Adrenal insufficiency medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Ayeesha Kattubadi, M.B.B.S[2]

Overview

Pharmacologic medical therapy is recommended among patients with adrenal insufficiency Pharmacologic medical therapies for adrenal insufficiency include lifelong glucocorticoid and mineralocorticoid replacement therapy. Mineralocorticoid replacement therapy is only used in patients with primary adrenal insufficiency.

Medical Therapy

• Pharmacologic medical therapy is recommended among patients with adrenal insufficiency.
• Pharmacologic medical therapies for adrenal insufficiency include lifelong glucocorticoid replacement in both primary and secondary adrenal insufficiency. Mineralocorticoids replacement is recommended only in primary adrenal insufficiency. Rarely dehydroepiandrosterone (DHEA) in considered in patients with primary adrenal insufficiency in whom there is significant impairment in quality of life, decreased libido, women, depressed mood despite glucocorticoid and mineralocorticoid therapy.

Adrenal insufficiency

• Glucocorticoid replacement therapy
  • 1.1 Adult
    • Preferred regimen (1): Hydrocortisone 15-25mg PO, 2/3 of the total dose in the morning on awakening; 1/3 of the total dose in mid-afternoon lifelong
    • Preferred regimen (2): Hydrocortisone 15-25mg PO, three divided doses (10mg at 7 AM, 5mg at 12 PM, and 2.5-5mg at 4:30 PM. Avoid dosing after 6 PM) lifelong
    • Alternative regimen (1): Cortisone acetate 20-25mg PO, once in the morning, lifelong.
    • Alternative regimen (2): Prednisone 3-5mg/day PO, once in the morning lifelong.

Specific instructions:
Drug interactions:
Drugs increasing glucocorticoid dose requirement: Anticonvulsants like Barbiturates, Topiramate, Anti-tubercular drugs, Estrogens, Tamoxifen
Drugs decreasing glucocorticoid dose requirement: Licorice, Grapefruit juice, Colestipol
Monitoring:
Monitoring is done based on clinical improvement.
Symptoms that are suggestive of under-dosing: Persistence or the incomplete resolution of fatigue, nausea, postural hypotension, myalgia.
Symptoms that are suggestive of overdosing: weight gain, edema, abdominal striae.
There is no role of measuring ACTH and serum cortisol levels.
Side effects of glucocorticoid replacement therapy:
Weight gain, edema, increased appetite, weight gain, osteoporosis, dyslipidemia, increased cardiovascular risk.

• Glucocorticoid replacement therapy
  • 1.2 Pediatric
    • Preferred regimen: Hydrocortisone 7-10 mg/m2/day PO in three or four divided doses.

Specific instructions:
Avoid using prednisolone, hydrocortisone in children
Monitoring: Clinical improvement, tracking growth velocity, body weight, blood pressure, energy levels.

• Mineralocorticoid replacement therapy
  • 2.1 Adult
    • Preferred regimen: 9 α-fludrocortisone 0.05-0.2 mg/day PO single dose early morning.

Specific instructions:
Monitoring:
Based on the clinical picture Symptoms and signs that are suggestive of under-dosing: hypovolemia, orthostatic hypotension, hyperkalemia, hyperuricemia, increased plasma renin activity.
Symptoms and signs of overdosing: hypertension, hypokalemia, edema. If a patient on fludrocortisone develops hypertension first step is to reduce the dose. If the blood pressure remains elevated, start an antihypertensive medication, and continue fludrocortisone.

• Mineralocorticoid replacement therapy
  • 2.2 Pediatric
    • Preferred regimen: 9 α-fludrocortisone 0.05-0.2 mg/day PO single dose early morning.

Specific instructions:
In newborns and children, higher dose upto 0.5mg of fludrocortisone maybe required because of lower mineralocorticoid sensitivity.

• Dehydroepiandrosterone (DHEA):
  

Its use is not routinely recommended.
A six-month trial of DHEA can be considered in patients with significant impairment in quality of life, decreased libido, women, depressed mood despite glucocorticoid and mineralocorticoid therapy. If there is no improvement at the end of six months, its use has to be discontinued. Contraindications: People with breast and prostate cancer.