Adrenal failure (Adrenal Insufficiency)

Adrenal Failure (Adrenal Insufficiency) – Treatment Options

Introduction
Adrenal failure, also referred to as adrenal insufficiency, is a condition in which the adrenal glands fail to produce adequate amounts of glucocorticoids, mineralocorticoids, and sometimes androgens. It may be classified as primary adrenal insufficiency (Addison’s disease), where the adrenal cortex is directly affected, or secondary/tertiary adrenal insufficiency, resulting from pituitary or hypothalamic dysfunction leading to impaired adrenocorticotropic hormone (ACTH) or corticotropin-releasing hormone (CRH) secretion. Symptoms include fatigue, weight loss, hypotension, hyperpigmentation (in primary disease), hyponatremia, hyperkalemia, and hypoglycemia. Management aims to restore deficient hormones, prevent adrenal crisis, and optimize quality of life.

1. Glucocorticoid Replacement Therapy

• Hydrocortisone is the most commonly prescribed glucocorticoid due to its physiologic profile.

  • Typical dose: 15–25 mg/day in 2–3 divided doses (e.g., 10 mg in the morning, 5 mg in the afternoon, 5 mg in the evening if needed).

• Alternative options:

  • Prednisolone: 3–5 mg/day as a once-daily or twice-daily regimen.

  • Dexamethasone: Used less frequently because of long half-life and risk of overtreatment.

• Doses are adjusted based on clinical response, body weight, and stress conditions.

2. Mineralocorticoid Replacement (for Primary Adrenal Insufficiency)

• Fludrocortisone acetate is essential to replace aldosterone in patients with Addison’s disease.

  • Dose: 0.05–0.2 mg/day orally, adjusted to maintain blood pressure, electrolytes, and plasma renin activity.

• Adequate salt intake is encouraged, especially in hot climates or with heavy sweating.

3. Androgen Replacement (Optional in Women)

• Dehydroepiandrosterone (DHEA): 25–50 mg daily may improve mood, energy, and libido in women with adrenal insufficiency.

• Use is individualized and not routinely recommended for men.

4. Stress Dose Steroids

• During periods of illness, trauma, or surgery, patients require higher glucocorticoid doses.

  • Minor illness: Double or triple the usual oral dose.

  • Major stress (surgery, sepsis): IV hydrocortisone (e.g., 100 mg every 6–8 hours).

• Failure to increase steroids in stressful situations may precipitate adrenal crisis.

5. Management of Acute Adrenal Crisis in Chronic Patients

• Patients with adrenal failure are at lifelong risk of adrenal crisis.

• Emergency therapy includes:

  • Hydrocortisone 100 mg IV/IM, followed by 200 mg/24 hours infusion or divided doses.

  • Rapid IV 0.9% saline infusion with dextrose if hypoglycemia is present.

• After stabilization, transition back to oral replacement therapy.

6. Patient Education and Preventive Measures

• Patients should be instructed to carry a medical alert bracelet or card indicating their condition and treatment.

• They must keep an emergency hydrocortisone injection kit for self-administration in case of crisis.

• Education on stress dosing during febrile illness, surgery, or trauma is vital.

• Regular follow-up with endocrinology to assess symptoms, blood pressure, and electrolytes ensures safe long-term management.