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• THE FACTS YOU NEED TO KNOW•
Addison's disease is a severe or total deficiency of the hormones made in the adrenal cortex, caused by its
destruction. There are normally two adrenal glands, located one above each kidney. The adrenal glands are
really two endocrine (ductless or hormone producing) glands in one. The inner part of the adrenal gland
(called the medulla) produces epinephrine (also called adrenaline) which is produced at times of stress and
helps the body respond to "fight or flight" situations by raising the pulse rate, adjusting blood flow, and raising
blood sugar. However, the absence of the adrenal medulla and epinephrine does not cause disease.
In contrast, the outer portion of the adrenal gland, the cortex, is more critical. The adrenal cortex makes two
important steroid hormones, cortisol and aldosterone. Cortisol mobilizes nutrients, modifies the body's
response to inflammation, stimulates the liver to raise the blood sugar, and also helps to control the amount of
water in the body. Aldosterone regulates salt and water levels which affects blood volume and blood pressure.
Cortisol production is regulated by another hormone, adrenocorticotrophic hormone (ACTH), made in the
pituitary gland which is located just below the brain. Classical Addison's disease results from a loss of both
cortisol and aldosterone secretion due to the near total or total destruction of both adrenal glands. This condition
is also called primary adrenal insufficiency. If ACTH is deficient, there will not be enough cortisol produced,
although aldosterone may remain adequate. This is secondary adrenal insufficiency, which is distinctly
different, but similar to Addison's disease, since both include a loss of cortisol secretion.
When Dr. Thomas Addison's first described this disease in London in 1855, the most common cause was
tuberculosis. This remained the leading cause until the middle of the twentieth century when antibiotics progressively
reduced TB's incidence. Since then, the major cause of Addison's disease results from an autoimmune
reaction in which the body's immune system erroneously makes antibodies against the cells of the
adrenal cortex and slowly destroys them. That process takes months to years. There are also several less common
causes of Addison's disease: other chronic infections besides tuberculosis, especially certain fungal infections,
invasion of the adrenal by cancer cells that have spread from another part of the body, especially the
breast; CMV virus in association with AIDS; rarely, hemorrhage into the adrenals during shock; and the surgical
removal of both adrenals.
Since all of the manifestations of Addison's disease are caused by the lack of cortisol and aldosterone, the
treatment is to replace these with similar steroids. Cortisol is usually replaced orally by hydrocortisone or cortisone
acetate, less often with prednisone tablets, divided into morning and afternoon doses. Aldosterone is
replaced by an aldosterone-like synthetic steroid, fludrocortisone (Florinef) tablets given once daily. The doses
of each of these medications are adjusted for the individual's size and any co-existing medical conditions. In
emergencies or during surgery, hydrocortisone must be given intravenously. Patients with Addison's disease
should be taught to treat minor illnesses with extra salt, fluids and extra hydrocortisone. This is especially
important if fever, vomiting or diarrhea is present. Persistence of these signs requires immediate treatment in
an emergency room with intravenous saline (salt water) and hydrocortisone. Since Addison's disease is a
chronic condition, daily replacement medication can never be stopped.
Proper maintenance treatment requires regular visits to a physician for examinations, laboratory tests, and discussions
about symptoms. Certain blood tests, including sodium, potassium, blood counts and plasma renin are
very useful in monitoring the response to adjustments in dosage. There is no single blood or urine test that is
perfect by itself.
Endocrinologists are specialists in hormonal diseases, including Addison's disease. Because of the rarity of the
disease, an endocrinologist will have more training and experience in properly diagnosing and treating
Addison's disease than most physicians.
Secondary adrenal insufficiency, caused by a lack of ACTH, results in a deficiency of cortisol, but usually not
aldosterone. The cause is either pituitary disease, such as a tumor, or the prolonged use of "steroid" medication
that suppresses ACTH. The treatment is simply to replace cortisol, usually with the synthetic steroid prednisone,
but sometimes hydrocortisone or cortisone acetate.
