Adrenal%20insufficiency Treatment

• Replacement doses for glucocorticoids are the same for both primary and secondary adrenal insufficiency (AI)

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)

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