What is the treatment for adrenal insufficiency?

From the Guidelines

The treatment for adrenal insufficiency involves hormone replacement therapy, with glucocorticoid replacement using hydrocortisone (15-25 mg daily) and mineralocorticoid replacement with fludrocortisone (0.05-0.2 mg once daily), as recommended by the most recent guidelines 1. The primary goal of treatment is to replace the deficient hormones and prevent adrenal crisis.

• Glucocorticoid replacement: Hydrocortisone is the preferred medication, with a typical dose of 15-25 mg daily divided into 2-3 doses, with the largest dose in the morning 1.
• Mineralocorticoid replacement: Fludrocortisone is used to regulate sodium and potassium balance, with a typical dose of 0.05-0.2 mg once daily 1.
• DHEA supplementation may be considered for patients with androgen deficiency symptoms, but its use is controversial 1. During times of illness, injury, or surgery, patients need to increase their glucocorticoid dose to prevent an adrenal crisis.
• The dose of hydrocortisone should be increased to 2-3 times the normal dose during illness or injury, and decreased back to maintenance doses after 2 days 1.
• Patients should carry an emergency injection kit containing hydrocortisone (100 mg) and be trained in self-administration for emergency situations 1. Regular monitoring of symptoms, blood pressure, electrolytes, and plasma renin activity helps optimize the treatment regimen.
• Patients should be reviewed at least annually, with assessment of health and well-being, measurement of weight, blood pressure, and serum electrolytes 1. This hormone replacement therapy is lifelong for most patients with adrenal insufficiency, as it replaces the essential hormones that regulate metabolism, stress response, blood pressure, and electrolyte balance.
• The treatment should be individualized based on the patient's specific needs and response to therapy, with adjustments made as necessary to prevent adrenal crisis and optimize quality of life 1.

From the FDA Drug Label

CLINICAL PHARMACOLOGY Glucocorticoids, naturally occurring and synthetic, are adrenocortical steroids that are readily absorbed from the gastrointestinal tract. 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.

The treatment for adrenal insufficiency includes:

• Replacement therapy with glucocorticoids, such as hydrocortisone 2
• Fludrocortisone 3 for partial replacement therapy in primary and secondary adrenocortical insufficiency in Addison’s disease Key points:
• Glucocorticoids are used to replace the deficient hormones in adrenal insufficiency
• The choice of glucocorticoid and dosage will depend on the individual patient's needs and the severity of their condition 2, 3

From the Research

Treatment Overview

The treatment for adrenal insufficiency typically involves replacing the deficient hormones with medication.

• Glucocorticoid replacement is the primary treatment, usually with hydrocortisone (15-25 mg/day) in divided doses, as stated in 4 and 5.
• Mineralocorticoid replacement with fludrocortisone (0.05-0.2 mg/day) is also necessary for patients with primary adrenal insufficiency, aiming for normotension, normokalaemia, and a plasma renin activity in the upper normal range, as mentioned in 4.
• Dehydroepiandrosterone (DHEA) replacement (25-50 mg/day) may be beneficial for improving mood, fatigue, well-being, and sexuality, especially in women, as suggested in 4 and 5.

Stress Dose Hydrocortisone

During major stress, such as severe infection or surgery, patients with adrenal insufficiency require increased hydrocortisone cover to avoid an adrenal crisis.

• Continuous intravenous hydrocortisone infusion is recommended over intermittent bolus administration, as it can persistently achieve median cortisol concentrations in the range observed during major stress, according to 6.
• The optimal dose and mode of hydrocortisone administration during stress are still being researched, but current evidence suggests that a continuous intravenous infusion of 200 mg hydrocortisone over 24 hours, preceded by an initial bolus of 50-100 mg hydrocortisone, may be effective, as stated in 6.

Chronic Replacement Therapy

Chronic replacement therapy with glucocorticoids and mineralocorticoids requires careful monitoring, as current replacement strategies still need optimization, as mentioned in 7.

• Future studies will explore the potential of DHEA replacement and modified delayed-release hydrocortisone to improve outcomes in patients with adrenal insufficiency, as discussed in 7 and 8.
• Modified-release hydrocortisone treatments that mimic the physiological circadian pattern of cortisol secretion may be more effective than conventional glucocorticoid replacement therapies, as suggested in 8.