What is the primary treatment for adrenal insufficiency?

Primary Treatment for Adrenal Insufficiency

The primary treatment for adrenal insufficiency is glucocorticoid replacement with hydrocortisone 15-25 mg daily in divided doses, along with mineralocorticoid replacement using fludrocortisone 0.05-0.2 mg daily for patients with primary adrenal insufficiency. 1, 2, 3

Hormone Replacement Therapy

Glucocorticoid Replacement

• Hydrocortisone is the drug of choice for glucocorticoid replacement in adrenal insufficiency 2, 3
• Recommended daily dose: 15-25 mg in divided doses 1, 4
• Administration schedule:
  • First dose immediately after waking
  • Last dose at least 6 hours before bedtime
  • Use the lowest effective dose that maintains health and well-being 1

Mineralocorticoid Replacement

• Fludrocortisone 0.05-0.2 mg daily as a single dose for primary adrenal insufficiency 1, 5
• Not typically required in secondary adrenal insufficiency since aldosterone production remains intact 4
• Dose adjustments based on:
  • Blood pressure
  • Serum electrolytes (sodium and potassium)
  • Plasma renin activity 1

Monitoring and Assessment

• Regular assessment of:
  • Overall well-being
  • Weight
  • Blood pressure
  • Serum electrolytes (sodium and potassium) 1
• Morning cortisol levels can be used as an initial screening tool 1
• Electrolyte abnormalities in primary adrenal insufficiency typically include:
  • Low sodium
  • High potassium 1, 4

Stress Dosing Protocols

Patients must be educated on stress dosing protocols to prevent adrenal crisis 1:

1. Minor illness/stress: Double or triple usual daily dose
2. Moderate stress: Hydrocortisone 50-75 mg/day in divided doses
3. 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 Safety Measures

All patients with adrenal insufficiency should:

• Receive education on stress dosing protocols 1
• Have access to emergency injectable steroids 1, 4
• Wear medical alert identification 1
• Carry a steroid alert card 1
• Be advised to consume sodium salt without restriction (for primary adrenal insufficiency) 1
• Avoid potassium-containing salt substitutes 1

Special Considerations

Malabsorption Issues

• Small Intestinal Bacterial Overgrowth (SIBO) can affect medication absorption 1
• May require serum or salivary cortisol monitoring to guide dosing 1
• Morning post-dose peak and trough pre-dose levels help adjust timing and quantities 1

Potential Side Effects

• Higher doses of hydrocortisone may negatively impact bone mineral density 1
• Never abruptly discontinue steroids; always taper to prevent rebound adrenal insufficiency 1

Adrenal Crisis Management

Adrenal crisis is a life-threatening emergency requiring immediate treatment 4, 6:

• Immediate administration of hydrocortisone 100 mg IV 3, 4
• Fluid resuscitation
• Treatment of underlying precipitating factors
• All patients should be prescribed injectable glucocorticoids and trained in their use 4

Common Pitfalls to Avoid

1. Delayed diagnosis due to non-specific symptoms - maintain high clinical suspicion 6
2. Inadequate stress dosing during illness or procedures - ensure proper patient education 1
3. Abrupt discontinuation of glucocorticoids - always taper 1
4. Overlooking mineralocorticoid replacement in primary adrenal insufficiency 1, 5
5. Failure to provide emergency supplies and education on their use 1, 4

Despite optimal replacement therapy, patients with adrenal insufficiency often experience reduced quality of life and increased mortality, highlighting the importance of careful management and patient education 6.