What is the best approach for an 88-year-old patient with a history of right adrenalectomy for hypertension, who received a corticosteroid injection and had subsequent cortisol levels drawn, showing a response to an ACTH stimulation test?

From the Guidelines

The best approach for an 88-year-old patient with a history of right adrenalectomy for hypertension, who received a corticosteroid injection and had subsequent cortisol levels drawn, showing a response to an ACTH stimulation test, is to start glucocorticoid replacement therapy, specifically hydrocortisone at a typical starting dose of 15-20 mg per day, divided into 2-3 doses with the largest dose in the morning. This recommendation is based on the patient's history of adrenalectomy and the results of the ACTH stimulation test, which indicate adrenal insufficiency 1.

Key Considerations

• Patients with adrenal insufficiency are at risk of adrenal crisis, and it is essential to recognize and diagnose this medical emergency promptly 1.
• The goal of treatment is to mimic the body's natural cortisol production, alleviating symptoms of adrenal insufficiency while avoiding over-replacement and its associated risks 1.
• Patients should be educated about stress dosing, which involves doubling or tripling the usual dose during times of illness, surgery, or severe stress, and they should also wear a medical alert bracelet indicating adrenal insufficiency 1.
• Regular follow-up is necessary to adjust the dose based on clinical response and to monitor for side effects 1.

Management of Glucocorticoids

• Hydrocortisone 100 mg intravenously at the start of surgery, followed by an infusion of 200 mg/24 h, is recommended for patients with adrenal insufficiency undergoing surgery 1.
• For patients who are not undergoing surgery, the typical starting dose of hydrocortisone is 15-20 mg per day, divided into 2-3 doses with the largest dose in the morning 1.
• Mineralocorticoid replacement (fludrocortisone) is typically not needed in unilateral adrenalectomy but may be considered if there are signs of mineralocorticoid deficiency 1.

Patient Education and Collaboration

• Patients with adrenal insufficiency should be educated about sick day rules, which refer to doubling the dose of steroids during periods of physiological stress, and injecting hydrocortisone intramuscularly or intravenously in situations of major stress or surgery 1.
• Collaboration with the patient's endocrinologist is essential when planning scheduled surgery and when caring for postoperative cases, especially for patients with multiple risk factors (age, comorbidities) 1.

From the FDA Drug Label

The lowest possible dose of corticosteroids should be used to control the condition under treatment. When reduction in dosage is possible, the reduction should be gradual Drug-induced secondary adrenocortical insufficiency may be minimized by gradual reduction of dosage This type of relative insufficiency may persist for up to 12 months after discontinuation of therapy following large doses for prolonged periods; therefore, in any situation of stress occurring during that period, hormone therapy should be reinstituted.

The best approach for an 88-year-old patient with a history of right adrenalectomy for hypertension, who received a corticosteroid injection and had subsequent cortisol levels drawn, showing a response to an ACTH stimulation test, is to:

• Gradually reduce the corticosteroid dosage to minimize the risk of secondary adrenocortical insufficiency 2
• Monitor the patient's condition closely during the reduction period
• Be prepared to reinstitute hormone therapy in case of stress or adrenal insufficiency, considering the patient's history of adrenalectomy and potential for long-term adrenal suppression 2

From the Research

Approach to Managing Adrenal Insufficiency

The best approach for an 88-year-old patient with a history of right adrenalectomy for hypertension, who received a corticosteroid injection and had subsequent cortisol levels drawn, showing a response to an ACTH stimulation test, involves careful consideration of their glucocorticoid replacement therapy.

• The patient's response to the ACTH stimulation test indicates that their adrenal function is intact, but they may still require glucocorticoid replacement therapy to manage their adrenal insufficiency 3.
• The goal of glucocorticoid replacement therapy is to replicate the physiological concentrations of cortisol, which is essential for maintaining the patient's overall health and well-being 4, 5.
• A weight-related, thrice-daily dosing regimen of hydrocortisone has been shown to be effective in managing adrenal insufficiency, and can help to minimize the risk of over- or under-replacement 6, 7.
• Monitoring of the patient's treatment should be based on clinical symptoms, as well as serum cortisol measurements, to ensure that the dosing regimen is effective and to make any necessary adjustments 4, 7.

Considerations for Hydrocortisone Replacement Therapy

When managing the patient's hydrocortisone replacement therapy, several factors should be considered, including:

• The patient's weight, as this can affect the clearance of hydrocortisone and the dosing regimen 7.
• The timing of hydrocortisone administration, as this can impact the patient's cortisol levels and overall health 4, 5.
• The use of food to delay the absorption of hydrocortisone, which can help to minimize the risk of over-exposure to cortisol 7.
• The patient's response to the ACTH stimulation test, which can help to guide adjustments to their glucocorticoid replacement therapy 3.