What is the long-term treatment for patients after adrenalectomy?

Long-Term Treatment After Adrenalectomy

All patients undergoing adrenalectomy for functional adrenal tumors require lifelong glucocorticoid replacement therapy if bilateral adrenalectomy was performed, while those with unilateral adrenalectomy for cortisol-secreting tumors need temporary glucocorticoid replacement until the contralateral adrenal recovers, typically within 3-12 months. 1

Immediate Post-Operative Glucocorticoid Management

For Cortisol-Secreting Tumors (Cushing's Syndrome)

• Empirical perioperative glucocorticoid replacement is mandatory for patients with overt Cushing syndrome due to prolonged suppression of the contralateral adrenal gland 1
• Administer hydrocortisone 100 mg IV at induction, followed by continuous infusion of 200 mg/24 hours until oral intake is established 2
• Once stable and taking oral medications, double the usual replacement dose (typically 20-10-10 mg hydrocortisone) for 48 hours to one week depending on surgical complexity 2

For Mild Autonomous Cortisol Secretion

• Postoperative day 1 morning cortisol or cosyntropin stimulation testing can determine the need for glucocorticoid replacement 1
• If morning cortisol <5 μg/dL or inadequate response to stimulation, initiate replacement therapy 1

Long-Term Hormone Replacement by Tumor Type

Bilateral Adrenalectomy (Any Indication)

• Lifelong glucocorticoid AND mineralocorticoid replacement is required 2
• Standard maintenance: Hydrocortisone 15-25 mg daily in divided doses (typically 10-5-5 mg or 15-5-5 mg) 2
• Fludrocortisone 0.05-0.2 mg daily for mineralocorticoid replacement 2
• Patients must be educated on "Sick Day Rules": double glucocorticoid doses during illness, injury, or physiological stress 2

Unilateral Adrenalectomy for Cortisol-Secreting Adenoma

• Temporary glucocorticoid replacement is needed until contralateral adrenal recovery 1, 3
• Recovery timeline: typically 3-12 months, but can extend beyond one year in cases of severe or prolonged hypercortisolism 3
• Monitor with morning cortisol levels every 1-3 months; discontinue replacement when morning cortisol >10-15 μg/dL or adequate cosyntropin response is demonstrated 1
• Taper glucocorticoids gradually once recovery is confirmed to avoid withdrawal symptoms 2

Unilateral Adrenalectomy for Aldosteronoma

• No long-term hormone replacement is required as the contralateral adrenal maintains normal function 4, 5
• However, renin recovery occurs earlier (15-30 days) than aldosterone recovery (60+ days), resulting in transient post-operative hypoaldosteronism 3
• This transient hypoaldosteronism is typically asymptomatic and self-limited, requiring only monitoring of potassium and blood pressure 3
• Persistent hypertension requiring medication occurs in 72% of patients, though 92% experience improved blood pressure control compared to pre-operative status 4
• Monitor for recurrent hypokalemia, which occurs in approximately 4% of patients and may indicate contralateral disease 4

Unilateral Adrenalectomy for Pheochromocytoma

• No hormone replacement is needed for unilateral disease 4
• Clinical and biochemical cure achieved in 100% of sporadic cases at long-term follow-up 4
• Patients with MEN type 2 require lifelong surveillance for contralateral pheochromocytoma development, which may occur 4-5 years after initial surgery 4
• If bilateral adrenalectomy is eventually required, lifelong glucocorticoid and mineralocorticoid replacement becomes necessary 2

Critical Patient Education and Safety Measures

Emergency Preparedness

• All patients on glucocorticoid replacement must carry a steroid emergency card and wear medical alert identification 2
• Provide hydrocortisone emergency self-injection kits (100 mg IM) for use during severe illness, vomiting, or inability to take oral medications 2
• Educate patients and family members on recognizing adrenal crisis: severe weakness, persistent vomiting, hypotension, confusion, or collapse 2, 6

Stress Dosing Protocol

• Minor illness/stress: Double usual oral dose until recovery 2
• Major illness, surgery, or trauma: Hydrocortisone 100 mg IV/IM immediately, followed by 200 mg/24 hours continuous infusion or 50 mg IV/IM every 6 hours 2
• Labor and vaginal delivery: Hydrocortisone 100 mg IV at onset, followed by 200 mg/24 hours infusion 2

Long-Term Monitoring Requirements

For Patients on Glucocorticoid Replacement

• Monitor for signs of under-replacement: fatigue, orthostatic hypotension, hyponatremia, hyperkalemia 2, 6
• Monitor for signs of over-replacement: weight gain, hyperglycemia, hypertension, osteoporosis 2
• Annual clinical assessment of replacement adequacy and comorbidities 2

For Aldosteronoma Patients (No Replacement)

• Blood pressure monitoring is essential: 72% require ongoing antihypertensive medications despite surgical cure 4
• Annual potassium levels to detect rare contralateral disease 4
• No routine imaging follow-up needed if initial pathology confirmed benign adenoma 2

Common Pitfalls to Avoid

• Never use dexamethasone alone for primary adrenal insufficiency as it lacks mineralocorticoid activity 2
• Do not abruptly discontinue glucocorticoids in patients with unilateral cortisol-secreting tumors without confirming contralateral adrenal recovery 1
• Patients taking CYP3A4 inducers (rifampin, phenytoin, phenobarbital) may require higher hydrocortisone doses due to accelerated metabolism 2, 6
• Persistent pyrexia post-operatively should not prompt steroid withdrawal; maintain stress dosing until fever resolves 2