Trip Answers

Question answered:13/03/08

We found no guidance concerning post myocardial infarction management in patients with Addison’s disease and would thus advise seeking specialist advice on this issue. However, the following general information may be of some relevance.

 

An e-Medicine article on Addison’s disease notes in the section on physical findings:

 

“Usually, systolic and diastolic blood pressures are reduced; the systolic blood pressure is lower than 110 mm Hg.”

 

In the section entitled, ‘Work Up’, the authors of the article state:

 

• “The evaluation of patients with suspected Addison disease involves the diagnosis of adrenal insufficiency and then the identification of the site of the defect in the hypothalamic-pituitary axis.
o Addison disease is a primary adrenal insufficiency with the defect in the adrenal gland.
o Once the adrenal insufficiency is identified, the etiology of the adrenal insufficiency may be determined.
• Initially, serum electrolytes should be checked because the results will most likely be abnormal.
o Because aldosterone is absent, hyponatremia and hyperkalemia are often present.
o Hyponatremia is the most common finding and occurs in 90% of patients.
o Hyperkalemia is found in 60-70% of patients.
o Hypercalcemia is uncommon and found in approximately 5-10% of patients.” [1]

 

Please note this information relates to the initial workup and may not be valid in patients receiving treatment for Addison’s disease.

 

The CKS guideline on the secondary prevention of myocardial infarction issues the following cautions relating to ACE inhibitors, in the section on prescribing information:

 

“Who should avoid using ACE inhibitors?

 

• “Seek specialist advice when the person is at increased risk of severe first-dose hypotension because they:
o Are on high-dose diuretics (equivalent to 80 mg furosemide or above).
o Are on high-dose vasodilator therapy.
o Have hypovolemia or hyponatremia (sodium below 130 mmol/L).
o Have hypotension (systolic blood pressure of 90 mmHg or less).

 

• Specialist advice should also be sought if the person:
o Has unstable heart failure — theoretical concerns that hypotension due to ACE inhibitors may contribute to worsening heart failure.
o Has severe aortic stenosis — vasodilatation may result in reduced cardiac output.
• If baseline creatinine or potassium is raised (i.e. creatinine more than 200 micromoles/L or potassium 5.5 mmol/L or more), monitor closely and consider seeking specialist advice.” [2]

 

As mentioned above, due to the lack of specific information on the management of this case, we would advise seeking advice from a local specialist. Alternatively, we could forward this query to the Medicines Information service. Should you wish us to refer your query, please let us know via the ‘Contact Us’ option at: http://www.clinicalanswers.nhs.uk/index.cfm?action=contact

 

References
1. Liotta E. Addison disease. February 2007. (http://www.emedicine.com/derm/topic761.htm#section~Workup)
2. CKS. MI- Secondary prevention. December 2007.
(http://www.cks.library.nhs.uk/mi_secondary_prevention)

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