From the Guidelines
Secondary adrenal insufficiency is typically treated with hydrocortisone replacement therapy.
Treatment Overview
- The treatment approach depends on the severity of symptoms, with asymptomatic or mild symptoms managed with hydrocortisone 15-20 mg in divided doses 1.
- For moderate symptoms, outpatient corticosteroid treatment at 2-3 times maintenance (e.g., hydrocortisone 30-50 mg total dose or prednisone 20 mg daily) is recommended 1.
- In severe cases, IV stress dose steroids with hydrocortisone 50-100 mg Q 6-8 hours initial dosing is necessary, followed by tapering to oral maintenance doses over 5-7 days 1.
Key Considerations
- Endocrine consultation is essential for managing secondary adrenal insufficiency, especially for planning hormone replacement therapy and assessing the need for stress dosing 1.
- Education on stress dosing, emergency injectables, and medical alert bracelets is crucial for patients with secondary adrenal insufficiency 1.
- Hydrocortisone is preferred over long-acting steroids like prednisone to recreate the diurnal rhythm of cortisol, with 2/3 of the dose given in the morning and 1/3 in the early afternoon 1.
- Fludrocortisone may be required for primary adrenal insufficiency, but not typically for secondary adrenal insufficiency, unless there is a concomitant mineralocorticoid deficiency 1.
From the Research
Treatment for Secondary Adrenal Insufficiency
The treatment for secondary adrenal insufficiency typically involves hormonal replacement therapy with glucocorticoids, such as hydrocortisone 2, 3, 4, 5. The goal of treatment is to replace the deficient hormones and prevent adrenal crisis, a life-threatening complication of adrenal insufficiency 4.
Hormonal Replacement Therapy
- Glucocorticoid replacement therapy is the mainstay of treatment for secondary adrenal insufficiency, with hydrocortisone being the most commonly used medication 3, 5.
- The typical dosage of hydrocortisone is 15-25 mg/day in divided doses, with dose monitoring based on clinical judgement 3.
- Mineralocorticoid replacement therapy with fludrocortisone may also be necessary in some cases, aiming to achieve normotension, normokalaemia, and a plasma renin activity in the upper normal range 3.
Other Treatment Considerations
- Dehydroepiandosterone (DHEA) replacement therapy may be considered in some cases, as it has been shown to improve mood, fatigue, and well-being in patients with adrenal insufficiency 3.
- However, large Phase III trials of DHEA for adrenal insufficiency are still lacking, and it has not yet been approved for the treatment of this disease 3.
- Patients with adrenal insufficiency are at risk of adrenal crisis, and early dose adjustments are required to cover the increased glucocorticoid demand in stress 3, 4.
Monitoring and Education
- Careful and repeated education of patients and their partners is essential to prevent adrenal crisis and ensure proper management of the condition 3.
- Monitoring for adrenal insufficiency and adjusting treatment as needed is crucial to prevent over- or under-treatment, which can result in Cushing-like symptoms or adrenal crisis, respectively 5.