What is the primary treatment for secondary adrenal insufficiency?

Treatment of Secondary Adrenal Insufficiency

The primary treatment for secondary adrenal insufficiency is glucocorticoid replacement therapy with hydrocortisone 15-25 mg daily in divided doses, or alternatively prednisone 3-5 mg daily. 1, 2

Glucocorticoid Replacement Therapy

Recommended Regimens

• Hydrocortisone (first-line therapy):

  • Total daily dose: 15-25 mg 1, 2
  • Divided dosing options:
    • Three-dose regimen: 10 mg (morning) + 5 mg (noon) + 2.5-5 mg (afternoon) 1
    • Two-dose regimen: 15-20 mg (morning) + 5-10 mg (early afternoon) 1

• Alternative glucocorticoids (if compliance issues or intolerance to hydrocortisone):

  • Cortisone acetate: 25-37.5 mg daily in divided doses 1
  • Prednisolone: 4-5 mg daily 1, 2

Key Differences from Primary Adrenal Insufficiency

• Unlike primary adrenal insufficiency, secondary adrenal insufficiency does not require mineralocorticoid replacement (fludrocortisone), as aldosterone production remains intact due to preserved renin-angiotensin system function 1, 2
• Secondary adrenal insufficiency is characterized by low or low-normal corticotropin (ACTH) levels, whereas primary adrenal insufficiency shows high ACTH levels 2

Monitoring Treatment Adequacy

Clinical Assessment

• Monitor for symptoms of under-replacement:
  • Fatigue, nausea, poor appetite, weight loss 1
• Monitor for symptoms of over-replacement:
  • Weight gain, insomnia, peripheral edema 1
• Regular monitoring should include:
  • Blood pressure, weight, and general energy levels 1
  • Annual clinical assessment including serum electrolytes 1

Stress Dosing Protocol

Patients must be educated about increasing their glucocorticoid dose during periods of stress:

• Minor illness/stress (cold, mild fever):
  • Double or triple the usual daily dose 1
• Moderate stress (infection requiring antibiotics, minor surgery):
  • Hydrocortisone 50-75 mg/day in divided doses 1
• Severe stress (major illness, trauma, surgery):
  • Hydrocortisone 100 mg IV immediately followed by 100-300 mg/day as continuous infusion or divided doses every 6 hours 1
• Additional considerations:
  • Take extra hydrocortisone (5 mg) before intense exercise 1

Adrenal Crisis Management

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

• Immediate IV/IM hydrocortisone 100 mg, followed by 100 mg every 6-8 hours until recovered 1
• Fluid resuscitation with isotonic saline (3-4 L) 1
• Treatment should never be delayed for diagnostic procedures 1

Patient Education and Prevention

All patients with adrenal insufficiency should:

• Receive education on early recognition of adrenal crisis symptoms 1
• Learn proper stress dosing protocols 1
• Have an emergency hydrocortisone injection kit 1
• Wear medical alert identification and carry a steroid alert card 1

Important Considerations

• Drug-induced secondary adrenal insufficiency (the most common form) requires gradual dose reduction when discontinuing therapy 3
• Patients with secondary adrenal insufficiency may benefit from DHEA supplementation, particularly women, to improve well-being and sexual function 4
• Despite optimal replacement therapy, patients with adrenal insufficiency often report reduced quality of life and have increased mortality compared to the general population 5

Remember that early recognition and appropriate treatment of adrenal insufficiency are essential to prevent potentially fatal adrenal crisis and improve quality of life for affected patients.