DEAR DR. DONOHUE: My 37-year-old daughter has Addison’s disease. Many doctors saw her when she was hospitalized a year ago. She had to go back to the hospital because of stomach upset, back pain and dehydration. Her skin has darkened. She was told she would be fine after she started steroids. This hasn’t happened. She is constantly sick. Do you have any good news? — L.K.
ANSWER: With Addison’s disease, the adrenal glands have stopped producing their many hormones. Those hormones include cortisone and aldosterone. Cortisone gives us energy, combats inflammation and figures into many of the body’s most important functions. Aldosterone is essential for blood pressure maintenance. Without adrenal gland hormones, the skin darkens, especially the elbow skin and the creases in the hands.
Treatment is straightforward: Replace the missing hormones. Maybe the dosage of her hormone medicines needs revision. If she’s hasn’t shortly turned the corner, she should get a second opinion from an endocrinologist, a specialist in this kind of illness.
Cushing’s and Addison’s Disease. An endocrine NCLEX review on how to differentiate between Cushing’s Syndrome/Disease vs Addison’s and Addisonian Crisis. In this video, I will discuss the pathophysiology, signs & symptoms, and nursing interventions for these endocrine disorders of the adrenal cortex and pituitary glands.
Addison’s Disease and Cushing’s Syndrome/Disease review notes for nursing school and NCLEX exam. In nursing school and for the NCLEX exam, you will need to know how to provide care to a patient with either Addison’s Disease or Cushing’s.
However, many students get these two endocrine disorders confused, but these review notes will help you differentiate between them.
These NCLEX review notes will cover:
Signs and Symptoms of Addison’s Disease vs Cushing’s
Causes of Addison’s Disease and Cushing’s
Nursing Management of Addison’s Disease and Cushing’s
Role of Adrenal Cortex: releases steroid hormones and sex hormones
Role of Aldosterone: regulates blood pressure through renin-angiotensin-aldosterone system, helps retain sodium and secretes potassium (balances sodium and potassium levels).
Role of Cortisol: “STRESS Hormone” helps the body deal with stress such as illness or injury, increases blood glucose though glucose metabolism, break downs fats, proteins, and carbs, regulates electrolytes.
Cushing’s (Syndrome & Disease)
Cushing’s: hyper-secretion of CORTISOL (watch video for clever ways to remember this)
Cushing’s Syndrome vs Cushing’s Disease
Cushing’s Syndrome: caused by an outside cause or medical treatment such as glucocorticoid therapy
Cushing’s Disease: caused from an inside source due to the pituitary gland producing too much ACTH (Adrenocorticotropic hormone) which causes the adrenal cortex to release too much cortisol.
Signs & Symptoms of Cushing’s
Remember the mnemonic: “STRESSED” (remember there is too much of the STRESS hormone CORTISOL)
Skin fragile
Truncal obesity with small arms
Rounded face (appears like moon), Reproductive issues amennorhea and ED in male(due to adrenal cortex’s role in secreting sex hormones)
Ecchymosis, Elevated blood pressure
Striae on the extremities and abdomen (Purplish)
Sugar extremely high (hyperglycemia)
Excessive body hair especially in women…and Hirsutism (women starting to have male characteristics), Electrolytes imbalance: hypokalemia
Dorsocervical fat pad (Buffalo hump), Depression
Causes of Cushing’s
Glucocorticoid drug therapy ex: Prednisone
Body causing it: due to tumors and cancer on the *pituitary glands or adrenal cortex, or genetic predisposition
Nursing Management for Cushing’s Syndrome
Prep patient for Hypophysectomy to remove the pituitary tumor
Prep patient for Adrenalectomy:
If this is done educate pt about cortisol replacement therapy after surgery
Risk for infection and skin breakdown
Monitor electrolytes blood sugar, potassium, sodium, and calcium levels
Addison’s Disease
Addison’s: Hyposecretion of Aldosterone & Cortisol (watch the video for a clever way on how to remember this and not get it confused with Cushing’s)
Signs & Symptoms of Addison’s Disease
Remember the phrase: “Low STEROID Hormones” (remember you have low production of aldosterone & cortisol which are STEROID hormones)
Sodium & Sugar low (due to low levels of cortisol which is responsible for retention sodium and increases blood glucose), Salt cravings
Tired and muscle weakness
Electrolyte imbalance of high Potassium and high Calcium
Reproductive changes…irregular menstrual cycle and ED in men
lOw blood pressure (at risk for vascular collapse)….aldosterone plays a role in regulating BP
Increased pigmentation of the skin (hyperpigmentation of the skin)
Diarrhea and nausea, Depression
Causes of Addison’s Disease
Autoimmune due to the adrenal cortex becoming damaged due to the body attacking itself:
Tuberculosis/infections
Cancer
Hemorrhaging of the adrenal cortex due to a trauma
Nursing Management of Addison’s Disease
Watching glucose and K+ level
Administer medications to replace the low hormone levels of cortisol and aldosterone
For replacing cortisol:
ex: Prednisone, Hydrocortisone
Education: Patient needs to report if they are having stress such as illness, surgery, or extra stress in life ( will need to increase dosage), take medication exactly as prescribed….don’t stop abruptly without consulting with MD.
