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Addison's Disease Message Board

Addison's Disease Board Index

Re: Adrenal crisis
Jun 2, 2006
trakos, Here is a bit of information about how the ACTH stim test is supposed to be done. I hope you can find another endo to retest you.

Diagnostic Testing for Addison's Disease

TEST 1: Electrolyte profile:

OBJECT: To determine if the patient exhibits a normal serum (blood) sodium and potassium levels.

THE TEST: A blood draw followed by automated determination of sodium and potassium levels as well as other standard blood markers.

NORMAL RESULT (will vary somewhat from lab to lab): Sodium 135-150 mEq/L; Potassium 3.5-5.2 mEq/L

PRIMARY ADDISONIAN: Will show significantly below normal values of sodium and a elevated (above normal) levels of potassium.

REASON FOR ABNORMALITY: Low or no production of aldosterone from the adrenal cortex. This steroidal hormone regulates our mineral balance and is called a mineralocorticoid. Primary Addisonians lose sodium and retain potassium. Abnormal values here, in additon to physical signs and symptoms, require the next test.

TEST 2: The ACTH stimulation test:

OBJECT: To determine if the patient's adrenal glands can respond to the ACTH message from the pituitary to increase cortisol production in the adrenal cortex.

THE TEST: The test is usually given first thing in the morning when normal cortisol levels are highest. Blood is withdrawn from the patient to establish a baseline (No instructions regarding necessity for fasting). The patient is given 250 micrograms (ug) of ACTH (Cortrosyn, Cosyntropin, or Synacthen) by injection in saline at one time. Blood is drawn at 30 minutes and/or 60 minutes and the serum cortisol level is determined.

NORMAL RESULTS: Normal pre-injection levels of cortisol are 5-25 ug/dL (138-690 nmol/L). The value should double at 30-60 minutes with a minimum of 20 ug/dL (552 nmol/L). PRIMARY ADDISONIAN: There will be no or little increase in cortisol levels upon ACTH injection. Notes: It is stated in several places that a single test of cortisol levels, or even 24 h urinary levels of cortisol and its metabolites, are NOT DIAGNOSTIC! In the normal individual cortisol levels are seen to pulse. Low cortisol production in either the serum or the urine after ACTH stimulation is diagnostic of Addisons disease.

SECONDARY ADDISONIAN (Pituitary malfunction): Low cortisol production can be seen if the patient has "functional adrenal cortical atrophy" due to prolonged absence of normal ACTH secretion. This type of patient would not show the typical hyper-pigmentation of primary Addisons.

REASON FOR ABNORMALITY: Due to autoimmune, or other destruction of enzymatic (biocatalytic) machinery of the adrenal gland, there is no response to ACTH and no production of cortisol and other adrenal steroids necessary for life. If this test gives normal results and the patient has other signs and symptoms then one of the following tests is required.

TEST 3: The insulin stimulation test.

OBJECT: The purpose of this test is to determine whether the patient's pituitary gland can produce ACTH in response to an insulin stimulus. Abnormally high insulin will drive the patient into hypoglycemia and stimulate the production of ACTH from the pituitary. This test is called by Dr. Krasner (JAMA, 1999, 282 671-676) the traditional test to determine the integrity of the messenger pathway between the hypothalamus, pituitary and adrenal gland. He stresses that it should be given by qualified medical personnel under the direct supervision of a physician, because insulin shock can result.

THE TEST: Baseline blood levels are taken. Insulin is injected into the patient until the blood glucose level falls below 2.2 mmol/L (40 mg/dL). Blood is drawn at intervals up to 90 minutes and the serum cortisol is measured. (This is simpler than determining the ACTH level).

NORMAL RESULTS: A normal patient will show an increase of cortisol production (due to increased ACTH production of not less then 550 nmol/L or (20 ug/dL).

DISEASED PATIENT (SECONDARY ADDISONS): If there is no or little increase in cortisol production as measured by several blood draws after this test is given, then, according to Dr. Krasner, the patient has significant hypothalamic-pituitary-adrenal (HPA) axis impairment.

