Therapeutic Regimen for Secondary Adrenal Insufficiency
Hydrocortisone is the preferred glucocorticoid replacement therapy for secondary adrenal insufficiency, typically administered at 15-25 mg daily in divided doses (2/3 in the morning and 1/3 in the afternoon) to mimic physiological cortisol rhythm. 1
Maintenance Therapy
Glucocorticoid Replacement
- Standard dosing: 15-25 mg of hydrocortisone daily 1, 2
- Morning dose: 2/3 of total daily dose
- Afternoon dose: 1/3 of total daily dose
- This divided dosing schedule better mimics the natural circadian rhythm of cortisol
- Alternative: Prednisone 3-5 mg daily 2
Key Differences from Primary Adrenal Insufficiency
- Unlike primary adrenal insufficiency, mineralocorticoid replacement (fludrocortisone) is typically not required in secondary adrenal insufficiency 1, 2
- This is because the renin-angiotensin-aldosterone system remains intact in secondary adrenal insufficiency
Stress Dosing and Special Situations
Minor Illness/Stress
- Double the usual daily dose of glucocorticoids 3, 1
- Continue increased dosing until recovery (usually 2-3 days)
Major Illness/Surgery
- For major surgery: Hydrocortisone 100 mg IV at induction 1
- Followed by continuous infusion of 200 mg/24h until oral intake is possible 1
- Post-operative care: Double usual oral doses for 48 hours, then taper to normal doses 3, 1
Minor Procedures
- Hydrocortisone 2 mg/kg IV or IM at induction 3, 1
- Post-procedure: Double usual oral doses for 24-48 hours 3
Adrenal Crisis Management
Immediate Treatment
- Hydrocortisone 100 mg IV bolus immediately 1
- Follow with 100-300 mg/day as continuous infusion or divided doses every 6 hours 1
- Rapid IV administration of isotonic saline 1
- Blood glucose monitoring (check hourly if fasting exceeds 4 hours) 3
Patient Education and Monitoring
Essential Education Points
- Stress dosing instructions (when and how to increase dose) 1
- Recognition of adrenal crisis symptoms 1
- Emergency injection technique for injectable hydrocortisone 1, 2
- Importance of wearing medical alert bracelet/carrying steroid card 1
Monitoring
- Regular follow-up to assess replacement adequacy 1
- Watch for signs of over-replacement: weight gain, hypertension, impaired glucose tolerance 4
- Watch for signs of under-replacement: fatigue, nausea, weight loss, hypotension 2
Special Considerations
Diabetes Insipidus with Secondary Adrenal Insufficiency
- Requires particular attention as cortisol is needed to excrete water load 3
- Inadequate cortisol replacement may lead to water intoxication and hyponatremia 3
- Strict fluid balance monitoring with adequate cortisol replacement is mandatory 3
Long-term Complications
- Even with optimal replacement, patients may experience impaired quality of life and increased sick days 5
- Risk of adrenal crisis remains despite established hormone replacement therapy 5
- Bone health may be affected by higher doses of hydrocortisone 1
Common Pitfalls to Avoid
- Delayed diagnosis due to nonspecific symptoms 1
- Inadequate stress dosing during illness or procedures 1
- Failure to recognize adrenal crisis 1
- Insufficient patient education about emergency management 1
- Inappropriate glucocorticoid dosing leading to under or over-replacement 1
- Too rapid withdrawal of glucocorticoids, which may result in secondary adrenocortical insufficiency 6, 7
By following this therapeutic regimen, patients with secondary adrenal insufficiency can maintain normal daily activities while minimizing the risk of adrenal crisis during periods of stress or illness.