How are adrenal insufficiency symptoms managed?

Management of Adrenal Insufficiency Symptoms

Adrenal insufficiency symptoms should be managed with daily hydrocortisone replacement (15-25 mg daily in divided doses) plus fludrocortisone (0.05-0.2 mg daily) for primary adrenal insufficiency, along with patient education on stress dosing and emergency management. 1

Recognizing Adrenal Insufficiency Symptoms

Symptoms of adrenal insufficiency typically include:

• Fatigue and weakness (50-95% of patients)
• Nausea and vomiting (20-62%)
• Anorexia and weight loss (43-73%)
• Postural hypotension
• Abdominal pain
• Hyponatremia
• Salt craving (in primary adrenal insufficiency)
• Skin hyperpigmentation (in primary adrenal insufficiency) 2

Standard Glucocorticoid Replacement

First-line therapy:

• Hydrocortisone 15-25 mg daily in divided doses:
  • Typical regimen: 10 mg on waking, 5 mg at noon, 2.5 mg in late afternoon (16:00) 1
  • Alternative regimen: 15 mg + 5 mg, 10 mg + 10 mg, or 10 mg + 5 mg (two doses) 3

Alternative glucocorticoids:

• Cortisone acetate: 25-37.5 mg daily in divided doses 3
• Prednisolone: 4-5 mg daily (useful for patients with marked energy fluctuations) 3, 1

Mineralocorticoid Replacement (for Primary Adrenal Insufficiency)

• Fludrocortisone: 0.05-0.2 mg once daily upon awakening 1
• Higher doses (up to 0.5 mg daily) may be needed in children, younger adults, or during pregnancy 1
• Not required for secondary adrenal insufficiency (pituitary/hypothalamic causes) 3

Management of Adrenal Crisis

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

1. Hydrocortisone 100 mg IV bolus immediately 3
2. Followed by continuous infusion of 200 mg/24h or 100 mg every 6-8 hours 3
3. Rapid IV isotonic saline infusion (at least 2L) 3
4. Taper to maintenance dose over 1-3 days for uncomplicated cases or 7-14 days for severe cases 3

Prevention of Adrenal Crisis ("Sick Day Rules")

• Double or triple the usual glucocorticoid dose during:

  • Fever or illness with temperature >38°C
  • Gastroenteritis with vomiting/diarrhea
  • Surgery or dental procedures
  • Significant physical or emotional stress 1

• For vomiting or severe illness:

  • Use parenteral hydrocortisone 100 mg IM 1
  • Seek immediate medical attention 3

Patient Education and Safety Measures

All patients with adrenal insufficiency should:

1. Wear medical alert identification 1
2. Carry emergency injectable hydrocortisone 1
3. Carry a steroid card with emergency instructions 3
4. Receive education on stress dosing and adrenal crisis prevention 1
5. Have endocrine consultation prior to any surgical procedures 3
6. Eat unrestricted sodium but avoid potassium-containing salt substitutes 1

Monitoring and Follow-up

• Regular clinical assessment for signs of:

  • Under-replacement: fatigue, nausea, poor appetite, weight loss, increased pigmentation
  • Over-replacement: weight gain, insomnia, peripheral edema, hypertension 3, 1

• Laboratory monitoring:

  • Serum sodium and potassium
  • Plasma renin activity (for mineralocorticoid adjustment) 3
  • Morning cortisol levels are not useful for dose adjustment 3

Special Considerations

Morning symptoms:

• For patients with morning nausea/lack of appetite, waking earlier to take the first dose of hydrocortisone and then going back to sleep may help 3

Shift workers:

• Adjust dosing schedule according to work pattern (e.g., 10 mg upon awakening before night shift) 3

Drug interactions:

• CYP3A4 inducers (anti-epileptics, barbiturates, antituberculosis drugs) may increase hydrocortisone clearance, requiring higher doses 3
• Azole antifungals may decrease hydrocortisone clearance 3

Discontinuation of exogenous steroids:

• Taper gradually to prevent adrenal insufficiency
• Reduce by no more than 2.5-5 mg every 1-2 weeks
• Patients on prolonged therapy require even slower tapering 1, 4

By following these guidelines, most patients with adrenal insufficiency can achieve good symptom control and prevent life-threatening adrenal crises, though quality of life may remain somewhat reduced compared to the general population 5, 6.