From the Guidelines
Adrenal insufficiency should be treated with hormone replacement therapy, primarily with glucocorticoids like hydrocortisone (15-20 mg in divided doses), and mineralocorticoid replacement with fludrocortisone (0.05-0.1 mg/d) for primary adrenal insufficiency, with a focus on stress dosing, emergency medication, and patient education. The treatment approach for adrenal insufficiency involves replacing the deficient hormones to restore normal bodily functions and prevent complications such as adrenal crisis. According to the most recent guidelines 1, the management of adrenal insufficiency includes:
- Initiating replacement therapy with hydrocortisone (15-20 mg in divided doses) for patients with mild or moderate symptoms
- Adding fludrocortisone (0.05-0.1 mg/d) for primary adrenal insufficiency
- Educating patients on stress dosing, emergency injections, and the use of a medical alert bracelet or necklace
- Regular monitoring of blood tests for electrolytes and hormone levels to adjust treatment as needed
- Considering endocrinology consultation for guidance on hormone replacement and management of immune-related adverse events It is essential to note that the relationship between ACTH and cortisol levels can help distinguish between primary and secondary adrenal insufficiency, guiding the management approach 1. Additionally, the use of hydrocortisone allows for the recreation of the diurnal rhythm of cortisol, and patients should be educated on the importance of stress dosing during illness, surgery, or significant stress 1. Overall, the goal of treatment is to restore normal hormone levels, prevent complications, and improve the patient's quality of life, while minimizing the risk of adverse effects from hormone replacement therapy 1.
From the Research
Definition and Causes of Adrenal Insufficiency
- Adrenal insufficiency is a condition characterized by an absolute or relative deficiency of adrenal cortisol production 2.
- It can be caused by direct adrenal failure (primary AI), diseases affecting the pituitary (secondary AI), or diseases affecting the hypothalamus (tertiary AI) 2.
- The most prevalent form is tertiary AI, owing to exogenous glucocorticoid use 2.
Symptoms and Diagnosis
- Symptoms of adrenal insufficiency are non-specific, often overlooked or misdiagnosed, and are related to the lack of cortisol, adrenal androgen precursors, and aldosterone (especially in primary AI) 2.
- Diagnosis is based on measurement of the adrenal corticosteroid hormones, their regulatory peptide hormones, and stimulation tests 2.
Treatment and Management
- The goal of therapy is to establish a hormone replacement regimen that closely mimics the physiological diurnal cortisol secretion pattern, tailored to the patient's daily needs 2.
- Treatment may include hydrocortisone and fludrocortisone, with titration relying on clinical symptoms and biochemical indexes such as plasma sodium, potassium, and renin 3.
- DHEA replacement may improve quality of life and mood, and may increase lean body mass and bone mineral density, especially in women with adrenal insufficiency 3.
- New slow-release hydrocortisone formulations may help reproduce a more physiological cortisol plasma profile and reduce the impact of over-replacement on cardiovascular risk factors and glucose metabolism 3.
Adrenal Crisis and Self-Management
- Adrenal crisis is a life-threatening complication that requires urgent administration of parenteral hydrocortisone 4.
- Current patient education interventions remain ineffective, contributing to preventable hospitalizations and deaths 4.
- Factors influencing self-management of adrenal crises include knowledge and experience, tools and training, psychological and emotional impact, and support and dependence on others 4.
- Participants in a qualitative study reported challenges including delayed diagnosis, difficulties recognizing adrenal crisis symptoms, and the complexity of the hydrocortisone injection process 4.
- Effective adrenal crisis management requires patient-centered, evidence-based interventions focusing on education, healthcare professional training, and public awareness 4.