What are the treatment options for low Dehydroepiandrosterone (DHEA) levels?

Treatment Options for Low DHEA Levels

DHEA replacement therapy is recommended for patients with adrenal insufficiency who have persistent symptoms despite adequate primary replacement therapy, with a typical starting dose of 25-50 mg orally once daily in the morning. 1

Diagnostic Considerations Before Treatment

Before initiating DHEA treatment, it's important to understand the context of low DHEA levels:

• Determine if low DHEA is part of primary or secondary adrenal insufficiency

  • Primary: High ACTH, low cortisol, electrolyte abnormalities (↓Na, ↑K)
  • Secondary: Low ACTH, low cortisol, usually normal electrolytes 1

• Confirm diagnosis with appropriate testing:

  • Morning serum cortisol and ACTH levels
  • Cosyntropin stimulation test (gold standard)
  • DHEA/DHEAS blood levels 1

Treatment Algorithm for Low DHEA

1. For patients with diagnosed adrenal insufficiency:

   • Ensure adequate primary replacement therapy is established first (glucocorticoids and mineralocorticoids)
   • Consider DHEA supplementation only after primary therapy is optimized 1
   • Starting dose: 25-50 mg orally once daily in the morning 1

2. For patients with age-related DHEA decline:

   • DHEA supplementation is not routinely recommended as standard therapy
   • Consider treatment only if symptomatic and other causes have been ruled out 2, 3

Clinical Indications for DHEA Replacement

DHEA replacement may be beneficial for patients with:

• Persistent symptoms despite adequate primary adrenal replacement therapy 1, 2
• Symptoms that may benefit from DHEA supplementation:
  • Low energy and fatigue
  • Reduced quality of life
  • Sexual dysfunction
  • Depression or anxiety
  • Dry eyes, skin, and hair 4, 2

Monitoring and Follow-up

• Regular assessment of clinical response and symptoms
• Annual follow-up including:
  • Overall well-being assessment
  • Weight and blood pressure measurement
  • Serum electrolyte testing
  • Screening for other autoimmune disorders 1

Potential Benefits of DHEA Replacement

Research suggests DHEA supplementation may provide:

• Improved quality of life and psychological well-being 2, 3
• Enhanced body composition and muscle strength 3
• Improved bone mineral density 2, 3
• Beneficial effects on metabolic markers 2
• Immunomodulatory effects 3

Important Caveats and Limitations

• DHEA is not considered essential for life, unlike glucocorticoid and mineralocorticoid replacement 2
• Research results are inconsistent across studies 2
• In the US, DHEA is classified as a dietary supplement, not a medication 5
• In many European countries, DHEA is considered a hormone but not approved for routine use 5
• Long-term safety data is limited 3

Special Considerations

• DHEA replacement is particularly relevant for women with adrenal insufficiency who may experience more pronounced benefits 3, 5
• For patients with immune-related adverse events from immune checkpoint inhibitor therapy, DHEA replacement may be considered as part of the management strategy 6
• The age-related decline of DHEA (approximately 2% per year after adulthood) is a normal physiological process, not necessarily requiring intervention in all cases 7, 8