What is the initial treatment for a patient with confirmed adrenal insufficiency (low cortisol level)?

From the Guidelines

The initial treatment for a patient with confirmed adrenal insufficiency is immediate glucocorticoid replacement therapy, typically with hydrocortisone, at a dose of 15-20 mg in divided doses, as recommended by the most recent guidelines 1.

Key Considerations

• For acute management, intravenous hydrocortisone 100mg is administered as a bolus, followed by 50-100mg every 6-8 hours, along with intravenous fluid resuscitation using normal saline, as outlined in the guidelines 1.
• Once stabilized, patients transition to oral maintenance therapy consisting of hydrocortisone 15-25mg daily, divided into 2-3 doses (typically 10-15mg in the morning, 5-10mg in early afternoon, and sometimes a smaller evening dose) 1.
• Mineralocorticoid replacement with fludrocortisone 0.05-0.2mg once daily is also necessary for primary adrenal insufficiency but not typically for secondary forms 1.

Education and Emergency Preparedness

• Patients should be educated about stress dosing (doubling or tripling their glucocorticoid dose during illness, surgery, or significant stress) and should carry an emergency injection kit and medical alert identification 1.
• Endocrine consultation prior to surgery or any procedure for stress-dose planning is crucial 1.

Distinguishing Primary and Secondary Adrenal Insufficiency

• Primary and secondary adrenal insufficiency can be distinguished by the relationship between ACTH and cortisol, with low ACTH and low cortisol indicating secondary adrenal insufficiency 1.
• Management of secondary adrenal insufficiency is as per hypophysitis guidelines, and patients on corticosteroids for other conditions will have low morning cortisol as a result of iatrogenic, secondary adrenal insufficiency 1.

From the FDA Drug Label

To avoid drug-induced adrenal insufficiency, supportive dosage may be required in times of stress (such as trauma, surgery, or severe illness) both during treatment with fludrocortisone acetate and for a year afterwards The initial treatment for a patient with confirmed adrenal insufficiency (low cortisol level) is supportive dosage of corticosteroids, such as fludrocortisone acetate, to avoid drug-induced adrenal insufficiency, especially in times of stress 2.

• The lowest possible dose of corticosteroid should be used to control the condition being treated.
• A gradual reduction in dosage should be made when possible.

From the Research

Initial Treatment for Adrenal Insufficiency

The initial treatment for a patient with confirmed adrenal insufficiency (low cortisol level) typically involves replacement therapy with glucocorticoids and mineralocorticoids.

• The goal of treatment is to replace the deficient hormones and restore normal physiological levels.
• According to 3, patients with Addison's disease require mineralocorticoid replacement, such as fludrocortisone 0.05-0.20 mg once daily.
• 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 3.
• The Endocrine Society Guidelines recommend a daily glucocorticoid replacement dose of 15 to 25 mg with a midpoint of 20 mg of hydrocortisone (HC) in divided doses in otherwise healthy individuals with adrenal insufficiency 4, 5.

Treatment Options

There are several treatment options available for adrenal insufficiency, including:

• Oral glucocorticoid therapy, such as hydrocortisone or cortisone acetate 3, 6
• Subcutaneous hydrocortisone infusion, which can mimic the natural circadian rhythm of cortisol release 7
• Timed-release hydrocortisone tablets, which can provide a more physiological hormone profile 3
• Pulsatile subcutaneous hydrocortisone replacement, which can restore ultradian rhythmicity and maintain normal ACTH levels 7

Monitoring and Follow-up

• Patients with adrenal insufficiency should be educated about stress dosing and equipped with a steroid card and glucocorticoid preparation for parenteral emergency administration 5.
• Follow-up should aim at monitoring appropriate dosing of corticosteroids and associated autoimmune diseases, particularly autoimmune thyroid disease 5.
• The treatment regimen may need to be adjusted based on individual patient response and clinical outcomes 6, 4.