From the Guidelines
Adrenal axis insufficiency symptoms can be effectively managed with hormone replacement therapy, and the most recent guidelines recommend hydrocortisone as the preferred glucocorticoid for replacement therapy, with a typical dose of 15-20 mg in divided doses 1. The symptoms of adrenal axis insufficiency include:
- Profound fatigue, weakness, weight loss, decreased appetite, nausea, vomiting, abdominal pain, and salt cravings
- Low blood pressure, which may cause dizziness or fainting upon standing
- Skin changes such as hyperpigmentation, particularly in skin folds, scars, and pressure points
- Mood changes including irritability, depression, and difficulty concentrating
- Hypoglycemia, especially after fasting
- Reduced armpit and pubic hair, as well as menstrual irregularities in women In acute adrenal crisis, symptoms become severe and potentially life-threatening, including severe pain, profound weakness, confusion, and shock. Diagnosis typically involves blood tests measuring cortisol levels and ACTH stimulation tests. Treatment centers on hormone replacement therapy with glucocorticoids and sometimes mineralocorticoids to replace the missing hormones. The management of adrenal axis insufficiency should prioritize the patient's quality of life, morbidity, and mortality, and the most recent guidelines recommend a multidisciplinary approach, including endocrine consultation and education on stress dosing and emergency injectables 1. Some key considerations in the management of adrenal axis insufficiency include:
- Distinguishing between primary and secondary adrenal insufficiency based on the relationship between ACTH and cortisol
- Using hydrocortisone to recreate the diurnal rhythm of cortisol
- Initiating mineralocorticoid replacement with fludrocortisone in patients with primary adrenal insufficiency
- Educating patients on stress dosing, emergency injectables, and medical alert bracelets or necklaces
- Considering endocrine consultation prior to surgery or high-stress treatments to plan for stress-dose corticosteroids 1.
From the Research
Adrenal Axis Insufficiency Symptoms
The symptoms of adrenal axis insufficiency can be nonspecific and overlap with those of underlying and intercurrent conditions, making diagnosis challenging 2. Some common symptoms include:
- Fatigue
- Weight loss
- Hypotension
- Nausea and vomiting
- Abdominal pain
- Dizziness or fainting
Diagnosis and Treatment
Diagnosis of adrenal insufficiency is typically made with a stimulation test, such as the ACTH test 2. Treatment usually involves lifelong replacement therapy with glucocorticoids, with the goal of mimicking the natural circadian rhythm of cortisol release 3. However, current treatment regimens may not always be effective, and patients may experience increased morbidity and mortality due to over- or under-treatment 3.
Management of Adrenal Insufficiency
Management of adrenal insufficiency requires careful monitoring and adjustment of glucocorticoid replacement therapy, as well as education of patients and their partners to recognize and respond to signs of adrenal crisis 4. The use of stress dosages of glucocorticoids during ongoing glucocorticoid treatment is also an important consideration, although the indication for this is not always clear 2.
Challenges in Management
Despite the importance of optimal management, there are several challenges in the care of patients with adrenal insufficiency, including:
- Lack of objective assessment tools to monitor glucocorticoid replacement quality 5
- Insufficient physician knowledge and education on adrenal insufficiency, particularly in non-specialist settings 4
- Limited availability of specialized care and access to expert centers, particularly in certain regions 6