What is the primary treatment for adrenal insufficiency?

Primary Treatment for Adrenal Insufficiency

The primary treatment for adrenal insufficiency is glucocorticoid replacement with hydrocortisone (15-25 mg daily in divided doses) plus mineralocorticoid replacement with fludrocortisone (50-200 μg daily) in patients with primary adrenal insufficiency. 1

Glucocorticoid Replacement

Standard Dosing

• Hydrocortisone: 15-25 mg daily in divided doses 1, 2
  • Most common regimen: Three daily doses (morning, noon, afternoon)
    • Example: 10 mg + 5 mg + 2.5 mg or 15 mg + 5 mg + 5 mg
  • Two-dose regimen: Morning and noon (e.g., 15 mg + 5 mg)
• Alternative glucocorticoids:
  • Cortisone acetate: 25-37.5 mg daily (requires conversion to hydrocortisone)
  • Prednisone: 3-5 mg daily (only for compliance issues or when hydrocortisone is not tolerated) 1, 2

Dosing Principles

• First dose immediately after waking
• Last dose not less than 6 hours before bedtime
• Use the lowest dose compatible with health and well-being 1
• In children: 6-10 mg/m² of body surface area 1

Mineralocorticoid Replacement

• Fludrocortisone: 50-200 μg as a single daily dose 1, 3
• Higher doses (up to 500 μg daily) sometimes needed in:
  • Children
  • Younger adults
  • Last trimester of pregnancy 1
• Evaluation of adequacy:
  • Clinical: Absence of salt cravings, normal blood pressure, no postural hypotension
  • Laboratory: Normal serum sodium and potassium levels

Management of Adrenal Crisis

Adrenal crisis is a life-threatening emergency requiring immediate treatment:

1. Immediate administration of hydrocortisone: 100 mg IV/IM bolus followed by 100-300 mg/day as continuous infusion or divided doses every 6 hours 1
2. Fluid resuscitation: 1 L of isotonic saline over 1 hour, followed by 3-4 L over 24-48 hours 1
3. Treatment of precipitating conditions (infections, etc.)
4. Taper parenteral glucocorticoids over 1-3 days as condition improves
5. Restart fludrocortisone when hydrocortisone dose falls below 50 mg/day 1

Special Situations

Surgery and Invasive Procedures

• Major surgery: 100 mg hydrocortisone IM before anesthesia, continue 100 mg IM every 6 hours until able to take oral medication 1
• Minor surgery: 100 mg hydrocortisone IM before anesthesia, then double oral dose for 24 hours 1
• Dental procedures: Extra morning dose 1 hour prior to procedure 1

Intercurrent Illness

• Double or triple oral glucocorticoid dose during febrile illness, vomiting, or significant stress 1, 4
• Seek immediate medical attention if unable to retain oral medication

Patient Education and Crisis Prevention

All patients should:

• Wear medical alert identification
• Carry a steroid emergency card
• Have injectable hydrocortisone available for emergencies 1, 2, 4
• Receive education on dose adjustments during illness or stress
• Understand when to seek medical help

Follow-up Care

Annual follow-up should include:

• Assessment of replacement adequacy (weight, blood pressure, electrolytes)
• Screening for associated autoimmune conditions (thyroid function, vitamin B12, glucose)
• Review of emergency preparedness and previous crises
• Evaluation of quality of life and side effects of therapy 1

Common Pitfalls

1. Under-replacement of mineralocorticoid leading to salt craving, postural hypotension, and increased risk of adrenal crisis 1
2. Failure to adjust glucocorticoid doses during illness or stress, which can precipitate adrenal crisis 1, 4
3. Drug interactions affecting glucocorticoid metabolism (antiepileptics, antifungals) or mineralocorticoid effect (diuretics, NSAIDs) 1
4. Delayed recognition of adrenal crisis - mortality remains high despite available treatment 5
5. Failure to provide adequate patient education about crisis prevention 1, 4

Proper replacement therapy with appropriate dose adjustments during stress is essential for reducing morbidity and mortality in patients with adrenal insufficiency.