What is the recommended treatment for adrenal insufficiency?

Treatment of Adrenal Insufficiency

The recommended treatment for adrenal insufficiency includes glucocorticoid replacement with hydrocortisone 15-25 mg/day in divided doses, with the addition of mineralocorticoid replacement (fludrocortisone 0.05-0.2 mg/day) for patients with primary adrenal insufficiency. 1, 2

Glucocorticoid Replacement

Maintenance Therapy

• Primary medication: Hydrocortisone 15-25 mg/day divided into 2-3 doses 1, 2
  • Typically higher dose in morning, lower dose in afternoon/evening to mimic natural cortisol rhythm
  • Alternative: Prednisone 3-5 mg daily 2
• Dosing schedule:
  • Two-dose regimen: 2/3 of daily dose in morning, 1/3 in early afternoon
  • Three-dose regimen: 1/2 in morning, 1/4 at lunch, 1/4 in early evening

Mineralocorticoid Replacement

• Required for: Primary adrenal insufficiency only 1, 3
• Medication: Fludrocortisone 0.05-0.2 mg once daily 3, 2
• Monitoring:
  • Blood pressure
  • Serum potassium
  • Plasma renin activity (target: upper normal range) 1

Stress Dosing for Illness and Procedures

Minor Illness/Stress

• Double or triple usual daily hydrocortisone dose 1

Moderate Stress

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

Severe Stress/Adrenal Crisis

• Hydrocortisone 100 mg IV immediately
• Followed by 100-300 mg/day as continuous infusion or divided doses every 6 hours 1, 2
• Rapid IV administration of isotonic saline 1

Surgical Procedures

• Major surgery:

  • Hydrocortisone 100 mg IV at induction
  • Continuous infusion of 200 mg/24h or 50 mg every 6h IM
  • Double maintenance dose for 48h post-op if uncomplicated recovery, or up to a week following major surgery 4, 1

• Minor/intermediate surgery:

  • Hydrocortisone 100 mg IV at induction
  • Double regular glucocorticoid dose for 48h 4

Special Populations

Children

• Dosing: Based on weight 4, 1
  • Bolus: Hydrocortisone 2 mg/kg IV at induction
  • Maintenance:
    • Up to 10 kg: 25 mg/24h
    • 11-20 kg: 50 mg/24h
    • Over 20 kg (prepubertal): 100 mg/24h
    • Over 20 kg (pubertal): 150 mg/24h

Pregnant Patients

• Higher maintenance doses may be required during later pregnancy
• Labor/delivery: Hydrocortisone 100 mg at onset, then continuous IV infusion of 200 mg/24h or 50 mg IM every 6h until after delivery 4, 1

Adrenal Crisis Management

• Immediate treatment:
  • Hydrocortisone 100 mg IV bolus
  • Followed by 100-300 mg/day as continuous infusion or divided doses every 6h
  • IV isotonic saline for volume replacement 1, 2

Monitoring and Follow-up

• Regular monitoring of:
  • Clinical symptoms
  • Weight and blood pressure
  • Serum electrolytes
  • Morning cortisol levels 1
• Annual consultation to assess replacement adequacy 1

Common Pitfalls and Caveats

1. Failure to distinguish between primary and secondary adrenal insufficiency:

   • Primary: Requires both glucocorticoid AND mineralocorticoid replacement
   • Secondary: Requires glucocorticoid replacement ONLY 1, 2

2. Inadequate stress dosing:

   • Patients must be educated to increase glucocorticoid doses during illness or stress
   • All patients should have injectable glucocorticoids available for emergency use 2

3. Overtreatment risks:

   • Higher doses of hydrocortisone may negatively impact bone mineral density 1
   • Monitor for symptoms of Cushing's syndrome with excessive dosing

4. Failure to recognize adrenal crisis:

   • Can be fatal if not treated promptly
   • Symptoms include hypotension, shock, hyponatremia, altered mental status 2

5. Inadequate patient education:

   • Patients must understand when and how to adjust their medication
   • Medical alert identification is essential 1