From the Guidelines
Adrenal insufficiency should be treated with oral hydrocortisone (15-20 mg in divided doses) to replace cortisol, and sometimes fludrocortisone (0.05-0.1 mg/d) to replace aldosterone in primary adrenal insufficiency, with education on stress dosing, emergency injectables, and a medical alert bracelet or necklace, accessory, or system 1.
Treatment Overview
Adrenal insufficiency is a condition where the adrenal glands don't produce enough cortisol and sometimes aldosterone hormones. The treatment approach involves hormone replacement therapy, patient education, and regular monitoring.
- The goal of treatment is to replace the deficient hormones, manage symptoms, and prevent complications such as adrenal crisis.
- Treatment typically involves oral hydrocortisone (15-20 mg in divided doses) to replace cortisol, with the largest dose given in the morning to mimic the natural diurnal rhythm of cortisol 1.
- Sometimes, fludrocortisone (0.05-0.1 mg/d) is also prescribed to replace aldosterone in primary adrenal insufficiency, with the dose adjusted based on volume status, sodium level, and renin response 1.
Patient Education and Monitoring
- Patients must carry emergency injectable hydrocortisone (100 mg) and wear a medical alert bracelet or necklace, accessory, or system to alert emergency medical personnel in case of an adrenal crisis 1.
- During illness, surgery, or significant stress, the hydrocortisone dose should be doubled or tripled ("stress dosing") to prevent adrenal crisis 1.
- Regular monitoring with an endocrinologist is essential to adjust medication doses, manage symptoms, and prevent complications 1.
Important Considerations
- Primary and secondary adrenal insufficiency can be distinguished by the relationship between ACTH and cortisol, with low ACTH and low cortisol indicating secondary (central) adrenal insufficiency 1.
- Using hydrocortisone allows for recreation of the diurnal rhythm of cortisol, and long-acting steroids such as prednisone can be used in special circumstances, but carry a risk of over-replacement 1.
- All patients need education on stress dosing, emergency injectables, and when to seek medical attention for impending adrenal crisis, with early endocrinology consultation appropriate for planning before surgery or high-stress treatments 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 adrenal insufficiency), diseases affecting the pituitary (secondary adrenal insufficiency), or diseases affecting the hypothalamus (tertiary adrenal insufficiency) 2.
- The most prevalent form is tertiary adrenal insufficiency, often due to exogenous glucocorticoid use 2.
Symptoms and Diagnosis
- Symptoms of adrenal insufficiency are non-specific and may include fatigue, hypotension, and nausea 2.
- Diagnosis is based on measurement of adrenal corticosteroid hormones, their regulatory peptide hormones, and stimulation tests 2.
- A short corticotropin test is recommended as the "gold standard" diagnostic tool to establish the diagnosis 3.
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 options include hydrocortisone, cortisone acetate, and fludrocortisone, with dosing regimens varying depending on the individual patient's needs 4, 5, 6, 3.
- Patient education on stress dosing and emergency administration of glucocorticoids is crucial to prevent adrenal crises 2, 3.
Quality of Life and Complications
- Quality of life remains altered in patients with adrenal insufficiency despite treatment with hydrocortisone and fludrocortisone 5.
- DHEA replacement may improve quality of life and mood, and increase lean body mass and bone mineral density, especially in women with adrenal insufficiency 5.
- Acute adrenal insufficiency is a life-threatening complication that can be prevented with educational programs and emergency preparedness 5, 2.