From the Guidelines
Secondary adrenal insufficiency due to pituitary gland dysfunction should be treated with glucocorticoid replacement therapy, typically with hydrocortisone 15-20 mg daily divided into 2-3 doses, as recommended by the most recent guidelines 1. The treatment approach involves referral to endocrinology, education on steroid stress dosing, emergency injections, and a medical alert bracelet or necklace.
- The management of secondary adrenal insufficiency is based on the severity of symptoms, with asymptomatic or mild symptoms (G1) requiring consideration of holding immune checkpoint inhibitor therapy until the patient is stabilized on replacement hormones, and initiation of corticosteroid replacement with hydrocortisone 1.
- For moderate symptoms (G2), consideration of holding immune checkpoint inhibitor therapy and clinic evaluation to assess the need for steroids and volume repletion is necessary, with oral pulse dose therapy in patients with significant swelling or threatened optic chiasm compression 1.
- In cases of severe symptoms (G3-4), hospitalization or emergency department referral is required, with IV stress dose steroids and oral pulse dose therapy as needed 1. The goal of treatment is to replace the deficient cortisol production, and patient education on medication adherence and stress dose adjustments is essential for successful management.
- Regular monitoring of symptoms, electrolytes, and periodic ACTH stimulation tests help assess treatment adequacy, and patients should carry emergency medication (injectable hydrocortisone) and wear medical alert identification 1. During illness, surgery, or significant stress, glucocorticoid doses should be doubled or tripled ("stress dosing") to prevent adrenal crisis, as recommended by recent guidelines 1.
From the FDA Drug Label
Primary or secondary adrenocortical insufficiency (hydrocortisone or cortisone is the first choice; synthetic analogs may be used in conjunction with mineralocorticoids where applicable; in infancy mineralocorticoid supplementation is of particular importance) Drug-induced secondary adrenocortical insufficiency may be minimized by gradual reduction of dosage. Secondary adrenocortical and pituitary unresponsiveness, particularly in times of stress, as in trauma, surgery or illness
The diagnosis of secondary adrenal insufficiency is due to pituitary gland dysfunction. The treatment for secondary adrenal insufficiency includes hydrocortisone or cortisone as the first choice, with synthetic analogs and mineralocorticoids used in conjunction where applicable 2. It is also important to note that gradual reduction of dosage can help minimize drug-induced secondary adrenocortical insufficiency 3. Key considerations in treatment include:
- Hormone therapy should be reinstituted in situations of stress
- Mineralocorticoid supplementation is of particular importance in infancy
- Gradual reduction of dosage to minimize drug-induced secondary adrenocortical insufficiency 3
From the Research
Diagnosis of Secondary Adrenal Insufficiency
- Secondary adrenal insufficiency is caused by impairment of the corticotropic axis, resulting in deficient cortisol secretion 4
- Diagnosis is made by demonstrating low basal and/or stimulated serum cortisol, followed by investigations to establish the underlying aetiology 5
- Patients can present with an insidious onset of symptoms or acutely in adrenal crisis, which requires prompt recognition and treatment 5
Treatment of Secondary Adrenal Insufficiency
- Chronic glucocorticoid replacement consists of hydrocortisone 15-25 mg/day in divided doses, with dose monitoring largely based on clinical judgement 6
- Maintenance glucocorticoid replacement is usually given as a twice or thrice daily hydrocortisone preparation 5
- Regular monitoring for features of under- and over-replacement is essential during follow-up 5
- Patient education is a key feature of management of this condition 5
- Some studies suggest that dehydroepiandosterone 25-50 mg/day may improve mood, fatigue, well-being, and sexuality in patients with adrenal insufficiency, but large Phase III trials are still lacking 6, 7
Management of Adrenal Crisis
- Patients with adrenal insufficiency are at risk of adrenal crisis, usually precipitated by major stress, such as severe infection or surgery 6
- Early dose adjustments are required to cover the increased glucocorticoid demand in stress 6
- High-dose glucocorticoid treatment should be instituted immediately in cases of acute adrenal insufficiency 7