From the Guidelines
Adrenal insufficiency should be treated with hormone replacement therapy, including oral hydrocortisone (15-20 mg daily divided into 2-3 doses) and fludrocortisone (0.05-0.1 mg daily) for mineralocorticoid replacement in primary adrenal insufficiency, as recommended by the most recent guidelines 1. The symptoms of adrenal insufficiency include fatigue, weakness, weight loss, decreased appetite, abdominal pain, salt cravings, hypotension, and hyperpigmentation (in primary forms). The treatment regimen should be individualized, with dose adjustments based on symptoms, electrolytes, and blood pressure monitoring. Patients should also carry emergency injectable hydrocortisone (100 mg) and wear medical alert identification. During illness, surgery, or significant stress, glucocorticoid doses should be doubled or tripled ("stress dosing") 1. Regular monitoring and patient education on medication adherence and stress dose protocols are crucial for managing adrenal insufficiency and preventing complications. The condition results from inadequate production of adrenal hormones, either due to adrenal gland damage (primary) or pituitary dysfunction (secondary), disrupting essential metabolic processes, fluid balance, and stress response mechanisms. Key considerations in treatment include:
- Initiating replacement therapy with hydrocortisone (15-20 mg daily) and fludrocortisone (0.05-0.1 mg daily) for primary adrenal insufficiency 1
- Titrating doses based on symptoms and laboratory results 1
- Providing patient education on stress dosing, emergency injectables, and medical alert identification 1
- Monitoring for signs of adrenal crisis and adjusting treatment accordingly 1
From the FDA Drug Label
Primary or secondary adrenocortical insufficiency (hydrocortisone or cortisone is the drug of choice; synthetic analogs may be used in conjunction with mineralocorticoids where applicable; in infancy, mineralocorticoid supplementation is of particular importance)
The symptoms of adrenal insufficiency are not directly listed in the drug label. Treatment of adrenal insufficiency includes hydrocortisone or cortisone, and synthetic analogs may be used in conjunction with mineralocorticoids where applicable 2.
From the Research
Symptoms of Adrenal Insufficiency
- Fatigue (50%-95%) 3
- Nausea and vomiting (20%-62%) 3
- Anorexia and weight loss (43%-73%) 3
- Muscle weakness 4
- Low blood pressure 4
- Darkening of the skin 4
Diagnosis of Adrenal Insufficiency
- Early-morning (approximately 8 am) measurements of serum cortisol, corticotropin, and dehydroepiandrosterone sulfate (DHEAS) 3
- Corticotropin stimulation testing (measurement of cortisol before and 60 minutes after administration of cosyntropin, 250 µg) 3
- Primary adrenal insufficiency is typically characterized by low morning cortisol levels (<5 µg/dL), high corticotropin levels, and low DHEAS levels 3
- Patients with secondary and glucocorticoid-induced adrenal insufficiency typically have low or intermediate morning cortisol levels (5-10 µg/dL) and low or low-normal corticotropin and DHEAS levels 3
Treatment of Adrenal Insufficiency
- Supplemental glucocorticoids (eg, hydrocortisone, 15-25 mg daily, or prednisone, 3-5 mg daily) 3, 5
- Mineralocorticoids (eg, fludrocortisone, 0.05-0.3 mg daily) should be added for patients with primary adrenal insufficiency 3, 5
- Increased glucocorticoid dosage during acute illness and physical stress to prevent adrenal crisis 3, 5
- Injectable glucocorticoids (eg, hydrocortisone, 100 mg intramuscular injection) to prevent or treat adrenal crisis 3
- Modified-release hydrocortisone treatments that mimic the physiological circadian pattern of cortisol secretion may improve metabolic outcomes and quality of life 6, 7