From the Guidelines
Secondary adrenal insufficiency typically causes mild electrolyte abnormalities, and treatment focuses on glucocorticoid replacement with hydrocortisone 15-20 mg daily in divided doses, without the need for mineralocorticoid replacement with fludrocortisone, as stated in the 2021 ASCO guideline update 1. The main electrolyte finding in secondary adrenal insufficiency is mild hyponatremia, which occurs in about 20% of patients due to impaired free water excretion from cortisol deficiency. Some key points to consider in the management of secondary adrenal insufficiency include:
- Initiation of replacement therapy with hydrocortisone (15-20 mg in divided doses) for patients with asymptomatic or mild symptoms, as per the 2021 ASCO guideline update 1.
- Titration of hydrocortisone to a maximum of 30 mg daily total dose for residual symptoms of adrenal insufficiency, and reduction of maintenance dosing for symptoms of iatrogenic Cushing’s syndrome, as recommended in the 2021 ASCO guideline update 1.
- The use of fludrocortisone is generally not needed in secondary adrenal insufficiency, as aldosterone production remains largely intact, unlike in primary adrenal insufficiency, where fludrocortisone is often required to replace mineralocorticoid deficiency, as noted in the 2021 ASCO guideline update 1.
- Patients should increase their glucocorticoid dose during illness or stress, and electrolyte abnormalities typically resolve with appropriate glucocorticoid replacement, as stated in the 2021 ASCO guideline update 1.
- Regular monitoring of clinical symptoms rather than electrolyte levels is the mainstay of management, as electrolytes often remain normal even in undertreated patients, and patients should carry a steroid emergency card and wear medical alert identification to ensure proper treatment during emergencies, as recommended in the 2021 ASCO guideline update 1.
From the FDA Drug Label
Since mineralocorticoid secretion may be impaired, salt and/or a mineralocorticoid should be administered concurrently. Mineralocorticoids act on the distal tubules of the kidney to enhance the reabsorption of sodium ions from the tubular fluid into the plasma; they increase the urinary excretion of both potassium and hydrogen ions
In patients with secondary adrenal insufficiency, there may be an impairment of mineralocorticoid secretion, which can affect electrolyte balance. To manage this, salt and/or a mineralocorticoid should be administered concurrently with hydrocortisone therapy. The use of mineralocorticoids, such as fludrocortisone, can help enhance the reabsorption of sodium ions and increase the urinary excretion of potassium and hydrogen ions, thereby maintaining electrolyte balance 2 3.
- Key points:
- Impairment of mineralocorticoid secretion can affect electrolyte balance
- Salt and/or a mineralocorticoid should be administered concurrently with hydrocortisone therapy
- Mineralocorticoids can help maintain electrolyte balance by enhancing sodium reabsorption and increasing potassium and hydrogen ion excretion
From the Research
Secondary Adrenal Insufficiency and Electrolytes
- Secondary adrenal insufficiency is a condition where the adrenal glands do not produce enough cortisol due to a lack of adrenocorticotropic hormone (ACTH) stimulation from the pituitary gland 4, 5.
- The management of secondary adrenal insufficiency involves glucocorticoid replacement therapy, which can affect electrolyte levels 6, 7.
- Patients with primary adrenal insufficiency also require mineralocorticoid replacement, which helps regulate electrolyte levels, particularly sodium and potassium 6, 8.
- The treatment of adrenal insufficiency aims to replicate the natural circadian rhythm of cortisol release and to manage patients adequately during stress-related events to prevent over- or under-treatment, which can lead to electrolyte imbalances 7, 8.
- Electrolyte levels, such as plasma sodium, potassium, and renin, are used as biochemical indexes to titrate hydrocortisone and fludrocortisone doses and to monitor for signs of over- or under-replacement 8.