From the Guidelines
The treatment for a patient with low cortisol and low ACTH levels (secondary adrenal insufficiency) primarily involves glucocorticoid replacement therapy with hydrocortisone, typically given at a total daily dose of 15-20 mg in divided doses. This approach is based on the most recent and highest quality study available, which emphasizes the importance of initiating replacement therapy with hydrocortisone for patients with secondary adrenal insufficiency 1. The dosing of hydrocortisone should be titrated to a maximum of 30 mg daily total dose for residual symptoms of adrenal insufficiency, and patients should be educated on steroid stress dosing, emergency injections, and the need for a medical alert bracelet or necklace 1. Key considerations in the management of these patients include:
- Initiating replacement therapy with hydrocortisone (15-20 mg in divided doses) and titrating to a maximum of 30 mg daily total dose for residual symptoms of adrenal insufficiency 1
- Educating patients on steroid stress dosing, emergency injections, and the need for a medical alert bracelet or necklace 1
- Considering endocrine consultation for planning before surgery or high-stress treatments, as well as for recovery and weaning protocols using hydrocortisone in patients with symptoms of adrenal insufficiency after weaning off corticosteroids 1
- Being aware of the need to start corticosteroids first when planning hormone replacement therapy for multiple deficiencies, as other hormones can accelerate the clearance of cortisol and precipitate adrenal crisis 1
From the FDA Drug Label
ACTIONS Naturally occurring glucocorticoids (hydrocortisone and cortisone), which also have salt-retaining properties, are used as replacement therapy in adrenocortical deficiency states. INDICATIONS AND 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 a patient with low cortisol and low Adrenocorticotropic hormone (ACTH) levels may involve replacement therapy with glucocorticoids such as hydrocortisone 2 and mineralocorticoids such as fludrocortisone 3.
- Hydrocortisone is used as replacement therapy in adrenocortical deficiency states.
- Fludrocortisone is used as partial replacement therapy for primary and secondary adrenocortical insufficiency in Addison’s disease.
From the Research
Treatment for Low Cortisol and Low ACTH Levels
- The treatment for a patient with low cortisol and low Adrenocorticotropic hormone (ACTH) levels typically involves glucocorticoid replacement therapy 4.
- For symptomatic patients, replacement doses of 20 mg (0.30 mg/kg) hydrocortisone or 25 mg (0.35 mg/kg) cortisone acetate are usually sufficient 4.
- Administration of mineralocorticoids is generally not necessary as their production is maintained 4.
- In some cases, patients with mild, near-to-asymptomatic disease may not require glucocorticoid replacement therapy except during stressful events 4.
Important Considerations
- Patients with adrenal insufficiency should be aware of potential drug interactions that can affect glucocorticoid levels, such as rifampicin, which can increase the metabolism of hydrocortisone 5.
- Growth hormone replacement therapy can also modulate cortisol metabolism, and patients with ACTH deficiency may be at risk of cortisol deficiency when commenced on GH therapy 6.
- It is essential to monitor patients with adrenal insufficiency closely and adjust their treatment regimen as needed to prevent adrenal crisis 7.
Diagnostic Tests
- Morning serum cortisol levels below 3 microg/dl are virtually diagnostic for adrenal insufficiency, while cortisol values between 5-18 microg/dl require additional investigations, such as insulin tolerance test (ITT) or ACTH stimulation test 4.
- Plasma ACTH concentration and prolonged ACTH infusion test are useful in differential diagnosis between primary and secondary adrenal insufficiency 4.