Tennessee Medicine E-Journal


Addison’s disease is a rare disorder characterized by the failure of the adrenal cortex to produce sufficient amounts of cortisol and aldosterone. Uncontrolled Addison’s disease is associated with detrimental physiological and metabolic effects such as severe abdominal pain, dehydration, hypotension, syncope and hypoglycemia. Administration of synthetic gluco- and mineralcorticoids – a standard therapy for Addison’s disease – has shown to improve the patient’s prognosis and quality of life. However, it is not uncommon for patients on steroid replacement therapy to experience multiple side effects. Often, these side effects lead to self-adjustment of medication dosage and even discontinuation of treatment. We report a patient who fulfilled the criteria for the diagnosis of primary adrenocortical failure (Addison’s disease) but was inclined to stop her medications since she was unconvinced of the diagnosis and concerned about the side-effects of steroid therapy. The demonstration of persistent plasma adrenocoticotropic hormone (ACTH) elevation while on replacement steroids and explanation of the pathophysiology involved convinced the patient of the diagnosis of Addison’s disease and persuaded her to stay on her replacement therapy. We suggest that in patients with Addison’s disease on replacement corticosteroids, a persistently elevated plasma ACTH can serve as a confirmatory test. We postulate that the lack of pulsatility in hormone replacement regimens is likely responsible for the persistent ACTH elevation. The cost of the ACTH assay has declined over the years and we encourage providers to consider it in conjunction with measuring plasma cortisol. A suppressed ACTH in patients with Addison’s disease may indicate overzealous glucocorticoid treatment.