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PRAYER

Name of the disease & terminologiesEtiologyHistory, signs and symptomsPhysical examination InvestigationTreatment according to allopathic medicineOther therapiesYoga practicesBooks and journals for reference

ALTERNATIVE NAMES

Addison disease Adrenocortical hypofunction Chronic adrenocortical insufficiency Adrenal insufficiency

INTRODUCTION

Either of two small, dissimilarly shaped endocrine glands, one located above each kidney, consisting of the cortex, which secretes several steroid hormones, and the medulla, which secretes epinephrine.

Also called suprarenal gland. The adrenal glands, located on the cephalad

portion of each kidney, consist of a cortex and medulla, each with separate endocrine functions.

The adrenal cortex produces glucocorticoids (primarily cortisol), mineralocorticoids (primarily aldosterone), and androgens (primarily dehydroepiandrosterone and androstenedione).

Glucocorticoids promote and inhibit gene transcription in many cells and organ systems. Prominent effects include anti-inflammatory actions and increased hepatic gluconeogenesis.

Mineralocorticoids regulate electrolyte transport across epithelial surfaces, particularly renal conservation of Na in exchange for K.

Adrenal androgens' chief physiologic activity occurs after conversion to testosterone

Physiology of the pituitary-corticoadrenal system is further discussed in Principles of Endocrinology and discussed in Pituitary Disorders.

The adrenal medulla is composed of chromaffin cells, which synthesize and secrete catecholamines (mainly epinephrine and lesser amounts of norepinephrine

Chromaffin cells also produce bioactive amines and peptides (eg, histamine, serotonin, chromogranins, neuropeptide hormones).

Epinephrine and norepinephrine the major effector amines of the sympathetic nervous system, are responsible for the “flight or fight” response (ie, chronotropic and inotropic effects on the heart; bronchodilation; peripheral and splanchnic vasoconstriction with skeletal muscular vasodilation; metabolic effects including glycogenolysis, lipolysis, and renin release).

Most deficiency syndromes affect output of all adrenocortical hormones.

Hypofunction may be primary (malfunction of the adrenal gland itself, as in Addison's disease) or secondary (due to lack of adrenal stimulation by the pituitary or hypothalamus, although some experts refer to hypothalamic malfunction as tertiary).

Hyperfunction produces distinct clinical syndromes.

Hypersecretion of androgens results in adrenal virilism; of glucocorticoids, Cushing's syndrome; and of aldosterone, hyperaldosteronism (aldosteronism).

These syndromes frequently have overlapping features.

Hyperfunction may be compensatory, as in congenital adrenal hyperplasia, or due to acquired hyperplasia, adenomas, or adenocarcinomas.

Excess quantities of epinephrine and norepinephrine are produced in pheochromocytoma

Addison's disease is a hormone deficiency caused by damage to the outer layer of the adrenal gland (adrenal cortex).

Addison's disease is a disorder that results in the body producing insufficient amounts of certain hormones produced by the adrenal glands.

The adrenal glands are located just above each of two kidneys.

These glands are part of the endocrine system, and they produce hormones that give instructions to virtually every organ and tissue in the body.

In Addison's disease, adrenal glands produce too little cortisol, which is one of the hormones in a group called the glucocorticoids.

Sometimes, Addison's disease also involves insufficient production of aldosterone, one of the mineralocorticoid hormones.

Addison's disease can be life-threatening. Also called adrenal insufficiency or

hypocortisolism, Addison's disease can occur at any age, but is most common in people ages 30 to 50.

Treatment for Addison's disease involves taking hormones to replace the insufficient amounts being made by adrenal glands.

ETIOLOGY About 70% of cases in the US are due to idiopathic

atrophy of the adrenal cortex, probably caused by autoimmune processes.

The remainder result from destruction of the adrenal gland by granuloma (eg, TB), tumor, amyloidosis, hemorrhage, or inflammatory necrosis.

Hypoadrenocorticism can also result from administration of drugs that block corticosteroid synthesis (eg, ketoconazole, the anesthetic etomidate).

