What is the primary treatment for adrenal insufficiency?

From the Guidelines

The primary treatment for adrenal insufficiency is hormone replacement therapy with glucocorticoids and, if needed, mineralocorticoids, with hydrocortisone being the most commonly prescribed glucocorticoid at a total daily dose of 15-25 mg divided into 2-3 doses. This treatment approach is based on the most recent and highest quality study available, which emphasizes the importance of mimicking the body's natural cortisol rhythm and adjusting doses according to individual patient needs 1. The key components of this treatment include:

• Glucocorticoid replacement with hydrocortisone, typically given at a total daily dose of 15-25 mg divided into 2-3 doses
• Mineralocorticoid replacement with fludrocortisone, prescribed at a dose of 0.05-0.2 mg once daily for patients with primary adrenal insufficiency who have aldosterone deficiency
• Education on stress dosing, emergency injections, and medical alert identification
• Regular monitoring of symptoms, blood pressure, electrolytes, and plasma renin activity to optimize the treatment regimen It's also important to note that patients with adrenal insufficiency should carry emergency medication, such as injectable hydrocortisone, and wear medical alert identification, as stress situations require dose adjustments—typically doubling or tripling the glucocorticoid dose during minor illnesses with fever, and using injectable forms during severe illness, trauma, or vomiting 1. Additionally, endocrine consultation is recommended prior to surgery or any high-stress procedure to plan for stress-dose corticosteroids 1. Overall, the goal of treatment is to replace the deficient hormones and maintain normal bodily functions, while also minimizing the risk of adverse events and optimizing quality of life.

From the FDA Drug Label

ACTIONS Naturally occurring glucocorticoids (hydrocortisone and cortisone), which also have salt-retaining properties, are used as replacement therapy in adrenocortical deficiency states. INDICATIONS & USAGE Fludrocortisone acetate tablets, 0.1 mg are indicated as partial replacement therapy for primary and secondary adrenocortical insufficiency in Addison’s disease and for the treatment of salt-losing adrenogenital syndrome. INDICATIONS & USAGE When oral therapy is not feasible, and the strength, dosage form, and route of administration of the drug reasonably lend the preparation to the treatment of the condition, the intravenous or intramusculat use of SOLU-CORTEF Sterile Powder is indicated as follows: Endocrine disorders Primary or secondary adrenocortical insufficiency (hydrocortisone or cortisone is the drug of choice; synthetic analogs may be used in conjunction with mineralocorticoids where applicable; in infancy, mineralocorticoid supplementation is of particular importance)

The primary treatment for adrenal insufficiency is replacement therapy with glucocorticoids, such as hydrocortisone 2 or fludrocortisone 3, and mineralocorticoids. Hydrocortisone is the drug of choice for primary or secondary adrenocortical insufficiency 4.

From the Research

Adrenal Insufficiency Treatment

The primary treatment for adrenal insufficiency involves glucocorticoid substitution therapy, as well as stress adaptation to prevent adrenal crises 5.

• The goal of treatment is to reduce the signs and symptoms of the disease and prevent the development of an addisonian crisis, a clinical emergency characterized by hypovolemic shock 6.
• The treatment should attempt to mimic the normal circadian profile of cortisol secretion, using the lowest possible doses able to guarantee an adequate quality of life to patients 6.
• The currently available hydrocortisone or cortisone acetate preparations do not allow an accurate reproduction of the physiological secretion pattern of cortisol, but novel dual-release formulations of hydrocortisone may represent an advancement in the optimization of the clinical management of patients with adrenal insufficiency 6.

Glucocorticoid Replacement Dose

The recommended daily glucocorticoid replacement dose is:

• 15 to 25 mg with a midpoint of 20 mg of hydrocortisone (HC) (alternatively 3 to 5 mg prednisolone) in divided doses in otherwise healthy individuals with AI, according to the Endocrine Society Guidelines 7, 8.
• However, a daily glucocorticoid replacement dose of 4.3 to 26 mg/d HC with a midpoint of 15 mg/d is predicted from current measurements of daily cortisol production rates and oral HC bioavailability, suggesting that the higher HC doses recommended in the current guidelines may result in glucocorticoid overtreatment of some AI patients and associated long-term adverse outcomes 8.

Patient Education and Follow-up

• Patients should be educated about stress dosing and equipped with a steroid card and glucocorticoid preparation for parenteral emergency administration 7.
• Follow-up should aim at monitoring appropriate dosing of corticosteroids and associated autoimmune diseases, particularly autoimmune thyroid disease 7.