REASON FOR ABNORMALITY: Basically, either the pituitary or the hypothalamus glands are not showing normal physiology. There can be several reasons for this. The pituitary may have lost its ability to make ACTH due to autoimmune impairment. The hypothalamus may not be sending the right signal to pituitary. There may be a pituitary tumor. Finally, the HPA axis may be suppressed due to sustained therapeutic use of steroids like prednisone which is given to those with chronic inflammation of various kinds. Asthmatics sometimes get in this situation.

TEST 4: The overnight metyrapone test:

OBJECT: This test is an alternative to the insulin test mentioned above and has basically the same objective which is to determine if the pituitary is making ACTH in response to a stimulus. Metyrapone is a drug that blocks the last step of the synthesis of cortisol in the adrenal gland.

THE TEST: The patient is given 30 mg/kg(body weight) at midnight without food. Blood is drawn at 8 AM ad the levels of cortisol and 11-deoxycortisol are measured.

NORMAL RESULTS: A normal individual will show morning plasma cortisol levels below 10 ug/dL (276 nmol/L) and 11-deoxycortisol levels at 7-22 ug/dL (0.2 to 0.6 umol/L).

DISEASED PATIENT: A patient with HPA axis impairment will not show increased levels of 11-deoxycortisol. NOTE: This test can drive a patient into adrenal crisis!!!

REASON FOR ABNORMALITY: same as above, no ACTH production

TEST 5: CRH stimulation.

OBJECT: The purpose of this test is to determine whether CRH (cortico-releasing hormone) is being produced by the hypothalamus and is stimulating the pituitary to make ACTH, and thence the adrenal to make cortisol.

THE TEST: CRH is given the patient by injection and blood is drawn in the manner described above to determine whether cortisol is produced in response to the stimulus. CRH is very expensive and the test, while better than either of the other two above, is not as common for this reason.

NORMAL RESULTS: Serum cortisol levels are seen to increase following the injection just as in Test 3.

DISEASED PATIENT: If the previous tests were normal and this test gives a normal result, then hypothalamic disorder could be indicated. If the test does not give rise to increased cortisol production then the patient could have either primary (adrenal) or secondary (pituitary) adrenal cortical insufficiency. The tests above must distinguish.

RADIOGRAPHIC DIAGNOSTIC TESTS: MRI or CAT scans can be made of either the adrenals or pituitary to determine the presence of abnormalities, but they are only of value when they are done with the tests above

[QUOTE=trakos]Uggh, I typed this and the board messed up and now I have t retype it.

Last summer I was diagnosed hypothyroid TSH=200, started on T4 and prmotly had severe adrenbal like issue-specifically salt wasting. I went on florinef and have slowly weaned but have a lot of pain, tiredness, weakness, headaches, extreme varaiblity of how I feel-hypoglocemia-sort of helped by gorging food? and lots of vague abdominal pain-especially upper left quadrent, also oddly enough, abdominal pain there until I urinate in the morning. I started taking a bovine adrenal supplement and felt fantastic for about a week-all symptoms went away. I then broke out in an itchy rash ad stopped taking it.

On the second day I think I actually went into an adrenal crisis-feverish, shaking, very weak, unable to walk well, nausea, waves of nausea, abdominal pain and plain nastiness ( not sure the medical term there :) ) I took two of the supplemtns 50 ug of florinef and sat in the ER waiting room for about three hours till I felt a little more stable.

Saw my endo the next day and he said to wean slowly off the supplement-even though I seem to be allergic-and that my Stim test last august looked fine and I don't have adreanl insuffieciency issues as my blood pressure looks okay.

Does the above sound like an adrenal crisis?
How long does it take to get over an adrenal crisis-that day I thought I was going to die-seriously, yesterday felt horrible, today I feel cruddy but stable

How does the bovine supplement-dessicated adreanl cortex 250 mg-compare to a prednisone dose? I want to go a synthetic due to the allergy potential. Nothing like an allergic reaction combined with an adrenal crisis to kill me off pretty quick.

Know any good ERs in the san fransico area-I have to go there next week for work and I am terrified that this might happen away from home.

I am so tired but thanks for any help you can offer[/QUOTE]

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