Adrenal atrophy medical therapy: Difference between revisions
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==Overview== | ==Overview== | ||
Treatment of adrenal atrophy is conservative. In case of adrenal crisis | Treatment of adrenal atrophy is conservative. In case of adrenal crisis [[IV fluid]] and [[steroid]] are recommended. For long-term management supplementing with [[steroid]] and [[mineralocorticoid]] is necessary. | ||
==Medical therapy== | ==Medical therapy== | ||
Adrenal atrophy is the irreversible damage to the adrenal tissue, due to direct trauma or the secondary causes. As a result, treatment of the adrenal atrophy is a conservative treatment. | Adrenal atrophy is the irreversible damage to the adrenal tissue, due to direct trauma or the secondary causes. As a result, treatment of the adrenal atrophy is a conservative treatment. | ||
For adrenal crisis: | For adrenal crisis: | ||
*Intravenous fluids | *[[Intravenous fluids]] | ||
*Intravenous steroids | *Intravenous [[steroids ]] | ||
The cortisol deficiency is treated by supplementing with cortisol, prednisolone, prednisone, methylprednisolone, and dexamethasone. | *Detection of underlying cause | ||
The mineralocorticoid insufficiency is also cured by the fludrocortisone. <ref name="pmid19500761">{{cite journal |vauthors=Hahner S, Allolio B |title=Therapeutic management of adrenal insufficiency |journal=Best Pract Res Clin Endocrinol Metab |volume=23 |issue=2 |pages=167–79 |date=April 2009 |pmid=19500761 |doi=10.1016/j.beem.2008.09.009 |url=}}</ref><ref name="pmid7170268">{{cite journal |vauthors=Barnett AH, Espiner EA, Donald RA |title=Patients presenting with Addison's disease need not be pigmented |journal=Postgrad Med J |volume=58 |issue=685 |pages=690–2 |date=November 1982 |pmid=7170268 |pmc=2426562 |doi=10.1136/pgmj.58.685.690 |url=}}</ref> | |||
In [[adrenal crisis]], [[intravenous]] fluids in addition to intravenous [[steroids]] are prescribed. It is currently suggested to use 100 mg IV bolus of [[hydrocortisone]], followed by 50 mg IV every 6 hours (or 200 mg/24 hours as a continuous IV infusion for the first 24 hours) in patients presented with adrenal crisis. However, [[mineralocorticoid]] replacement is not necessary acutely because it takes several days for its sodium-retaining effects to appear, and adequate [[sodium]] replacement can be achieved by IV [[saline]] alone. After the initial bolus, hydrocortisone 50 mg IV bolus is administered every six hours until stabilization of [[vital signs]] and capacity to eat and take medication orally. | |||
The detection of the underlying condition, which has yielded to [[adrenal crisis]], including severe systemic [[illness]], [[infection]], [[fasting]], or [[surgery]], should be detected and managed, appropriately. | |||
In the long-term management of patients with adrenal atrophy, the [[cortisol]] deficiency is treated by supplementing with [[cortisol]], [[prednisolone]], [[prednisone]], [[methylprednisolone]], and [[dexamethasone]]. The ideal [[glucocorticoid]] replacement therapy should mimic the endogenous cortisol rhythm, with a nadir at bedtime and peak values in the early morning before waking. Use of short-acting [[glucocorticoid]], [[hydrocortisone]], in two or three divided doses is though suggested to mimic the natural [[biorhythm]]. It is currently suggested to supply a total daily hydrocortisone dose of 10 to 12 mg/m2. | |||
The mineralocorticoid insufficiency is also cured by the [[fludrocortisone]], which is given orally in a usual dose of 0.1 mg/day. A lower dose (such as 0.05 mg/day) may be sufficient in patients receiving [[hydrocortisone]], which has some [[mineralocorticoid]] activity. The mineralocorticoid dose may have to be increased in the summer, when salt loss in perspiration increases. However, the adequacy of mineralocorticoid replacement should be monitored by asking about symptoms of postural [[hypotension]] and measuring supine and upright [[blood pressure]] and pulse, serum [[potassium]], and plasma [[renin]] activity. | |||
