What is the primary treatment for adrenal insufficiency?

Primary Treatment for Adrenal Insufficiency

The primary treatment for adrenal insufficiency requires replacement therapy with both glucocorticoids (hydrocortisone 15-25 mg daily in divided doses) and mineralocorticoids (fludrocortisone 0.05-0.2 mg daily). 1, 2, 3

Medication Regimen

Glucocorticoid Replacement

• Hydrocortisone: First-line glucocorticoid replacement
  • Dosage: 15-25 mg daily in divided doses 1, 4
  • Typically administered in a pattern that mimics physiological cortisol secretion:
    • Larger dose in the morning (e.g., 10-15 mg)
    • Smaller dose in the afternoon (e.g., 5-10 mg)
  • Alternative: Prednisone 3-5 mg daily 4

Mineralocorticoid Replacement

• Fludrocortisone: Required for primary adrenal insufficiency
  • Dosage: 0.05-0.2 mg daily 1, 3
  • Not typically needed in secondary adrenal insufficiency as the renin-angiotensin-aldosterone system remains intact 4

Stress Dosing Protocol

Patients must be educated on adjusting medication during periods of stress or illness:

• Minor illness/stress: Double or triple the usual daily glucocorticoid dose 1
• Moderate stress: Hydrocortisone 50-75 mg/day in divided doses 1
• Severe stress: Hydrocortisone 100 mg IV immediately, followed by 100-300 mg/day as continuous infusion or divided doses every 6 hours 1, 5

Adrenal Crisis Management

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

• Immediate treatment: Hydrocortisone 100 mg IV/IM 5, 4
• Follow-up: Continue with high-dose hydrocortisone until stabilization 1
• Prevention measures:
  • Medical alert identification
  • Steroid alert card
  • Emergency hydrocortisone injection kit
  • Patient education on early recognition of symptoms 1, 6

Monitoring and Follow-up

Regular monitoring is essential to ensure adequate replacement therapy:

• Annual assessments:
  • Overall well-being
  • Weight and blood pressure measurement
  • Serum electrolyte testing
  • Screening for other autoimmune disorders 1
• Bone mineral density: Assessment every 3-5 years 1

Additional Considerations

• DHEA replacement: May be considered for patients with persistent symptoms despite adequate primary replacement therapy
  • Typical starting dose: 25-50 mg orally once daily in the morning 1, 7
  • Particularly beneficial for women regarding well-being and sexual function 7

Potential Pitfalls and Caveats

• Medication interactions: CYP3A4 inducers and bulking agents like psyllium may interfere with glucocorticoid absorption, potentially triggering adrenal crisis 1
• Under-replacement: Can lead to persistent fatigue, weight loss, and risk of adrenal crisis 4, 6
• Over-replacement: May cause cushingoid features, osteoporosis, and metabolic complications 8
• Inadequate stress dosing: Failure to increase glucocorticoid doses during illness or stress is a common cause of adrenal crisis 1, 6
• Delayed diagnosis: The non-specific presentation often leads to delayed diagnosis; increased physician awareness is crucial 6

Despite optimized replacement therapy, patients with adrenal insufficiency often experience impaired quality of life and increased mortality compared to the general population 9, 8, 6. This underscores the importance of careful monitoring and patient education as integral components of management.