Adrenal Insufficiency

Adrenal Insufficiency – Treatment Options

Introduction
Adrenal insufficiency is a disorder in which the adrenal glands fail to produce sufficient amounts of glucocorticoids, mineralocorticoids, and in some cases androgens. It may be primary (Addison’s disease), caused by direct adrenal gland damage, or secondary/tertiary, resulting from impaired hypothalamic-pituitary signaling (low ACTH or CRH). Clinical features include fatigue, weight loss, hypotension, salt craving, abdominal pain, hyperpigmentation (in primary disease), and hypoglycemia. Management aims to restore deficient hormones, prevent adrenal crisis, and ensure long-term stability.

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1. Glucocorticoid Replacement

• Hydrocortisone is the preferred drug due to its short half-life and physiologic cortisol profile.

  • Dose: 15–25 mg/day orally, divided into 2–3 doses (e.g., 10 mg morning, 5 mg afternoon, 5 mg evening).

• Alternative agents:

  • Prednisolone: 3–5 mg/day once or twice daily.

  • Dexamethasone: Rarely used because of difficulty in dose titration and risk of overtreatment.

• Doses are individualized to minimize symptoms without causing Cushingoid features.

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2. Mineralocorticoid Replacement (Primary Adrenal Insufficiency)

• Fludrocortisone acetate provides aldosterone replacement.

  • Dose: 0.05–0.2 mg/day orally.

• Adjusted according to blood pressure, electrolytes (sodium, potassium), and plasma renin activity.

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

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3. Androgen Replacement (in Women)

• Dehydroepiandrosterone (DHEA): 25–50 mg/day orally may be considered in women with low energy, mood disturbances, or reduced libido.

• Routine use in men is not recommended since they produce sufficient androgens from the testes.

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4. Stress Dose Adjustments

• Minor illness (e.g., fever, flu): Double or triple usual glucocorticoid dose orally until recovery.

• Major illness, trauma, or surgery: IV hydrocortisone 100 mg at induction of anesthesia or onset of crisis, then 50 mg IV every 6–8 hours, with fluid and electrolyte support.

• Return to baseline oral doses after stabilization.

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5. Management of Adrenal Crisis in Known Patients

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

• IV 0.9% saline for volume resuscitation and dextrose if hypoglycemia is present.

• Identification and management of triggers (infection, surgery, missed doses).

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6. Patient Education and Prevention

• Patients should carry a medical alert bracelet and a steroid emergency card.

• An emergency hydrocortisone injection kit (100 mg IM/IV) should be available at all times.

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

• Regular follow-up with endocrinology ensures proper dose titration and monitoring for complications.