. <ref name="pmid19500761">{{cite journal |vauthors=Hahner S, Allolio B |title=Therapeutic management of adrenal insufficiency |journal=Best Pract Res Clin Endocrinol Metab |volume=23 |issue=2 |pages=167–79 |date=April 2009 |pmid=19500761 |doi=10.1016/j.beem.2008.09.009 |url=}}</ref><ref name="pmid7170268">{{cite journal |vauthors=Barnett AH, Espiner EA, Donald RA |title=Patients presenting with Addison's disease need not be pigmented |journal=Postgrad Med J |volume=58 |issue=685 |pages=690–2 |date=November 1982 |pmid=7170268 |pmc=2426562 |doi=10.1136/pgmj.58.685.690 |url=}}</ref><ref name="pmid8161268">{{cite journal |vauthors=Salem M, Tainsh RE, Bromberg J, Loriaux DL, Chernow B |title=Perioperative glucocorticoid coverage. A reassessment 42 years after emergence of a problem |journal=Ann Surg |volume=219 |issue=4 |pages=416–25 |date=April 1994 |pmid=8161268 |pmc=1243159 |doi=10.1097/00000658-199404000-00013 |url=}}</ref><ref name="pmid32419166">{{cite journal |vauthors=Hussain S, Hussain S, Mohammed R, Meeran K, Ghouri N |title=Fasting with adrenal insufficiency: Practical guidance for healthcare professionals managing patients on steroids during Ramadan |journal=Clin Endocrinol (Oxf) |volume=93 |issue=2 |pages=87–96 |date=August 2020 |pmid=32419166 |doi=10.1111/cen.14250 |url=}}</ref><ref name="pmid26760044">{{cite journal |vauthors=Bornstein SR, Allolio B, Arlt W, Barthel A, Don-Wauchope A, Hammer GD, Husebye ES, Merke DP, Murad MH, Stratakis CA, Torpy DJ |title=Diagnosis and Treatment of Primary Adrenal Insufficiency: An Endocrine Society Clinical Practice Guideline |journal=J Clin Endocrinol Metab |volume=101 |issue=2 |pages=364–89 |date=February 2016 |pmid=26760044 |pmc=4880116 |doi=10.1210/jc.2015-1710 |url=}}</ref><ref name="pmid6140341">{{cite journal |vauthors=Smith SJ, MacGregor GA, Markandu ND, Bayliss J, Banks RA, Prentice MG, Dorrington-Ward P, Wise P |title=Evidence that patients with Addison's disease are undertreated with fludrocortisone |journal=Lancet |volume=1 |issue=8367 |pages=11–4 |date=January 1984 |pmid=6140341 |doi=10.1016/s0140-6736(84)90181-8 |url=}}</ref><ref name="pmid2061574">{{cite journal |vauthors=Jadoul M, Ferrant A, De Plaen JF, Crabbé J |title=Mineralocorticoids in the management of primary adrenocortical insufficiency |journal=J Endocrinol Invest |volume=14 |issue=2 |pages=87–91 |date=February 1991 |pmid=2061574 |doi=10.1007/BF03350272 |url=}}</ref> | |||
==References== | ==References== | ||
Latest revision as of 02:27, 10 June 2022
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Maryam Hadipour, M.D.[2]
Overview
Treatment of adrenal atrophy is conservative. In case of adrenal crisis IV fluid and steroid are recommended. For long-term management supplementing with steroid and mineralocorticoid is necessary.
Medical therapy
Adrenal atrophy is the irreversible damage to the adrenal tissue, due to direct trauma or the secondary causes. As a result, treatment of the adrenal atrophy is a conservative treatment. For adrenal crisis:
- Intravenous fluids
- Intravenous steroids
- Detection of underlying cause
In adrenal crisis, intravenous fluids in addition to intravenous steroids are prescribed. It is currently suggested to use 100 mg IV bolus of hydrocortisone, followed by 50 mg IV every 6 hours (or 200 mg/24 hours as a continuous IV infusion for the first 24 hours) in patients presented with adrenal crisis. However, mineralocorticoid replacement is not necessary acutely because it takes several days for its sodium-retaining effects to appear, and adequate sodium replacement can be achieved by IV saline alone. After the initial bolus, hydrocortisone 50 mg IV bolus is administered every six hours until stabilization of vital signs and capacity to eat and take medication orally.
