Adrenal insufficiency medical therapy: Difference between revisions

Jump to navigation Jump to search
VisualWikitext
(Created page with "__NOTOC__ {{Adrenal insufficiency}} {{CMG}}; {{AE}} ==Overview== There is no treatment for [disease name]; the mainstay of therapy is supportive care. OR Supportive therapy...")
 
Line 47: Line 47:


==Medical Therapy==
==Medical Therapy==
*Pharmacologic medical therapy is recommended among patients with [disease subclass 1], [disease subclass 2], and [disease subclass 3].  
*Pharmacologic medical therapy is recommended among patients with [[adrenal insufficiency]].
*Pharmacologic medical therapies for [disease name] include (either) [therapy 1], [therapy 2], and/or [therapy 3].
*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. <ref name="BornsteinAllolio2016">{{cite journal|last1=Bornstein|first1=Stefan R.|last2=Allolio|first2=Bruno|last3=Arlt|first3=Wiebke|last4=Barthel|first4=Andreas|last5=Don-Wauchope|first5=Andrew|last6=Hammer|first6=Gary D.|last7=Husebye|first7=Eystein S.|last8=Merke|first8=Deborah P.|last9=Murad|first9=M. Hassan|last10=Stratakis|first10=Constantine A.|last11=Torpy|first11=David J.|title=Diagnosis and Treatment of Primary Adrenal Insufficiency: An Endocrine Society Clinical Practice Guideline|journal=The Journal of Clinical Endocrinology & Metabolism|volume=101|issue=2|year=2016|pages=364–389|issn=0021-972X|doi=10.1210/jc.2015-1710}}</ref> <ref name="OpreaBonnet2019">{{cite journal|last1=Oprea|first1=Alina|last2=Bonnet|first2=Nicolas C. G.|last3=Pollé|first3=Olivier|last4=Lysy|first4=Philippe A.|title=Novel insights into glucocorticoid replacement therapy for pediatric and adult adrenal insufficiency|journal=Therapeutic Advances in Endocrinology and Metabolism|volume=10|year=2019|pages=204201881882129|issn=2042-0188|doi=10.1177/2042018818821294}}</ref><ref>https://www.elsevier.es/index.php?p=revista&pRevista=pdf-simple&pii=S2173509314700698</ref>
*Empiric therapy for [disease name] depends on [disease factor 1] and [disease factor 2].
*Patients with [disease subclass 1] are treated with [therapy 1], whereas patients with [disease subclass 2] are treated with [therapy 2].
===Disease Name===


* '''1 Stage 1 - Name of stage'''
** 1.1 '''Specific Organ system involved 1'''
*** 1.1.1 '''Adult'''
**** Preferred regimen (1): [[drug name]] 100 mg PO q12h for 10-21 days '''(Contraindications/specific instructions)''' 
**** Preferred regimen (2): [[drug name]] 500 mg PO q8h for 14-21 days
**** Preferred regimen (3): [[drug name]] 500 mg q12h for 14-21 days
**** Alternative regimen (1): [[drug name]] 500 mg PO q6h for 7–10 days 
**** Alternative regimen (2): [[drug name]] 500 mg PO q12h for 14–21 days
**** Alternative regimen (3): [[drug name]] 500 mg PO q6h for 14–21 days
*** 1.1.2 '''Pediatric'''
**** 1.1.2.1 (Specific population e.g. '''children < 8 years of age''')
***** Preferred regimen (1): [[drug name]] 50 mg/kg PO per day q8h (maximum, 500 mg per dose) 
***** Preferred regimen (2): [[drug name]] 30 mg/kg PO per day in 2 divided doses (maximum, 500 mg per dose)
***** Alternative regimen (1): [[drug name]]10 mg/kg PO q6h (maximum, 500 mg per day)
***** Alternative regimen (2): [[drug name]] 7.5 mg/kg PO q12h (maximum, 500 mg per dose)
***** Alternative regimen (3): [[drug name]] 12.5 mg/kg PO q6h (maximum, 500 mg per dose)
****1.1.2.2 (Specific population e.g. '<nowiki/>'''''children < 8 years of age'''''')
***** Preferred regimen (1): [[drug name]] 4 mg/kg/day PO q12h（maximum, 100 mg per dose）
***** Alternative regimen (1): [[drug name]] 10 mg/kg PO q6h (maximum, 500 mg per day)
***** Alternative regimen (2): [[drug name]] 7.5 mg/kg PO q12h (maximum, 500 mg per dose) 
***** Alternative regimen (3): [[drug name]] 12.5 mg/kg PO q6h (maximum, 500 mg per dose)
** 1.2 '''Specific Organ system involved 2'''
*** 1.2.1 '''Adult'''
**** Preferred regimen (1): [[drug name]] 500 mg PO q8h
*** 1.2.2  '''Pediatric'''
**** Preferred regimen (1): [[drug name]] 50 mg/kg/day PO q8h (maximum, 500 mg per dose)


