What is the best course of action for managing adrenal insufficiency in a type 1 diabetic patient with low DHEA sulfate, normal ACTH, and a myelolipoma on the right adrenal gland, taking Trelegy (fluticasone furoate, umeclidinium, and vilanterol)?

Management of Adrenal Insufficiency in a Type 1 Diabetic Patient with Low DHEA Sulfate

The patient should be evaluated for secondary adrenal insufficiency caused by inhaled corticosteroids from Trelegy, with appropriate glucocorticoid replacement therapy initiated if confirmed by an ACTH stimulation test. 1, 2

Assessment of Adrenal Function

• The patient's clinical presentation suggests possible adrenal insufficiency:

  • Low DHEA sulfate levels
  • Normal ACTH levels
  • Type 1 diabetes (autoimmune condition that may increase risk of other autoimmune disorders)
  • Use of Trelegy (contains fluticasone furoate, an inhaled corticosteroid)
  • Adrenal myelolipoma (0.9 cm on right adrenal gland)

• Diagnostic approach:

  1. Complete the pending 17-OHP test to rule out congenital adrenal hyperplasia
  2. Perform morning cortisol measurement (8 AM)
  3. Conduct ACTH stimulation test (gold standard) - peak serum cortisol <500 nmol/L is diagnostic for adrenal insufficiency 1

Management Algorithm

Step 1: Determine type of adrenal insufficiency

• Normal ACTH with low DHEA sulfate suggests secondary adrenal insufficiency, likely due to inhaled corticosteroids in Trelegy 1, 2
• The small myelolipoma (0.9 cm) is likely an incidental finding and not the cause of symptoms, as myelolipomas are typically hormonally inactive 3, 4

Step 2: Initiate appropriate replacement therapy

• If adrenal insufficiency is confirmed:
  • Start hydrocortisone 15-20 mg daily in divided doses (typically 10-15 mg in morning, 5 mg in afternoon) 1
  • Monitor for symptoms of under-replacement (fatigue, nausea, hypotension) or over-replacement (weight gain, insomnia, hyperglycemia) 1
  • Carefully monitor blood glucose levels as glucocorticoid replacement may affect diabetes control

Step 3: Consider medication adjustments

• Evaluate the need for Trelegy and consider alternatives with lower systemic corticosteroid effects
• If Trelegy must be continued, adjust glucocorticoid replacement accordingly

Step 4: Adrenal crisis prevention

• Provide emergency management education:
  • Double or triple daily glucocorticoid dose during minor illnesses
  • Use parenteral hydrocortisone 100 mg during severe illness
  • Provide medical alert bracelet/card with emergency instructions 1

Special Considerations for Type 1 Diabetes

• More frequent blood glucose monitoring is essential when initiating glucocorticoid therapy
• Insulin requirements may increase with glucocorticoid replacement
• Patients with diabetes have higher risk of adrenal crisis 1
• Coordinate care with endocrinologist to manage both conditions

Management of Myelolipoma

• The 0.9 cm myelolipoma requires no specific intervention as it is:
  • Small in size (<6 cm)
  • Likely asymptomatic
  • Hormonally inactive 3, 4
• Annual imaging follow-up to monitor size is recommended

DHEA Replacement Considerations

• DHEA replacement (10-50 mg daily) may be considered if the patient has persistent symptoms despite optimized glucocorticoid replacement 5
• However, evidence for clinical benefit is limited, especially in male patients 5
• If initiated, DHEA levels should be monitored to maintain normal range 5, 6

Follow-up Plan

• Regular monitoring of:
  • Blood pressure and electrolytes
  • Symptoms of adrenal insufficiency
  • Diabetes control
  • DHEA sulfate levels if replacement is initiated
  • Size of myelolipoma annually

By following this management approach, the patient's adrenal insufficiency can be appropriately treated while accounting for the complexities of type 1 diabetes and the presence of an adrenal myelolipoma.