#411 Adrenal Insufficiency with Dr. Atil Kargi

In this episode of The Curbsiders, Dr. Matthew Watto, Dr. Paul Nelson-Williams, and guest host Dr. Elena Gibson interview Dr. Atil Kargi about adrenal insufficiency. Dr. Kargi explains the hypothalamic-pituitary-adrenal axis, distinguishing between primary and secondary adrenal insufficiency, diagnostic testing including morning cortisol levels and ACTH stimulation tests, common pitfalls in diagnosis, and treatment options with hydrocortisone and fludrocortisone. He also discusses stress dose education, medic alert bracelets, and emergency injection kits. The conversation covers causes, further evaluation, and management of adrenal insufficiency, with a focus on practical advice for primary care physicians and the importance of endocrinologist involvement.

Outlines

Part 1: Introduction and Guest Setup

Part 2: Adrenal Insufficiency - Diagnosis

Part 3: Adrenal Insufficiency - Treatment

Part 4: Key Takeaways and Outro

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The Curbsiders Internal Medicine Podcast

Part 1: Introduction and Guest Setup

00:00Introduction to Curbsiders Patreon and Show Content

Introduction to Curbsiders Patreon and Show Content

00:47Show Introduction and Adrenal Insufficiency Topic

Show Introduction and Adrenal Insufficiency Topic

02:46Guest Introduction and Episode Overview

Guest Introduction and Episode Overview

04:44Patreon Promotion and Guest Introduction

Patreon Promotion and Guest Introduction

07:01Meaningful Advice and Favorite Failure

Meaningful Advice and Favorite Failure

08:50Tennis vs. Pickleball and Adrenal Crisis Management

Tennis vs. Pickleball and Adrenal Crisis Management

Part 2: Adrenal Insufficiency - Diagnosis

11:31Case Presentation and Initial Considerations for Adrenal Insufficiency

Case Presentation and Initial Considerations for Adrenal Insufficiency

13:45Challenges in Diagnosing Adrenal Insufficiency and HPA Axis Review

Challenges in Diagnosing Adrenal Insufficiency and HPA Axis Review

16:12Primary vs. Secondary Adrenal Insufficiency

Primary vs. Secondary Adrenal Insufficiency

17:59Pathway Advertisement

Pathway Advertisement

19:52Causes of Primary Adrenal Insufficiency

Causes of Primary Adrenal Insufficiency

22:42Addison's Disease Definition and Clues for Adrenal Insufficiency

Addison's Disease Definition and Clues for Adrenal Insufficiency

24:13Diagnostic Testing Options for Adrenal Insufficiency

Diagnostic Testing Options for Adrenal Insufficiency

27:30ACTH Testing and Interpretation

ACTH Testing and Interpretation

30:36Cosyntropin Stimulation Test and Simplified Approach

Cosyntropin Stimulation Test and Simplified Approach

33:37Low Dose Cosyntropin Test and Endocrinology Referral

Low Dose Cosyntropin Test and Endocrinology Referral

35:54NetSuite Advertisement

NetSuite Advertisement

37:36Pitfalls in Diagnostic Testing: Time of Day, Albumin, and Sepsis

Pitfalls in Diagnostic Testing: Time of Day, Albumin, and Sepsis

40:43ACTH Assay Issues and Oral Estrogen Effects

ACTH Assay Issues and Oral Estrogen Effects

42:21Handling Testing After Hospital Diagnosis and Primary Adrenal Insufficiency

Handling Testing After Hospital Diagnosis and Primary Adrenal Insufficiency

44:22Further Evaluation for Primary Adrenal Insufficiency

Further Evaluation for Primary Adrenal Insufficiency

46:22Imaging and Adrenoleukodystrophy

Imaging and Adrenoleukodystrophy

48:28Grammarly Advertisement

Grammarly Advertisement

49:55Recap of Key Diagnostic Points

Recap of Key Diagnostic Points

Part 3: Adrenal Insufficiency - Treatment

52:33Initial Steroid Dosing for Primary Adrenal Insufficiency

Initial Steroid Dosing for Primary Adrenal Insufficiency

55:01Monitoring and Fludrocortisone Replacement

Monitoring and Fludrocortisone Replacement

57:50Fludrocortisone Dosing and DHEA Considerations

Fludrocortisone Dosing and DHEA Considerations

1:00:08Sick Day Rules and Stress Dose Education

Sick Day Rules and Stress Dose Education

1:04:44Emergency Injection Kits and Second Case Presentation

Emergency Injection Kits and Second Case Presentation

1:07:26Steroid Exposure and Dose Equivalencies

Steroid Exposure and Dose Equivalencies

1:09:10Managing Symptoms During Steroid Tapering

Managing Symptoms During Steroid Tapering

1:12:45Strategies for Steroid Withdrawal

Strategies for Steroid Withdrawal

1:15:27Managing Steroid Tapering and Inhaled Medications

Managing Steroid Tapering and Inhaled Medications

1:18:04Inhaled Glucocorticoids and Drug Interactions

Inhaled Glucocorticoids and Drug Interactions

1:21:24Managing Hypertension in Adrenal Insufficiency

Managing Hypertension in Adrenal Insufficiency

Part 4: Key Takeaways and Outro

1:24:47Take-Home Points and Don't Be Afraid to Check Cortisol

Take-Home Points and Don't Be Afraid to Check Cortisol

1:26:05No Such Thing as Adrenal Fatigue

No Such Thing as Adrenal Fatigue