Adrenal%20insufficiency Treatment
Principles of Therapy
- Replacement doses for glucocorticoids are the same for both primary and secondary adrenal insufficiency (AI)
Pharmacotherapy
Glucocorticoid Replacement Therapy
- Cortisone
- Effects: Potent glucocorticoid with some mineralocorticoid activity
- Requires enzymatic activation in the liver causing the effect to have a slower and less predictable onset
- Short-acting therefore, 2-3 doses must be given throughout the day
- Hydrocortisone
- Usually considered 1st-line agent as it is the true replacement of cortisol
- Effects: Potent glucocorticoid with some mineralocorticoid activity
- Short-acting therefore, 2-3 doses must be given throughout the day
- Long-acting glucocorticoids
- Prednisolone is the preferred alternative to Hydrocortisone especially in patients with primary adrenal insufficiency who are noncompliant
- Dexamethasone is the least preferred alternative to Hydrocortisone in patients with primary adrenal insufficiency due to high risk for Cushingoid side effects because of dose titration difficulties
- Effects: Potent glucocorticoid with less mineralocorticoid activity than short-acting glucocorticoids
- Long-acting which may prevent excessive high peak levels and periods of inadequate replacement that may occur with Hydrocortisone and Cortisone
- Clinical assessment of body weight, postural blood pressure, energy levels and signs of flank glucocorticoid excess are used to monitor glucocorticoid replacement therapy
Dosing Equivalents of Systemic Corticosteroids (IV/Oral)
Glucocorticoid | Equivalent Doses (mg) |
Short acting | |
Cortisone acetate | 25 |
Hydrocortisone | 20 |
Intermediate acting | |
Methylprednisolone | 4 |
Prednisolone | 5 |
Prednisone | 5 |
Triamcinolone | 4 |
Long acting | |
Betamethasone | 0.6 |
Dexamethasone | 0.75 |
Mineralocorticoid Replacement Therapy
- Mineralocorticoid replacement is necessary in all primary adrenal insufficiency patients
- Prevents sodium loss, intravascular volume depletion and hypercalcemia
- Fludrocortisone is the preferred choice with no salt intake restriction
- Effects: Potent mineralocorticoid with some glucocorticoid activity
- Dose reduction is suggested if hypertension developed during Fludrocortisone therapy
- Clinical assessment of salt craving, postural hypertension or edema and blood electrolyte measurements are used to monitor mineralocorticoid replacement therapy
Androgen Replacement Therapy
- Use of Prasterone (Dehydroepiandrosterone, DHEA) may improve well-being and sexuality in women with adrenal insufficiency (AI)
- Recommended in women who have primary adrenal insufficiency and low libido, depressive symptoms and/or low energy levels despite optimal glucocorticoid and mineralocorticoid replacement therapy
- Initial period of 6 months, if no benefits observed discontinue use
Treatment During Medical or Surgical Stress
- Patients with AI may require glucocorticoid per orem or intravenous (PO or IV) supplement
- Glucocorticoid replacement needs to be individualized
- Patient with secondary AI caused by long-term glucocorticoid therapy may not need replacement
- Mineralocorticoid supplement is usually not needed
- Initial goals of therapy are treatment of hypotension, correction of electrolyte abnormalities and correction of cortisol deficiency
- Immediate intravenous (IV) dose of Hydrocortisone at an appropriate stress dose should be given
- Prednisolone is the alternative if Hydrocortisone is not available
- Dexamethasone IV bolus, Hydrocortisone IV bolus or any IV glucocorticoid preparation may be used in patients with known diagnosis of adrenal insufficiency
- 2-3 L of saline solution (0.9% or 5% dextrose in 0.9% saline)
should be administered as quickly as possible to restore intravascular
volume and replace urinary salt losses
- Monitor for signs of fluid overload
- Mineralocorticoid replacement is not needed acutely because its sodium-retaining abilities become apparent only after several days
- Adequate sodium replacement is achieved by IV saline infusion
- May be started once saline infusion is discontinued
- Monitor blood glucose
- If blood glucose is <4 mmol/L, give 20% dextrose over 10-15 minutes stat
- Identify and treat underlying problem that triggered the acute crisis
- Most patients who experience adrenal crisis have primary adrenal insufficiency and require lifetime glucocorticoid and mineralocorticoid replacement therapy