eMedicine Specialties > Dermatology > Internal Medicine

Addison Disease: Follow-up

Author: Elizabeth A Liotta, MD, Assistant Professor, Department of Dermatology, Uniformed Services University of the Health Sciences
Coauthor(s): Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center; Alexander Brough, MD, Consulting Surgeon, Department of Dermatology, Sewell's Point Clinic
Contributor Information and Disclosures

Updated: Jan 21, 2009

Follow-up

Further Inpatient Care

  • Admit patients with any of the systemic manifestations of Addison disease to the hospital.
    • Immediately treat patients with acute adrenal insufficiency with glucocorticoid replacement. Hydrocortisone can be administered both as a bolus and as an infusion.
    • Treat hypovolemia and hyponatremia with intravenous fluid and sodium replacement until the patient's condition is stable and he or she can tolerate oral fluids.
    • Consider treating the patient on an outpatient basis once the symptoms of adrenal insufficiency improve enough to enable oral replacement therapy.

Further Outpatient Care

  • Monitoring glucocorticoid and mineralocorticoid replacement therapy is perhaps more of an art than a science.
    • The ideal dose of glucocorticoids in replacement therapy adequately supplements the adrenal insufficiency while minimizing any adverse effects.
    • If the dose of the replacement glucocorticoids is too low, adrenal insufficiency continues.
    • In children, nocturnal hypoglycemia may result in seizures.
    • Overdoses of replacement glucocorticoids result in many undesired adverse effects, including weight gain and osteoporosis.
    • Correct dosing may be guided by monitoring urine cortisol levels.
  • Monitor mineralocorticoid replacement by observing the patient's blood pressure levels, which are low when doses of the mineralocorticoid are too low.
    • Monitor serum potassium levels to ensure resolution of the initial hyperkalemia.
    • Plasma renin concentrations may be monitored as well.
    • An overdose of fludrocortisone is difficult to assess, but overdoses may result in hypokalemia and increased atrial natriuretic peptide levels.
  • Exact dosing of both glucocorticoid and mineralocorticoid replacement is elusive.

Deterrence/Prevention

  • Avoid the use of diuretics to prevent excessive sodium loss.

Complications

  • Pay attention to potential drug interactions. Concomitant use of rifampin, phenytoin, or barbiturates increases the metabolism of replaced hormones; therefore, the patient's hormone levels may decrease to subtherapeutic levels.
  • Excessive sodium loss may result from the use of diuretics.

Prognosis

  • With proper control, the long-term prognosis is good.

Patient Education

  • Advise patients to wear medical alert tags at all times to reduce the time to the treatment and diagnosis of an addisonian crisis.
  • Inform patients about salt loss during vigorous exercise.

Miscellaneous

Medicolegal Pitfalls

  • Failure to diagnose and treat acute adrenal insufficiency immediately when the condition is suspected is a pitfall.
  • Failure to perform diagnostic laboratory tests when acute adrenal insufficiency is suspected is a pitfall.

Special Concerns

  • Pregnancy increases the physiologic stress on the patient.
    • The diagnosis of Addison disease may be delayed in pregnant women because the presenting symptoms of nausea, vomiting, and skin hyperpigmentation may be confused with symptoms of pregnancy.
    • Glucocorticoid and mineralocorticoid doses may need to be adjusted in patients who are pregnant. For example, the fludrocortisone dose may need to be decreased if preeclampsia develops.
    • Glucocorticoid and mineralocorticoid doses may need to be increased, especially during labor. Commonly, 1-3 doses of hydrocortisone 100 mg are intramuscularly or intravenously administered during labor.
  • Pediatric patients receiving adequate hormone replacement maintain a normal growth pattern, although their growth is rarely above the 50th percentile. Pubertal development is also normal.
  • The presenting symptoms of Addison disease in children are similar to those in adults, with the exception of weight loss, which is not a common finding in the pediatric population.
 
Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author, Dr. Quenby Erickson, to the development and writing of this article. The authors and editors of eMedicine also gratefully acknowledge the contributions of previous Chief Editor, William D. James, MD, to the development and writing of this article.