Auto-immune Addison's disease, the most common type, can be associated with other autoimmune diseases
that similarly affect other endocrine glands. The most common one is the thyroid. If an underactive thyroid
(hypothyroidism) coexists with Addison's disease, this is called Schmidt's syndrome. Less commonly associated
auto-immune diseases are insulin dependent diabetes mellitus, and insufficiencies of the parathyroid glands,
gonads, and vitamin B12 absorption (pernicious anemia).
WHY IS IT CONSIDERED
A RARE DISORDER?
There are no accurate statistics on the incidence of Addison's disease in the United States. A study in London
showed thirty-nine cases per million population as of 1960. Twelve were due to tuberculosis. In the non-tuberculosis
group, women were three times more likely to have Addison's disease. Extrapolation of these figures to
the U.S. would give about 8,800 cases, but this is probably an underestimation.
WHAT ARE THE
The slowly progressive loss of cortisol and aldosterone secretion usually produces a chronic, steadily worsening
fatigue, a loss of appetite, and some weight loss. Blood pressure is low and falls further when a person is
standing, producing lightheadedness. Nausea, sometimes with vomiting, and diarrhea are common. The muscles
are weak and often go into spasm. There are often emotional changes, particularly irritability and depression.
Because of salt loss, a craving for salty foods is common. Finally, the increase in ACTH due to the loss
of cortisol will usually produce a darkening of the skin that may look like an inappropriate tan on a person
who feels very sick. Unfortunately, the slowly progressive chronic symptoms are usually missed or ignored
until a sudden event like a flu virus, an accident, or the need for surgery suddenly precipitates a dramatic
change for the worse because of the deficient response from the adrenals to one of these stresses. This is
referred to as an Addisonian crisis and is a medical emergency.
A medical history of the symptoms mentioned above, especially hyperpigmentation of the skin or gums, is
often enough to raise a strong suspicion, prompting the appropriate tests. Quite often, however, the first clue is
from the abnormal results of routine tests done in a hospital or doctor's office. These may include an elevated
blood level of potassium, a low blood level of sodium, a shift in the ratio of certain white blood cells, or surprising
changes on an EKG or chest x-ray that are caused by high potassium or low blood volume. Other causes
for these changes, particularly from medications, must be considered first. A definitive diagnosis of
Addison's disease requires that definitive tests be carried out. These tests measure the amount of cortisol and
aldosterone in the blood and urine, and document a lack of the normal increase in the levels of these two hormones
after administration of ACTH given by injection. An elevated blood level of ACTH should also be
found. If the patient is very sick and Addison's disease is suspected, treatment can be initiated while the diagnostic
tests are being done. Once the diagnosis of Addison's disease is established, an effort should be made to
find the cause by checking for tuberculosis and other infections through skin tests and x-rays. Antibodies to
adrenal tissue, especially to 21OH can now be measured, and are specific to autoimmune Addison’s disease.
HOW NORMAL IS AN
As long as the proper dose of replacement medication is taken every day, an Addisonian can have a normal
crisis-free life. There are no specific physical or occupational restrictions. Routine care includes regular physician
visits, avoidance of dehydration, and the use of extra medication during illness. Pregnancy is possible, but
will require extra monitoring of the replacement medication. Every Addisonian should wear an identification
bracelet or preferably a necklace stating that he or she has the disease, to insure proper emergency treatment.
An identification card outlining treatment is also suggested. Today, people with Addison's disease should have a normal life expectancy.
NADF endorses the use of the Medic Alert™ emblem.
Written by: Paul Margulies, M.D., F.A.C.P., F.A.C.E.
Medical Director, NADF
Clinical Associate Professor of Medicine
New York University Medical School
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support to all persons affected by adrenal disease. For more information on joining NADF, or to find a support
group in your area, contact:
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