From the Guidelines
Adrenal insufficiency symptoms should be managed with hormone replacement therapy, prioritizing corticosteroids, and patients should be educated on stress dosing, emergency steroid injectables, and medical alert bracelets to prevent adrenal crisis, as recommended by the most recent guidelines 1.
Key Symptoms
Adrenal insufficiency presents with a range of symptoms, including:
- Extreme fatigue
- Weight loss
- Decreased appetite
- Low blood pressure, especially upon standing
- Salt craving
- Hyperpigmentation
- Nausea
- Vomiting
- Abdominal pain
- Muscle and joint pain
- Irritability
- Depression
- Low blood sugar
Treatment Approach
Treatment involves hormone replacement therapy, typically with oral hydrocortisone to replace cortisol, and sometimes fludrocortisone to replace aldosterone in primary adrenal insufficiency 1.
Important Considerations
- Patients on corticosteroids for other conditions may develop isolated central adrenal insufficiency with a low ACTH, and the HPA axis should be tested for recovery after 3 months of maintenance therapy with hydrocortisone 1.
- Laboratory confirmation of adrenal insufficiency should not be attempted in patients given high-dose corticosteroids for other conditions until treatment is ready to be discontinued 1.
- AM cortisol in a patient on corticosteroids is not diagnostic, and hydrocortisone needs to be held for 24 hours and other steroids for longer before endogenous function is assessed 1.
Patient Education and Support
Patients must carry emergency medication (injectable hydrocortisone) and wear medical identification to ensure proper treatment during crises 1.
Ongoing Care
Annual consultations should include questions regarding family relationships, professional duties, self-esteem, and possible complaints due to primary adrenal insufficiency, as well as questions about the quality of daily replacement therapy, self-medication during intercurrent illness, and previous adrenal crises 1.
From the Research
Adrenal Insufficiency Symptoms
- Adrenal insufficiency is associated with an impairment in daily life activities and a higher number of sick-days, even under established replacement therapy 2.
- The frequency of glucocorticoid side effects is low in patients with individually adjusted glucocorticoid doses 2.
- Adrenal crisis is a potential threat for patients with chronic adrenal insufficiency, triggered by infectious diseases mostly, with primary adrenal insufficiency, comorbidities, and previous adrenal crisis identified as risk factors 2.
- The clinical picture of adrenal insufficiency is determined by the glucocorticoid deficit, which may be accompanied by a deficit of mineralcorticoids and adrenal androgens 3.
- Patients with adrenal insufficiency still suffer from increased morbidity and mortality, despite being on glucocorticoid replacement therapy, due to the inability of conventional glucocorticoid treatment to mirror the physiological cortisol rhythm 4.
Treatment and Management
- Glucocorticoid replacement therapy is the standard treatment for adrenal insufficiency, with the goal of reducing signs and symptoms of the disease and preventing adrenal crisis 5, 3.
- Novel strategies to replicate the cortisol rhythm using hydrocortisone infusion pumps and oral modified release hydrocortisone have been developed and offer benefits to patients 4.
- Advances in glucocorticoid replacement for patients with adrenal insufficiency are ongoing, with novel approaches aiming to improve patient health 4.
- A nation-wide standardized education program for patients and relatives has been established in Germany to improve emergency management in patients with adrenal insufficiency 2.
Quality of Life and Outcomes
- Life expectancy with conventional glucocorticoid replacement therapy is reduced, and morbidity remains high 5.
- The increased morbidity and decreased life expectancy are due to both increased exposure to cortisol and insufficient cortisol coverage during infections and other stress-related events 5.
- Novel treatments, such as Plenadren and Chronocort, have been shown to improve quality of life, reduce weight, and decrease infections in patients with adrenal insufficiency 4.