Adrenocortical Insufficiency

Adrenocortical Insufficiency – Treatment Options

Introduction
Adrenocortical insufficiency is a clinical condition characterized by inadequate secretion of glucocorticoids, mineralocorticoids, and in some cases adrenal androgens. It may be primary (Addison’s disease), resulting from direct destruction or dysfunction of the adrenal cortex, or secondary/tertiary, due to hypothalamic-pituitary disorders or suppression from chronic exogenous corticosteroid therapy. The hallmark features include fatigue, weight loss, hypotension, salt craving, hyponatremia, hyperkalemia, and hypoglycemia. Without treatment, patients are at risk of adrenal crisis, a life-threatening emergency. Management focuses on lifelong hormone replacement, prevention of crises, and adjustment of therapy during stress.

---

1. Glucocorticoid Replacement

• Hydrocortisone is the preferred agent because of its physiologic cortisol profile.

  • Dose: 15–25 mg/day orally, in 2–3 divided doses (largest dose in the morning, smaller dose in afternoon/evening).

• Alternatives:

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

  • Dexamethasone: Rarely used due to long half-life and risk of overtreatment.

• Dose is individualized to relieve symptoms while avoiding Cushingoid side effects.

---

2. Mineralocorticoid Replacement (in Primary Disease)

• Fludrocortisone acetate replaces aldosterone.

  • Dose: 0.05–0.2 mg/day orally.

• Adjusted according to blood pressure, plasma renin activity, and serum electrolytes.

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

---

3. Androgen Replacement (Optional, in Women)

• Dehydroepiandrosterone (DHEA): 25–50 mg/day may improve mood, energy, and libido.

• Not routinely required in men.

---

4. Stress Dose Adjustments

• Minor illness (e.g., fever, mild infection): Double or triple the daily glucocorticoid dose until recovery.

• Major illness, trauma, or surgery:

  • Hydrocortisone 100 mg IV at onset, followed by 50 mg every 6–8 hours or 200 mg/24 hours by infusion.

  • Supportive IV fluids and glucose administered as needed.

• After stabilization, taper back to baseline oral replacement.

---

5. Acute Adrenal Crisis Management

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

• IV 0.9% saline for hypovolemia and electrolyte correction.

• Dextrose infusion if hypoglycemia is present.

• Management of precipitating factors such as infection, trauma, or surgery.

---

6. Monitoring and Long-Term Care

• Regular assessment of symptoms, body weight, blood pressure, electrolytes, and plasma renin.

• Adjustment of steroid doses to balance symptom control and avoid overtreatment.

• Periodic endocrine evaluation for secondary/tertiary forms, with attention to other pituitary hormone deficiencies.

---

7. Patient Education and Prevention

• Patients should carry a medical alert bracelet and 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 vital to prevent adrenal crisis.

• Lifelong adherence to therapy and routine follow-up with endocrinology ensure safety and stability.