Adrenal Gland Disorders

Adrenal Gland Disorders – Treatment Options

Introduction
Adrenal gland disorders are a group of conditions that affect the production of hormones from the adrenal cortex (cortisol, aldosterone, and androgens) or adrenal medulla (catecholamines: epinephrine and norepinephrine). These disorders can result in hormone excess (e.g., Cushing’s syndrome, primary hyperaldosteronism, pheochromocytoma) or hormone deficiency (e.g., Addison’s disease, adrenal crisis). Clinical manifestations vary depending on the hormone imbalance, and treatment is tailored to the underlying cause, aiming to restore normal hormone levels, manage symptoms, and prevent complications.

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1. Addison’s Disease (Primary Adrenal Insufficiency)

• Glucocorticoid replacement: Hydrocortisone 15–25 mg/day in divided doses, or prednisolone 3–5 mg/day.

• Mineralocorticoid replacement: Fludrocortisone 0.05–0.2 mg/day to maintain blood pressure and electrolytes.

• Androgen replacement (in women): Dehydroepiandrosterone (DHEA) 25–50 mg/day may improve mood and libido.

• Stress dosing: Increased steroid doses during illness, surgery, or trauma.

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2. Adrenal Crisis (Acute Adrenal Insufficiency)

• Immediate hydrocortisone: 100 mg IV bolus, followed by 200 mg/24 h infusion or divided doses.

• Fluid resuscitation: Rapid IV normal saline, with dextrose if hypoglycemia is present.

• Electrolyte correction: Manage hyponatremia and hyperkalemia.

• Underlying trigger treatment: Infections, trauma, or steroid withdrawal addressed promptly.

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3. Cushing’s Syndrome (Excess Cortisol)

• Surgical removal: First-line therapy for cortisol-secreting adrenal tumors or ACTH-secreting pituitary tumors.

• Medical therapy (when surgery is not possible or as adjunct):

  • Ketoconazole, metyrapone, mitotane, mifepristone – inhibit cortisol synthesis or action.

• Radiotherapy: Option for pituitary-dependent Cushing’s disease.

• Gradual steroid tapering: If caused by long-term corticosteroid use.

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4. Primary Hyperaldosteronism (Conn’s Syndrome)

• Surgical removal: Adrenalectomy for unilateral aldosterone-producing adenoma.

• Medical therapy: Mineralocorticoid receptor antagonists such as spironolactone (25–400 mg/day) or eplerenone (25–100 mg/day) for bilateral adrenal hyperplasia or patients not suitable for surgery.

• Blood pressure and electrolyte monitoring guide therapy.

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5. Congenital Adrenal Hyperplasia (CAH)

• Glucocorticoid replacement: Hydrocortisone in children, prednisolone or dexamethasone in adults to suppress excess ACTH.

• Mineralocorticoid replacement: Fludrocortisone in salt-wasting forms.

• Sodium supplementation: Particularly in infants with salt-wasting CAH.

• Fertility and gender management: May require additional hormonal and surgical support.

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6. Pheochromocytoma and Paraganglioma (Catecholamine-Secreting Tumors)

• Preoperative medical therapy:

  • Alpha-blockers (phenoxybenzamine or doxazosin) to control hypertension.

  • Beta-blockers added after alpha-blockade to control tachycardia.

• Definitive treatment: Surgical removal of the tumor.

• Postoperative monitoring: For blood pressure, blood glucose, and recurrence.

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7. Adrenal Incidentalomas (Adrenal Masses Discovered Incidentally)

• Non-functional small tumors (<4 cm): Regular monitoring with imaging and hormonal testing.

• Functional tumors or masses >4–6 cm: Surgical removal recommended due to malignancy risk.