More on Addison Disease

Overview: Addison Disease
Differential Diagnoses & Workup: Addison Disease
Treatment & Medication: Addison Disease
Follow-up: Addison Disease
Multimedia: Addison Disease
References
[ CLOSE WINDOW ]

References

  1. Bergthorsdottir R, Leonsson-Zachrisson M, Oden A, Johannsson G. Premature mortality in patients with Addison's disease: a population-based study. J Clin Endocrinol Metab. Dec 2006;91(12):4849-53. [Medline].

  2. Burk CJ, Ciocca G, Heath CR, Duarte A, Dohil M, Connelly EA. Addison's disease, diffuse skin, and mucosal hyperpigmenation with subtle "flu-like" symptoms--a report of two cases. Pediatr Dermatol. Mar-Apr 2008;25(2):215-8. [Medline].

  3. Lamey PJ, Carmichael F, Scully C. Oral pigmentation, Addison's disease and the results of screening for adrenocortical insufficiency. Br Dent J. Apr 20 1985;158(8):297-8. [Medline].

  4. Shah SS, Oh CH, Coffin SE, Yan AC. Addisonian pigmentation of the oral mucosa. Cutis. Aug 2005;76(2):97-9. [Medline].

  5. Prat C, Vinas M, Marcoval J, Jucgla A. Longitudinal melanonychia as the first sign of Addison's disease. J Am Acad Dermatol. Mar 2008;58(3):522-4. [Medline].

  6. Adams R, Hinkebein MK, McQuillen M, Sutherland S, El Asyouty S, Lippmann S. Prompt differentiation of Addison's disease from anorexia nervosa during weight loss and vomiting. South Med J. Feb 1998;91(2):208-11. [Medline].

  7. Albert E, Dalaker K, Jorde R, Berge LN. Addison's disease and pregnancy. Acta Obstet Gynecol Scand. 1989;68(2):185-7. [Medline].

  8. Kita M, Mandala E, Saratzis A, et al. Primary adrenal lymphoma presenting as Addison's disease. Case report and review of the literature. Exp Clin Endocrinol Diabetes. Jun 2008;116(6):363-5. [Medline].

  9. Baker DE, Glazer GM, Francis IR. Adrenal magnetic resonance imaging in Addison's disease. Urol Radiol. 1988;9(4):199-203. [Medline].

  10. Arlt W, Callies F, van Vlijmen JC, Koehler I, Reincke M, Bidlingmaier M, et al. Dehydroepiandrosterone replacement in women with adrenal insufficiency. N Engl J Med. Sep 30 1999;341(14):1013-20. [Medline].

  11. Oelkers W. Dehydroepiandrosterone for adrenal insufficiency. N Engl J Med. Sep 30 1999;341(14):1073-4. [Medline].

  12. Cohen N, Gilbert R, Wirth A, Casley D, Jerums G. Atrial natriuretic peptide and plasma renin levels in assessment of mineralocorticoid replacement in Addison's disease. J Clin Endocrinol Metab. Apr 1996;81(4):1411-5. [Medline].

  13. Bauerschmitz J, Bork K. Multifocal disseminated lipoatrophy secondary to intravenous corticosteroid administration in a patient with adrenal insufficiency. J Am Acad Dermatol. May 2002;46(5 Suppl):S130-2. [Medline].

  14. Ai J, Leonhardt JM, Heymann WR. Autoimmune thyroid diseases: etiology, pathogenesis, and dermatologic manifestations. J Am Acad Dermatol. May 2003;48(5):641-59; quiz 660-2. [Medline].

  15. Betterle C, Volpato M. Adrenal and ovarian autoimmunity. Eur J Endocrinol. Jan 1998;138(1):16-25. [Medline].

  16. Burke MP, Opeskin K. Adrenocortical insufficiency. Am J Forensic Med Pathol. Mar 1999;20(1):60-5. [Medline].

  17. Dunlop D. Eighty-six cases of Addison's Disease. Br Med J. Oct 12 1963;5362:887-91. [Medline].

  18. Grant DB, Barnes ND, Moncrieff MW, Savage MO. Clinical presentation, growth, and pubertal development in Addison's disease. Arch Dis Child. Oct 1985;60(10):925-8. [Medline].

  19. Grinspoon SK, Biller BM. Clinical review 62: Laboratory assessment of adrenal insufficiency. J Clin Endocrinol Metab. Oct 1994;79(4):923-31. [Medline].

  20. Hunt G, Todd C, Kyne S, Thody AJ. ACTH stimulates melanogenesis in cultured human melanocytes. J Endocrinol. Jan 1994;140(1):R1-3. [Medline].

