Treatment of Adrenal Insufficiency: No Role for Bicarbonate
Bicarbonate is not recommended for the treatment of adrenal insufficiency. 1
Standard Treatment for Adrenal Insufficiency
The cornerstone of adrenal insufficiency treatment consists of:
- Glucocorticoid replacement: Hydrocortisone 15-25 mg daily in divided doses (typically 10 mg on waking, 5 mg at noon, 2.5-5 mg in late afternoon) 1, 2
- Mineralocorticoid replacement: Fludrocortisone 50-200 μg once daily (for primary adrenal insufficiency only) 1, 2
- Unrestricted salt intake: Patients should consume sodium salt and salty foods without restriction 1, 2
Management of Adrenal Crisis
Adrenal crisis requires immediate intervention with:
- Intravenous or intramuscular hydrocortisone 100 mg bolus, followed by 100-300 mg/day as continuous infusion or divided doses every 6 hours 1, 2
- Rapid intravenous administration of isotonic (0.9%) saline at an initial rate of 1 L/hour until hemodynamic improvement 1, 2
- Identification and treatment of the precipitating cause (e.g., infection) 1
Why Bicarbonate is Not Used
Bicarbonate administration is specifically not recommended in adrenal insufficiency management for several reasons:
- No evidence supports its use in adrenal insufficiency treatment protocols 1, 2
- Routine administration of sodium bicarbonate is not recommended in the management of cardiac arrest according to pediatric life support guidelines 1
- One multicenter retrospective study found that sodium bicarbonate administered during cardiac arrest was associated with decreased survival 1
- Bicarbonate can cause extracellular alkalosis, shifting the oxyhemoglobin curve and inhibiting oxygen release 3
- It can lead to hypernatremia and hyperosmolarity 3
- Bicarbonate may cause paradoxical intracellular acidosis due to excess CO2 production 3
- It can inactivate simultaneously administered catecholamines, which may be needed during adrenal crisis 3
Prevention of Adrenal Crisis
To prevent adrenal crisis, patients should:
- Wear medical alert identification jewelry and carry a steroid alert card 1, 2
- Receive education on managing daily medications and minor illnesses 1, 2
- Have supplies for self-injection of parenteral hydrocortisone 1, 2
- Increase glucocorticoid doses during intercurrent illnesses, vomiting, injuries, or other stressors 4
- Seek immediate medical attention when unable to take oral medications or experiencing severe illness 1, 4
Common Pitfalls in Adrenal Insufficiency Management
- Under-replacement with mineralocorticoids is common and sometimes compensated for by over-replacement with glucocorticoids 2, 5
- Delayed diagnosis due to non-specific initial presentation can lead to life-threatening adrenal crisis 6
- Failure to increase glucocorticoid doses during acute stress can lead to adrenal crisis and increased mortality 4
- Essential hypertension should be treated by adding a vasodilator and reducing (not stopping) the fludrocortisone dose 2
- Certain medications can affect hydrocortisone metabolism, requiring dose adjustments (e.g., anti-epileptics, antifungals, grapefruit juice) 1