What is the treatment for adrenal fatigue?

Adrenal Fatigue: A Non-Medical Condition Without Scientific Basis

"Adrenal fatigue" is not a recognized medical condition and has no scientific basis for treatment, as it does not exist according to systematic reviews of the medical literature. 1

Understanding "Adrenal Fatigue" vs. Actual Adrenal Insufficiency

• "Adrenal fatigue" is a term used in popular media and by some healthcare providers to describe alleged symptoms caused by chronic stress, but it has not been recognized by any endocrinology society 1, 2
• Systematic reviews have found no substantiation that "adrenal fatigue" is an actual medical condition 1
• This concept should be distinguished from true adrenal insufficiency, which is a well-defined medical condition with specific diagnostic criteria 3

True Adrenal Insufficiency

True adrenal insufficiency is categorized as:

• Primary adrenal insufficiency: Deficiency of all adrenocortical hormones due to adrenal gland damage 3
• Secondary adrenal insufficiency: Caused by disorders affecting the pituitary gland 3
• Glucocorticoid-induced adrenal insufficiency: Caused by administration of supraphysiological doses of glucocorticoids 3

Diagnosis of True Adrenal Insufficiency

• Early-morning (approximately 8 am) measurements of serum cortisol, corticotropin (ACTH), and dehydroepiandrosterone sulfate (DHEAS) 3, 4
• Primary adrenal insufficiency: Low morning cortisol (<5 µg/dL), high ACTH, and low DHEAS 3
• Secondary adrenal insufficiency: Low or intermediate morning cortisol (5-10 µg/dL) and low or low-normal ACTH and DHEAS 3
• Synacthen test (ACTH stimulation test) for inconclusive cases 4

Treatment of True Adrenal Insufficiency

For patients with confirmed adrenal insufficiency, treatment includes:

• Glucocorticoid replacement: Hydrocortisone 15-25 mg daily in divided doses (typically 2-3 times daily) 5, 3
• Mineralocorticoid replacement (for primary adrenal insufficiency): Fludrocortisone 50-200 μg once daily 5
• Patient education on stress dosing and emergency management 5

Management During Stress and Illness

• Minor illness with fever: Double or triple the usual glucocorticoid dose 5
• Adrenal crisis requires immediate treatment with hydrocortisone 100 mg IV bolus followed by 100-300 mg/day as continuous infusion or divided doses 5, 6
• IV isotonic saline (0.9%) at an initial rate of 1 L/hour, followed by 3-4 L over 24 hours 6, 5

Why "Adrenal Fatigue" Is Not a Valid Diagnosis

• Studies examining the hypothalamic-pituitary-adrenal axis in patients with fatigue have produced conflicting results 1, 2
• Proposed methods to assess "adrenal fatigue" have been methodologically flawed 1
• Current evidence does not support the existence of "adrenal fatigue" or the usefulness of supplements to support adrenal function 2
• The symptoms attributed to "adrenal fatigue" (fatigue, insomnia, joint pain, weight gain) are non-specific and may be due to various other conditions 1, 2

Addressing Fatigue Symptoms

For patients presenting with fatigue without adrenal insufficiency:

• Evaluate for other medical causes of fatigue, including thyroid dysfunction, anemia, sleep disorders, depression, and other endocrine disorders 6
• Annual screening should include thyroid function tests (TSH, FT4, TPO-Ab), plasma glucose levels, HbA1c, and complete blood count 6
• Consider vitamin B12 deficiency, which can contribute to fatigue 6
• Investigate for other autoimmune conditions that may cause fatigue 6

Common Pitfalls

• Misdiagnosing non-specific symptoms as "adrenal fatigue" when they may be due to other medical conditions 1, 2
• Using unvalidated tests to diagnose "adrenal fatigue" 1
• Prescribing supplements or treatments for "adrenal fatigue" without scientific evidence 2
• Failing to diagnose true adrenal insufficiency, which is a life-threatening condition requiring prompt treatment 7