Management of Adrenal Insufficiency in a 36-Year-Old Female with Fatigue
The management of adrenal insufficiency in a 36-year-old female with fatigue requires immediate diagnostic confirmation followed by appropriate hormone replacement therapy with hydrocortisone (10-20 mg orally every morning, 5-10 mg orally in early afternoon) and possibly fludrocortisone (0.1 mg daily) for primary adrenal insufficiency. 1
Diagnostic Approach
Initial Evaluation
- Morning (8 AM) cortisol and ACTH levels
- Low cortisol with high ACTH suggests primary adrenal insufficiency
- Low cortisol with low/normal ACTH suggests secondary adrenal insufficiency 1
- Basic metabolic panel to check for electrolyte abnormalities
- Hyponatremia and hyperkalemia suggest primary adrenal insufficiency 1
Confirmatory Testing
- ACTH stimulation test (cosyntropin test) if initial results are indeterminate
- Administration of 0.25 mg cosyntropin IM or IV
- Measure serum cortisol at 30 and/or 60 minutes
- Normal response: cortisol should exceed 550 nmol/L 1
- Do not delay treatment if adrenal crisis is suspected 2
Treatment Protocol
Immediate Management
- If signs of adrenal crisis (hypotension, severe symptoms):
- Hydrocortisone 100 mg IV/IM immediately
- Isotonic (0.9%) saline solution at rapid rate (1 L/hour initially)
- Treat underlying precipitant (e.g., infection) 1
Maintenance Therapy
- For primary adrenal insufficiency:
- Hydrocortisone 10-20 mg orally every morning, 5-10 mg orally in early afternoon
- Fludrocortisone 0.1 mg daily for mineralocorticoid replacement 1
- For secondary adrenal insufficiency:
- Hydrocortisone in similar doses without fludrocortisone 1
Dose Adjustments
- Titrate dose based on clinical response
- During periods of stress, illness, or surgery:
- Minor illness: Double or triple daily dose
- Major stress/surgery: Hydrocortisone 100 mg IV/IM, followed by increased doses 2
Patient Education and Follow-up
Essential Patient Education
- Obtain and wear medical alert bracelet/identification
- Carry steroid emergency card
- Learn to self-administer injectable hydrocortisone for emergencies
- Recognize early signs of adrenal crisis 1, 2
Follow-up Care
- Review at least annually:
- Assessment of health and well-being
- Weight and blood pressure measurement
- Serum electrolyte monitoring
- Screen for development of other autoimmune disorders (particularly hypothyroidism)
- Bone mineral density assessment every 3-5 years 1
Special Considerations
Addressing Fatigue
- Fatigue is common in adrenal insufficiency, affecting 41-50% of patients 3
- Contributing factors include:
- Psychological distress
- Sleep disturbance
- Reduced physical activity
- Concentration problems 3
- Optimize hormone replacement therapy first
- Address psychological and lifestyle factors
Medication Interactions
- Use caution with:
Common Pitfalls to Avoid
- Delaying treatment when adrenal crisis is suspected
- Inadequate mineralocorticoid replacement in primary adrenal insufficiency
- Failure to increase doses during illness or stress
- Abrupt discontinuation of glucocorticoid therapy 2
- Overlooking the possibility of underlying autoimmune disorders
Etiologic Workup
If primary adrenal insufficiency is confirmed:
- Test for 21-hydroxylase antibodies (21OH-Ab) to identify autoimmune etiology (accounts for ~85% of cases)
- If 21OH-Ab negative, consider:
- Adrenal CT to evaluate for hemorrhage, tumor, or tuberculosis
- In young patients, consider genetic causes 1
By following this structured approach to diagnosis and management, the patient's symptoms of fatigue should improve with appropriate hormone replacement therapy, and the risk of life-threatening adrenal crisis can be minimized through proper education and follow-up.