Addison's disease may coexist with diabetes mellitus or hypothyroidism in polyglandular deficiency syndrome.

SIGNS AND SYMPTOMSSigns and symptoms of Addison's disease usually develop slowly, often over several months, and may include:

Muscle weakness and fatigue Weight loss and decreased appetite Darkening of the skin (hyperpigmentation) Low blood pressure, even fainting Salt craving Low blood sugar (hypoglycemia) Nausea, diarrhea or vomiting Irritability Depression

Sometimes, however, the signs and symptoms of Addison's disease may appear suddenly.

In acute adrenal failure (addisonian crisis), the signs and symptoms may also include:

Pain in the lower back, abdomen or legs Severe vomiting and diarrhea, leading to

dehydration Low blood pressure Loss of consciousness

CAUSES Adrenal glands are composed of two sections. The interior (medulla) produces adrenaline-

like hormones. The outer layer (cortex) produces a group of

hormones called corticosteroids, which include glucocorticoids, mineralocorticoids and male sex hormones (androgens).

Some of the hormones the cortex produces are essential for life — the glucocorticoids and the mineralocorticoids.

Glucocorticoids. These hormones influence the body's ability to convert food fuels into energy, play a role in the immune system's inflammatory response, and help body respond to stress.

Mineralocorticoids. These hormones maintain the body's balance of sodium and potassium and water to keep blood pressure normal.

Primary adrenal insufficiency

Addison's disease occurs when the cortex is damaged and doesn't produce its hormones in adequate quantities.

Doctors refer to the condition involving damage to the adrenal glands as primary adrenal insufficiency.

The failure of the adrenal glands to produce adrenocortical hormones is most commonly the result of the body attacking itself (autoimmune disease).

For unknown reasons, immune system views the adrenal cortex as foreign, something to attack and destroy.

Other causes of adrenal gland failure may include:

Tuberculosis Other infections of the adrenal glands Spread of cancer to the adrenal glands Bleeding into the adrenal glands

Secondary adrenal insufficiency Adrenal insufficiency can also occur if the

pituitary gland is diseased. The pituitary gland makes a hormone called

adrenocorticotropic hormone (ACTH), which stimulates the adrenal cortex to produce its hormones.

Inadequate production of ACTH can lead to insufficient production of hormones normally produced by adrenal glands, even though adrenal glands aren't damaged.

Doctors call this condition secondary adrenal insufficiency.

Addisonian crisis

Another more common possible cause of secondary adrenal insufficiency occurs when people who take corticosteroids for treatment of chronic conditions, such as asthma or arthritis, abruptly stop taking the corticosteroids.

Addisonian crisis may be provoked by physical stress (such as injury, infection or illness), if Addison's disease is untreated

WHEN TO SEEK MEDICAL ADVICE

If severe fatigue, unintentionally lost weight, feel progressively weaker, experience abdominal pain, fainting spells and the skin has become darker, see the doctor to determine whether Addison's disease or some other medical condition may be the cause.

Adrenal glands, located above each of kidneys, produce a number of hormones, among them the glucocorticoids and the mineralocorticoids.

SCREENING AND DIAGNOSIS

Blood test. ACTH stimulation test. Insulin-induced hypoglycemia test. Imaging tests.

Doctor will talk first about the medical history and the signs and symptoms.

If doctor thinks that patient may have Addison's disease, may undergo some of the following tests:

Blood test

Measuring blood levels of sodium, potassium, cortisol and ACTH gives the doctor an initial indication of whether adrenal insufficiency may be causing the signs and symptoms.

A blood test can also measure antibodies associated with autoimmune Addison's disease.

ACTH stimulation test

This test involves measuring the level of cortisol in the blood before and after an injection of synthetic ACTH.

ACTH signals – adrenal glands to produce cortisol.

If adrenal glands are damaged, the ACTH stimulation test shows that the output of cortisol in response to synthetic ACTH is blunted or nonexistent.

Insulin-induced hypoglycemia test

Occasionally, doctors suggest this test if pituitary disease is a possible cause of adrenal insufficiency (secondary adrenal insufficiency).

