From the Guidelines
Adrenal insufficiency should be treated with hormone replacement therapy, specifically hydrocortisone (15-20 mg in divided doses) for glucocorticoid replacement, and fludrocortisone (0.05-0.1 mg daily) for mineralocorticoid replacement in primary adrenal insufficiency, as recommended by the most recent guidelines 1.
Treatment Overview
The treatment of adrenal insufficiency involves replacing the deficient hormones with glucocorticoids and mineralocorticoids.
- Hydrocortisone is the preferred glucocorticoid for replacement therapy due to its ability to mimic the natural diurnal rhythm of cortisol production.
- The initial dose of hydrocortisone is typically 15-20 mg daily in divided doses, with adjustments made based on clinical response and laboratory results.
- Fludrocortisone is used for mineralocorticoid replacement in primary adrenal insufficiency, with a starting dose of 0.05-0.1 mg daily.
Management of Adrenal Insufficiency
The management of adrenal insufficiency involves:
- Education on steroid stress dosing, emergency injections, and the use of a medical alert bracelet or necklace.
- Regular monitoring of symptoms, blood pressure, and electrolytes to adjust replacement therapy as needed.
- Increasing glucocorticoid doses during illness, surgery, or significant stress to prevent adrenal crisis.
- Annual consultation with an endocrinologist to assess the patient's condition and adjust treatment as necessary.
Adrenal Crisis
Adrenal crisis is a life-threatening complication of adrenal insufficiency, characterized by severe hypotension, electrolyte imbalances, and shock.
- Treatment of adrenal crisis involves immediate administration of intravenous hydrocortisone (100 mg) and isotonic saline solution, as well as identification and treatment of the underlying cause of the crisis 1.
Key Considerations
- Patients with adrenal insufficiency should carry an emergency kit containing injectable hydrocortisone and wear medical identification.
- Regular monitoring of bone mineral density is recommended to assess the risk of osteoporosis associated with glucocorticoid therapy.
- Patients should be educated on the importance of adhering to their replacement therapy regimen and seeking medical attention immediately if they experience symptoms of adrenal crisis.
From the Research
Definition and Causes of Adrenal Insufficiency
- Adrenal insufficiency is a condition characterized by an absolute or relative deficiency of adrenal cortisol production 2.
- Primary adrenal insufficiency is rare and is caused by direct adrenal failure, whereas secondary adrenal insufficiency is more frequent and is caused by diseases affecting the pituitary 2.
- The most frequent cause of primary adrenal insufficiency in western countries is autoimmune adrenalitis, whereas secondary adrenal insufficiency is most often caused by pituitary tumours and their treatment 3.
Symptoms and Diagnosis
- Symptoms of adrenal insufficiency are non-specific, often overlooked or misdiagnosed, and are related to the lack of cortisol, adrenal androgen precursors and aldosterone 2.
- Diagnosis is based on measurement of the adrenal corticosteroid hormones, their regulatory peptide hormones and stimulation tests 2.
Treatment and Management
- The goal of therapy is to establish a hormone replacement regimen that closely mimics the physiological diurnal cortisol secretion pattern, tailored to the patient's daily needs 2.
- Chronic glucocorticoid replacement consists of hydrocortisone 15-25 mg/day in divided doses, and fludrocortisone 0.05-0.2 mg/day is given for substitution in mineralocorticoid deficiency 3.
- Dehydroepiandosterone 25-50 mg/day may improve mood, fatigue, well-being and, in women, also sexuality, but large Phase III trials are still lacking 3.
- Patients with adrenal insufficiency are at risk of adrenal crisis, usually precipitated by major stress, such as severe infection or surgery, and early dose adjustments are required to cover the increased glucocorticoid demand in stress 3.
Quality of Life and Education
- Quality of life remains altered in the adrenal insufficient patient treated by hydrocortisone and fludrocortisone 4.
- Educational programs towards the adrenal insufficient patient are crucial to prevent acute adrenal insufficiency and adrenal crisis 4, 5.
- Patient education, glucocorticoid emergency cards and injection kits are important strategies for prevention of life-threatening adrenal emergencies 2.
Daily Glucocorticoid Replacement Dose
- The recommended daily glucocorticoid replacement dose is 15 to 25 mg with a midpoint of 20 mg of hydrocortisone in divided doses in otherwise healthy individuals with adrenal insufficiency 6.
- However, a daily glucocorticoid replacement dose of 4.3 to 26 mg/d hydrocortisone with a midpoint of 15 mg/d is predicted from current measurements of daily cortisol production rates and oral hydrocortisone bioavailability 6.