For replacing aldosterone:
ex: Fludrocortisone aka Florinef
Education: consume enough salt..may need extra salt
Wearing a medical alert bracelet
Eat diet high in proteins and carbs, and make sure to consume enough sodium
Avoid illnesses, stress, strenuous exercise
Watch for Addisonian Crisis
This develops when Addison’s Disease isn’t treated.
In addisonian crisis, the patient has extremely LOW CORTISOL levels (life threatening).
Remember the 5 S’s
Sudden pain in stomach, back, and legs
Syncope (going unconscious)
Shock
Super low blood pressure
Severe vomiting, diarrhea and headache
NEED IV Cortisol STAT:
Solu-Cortef and IV fluids (D5NS to keep blood sugar and sodium levels good and fluid status)
Watch for risk for infection, neuro status (confusion, agitation), electrolyte levels (sodium and potassium, glucose)
Oral Session: Cushing’s Syndrome and Primary Adrenal Disorders
Patients with diabetes mellitus diagnosed with Addison’s disease have a markedly increased additional risk of death
D Chantzichristos, A Persson, B Eliasson, M Miftaraj, S Franzén, R Bergthorsdottir, S Gudbjörnsdottir, A-M Svensson, G Johannsson
Summary: Researchers sought to determine if patients with diabetes (DM) who are diagnosed with Addison’s disease (AD) have an increased risk of mortality (DM+AD). They concluded that patients diagnosed with DM+AD had a nearly 4-fold increased risk of mortality compared to controls.
Methods:
Researchers identified patients who were first diagnosed with DM (type 1 or 2) and then AD using both the Swedish National Diabetes Register (NDR) and the National Inpatient Register between January 1st, 1996 and December 31th, 2012.
Each patients was matched with 5 controls based on sex, year of birth, type of DM, year when DM was diagnosed, and period of time in NDR were selected in NDR.
Researchers obtained causes of death data for both groups during the same time period from the Swedish Register for Cause-Specific Mortality.
Results:
A total of 1,355 patients were identified: 226 patients had DM (type 1 or 2) and AD and 1,129 matched DM controls.
At baseline, patients with DM+AD and patients with DM had a mean (±SD) age of 52.3 (±20.1) and 54.1 (±18.9) years, respectively.
In both groups, 47% were women and 65% had type 1 DM.
Mean (±SD) HbA1c at baseline was 7.8% (±3.5%) or 62.0 (±14.7) mmol/mol for the DM+AD group and 7.6% (±3.5%) or 59.6 (±14.7) mmol/mol for the DM controls.
More than one-quarter of patients with DM+AD (64/226, 28%) died vs 112 of 1,129 controls (10%).
The estimated relative risk increase (hazard ratio) in overall mortality in the DM+AD group was 3.83 (95% confidence interval, 2.80 to 5.24) compared with the DM controls.
There was no significant association between type of DM and gender on relative mortality risk.
The most common cause of death in both groups was cardiovascular diseases (33% and 34%, respectively).
The second most common cause of death in DM+AD patients was DM and its related complications (23%) and cancer in the DM group (29%).
