Primary Treatment for Adrenal Insufficiency
The primary treatment for adrenal insufficiency is glucocorticoid replacement therapy, with hydrocortisone (15-25 mg daily in divided doses) being the preferred medication, along with mineralocorticoid replacement using fludrocortisone (50-200 μg daily) for patients with primary adrenal insufficiency. 1
Glucocorticoid Replacement Options
First-Line Treatment:
- Hydrocortisone: 15-25 mg daily in divided doses 1, 2
- Typically administered in 2-3 divided doses to mimic natural cortisol rhythm
- Morning dose should be higher (typically 50-60% of total daily dose)
- Remaining dose(s) given in afternoon/early evening
Alternative Regimens:
- Prednisone: 3-7.5 mg daily 1, 3, 2
- Longer half-life than hydrocortisone
- Can be given once or twice daily
- FDA-approved for primary or secondary adrenocortical insufficiency 3
Mineralocorticoid Replacement
- Fludrocortisone: 50-200 μg daily 1, 4
- Required for patients with primary adrenal insufficiency (Addison's disease) 4, 2
- Not typically needed in secondary adrenal insufficiency (pituitary disorder)
- FDA-indicated as partial replacement therapy for primary and secondary adrenocortical insufficiency and for salt-losing adrenogenital syndrome 4
Additional Treatment Considerations
DHEA Supplementation
- May be considered for patients with persistent symptoms despite adequate primary replacement therapy 1
- Typical starting dose: 25-50 mg orally once daily in the morning 1
- Particularly beneficial for women with adrenal insufficiency regarding well-being and sexual function 5
Stress Dosing Protocol
For preventing adrenal crisis during illness or stress, the following protocol is recommended 1:
- Minor illness/stress: Double or triple the usual daily dose
- Moderate stress: Hydrocortisone 50-75 mg/day in divided doses
- Severe stress: Hydrocortisone 100 mg IV immediately followed by 100-300 mg/day as continuous infusion or divided doses every 6 hours
Patient Education and Monitoring
Essential Education Points:
- Recognizing early symptoms of adrenal crisis
- Wearing medical alert identification
- Carrying a steroid alert card
- Having an emergency hydrocortisone injection kit 1
Follow-up Monitoring:
- Annual assessment of well-being
- Weight and blood pressure measurement
- Serum electrolyte testing
- Screening for other autoimmune disorders
- Bone mineral density assessment every 3-5 years 1
Clinical Pearls and Pitfalls
- Pitfall: Failure to increase glucocorticoid doses during illness or stress can lead to life-threatening adrenal crisis 2, 6
- Pitfall: Standard replacement therapy often fails to replicate the natural circadian rhythm of cortisol, potentially leading to over- or under-treatment 6
- Pearl: Morning serum cortisol combined with ACTH levels is crucial for diagnosis: ≥300 nmol/L (≥10.8 μg/dL) excludes adrenal insufficiency, <110 nmol/L (<4 μg/dL) suggests adrenal insufficiency 1
- Pearl: Primary adrenal insufficiency typically presents with low cortisol, high ACTH, low sodium, and high potassium, while secondary shows low cortisol, low ACTH, and normal electrolytes 1, 2
Remember that untreated adrenal insufficiency is potentially fatal, and proper replacement therapy is essential for preventing adrenal crisis and maintaining quality of life 2, 7.