  21. Jabbour SA. Cutaneous manifestations of endocrine disorders: a guide for dermatologists. Am J Clin Dermatol. 2003;4(5):315-31. [Medline].

  22. Jeffcoate W. Assessment of corticosteroid replacement therapy in adults with adrenal insufficiency. Ann Clin Biochem. Mar 1999;36 ( Pt 2):151-7. [Medline].

  23. Kong MF, Jeffcoate W. Eighty-six cases of Addison's disease. Clin Endocrinol (Oxf). Dec 1994;41(6):757-61. [Medline].

  24. Laureti S, Vecchi L, Santeusanio F, Falorni A. Is the prevalence of Addison's disease underestimated?. J Clin Endocrinol Metab. May 1999;84(5):1762. [Medline].

  25. Luken KK. Clinical manifestations and management of Addison's disease. J Am Acad Nurse Pract. Apr 1999;11(4):151-4. [Medline].

  26. Mason AS, Meade TW, Lee JA, Morris JN. Epidemiological and clinical picture of Addison's disease. Lancet. Oct 5 1968;2(7571):744-7. [Medline].

  27. Nerup J. Addison's disease--clinical studies. A report fo 108 cases. Acta Endocrinol (Copenh). May 1974;76(1):127-41. [Medline].

  28. Nieman LK, Chanco Turner ML. Addison's disease. Clin Dermatol. Jul-Aug 2006;24(4):276-80. [Medline].

  29. Orth DN, Kovacs WJ. The adrenal cortex. In: DeGroot LJ, Jameson JL, eds. William's Textbook of Endocrinology. 9th ed. Philadelphia, Pa: WB Saunders; 1998.

  30. Tobin MV, Aldridge SA, Morris AI, Belchetz PE, Gilmore IT. Gastrointestinal manifestations of Addison's disease. Am J Gastroenterol. Oct 1989;84(10):1302-5. [Medline].

  31. Villabona CM, Sahun M, Ricart W, Serres X, Maroto A, Fernandez-Real JM, et al. Tuberculous Addison's disease. Utility of CT in diagnosis and follow-up. Eur J Radiol. Nov 1993;17(3):210-3. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

Addison disease, Addison's disease, primary adrenal insufficiency, chronic adrenal insufficiency, hypoadrenalism, polyglandular autoimmune diseases, polyglandular autoimmune disease I, PGAD I, polyglandular autoimmune disease II, PGAD II, Schmidt syndrome, addisonian crisis, adrenocorticotropic hormone, ACTH, corticotropin, melanocyte-stimulating hormone, MSH

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Elizabeth A Liotta, MD, Assistant Professor, Department of Dermatology, Uniformed Services University of the Health Sciences
Elizabeth A Liotta, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

Coauthor(s)

Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center
Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

Alexander Brough, MD, Consulting Surgeon, Department of Dermatology, Sewell's Point Clinic
Alexander Brough, MD is a member of the following medical societies: American Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Robin Travers, MD, Assistant Professor of Medicine (Dermatology), Dartmouth University School of Medicine; Staff Dermatologist, New England Baptist Hospital; Private Practice, SkinCare Physicians
Robin Travers, MD is a member of the following medical societies: American Academy of Dermatology, American Medical Informatics Association, Massachusetts Medical Society, Medical Dermatology Society, and Women's Dermatologic Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Michael J Wells, MD, Associate Professor, Department of Dermatology, Texas Tech University Health Sciences Center
Michael J Wells, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, and Texas Medical Association
Disclosure: Nothing to disclose.

Managing Editor

Jeffrey P Callen, MD, Professor of Medicine, Chief, Division of Dermatology, University of Louisville School of Medicine
Jeffrey P Callen, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American College of Physicians, and American College of Rheumatology
Disclosure: Amgen Honoraria Consulting; Abbott Honoraria Consulting; Electrical Optical Sciences Honoraria Consulting; Centocor Honoraria Consulting; Genetech Honoraria Consulting; Celgene Honoraria Consulting

CME Editor

Glen H Crawford, MD, Assistant Clinical Professor, Department of Dermatology, University of Pennsylvania School of Medicine; Chief, Division of Dermatology, The Pennsylvania Hospital
Glen H Crawford, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, Phi Beta Kappa, and Society of USAF Flight Surgeons
Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center
Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.