Fourteen percent of DM+AD patients died from cancer.
Secondary Adrenal Insufficiency and Addison’s Disease can be deadly, mostly because of the lack of education and awareness. We have lost too many and need to be proactive in preventing unnecessary deaths! Join us as we educate on what these diseases are, how easily they can become deadly and preventive measures we can all take to help this community. Brought to you by the National Adrenal Disease Foundation, with speakers who have personal experience with these diseases.
Our program will include:
Senior Administrator Nichole Klute Rushton••• of the Addison’s Disease Support Group (https://www.facebook.com/groups/addisons.support/) on Facebook, will speak in detail about the unfortunate adrenal insufficient patients who have tragically passed, reminding us that the danger of loss of life is a reality for every person with adrenal insufficiency who doesn’t receive the vital hormones they need
Administrator Debby Hunter ••• of the Living With Addison’s Disease Support on Facebook (https://www.facebook.com/groups/LivingWithAddisonsDisease/) who will give us tips on how we can approach our local emergency facilities and hospitals with information about adrenal insufficiency and its care in a crisis situation. She will also share her own personal experience with going through an adrenal crisis.
Deputy Sheriff Chris Spires••• who will speak on life as the husband of an Addison’s disease patient, and share with us how the law enforcement community views adrenal insufficient patients
Melanie Wong ••• National Adrenal Disease Foundation (http://www.NADF.us) Executive Director, who will speak about the recent tragic losses, and the vital importance of reminding the medical community about adrenal insufficiency, as well as NADF’s latest project to get NADF Adrenal Crisis Care posters displayed in every emergency room facility in the United States.
Dutch adults with primary adrenal insufficiency reported abnormal or severe fatigue, reduced physical activity and significantly reduced quality of life vs. healthy controls, according to recent survey results.
In a cross-sectional study, Eline S. van der Valk, MD, of Amphia Hospital in Breda, the Netherlands, and colleagues also found that patients with Addison’s disease reported physical activity levels that were significantly lower than those reported by other Dutch chronically ill patients.
“The clinical relevance of the impaired [quality of life] and increased fatigue found in our study is supported by the size of the differences in scores and the restriction in physical activity in patients with [Addison’s disease], an important activity in daily life,” the researchers wrote. “Physical inactivity could be very detrimental in [Addison’s disease] because the prevalence of other cardiovascular risk factors is already increased, and it has been demonstrated that patients with [Addison’s disease] have an up to twofold increased mortality rate from [CVDs].”
Researchers analyzed survey data from 328 Dutch adults with Addison’s disease on stable glucocorticoid replacement therapy with hydrocortisone or cortisone acetate (mean age, 53 years; 223 women; mean duration of disease after diagnosis, 15.6 years). Participants attended outpatient clinics at University Medical Center Utrecht and Radboud University Nijmegen Medical Centre, or were members of the Dutch Association of Addison and Cushing Patients. They completed general and health-related quality of life (Short Form 36; Checklist Individual Strength) and physical activity questionnaires. Scores were compared with a random sample of 1,718 adults who completed a Dutch National Health Survey (controls).
Within the cohort, 53% of participants had isolated Addison’s disease; 74.1% received hydrocortisone therapy; 25.9% received cortisone acetate therapy; 87.2% received fludrocortisone therapy; and 23.2% received dehydroepiandrosterone replacement therapy.
Researchers found that 45.7% of participants with Addison’s disease met the standard of physical activity (Dutch standard of healthy physical exercise, defined as moderately intensive physical exercise for 30 minutes daily 5 days per week; “Fitnorm,” defined as 20 minutes of intensive physical exercise at least 3 days per week) vs. 67.8% of controls (P < .01). Researchers found 61% of participants with Addison’s disease reported abnormal fatigue, and 43% reported severe fatigue. Mean fatigue scores were significantly higher vs. controls (mean difference, 32.6; 95% CI, 24-41).
In both men and women with Addison’s disease, researchers found that quality of life scores in all component summaries were significantly decreased compared with controls, particularly in participants aged 65 years and younger. – by Regina Schaffer
Disclosure: The researchers report no relevant financial disclosures.
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