The detection of the underlying condition, which has yielded to adrenal crisis, including severe systemic illness, infection, fasting, or surgery, should be detected and managed, appropriately.
In the long-term management of patients with adrenal atrophy, the cortisol deficiency is treated by supplementing with cortisol, prednisolone, prednisone, methylprednisolone, and dexamethasone. The ideal glucocorticoid replacement therapy should mimic the endogenous cortisol rhythm, with a nadir at bedtime and peak values in the early morning before waking. Use of short-acting glucocorticoid, hydrocortisone, in two or three divided doses is though suggested to mimic the natural biorhythm. It is currently suggested to supply a total daily hydrocortisone dose of 10 to 12 mg/m2. The mineralocorticoid insufficiency is also cured by the fludrocortisone, which is given orally in a usual dose of 0.1 mg/day. A lower dose (such as 0.05 mg/day) may be sufficient in patients receiving hydrocortisone, which has some mineralocorticoid activity. The mineralocorticoid dose may have to be increased in the summer, when salt loss in perspiration increases. However, the adequacy of mineralocorticoid replacement should be monitored by asking about symptoms of postural hypotension and measuring supine and upright blood pressure and pulse, serum potassium, and plasma renin activity. . [1][2][3][4][5][6][7]
References
- ↑ Hahner S, Allolio B (April 2009). "Therapeutic management of adrenal insufficiency". Best Pract Res Clin Endocrinol Metab. 23 (2): 167–79. doi:10.1016/j.beem.2008.09.009. PMID 19500761.
- ↑ Barnett AH, Espiner EA, Donald RA (November 1982). "Patients presenting with Addison's disease need not be pigmented". Postgrad Med J. 58 (685): 690–2. doi:10.1136/pgmj.58.685.690. PMC 2426562. PMID 7170268.
- ↑ Salem M, Tainsh RE, Bromberg J, Loriaux DL, Chernow B (April 1994). "Perioperative glucocorticoid coverage. A reassessment 42 years after emergence of a problem". Ann Surg. 219 (4): 416–25. doi:10.1097/00000658-199404000-00013. PMC 1243159. PMID 8161268.
- ↑ Hussain S, Hussain S, Mohammed R, Meeran K, Ghouri N (August 2020). "Fasting with adrenal insufficiency: Practical guidance for healthcare professionals managing patients on steroids during Ramadan". Clin Endocrinol (Oxf). 93 (2): 87–96. doi:10.1111/cen.14250. PMID 32419166 Check
|pmid=value (help). - ↑ Bornstein SR, Allolio B, Arlt W, Barthel A, Don-Wauchope A, Hammer GD, Husebye ES, Merke DP, Murad MH, Stratakis CA, Torpy DJ (February 2016). "Diagnosis and Treatment of Primary Adrenal Insufficiency: An Endocrine Society Clinical Practice Guideline". J Clin Endocrinol Metab. 101 (2): 364–89. doi:10.1210/jc.2015-1710. PMC 4880116. PMID 26760044.
- ↑ Smith SJ, MacGregor GA, Markandu ND, Bayliss J, Banks RA, Prentice MG, Dorrington-Ward P, Wise P (January 1984). "Evidence that patients with Addison's disease are undertreated with fludrocortisone". Lancet. 1 (8367): 11–4. doi:10.1016/s0140-6736(84)90181-8. PMID 6140341.
- ↑ Jadoul M, Ferrant A, De Plaen JF, Crabbé J (February 1991). "Mineralocorticoids in the management of primary adrenocortical insufficiency". J Endocrinol Invest. 14 (2): 87–91. doi:10.1007/BF03350272. PMID 2061574.