From the Guidelines
Adrenal insufficiency due to low cortisol levels presents with symptoms including fatigue, weakness, weight loss, decreased appetite, abdominal pain, nausea, vomiting, diarrhea, low blood pressure, dizziness when standing, salt cravings, and hyperpigmentation (darkening of skin). The treatment primarily involves hormone replacement therapy with glucocorticoids such as hydrocortisone (typically 15-20 mg daily divided into 2-3 doses, with two-thirds in the morning and one-third in the afternoon) as recommended by 1. Mineralocorticoid replacement with fludrocortisone (0.05-0.1 mg daily) is also necessary for primary adrenal insufficiency to regulate sodium and potassium balance, as stated in 1. Some key points to consider in the management of adrenal insufficiency include:
- Patients must carry emergency medication (injectable hydrocortisone) and wear medical identification.
- During illness, surgery, or other physical stress, glucocorticoid doses should be doubled or tripled temporarily to prevent adrenal crisis, as suggested by 1 and 1.
- Regular monitoring of symptoms, blood pressure, and electrolytes is essential to adjust medication dosages.
- Treatment is lifelong, and patients need education about stress dosing and recognizing signs of under or over-replacement.
- The therapy aims to mimic the body's natural cortisol rhythm, with higher doses in the morning when cortisol levels are naturally highest. It is crucial to follow the guidelines for the management of glucocorticoids during the peri-operative period for patients with adrenal insufficiency, as outlined in 1 and 1, to prevent adrenal crisis and ensure the best possible outcomes for patients. In terms of specific treatment recommendations, hydrocortisone 100 mg intravenously at the start of surgery, followed by an infusion of 200 mg/24h is recommended for patients with adrenal insufficiency undergoing surgery, as stated in 1. Additionally, patients with a long-standing diagnosis of adrenal insufficiency are often well informed about their disease, and anaesthetists should enquire closely about the patient’s history of glucocorticoid self-management, any previous episodes of adrenal crisis, and how practised they are at medication adjustments for illness, injury, or postoperative recovery, as suggested by 1.
From the FDA Drug Label
WARNINGS In patients on corticosteroid therapy subjected to unusual stress, increased dosage of rapidly acting corticosteroids before, during, and after the stressful situation is indicated. Infants born of mothers who have received substantial doses of corticosteroids during pregnancy, should be carefully observed for signs of hypoadrenalism. Secondary adrenocortical and pituitary unresponsiveness, particularly in times of stress, as in trauma, surgery or illness
The symptoms of low cortisol (adrenal insufficiency) include:
- Hypoadrenalism
- Secondary adrenocortical and pituitary unresponsiveness Treatment may involve increased dosage of rapidly acting corticosteroids before, during, and after stressful situations 2. In cases of adrenal insufficiency, patients should be carefully observed for signs of hypoadrenalism, especially in times of stress 2.
From the Research
Symptoms of Low Cortisol
- Fatigue, weakness, and loss of energy 3, 4, 5
- Weight loss, decreased appetite 3, 4
- Low blood pressure, dizziness, and fainting 3, 4
- Nausea, vomiting, and abdominal pain 3, 4
- Hyponatremia, hyperkalemia, and hypotension that are refractory to fluids and vasopressors 4
- Enhanced stress sensitivity, pain, and fatigue in patients with stress-related disorders such as chronic fatigue syndrome, fibromyalgia, and post-traumatic stress disorder 5
Diagnosis of Adrenal Insufficiency
- Low baseline cortisol levels (often <100 nmol/L) alongside raised adrenocorticotropic hormone (ACTH) can be enough to diagnose primary adrenal insufficiency 3
- Cosyntropin (Synacthen®) stimulation test or the insulin tolerance test can be used for confirmatory testing 3, 6
- Adrenocorticotropic hormone (ACTH) stimulation test is the most commonly used test in the intensive care unit 4
- Corticotropin-releasing hormone (CRH) stimulation test is reliable for diagnosing pituitary or hypothalamic adrenal insufficiency 7
Treatment of Adrenal Insufficiency
- Administration of fluids and corticosteroids is necessary to treat adrenal crisis, a life-threatening medical emergency 3, 4
- Hydrocortisone 200-300 mg/day, administered in divided doses or as a continuous infusion, is the preferred corticosteroid in patients with septic shock 4
- Low-dose corticosteroids for a longer duration decreases both the amount of time that vasopressors are required and mortality at 28 days 4
- Patients must be educated and empowered to take control of their own medical management 3