What is the treatment for adrenal fatigue?

"Adrenal Fatigue" Is Not a Recognized Medical Condition and Has No Evidence-Based Treatment

"Adrenal fatigue" is not a recognized medical diagnosis in conventional medicine, and there is no evidence-based treatment for this proposed condition. Instead, patients with symptoms attributed to "adrenal fatigue" should be evaluated for true adrenal insufficiency or other medical conditions.

Understanding Adrenal Insufficiency vs. "Adrenal Fatigue"

• "Adrenal fatigue" is a term used in alternative medicine to describe a collection of nonspecific symptoms like fatigue, body aches, and sleep disturbances, but it is not recognized by any endocrine medical society 1
• True adrenal insufficiency (Addison's disease) is a well-defined medical condition with specific diagnostic criteria and treatment protocols 2, 3
• Primary adrenal insufficiency involves deficiency of all adrenocortical hormones due to destruction of the adrenal cortex 3
• Secondary adrenal insufficiency results from disorders affecting the pituitary gland 3

Diagnosis of True Adrenal Insufficiency

• Diagnosis of true adrenal insufficiency involves early-morning measurement of cortisol, ACTH, and DHEAS levels 3
• Confirmatory testing includes the cosyntropin (Synacthen) stimulation test 4
• Primary adrenal insufficiency typically shows low morning cortisol (<5 µg/dL), high ACTH levels, and low DHEAS levels 3
• Secondary adrenal insufficiency shows low or intermediate morning cortisol (5-10 µg/dL) and low or low-normal ACTH and DHEAS levels 3

Treatment of Confirmed Adrenal Insufficiency

• Treatment for primary adrenal insufficiency includes both glucocorticoid and mineralocorticoid replacement 1, 3
• Hydrocortisone is the preferred glucocorticoid, typically administered in a total daily dose of 15-25 mg divided into multiple doses 1
• Common dosing schedules include three daily doses: 10 mg + 5 mg + 2.5 mg (morning, midday, afternoon) 1
• Fludrocortisone (50-200 μg once daily) provides mineralocorticoid replacement for patients with primary adrenal insufficiency 1, 5
• Patients should be advised to consume salt and salty foods without restriction 1

Management During Stress and Illness

• During minor illnesses with fever, the usual glucocorticoid dose should be doubled or tripled 1
• Adrenal crisis requires immediate treatment with hydrocortisone 100 mg IV bolus followed by 100-300 mg/day as continuous infusion or divided doses 1, 2
• Rapid IV administration of isotonic saline (0.9%) at an initial rate of 1 L/hour is also essential 1, 2
• All patients should wear medical alert identification jewelry 1

Prevention and Follow-up

• Annual follow-up should include assessment of symptoms, weight, blood pressure, and laboratory tests 1
• Screening for associated autoimmune conditions, particularly thyroid dysfunction, should be performed 1, 6
• Patient education should emphasize the importance of increasing steroid doses during intercurrent illnesses, injuries, or other stressors 1, 2

Important Caveats

• Under-replacement with mineralocorticoids is common and can predispose patients to recurrent adrenal crises 1, 5
• Medications that can affect glucocorticoid metabolism (requiring dose adjustments) include anti-epileptic drugs, barbiturates, and antifungal drugs 1
• If symptoms persist after appropriate evaluation for adrenal insufficiency, other medical conditions should be considered 3, 4
• Up to 50% of patients with primary adrenal insufficiency develop another autoimmune disorder during their lifetime, requiring vigilance for concomitant conditions 6