The test involves checking the blood sugar (blood glucose) and cortisol levels at various intervals after an injection of insulin.

In healthy people, glucose levels fall and cortisol levels increase.

Imaging tests

Computerized tomography (CT) scan of the abdomen to check the size of adrenal glands and look for other abnormalities that may give insight to the cause of the adrenal insufficiency.

And may also suggest a CT scan or magnetic resonance imaging (MRI) scan of the pituitary gland if testing indicates the patient have secondary adrenal insufficiency.

Test Results Suggesting Addison's Disease

Blood chemistry

• Low serum Na (< 135 mEq/L)• High serum K (> 5 mEq/L)• Ratio of serum Na:K: < 30:1• Low fasting blood glucose (< 50 mg/dL

[< 2.78 mmol/L])• Decreased plasma HCO3 (< 20 mEq/L)• Elevated BUN (> 20 mg/dL [> 7.1

mmol/L])

Hematology • Elevated Hct• Low WBC count• Relative lymphocytosis• Increased eosinophils

Imaging tests

Evidence of:• Calcification in the adrenal areas• Renal TB• Pulmonary TB

TREATMENT If patient receive an early diagnosis of Addison's

disease, treatment may involve taking prescription corticosteroids.

Because the body isn't producing sufficient steroid hormones, doctor may have recommend to take one or more hormones to replace the deficiency.

Cortisol is replaced using hydrocortisone (Cortef), prednisone or cortisone. Fludrocortisone (Florinef) replaces aldosterone, which controls the body's sodium and potassium needs and keeps the blood pressure normal.

In addition, doctor may recommend treating androgen deficiency with an androgen replacement called dehydroepiandrosterone.

Some studies indicate that, for women with Addison's disease, androgen replacement therapy may improve overall sense of well-being, libido and sexual satisfaction.

These hormones are given orally in daily doses that mimic the amount body normally would make, thereby minimizing side effects.

If facing a stressful situation, such as an operation, an infection or a minor illness, doctor will suggest a temporary increase in dosage.

If ill with vomiting and can't retain oral medications, may need corticosteroid injections.

Addisonian crisis

An addisonian crisis is a life-threatening situation that results in low blood pressure, low blood levels of sugar and high blood levels of potassium.

This situation requires immediate medical care.

Treatment typically includes intravenous injections of:

Hydrocortisone Saline solution Sugar (dextrose)

COPING SKILLS Carry a medical alert card and bracelet at all

times. In the event incapacitated, emergency medical personnel know what kind of care is needed.

Stay in contact with doctor. Keep an ongoing relationship with doctor to make sure that the doses or replacement hormones are adequate but not excessive. If patient is having persistent problems with medications, may need adjustments in the doses or timing of the medications.

Keep extra medication handy. Because missing even one day of therapy may be dangerous, it's a good idea to keep a small supply of medication at work, at a vacation home and in travel bag in the event patient may forget to take pills. Also, have doctor prescribe a needle, syringe and injectable form of corticosteroids to have with in case of an emergency.

YOGA PRACTICES

YOGA IS BALANCE (SAMATVAM)

I A Y T CORRECTS IMBALANCES

AIMS :

• STRESS REDUCTION

• RELIEF OF PAIN

• MEDICATION REDUCTION

INTEGRATED YOGA MODULE FOR DISORDERS OF ADRENAL CORTEX

Breathing exercise Folded leg lumbar stretch Crossed leg lumbar stretch Pavanamuktasana lumbar stretch Setubandhasana lumbar stretch Dorsal stretch Tiger breathing Sasankasana breathing Bhujangasana breathing Straight leg raising (alternate legs) Side leg lumbar stretchRelax in Makarasana

Yogasanas Ardhakaticakrasana Viparitakarani (with wall support) Matsyasana Ustrasana Deep relaxation technique (DRT)

Pranayama Vibhaga pranayama (sectional breathing) Nadi suddhi Sitali/ Sitkari/ Sadanta pranayama Bhramari

Meditation (Dhyana Dharana) Nadanusandhana OM meditation

Kriyas Jala Neti Sutra Neti

SPECIFIC PRACTICES