What is the immediate treatment for adrenal insufficiency?

From the Guidelines

The immediate treatment for adrenal insufficiency is prompt administration of hydrocortisone, typically given as 50-100 mg intravenously every 6-8 hours, accompanied by fluid resuscitation with normal saline to correct hypotension and electrolyte abnormalities, as recommended by the most recent guidelines 1.

Key Considerations

• The treatment should be individualized based on the severity of symptoms and the patient's overall condition.
• For patients with severe symptoms, hospitalization may be necessary to provide close monitoring and supportive care.
• The use of hydrocortisone allows for the recreation of the diurnal rhythm of cortisol, with 2/3 of the dose given in the morning and 1/3 in the early afternoon.
• Patients should be educated on stress dosing, emergency injectable, and a medical alert bracelet or necklace for adrenal insufficiency to trigger stress-dose corticosteroids by emergency medical personnel.

Management of Adrenal Insufficiency

• For grade 1 (asymptomatic or mild symptoms), consider holding immune checkpoint inhibitor therapy until the patient is stabilized on replacement hormone, and initiate replacement therapy with hydrocortisone (15-20 mg in divided doses) 1.
• For grade 2 (moderate symptoms), consider holding immune checkpoint inhibitor therapy until the patient is stabilized on replacement hormone, and initiate outpatient corticosteroid treatment at 2-3 times maintenance (e.g., hydrocortisone 30-50 mg total dose or prednisone 20 mg daily) 1.
• For grade 3-4 (severe symptoms), hold immune checkpoint inhibitor therapy until the patient is stabilized on replacement hormone, and provide inpatient management with normal saline (at least 2L) and IV stress dose steroids: hydrocortisone 50-100 mg Q 6-8 hours initial dosing 1.

Additional Considerations

• Primary and secondary adrenal insufficiency can be distinguished by the relationship between ACTH and cortisol, and management should be tailored accordingly 1.
• DHEA replacement is controversial, but deficiency can be tested and replacement considered in women with low libido and/or energy who are judged to be otherwise well replaced 1.
• All patients need education on stress dosing for sick days, use of emergency injectables, and a medical alert bracelet or necklace for adrenal insufficiency to trigger stress-dose corticosteroids by emergency medical personnel 1.

From the FDA Drug Label

PRECAUTIONS General Precautions ... in any situation of stress occurring during that period, hormone therapy should be reinstituted

Since mineralocorticoid secretion may be impaired, salt and/or a mineralocorticoid should be administered concurrently.

The immediate treatment for adrenal insufficiency is hormone therapy, which may include the administration of salt and/or a mineralocorticoid such as fludrocortisone 2 or a corticosteroid like hydrocortisone 3.

From the Research

Immediate Treatment for Adrenal Insufficiency

The immediate treatment for adrenal insufficiency, particularly in cases of adrenal crisis, requires prompt recognition and intervention. The key aspects of treatment include:

• Administering glucocorticoids, such as hydrocortisone, to replace the deficient hormones 4, 5, 6
• Providing mineralocorticoids, like fludrocortisone, for patients with primary adrenal insufficiency to address the lack of aldosterone 4, 7, 8
• Ensuring adequate fluid and electrolyte replacement to manage potential dehydration and electrolyte imbalances 5, 6

Management and Prevention of Adrenal Crisis

To prevent adrenal crisis, it is crucial to:

• Educate patients about their condition, the importance of adherence to their glucocorticoid and mineralocorticoid replacement regimen, and the need for stress dosing during illness or surgery 7, 5, 6
• Use glucocorticoid emergency cards and injection kits as part of prevention strategies 6
• Monitor patients regularly for signs of under- or over-replacement and adjust their hormone replacement therapy as needed 4, 8

Hormone Replacement Therapy

Hormone replacement therapy for adrenal insufficiency aims to mimic the natural diurnal cortisol secretion pattern. This can be achieved with:

• Hydrocortisone given in two or three daily doses, with the highest dose in the morning 4, 8
• The use of new slow-release hydrocortisone formulations to reduce the impact of over-replacement on cardiovascular risk factors and glucose metabolism 8
• Consideration of DHEA replacement for potential benefits in quality of life, mood, lean body mass, and bone mineral density, especially in women 8