Treatment for Autoimmune Adrenalitis
The primary treatment for autoimmune adrenalitis consists of lifelong hormone replacement therapy with glucocorticoids (hydrocortisone 15-25 mg daily in divided doses) and mineralocorticoids (fludrocortisone 0.05-0.2 mg daily). 1
Standard Replacement Therapy
Glucocorticoid Replacement
- First-line: Hydrocortisone 15-25 mg daily in divided doses 1
- Typical regimen: 2-3 doses per day to mimic physiological cortisol rhythm
- Morning dose should be highest (50-60% of total daily dose)
- Remaining dose(s) given in early afternoon/evening
- Alternative: Prednisone 5-7.5 mg daily 1
- Less preferred as it doesn't recreate natural diurnal rhythm as effectively
Mineralocorticoid Replacement
- Fludrocortisone 0.1 mg daily (range 0.05-0.2 mg) 1, 2
- Administered once daily in the morning
- Dosage adjusted based on:
- Blood pressure
- Serum electrolytes (sodium and potassium)
- Presence of salt cravings
Stress Dosing Protocol
Patients with adrenal insufficiency cannot mount a normal stress response and require increased glucocorticoid doses during illness or stress:
- Minor illness/stress: Double or triple usual daily dose 1
- Moderate stress: Hydrocortisone 50-75 mg/day in divided doses 1
- Severe stress/procedures: Hydrocortisone 100 mg IV immediately, followed by 100-300 mg/day 1
- During delivery: 100 mg hydrocortisone IM bolus, repeated every 6 hours if necessary 1
Adrenal Crisis Management
Adrenal crisis is a life-threatening emergency requiring immediate treatment:
- Immediate IV administration of 100 mg hydrocortisone 1
- Rapid infusion of 0.9% saline 1
- Treatment should never be delayed for diagnostic procedures 1
Monitoring and Follow-up
Annual follow-up should include:
- Assessment of overall well-being
- Weight and blood pressure measurement
- Serum electrolyte testing
- Screening for other autoimmune disorders 3, 1
- Thyroid function (TSH, FT4, TPO-Ab) every 12 months
- Plasma glucose and HbA1c (for diabetes)
- Complete blood count (for anemia)
- B12 levels (for autoimmune gastritis)
- In women: monitoring for premature ovarian insufficiency
- Bone mineral density assessment every 3-5 years 1
Patient Education - Critical Components
All patients must be educated on:
- Recognizing early symptoms of adrenal crisis
- Wearing medical alert identification
- Carrying a steroid alert card
- Having an emergency hydrocortisone injection kit
- When and how to adjust medication during illness or stress 1
Special Considerations
- Exercise: For intense or prolonged exercise, increase hydrocortisone and salt intake; for marathon-like events, take an extra 5 mg hydrocortisone before the event 1
- DHEA replacement: May be considered for patients with persistent symptoms despite adequate primary replacement therapy (typical starting dose: 25-50 mg orally once daily) 1
- Spontaneous recovery: Extremely rare but has been documented in isolated cases 4
Common Pitfalls to Avoid
- Undertreatment: Can lead to fatigue, weight loss, and adrenal crisis
- Overtreatment: Can cause Cushingoid symptoms (bruising, thin skin, edema, weight gain, hypertension, hyperglycemia) 1
- Delayed diagnosis: Symptoms can be subtle (hyperpigmentation, fatigue, anorexia, orthostasis, nausea, muscle/joint pain, salt craving) 5
- Failure to screen for associated autoimmune disorders: Up to 50% of patients develop another autoimmune disorder during their lifetime 5
- Inadequate patient education: Patients must understand stress dosing and crisis management
Autoimmune adrenalitis requires lifelong hormone replacement therapy and vigilant monitoring for associated conditions to ensure optimal patient outcomes and quality of life.