glabra
  • Rehmannia glutinosa
  • Astragalus membranaceus
  • Eleutherococcus senticosus
  • Ganoderma lucidum

Author:

Justin Cooke

The Sunlight Experiment

Updated: June 2018


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References:

  1. Arlt, W., & Allolio, B. (2003). Adrenal insufficiency. The Lancet361(9372), 1881-1893. Link
  2. Irwin, M., Patterson, T., Smith, T. L., Caldwell, C., Brown, S. A., Gillin, J. C., & Grant, I. (1990). Reduction of immune function in life stress and depression. Biological psychiatry, 27(1), 22-30. [review]
  3. Iddah, M. A., & Macharia, B. N. (2013). Autoimmune thyroid disorders. ISRN endocrinology, 2013.