What is the treatment for adrenal insufficiency?

From the Guidelines

The treatment for adrenal insufficiency involves hormone replacement therapy, with the primary treatment consisting of glucocorticoid replacement, typically with hydrocortisone (15-25 mg daily divided into 2-3 doses), and mineralocorticoid replacement with fludrocortisone (0.05-0.2 mg once daily) for patients with primary adrenal insufficiency. The most recent and highest quality study, 1, provides guidance on the management of adrenal insufficiency, including the use of hydrocortisone and fludrocortisone. Some key points to consider in the treatment of adrenal insufficiency include:

• Glucocorticoid replacement with hydrocortisone, typically 15-25 mg daily divided into 2-3 doses, with the largest dose in the morning
• Mineralocorticoid replacement with fludrocortisone, typically 0.05-0.2 mg once daily, for patients with primary adrenal insufficiency
• DHEA supplementation, 25-50 mg daily, may be considered for some patients, particularly women, to improve quality of life
• During times of illness, injury, or surgery, patients should increase their glucocorticoid dose, typically doubling or tripling the normal dose, to prevent an adrenal crisis
• All patients should carry an emergency injection kit containing hydrocortisone (100 mg) for emergency administration and wear medical alert identification
• Regular monitoring of symptoms, blood pressure, electrolytes, and plasma renin activity helps optimize treatment The study 1 also emphasizes the importance of patient education on stress dosing, emergency injections, and medical alert identification, as well as the need for endocrinology consultation in the management of adrenal insufficiency. Additionally, the study 1 provides guidance on the management of glucocorticoids during the peri-operative period for patients with adrenal insufficiency, including the use of hydrocortisone 100 mg by intravenous injection at induction of anesthesia, followed by a continuous infusion of hydrocortisone. Overall, the treatment of adrenal insufficiency requires a comprehensive approach, including hormone replacement therapy, patient education, and regular monitoring, to optimize outcomes and prevent adrenal crisis.

From the FDA Drug Label

Fludrocortisone acetate tablets, 0.1 mg are indicated as partial replacement therapy for primary and secondary adrenocortical insufficiency in Addison’s disease Naturally occurring glucocorticoids (hydrocortisone and cortisone), which also have salt-retaining properties, are used as replacement therapy in adrenocortical deficiency states.

The treatment for adrenal insufficiency includes replacement therapy with medications such as:

• Fludrocortisone for primary and secondary adrenocortical insufficiency in Addison’s disease
• Hydrocortisone as replacement therapy in adrenocortical deficiency states 2 3

From the Research

Definition of Adrenal Insufficiency

• Adrenal insufficiency (AI) is a condition characterized by an absolute or relative deficiency of adrenal cortisol production 4.
• It can be primary (PAI), secondary (SAI), or tertiary (TAI), with the most prevalent form being TAI due to exogenous glucocorticoid use 4.

Symptoms and Diagnosis

• Symptoms of AI are non-specific, often overlooked or misdiagnosed, and are related to the lack of cortisol, adrenal androgen precursors, and aldosterone (especially in PAI) 4.
• Diagnosis is based on measurement of the adrenal corticosteroid hormones, their regulatory peptide hormones, and stimulation tests 4.
• Clinical manifestations before an adrenal crisis can include hyperpigmentation, fatigue, anorexia, orthostasis, nausea, muscle and joint pain, and salt craving 5.

Treatment

• 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 4.
• Treatment of primary adrenal insufficiency requires replacement of mineralocorticoids and glucocorticoids 5.
• Patients with Addison's disease require mineralocorticoid replacement, i.e., fludrocortisone 0.05 - 0.20 mg once daily, and starting doses of glucocorticoids should be 15 - 20 mg for hydrocortisone or 20 - 30 mg for cortisone acetate, divided into two or three doses, and preferentially weight-adjusted 6.
• Timed-release hydrocortisone tablets and continuous subcutaneous hydrocortisone infusion are promising new treatment modalities 6.
• During times of stress, stress-dose glucocorticoids are required because destruction of the adrenal glands prevents an adequate physiologic response 5.

Management and Prevention

• Management of primary adrenal insufficiency or autoimmune adrenalitis requires vigilance for concomitant autoimmune diseases; up to 50% of patients develop another autoimmune disorder during their lifetime 5.
• Patient education, glucocorticoid emergency cards, and injection kits are essential for preventing life-threatening adrenal emergencies (acute AI and adrenal crisis) 4.
• Dual-release hydrocortisone may improve the long-term outcome in patients under GC substitution therapy by guaranteeing a more physiological serum cortisol concentration time-profile 7.