What is the treatment for someone with adrenal insufficiency?

Treatment for Adrenal Insufficiency

The cornerstone of adrenal insufficiency treatment is glucocorticoid replacement with hydrocortisone 15-25 mg/day divided into 2-3 doses, plus mineralocorticoid replacement with fludrocortisone 0.05-0.3 mg daily for patients with primary adrenal insufficiency. 1, 2

Types of Adrenal Insufficiency and Diagnosis

Adrenal insufficiency is categorized as:

1. Primary adrenal insufficiency (Addison's disease):

   • Characterized by low morning cortisol (<5 μg/dL), high ACTH levels, and low DHEAS
   • Requires both glucocorticoid AND mineralocorticoid replacement
   • Often presents with hyperpigmentation, salt craving, hyponatremia, and hyperkalemia 1, 2

2. Secondary adrenal insufficiency:

   • Characterized by low/intermediate morning cortisol (5-10 μg/dL) and low/normal ACTH
   • Requires glucocorticoid replacement only
   • Electrolytes generally normal, no hyperpigmentation 1

3. Glucocorticoid-induced adrenal insufficiency:

   • From prolonged exogenous glucocorticoid use
   • Requires gradual tapering to prevent symptoms 2

Standard Replacement Therapy

Glucocorticoid Replacement

• Hydrocortisone: 15-25 mg/day divided into 2-3 doses 1, 2
  • Typically higher dose in morning (e.g., 10-15 mg) and smaller dose(s) later in day
  • Alternative: Prednisone 3-5 mg daily 2

Mineralocorticoid Replacement (for primary adrenal insufficiency only)

• Fludrocortisone: 0.05-0.3 mg daily 3, 2
• Indicated for primary adrenal insufficiency and salt-losing adrenogenital syndrome 3

Stress Dosing Protocol

Increased dosage is critical during periods of stress to prevent adrenal crisis:

1. Minor illness/stress (fever, minor infection):

   • Double or triple usual daily dose 1

2. Moderate stress (severe infection, minor surgery):

   • Hydrocortisone 50-75 mg/day in divided doses 1

3. Severe stress (major surgery, trauma, severe illness):

   • Hydrocortisone 100 mg IV immediately
   • Followed by 100-300 mg/day as continuous infusion or divided doses every 6 hours 1, 4
   • For surgical patients: 100 mg IV at induction, followed by continuous infusion of 200 mg/24h 1

Adrenal Crisis Management

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

• Immediate intervention: Hydrocortisone 100 mg IV/IM immediately 2
• Fluid resuscitation: IV normal saline for volume replacement
• Continued treatment: High-dose hydrocortisone (100-300 mg/day) until stabilized 1
• Prevention: All patients should have emergency injectable hydrocortisone and proper training for self-administration 2, 5

Monitoring and Follow-up

• Monitor electrolytes (sodium, potassium), especially in primary adrenal insufficiency 1
• Monitor blood glucose levels as hyperglycemia is a common side effect 1
• Monitor weight, blood pressure, and signs of over/under replacement 1
• Avoid excessive replacement to prevent adverse effects on bone mineral density 1

Patient Education

Patient education is critical to prevent adrenal crisis:

• Provide written instructions for stress dosing 1
• Issue steroid alert card/bracelet 5
• Train patients and family members on emergency hydrocortisone injection 5
• Educate about increasing medication during illness, procedures, and stress 5

Special Considerations

• Surgery: Higher doses required (100 mg IV at induction, 200 mg/24h continuous infusion) 1
• Post-stress tapering: Maintain double dose for 48 hours after uncomplicated recovery; up to one week if complications 1
• DHEA supplementation: May benefit some women with adrenal insufficiency for well-being and sexual function 6
• Infection risk: Consider prophylaxis for patients on higher doses of glucocorticoids 1

Despite optimal replacement therapy, patients with adrenal insufficiency often experience reduced quality of life, increased sick days, and higher mortality, highlighting the importance of careful management and patient education 7, 5.