What is the treatment for adrenal insufficiency?

Treatment for Adrenal Insufficiency

The treatment for adrenal insufficiency requires glucocorticoid replacement with hydrocortisone (10-20 mg orally every morning, 5-10 mg orally in early afternoon) or prednisone (5-10 mg daily), plus mineralocorticoid replacement with fludrocortisone (0.1 mg/day) in primary adrenal insufficiency. 1

Diagnostic Approach

Before initiating treatment, confirm the diagnosis:

• Morning (8 AM) ACTH and cortisol levels
• Basic metabolic panel (sodium, potassium, CO2, glucose)
• Consider ACTH stimulation test for indeterminate results
• Distinguish between primary (high ACTH, low cortisol) and secondary (low ACTH, low cortisol) adrenal insufficiency 1

Treatment Algorithm Based on Severity

Mild Symptoms (Outpatient Management)

• Glucocorticoid replacement:
  • Hydrocortisone 10-20 mg orally in the morning and 5-10 mg in early afternoon
  • OR Prednisone 5-10 mg daily 1, 2
• Mineralocorticoid replacement (for primary adrenal insufficiency only):
  • Fludrocortisone 0.1 mg daily, titrated based on symptoms 1, 3
• Endocrine consultation recommended 1

Moderate Symptoms

• Initiate outpatient treatment at 2-3 times maintenance dose:
  • Hydrocortisone 20-30 mg in morning, 10-20 mg in afternoon
  • OR Prednisone 20 mg daily 1
• Taper stress-dose corticosteroids to maintenance over 5-10 days
• Continue mineralocorticoid replacement as above 1

Severe Symptoms/Adrenal Crisis (Emergency Treatment)

• Immediate IV hydrocortisone 100 mg bolus
• Continue with 100-300 mg/day as continuous infusion or IV/IM boluses every 6 hours
• IV isotonic saline (3-4 L) with initial rate of approximately 1 L/hour
• Taper parenteral glucocorticoids over 1-3 days to oral maintenance therapy 1
• Resume mineralocorticoid replacement when hydrocortisone dose falls below 50 mg/day 1

Long-term Management

Maintenance Therapy

• Daily glucocorticoid replacement:
  • Hydrocortisone 15-25 mg daily (typically divided: 2/3 in morning, 1/3 in afternoon)
  • OR Prednisone 3-5 mg daily 2
• Daily mineralocorticoid replacement (for primary adrenal insufficiency):
  • Fludrocortisone 0.05-0.3 mg daily 3, 2
• Titrate doses based on clinical response (appetite, weight, energy, blood pressure) 1

Stress Dosing Education

• Critical for preventing adrenal crisis:
  • Double or triple glucocorticoid dose during minor illness, fever, or stress
  • For severe illness, trauma, or surgery: hydrocortisone 100 mg IM/IV
  • Provide injectable hydrocortisone and training for self-administration 1, 4
• Medical alert bracelet for adrenal insufficiency 1

Annual Follow-up

• Assess adequacy of replacement therapy
• Monitor for complications of therapy and associated autoimmune conditions
• Screen for thyroid dysfunction, diabetes, vitamin B12 deficiency, and celiac disease 1

Common Pitfalls and Caveats

• Undertreatment risks: Adrenal crisis, fatigue, weight loss, hypotension
• Overtreatment risks: Cushingoid features, osteoporosis, cardiovascular complications 5
• Failure to educate patients about stress dosing is a major cause of preventable adrenal crises 4
• Conventional therapy often fails to replicate natural circadian cortisol rhythm, contributing to suboptimal outcomes 6
• Patients with primary adrenal insufficiency require both glucocorticoid AND mineralocorticoid replacement 1
• Secondary adrenal insufficiency requires glucocorticoid but NOT mineralocorticoid replacement 1

Despite optimal replacement therapy, patients with adrenal insufficiency may still experience reduced quality of life and increased mortality compared to the general population, highlighting the importance of careful monitoring and patient education 5, 6.