From the Guidelines
The primary management approach for adrenal insufficiency is hormone replacement therapy with glucocorticoids and, if needed, mineralocorticoids, with hydrocortisone being the preferred glucocorticoid, typically administered at 15-20 mg daily divided into 2-3 doses, as recommended by the most recent guidelines 1.
Key Components of Management
- Hydrocortisone is the preferred glucocorticoid for replacement therapy, allowing 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 1.
- For mineralocorticoid replacement, fludrocortisone (Florinef) is prescribed at 0.05-0.1 mg once daily for patients with primary adrenal insufficiency, with adjustments based on volume status, sodium level, and renin response 1.
- Patients must carry an emergency kit containing injectable hydrocortisone (100 mg) and wear medical identification, and should be educated on stress dosing for sick days, use of emergency injectables, and when to seek medical attention for impending adrenal crisis 1.
Stress Dosing and Monitoring
- During illness, surgery, or other stressors, glucocorticoid doses should be doubled or tripled ("stress dosing") to prevent adrenal crisis, with the goal of maintaining clinical stability and preventing morbidity and mortality 1.
- Regular monitoring of clinical symptoms, electrolytes, and blood pressure helps optimize therapy, with adjustments made as needed to prevent complications and ensure quality of life 1.
Patient Education and Support
- Patient education is crucial, including recognition of adrenal crisis symptoms (severe weakness, confusion, vomiting, hypotension) and when to increase medication doses, as well as the importance of carrying emergency kits and wearing medical identification 1.
- Early endocrinology consultation is recommended for planning before surgery or high-stress treatments, and for ongoing management and support of patients with adrenal insufficiency 1.
From the FDA Drug Label
PRECAUTIONS General Precautions Drug-induced secondary adrenocortical insufficiency may be minimized by gradual reduction of dosage. This type of relative insufficiency may persist for months after discontinuation of therapy; therefore, 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 primary management approach for adrenal insufficiency involves hormone therapy, which should be reinstituted in situations of stress. Additionally, salt and/or a mineralocorticoid should be administered concurrently if mineralocorticoid secretion is impaired 2.
- Gradual reduction of dosage is recommended to minimize drug-induced secondary adrenocortical insufficiency.
- Hormone therapy should be used to control the condition, with the lowest possible dose and gradual reduction when possible.
From the Research
Adrenal Insufficiency Management
The primary management approach for adrenal insufficiency involves glucocorticoid replacement therapy. This therapy aims to reduce the signs and symptoms of the disease and prevent the development of an Addisonian crisis, a clinical emergency characterized by hypovolemic shock 3.
Glucocorticoid Replacement Therapy
The current standard treatment regimen involves twice- or thrice-daily dosing with a glucocorticoid, most commonly oral hydrocortisone 4. However, this regimen has been shown to have limitations, including increased morbidity and reduced life expectancy due to both increased exposure to cortisol and insufficient cortisol coverage during infections and other stress-related events 4, 5.
Treatment Options and Recommendations
Recent developments in treatment have led to the development of new modes of replacement that aim to mimic normal glucocorticoid physiology, including novel dual-release formulations of hydrocortisone 3, 6. The choice of glucocorticoid replacement formulation and treatment regimen should be individualized to each patient, taking into account their specific needs and circumstances 6.
Key Considerations
- The goal of treatment is to mimic the normal circadian profile of cortisol secretion, using the lowest possible doses that guarantee an adequate quality of life for patients 3.
- Patients with adrenal insufficiency require life-long glucocorticoid substitution therapy, as well as stress adaptation to prevent adrenal crises 6.
- The impact of glucocorticoid replacement therapy on cognition is an important consideration, with evidence suggesting that prolonged phases of hypo- or hypercortisolism are associated with impaired cognitive functioning 7.