The infiltration of the adrenals by tumor and their destruction by hemorrhage are the two most common causes. In addition, the immunologic checkpoint inhibiting antibodies, ipilimumab, nivolumab, and pembrolizumab can produce an autoimmune hypophysitis that leads to adrenal insufficiency. Symptoms such as nausea, vomiting, anorexia, and orthostatic hypotension may be attributed to progressive cancer or to treatment side effects. Certain treatments (e.g., ketoconazole, aminoglutethimide) may directly interfere with steroid synthesis in the adrenal.
Treatment: Adrenal Insufficiency In emergencies, a bolus of 100-mg IV hydrocortisone is followed by a continuous infusion of 10 mg/h. In nonemergent but stressful circumstances, 100-200 mg/d oral hydrocortisone is the beginning dose, tapered to maintenance of 15-37.5 mg/d. Fludrocortisone (0.1 mg/d) may be required in the presence of hyperkalemia. |
Section 2. Medical Emergencies