Pharmacology · patient case with 1 question
Newly diagnosed primary adrenal insufficiency
Patient: Female, 38 years old
Chief Complaint: “I have brown patches inside my mouth and I am exhausted all the time.”
Background: Six months of progressive fatigue, weight loss and salt craving. Referred by her dentist and recently diagnosed by an endocrinologist.
Vital Signs: BP 86/56 mmHg with a further drop on standing · HR 96 bpm · T 98.1°F · serum sodium low, potassium high
Findings: Diffuse brown macular pigmentation of the buccal mucosa and gingiva. Generalized skin bronzing, accentuated at the palmar creases. Requires two restorations and a scaling.
Question 1
Which class of medication is the mainstay of treatment for this condition?
Show answer and explanation
Correct answer: C. Corticosteroid replacement therapy
- A. Thyroid replacement treats hypothyroidism. The two can coexist as part of autoimmune polyglandular syndrome, but levothyroxine does nothing for adrenal failure — and given in an untreated Addisonian patient it can PRECIPITATE a crisis by raising cortisol clearance.
- B. A potassium-sparing diuretic such as spironolactone is an ALDOSTERONE ANTAGONIST — the exact opposite of what is needed in a patient who is already hyponatraemic, hyperkalaemic and hypotensive from mineralocorticoid deficiency.
- C. CORRECT. Primary adrenal insufficiency is a deficiency of adrenal cortical hormones, so treatment is REPLACEMENT of what is missing: a GLUCOCORTICOID, usually hydrocortisone in divided doses mimicking the diurnal rhythm, together with a MINERALOCORTICOID, fludrocortisone, which the primary form requires and the secondary form does not. Loss of the cortisol negative feedback drives ACTH — and the POMC precursor it comes from — to very high levels, and it is that excess ACTH acting on melanocortin receptors that produces both the mucosal pigmentation and the skin bronzing.
- D. Metformin lowers blood glucose in type 2 diabetes. Addison disease tends toward HYPOglycaemia, so this would be actively harmful.
Note: What this item adds is the MANAGEMENT and its dental consequence. Adrenal CRISIS — hypotension, abdominal pain, vomiting, collapse — is the emergency to know: treat with intravenous hydrocortisone 100 mg, fluids and glucose, and activate emergency services. Current evidence does NOT support routine 'steroid cover' before ordinary dental care for patients on stable replacement; ensure the usual morning dose has been taken, keep appointments short and stress low, give profound anaesthesia, and discuss supplementation with the endocrinologist only for major surgery.