* 2 '''Stage 2 - Name of stage'''
===Adrenal insufficiency===
** 2.1 '''Specific Organ system involved 1 '''
 
**: '''Note (1):'''  
* '''Glucocorticoid replacement therapy'''
**: '''Note (2)''':
** 1.1 '''Adult'''
**: '''Note (3):'''
*** 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
*** 2.1.1 '''Adult'''
*** 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
**** Parenteral regimen
*** Alternative regimen (1): [[Cortisone acetate]] 20-25mg PO, once in the morning, lifelong.
***** Preferred regimen (1): [[drug name]] 2 g IV q24h for 14 (14–21) days
*** Alternative regimen (2): [[Prednisone]] 3-5mg/day PO, once in the morning lifelong.
***** Alternative regimen (1): [[drug name]] 2 g IV q8h for 14 (14–21) days
'''Specific instructions:'''<br>
***** Alternative regimen (2): [[drug name]] 18–24 MU/day IV q4h for 14 (14–21) days
[[Drug interactions]]:<br>
**** Oral regimen
Drugs increasing glucocorticoid dose requirement: Anticonvulsants like Barbiturates, Topiramate, Anti-tubercular drugs, Estrogens, Tamoxifen<br>
***** Preferred regimen (1): [[drug name]] 500 mg PO q8h for 14 (14–21) days
Drugs decreasing glucocorticoid dose requirement: Licorice, Grapefruit juice, Colestipol<br>
***** Preferred regimen (2): [[drug name]] 100 mg PO q12h for 14 (14–21) days
Monitoring:<br>
***** Preferred regimen (3): [[drug name]] 500 mg PO q12h for 14 (14–21) days
Monitoring is done based on clinical improvement.<br>
***** Alternative regimen (1): [[drug name]] 500 mg PO q6h for 7–10 days 
Symptoms that are suggestive of under-dosing: Persistence or the incomplete resolution of fatigue, nausea, postural hypotension, myalgia.<br>
***** Alternative regimen (2): [[drug name]] 500 mg PO q12h for 14–21 days
Symptoms that are suggestive of overdosing: weight gain, edema, abdominal striae.<br>
***** Alternative regimen (3):[[drug name]] 500 mg PO q6h for 14–21 days
There is no role of measuring ACTH and serum cortisol levels.<br>
*** 2.1.2 '''Pediatric'''
Side effects of glucocorticoid replacement therapy:<br>
**** Parenteral regimen
Weight gain, edema, increased appetite, weight gain, osteoporosis, dyslipidemia, increased cardiovascular risk.
***** Preferred regimen (1): [[drug name]] 50–75 mg/kg IV q24h for 14 (14–21) days (maximum, 2 g)
* '''Glucocorticoid replacement therapy'''
***** Alternative regimen (1): [[drug name]] 150–200 mg/kg/day IV q6–8h for 14 (14–21) days (maximum, 6 g per day)
** 1.2 '''Pediatric'''
***** Alternative regimen (2):  [[drug name]] 200,000–400,000 U/kg/day IV q4h for 14 (14–21) days (maximum, 18–24 million U per day) '<nowiki/>'''''(Contraindications/specific instructions)''''''
*** Preferred regimen: [[Hydrocortisone]] 7-10 mg/m2/day PO in three or four divided doses.
**** Oral regimen
'''Specific instructions: <br>
***** Preferred regimen (1):  [[drug name]] 50 mg/kg/day PO q8h for 14 (14–21) days  (maximum, 500 mg per dose)
Avoid using prednisolone, hydrocortisone in children <br>
***** Preferred regimen (2): [[drug name]] '''(for children aged ≥ 8 years)''' 4 mg/kg/day PO q12h for 14 (14–21) days (maximum, 100 mg per dose)
Monitoring: Clinical improvement, tracking growth velocity, body weight, blood pressure, energy levels.
***** Preferred regimen (3): [[drug name]] 30 mg/kg/day PO q12h for 14 (14–21) days  (maximum, 500 mg per dose)
 
***** Alternative regimen (1): [[drug name]] 10 mg/kg PO q6h 7–10 days  (maximum, 500 mg per day)
*'''Mineralocorticoid replacement therapy'''
***** Alternative regimen (2): [[drug name]] 7.5 mg/kg PO q12h for 14–21 days  (maximum, 500 mg per dose)
**2.1 Adult
***** Alternative regimen (3): [[drug name]] 12.5 mg/kg PO q6h for 14–21 days  (maximum,500 mg per dose)
***Preferred regimen: [[9 α-fludrocortisone]] 0.05-0.2 mg/day PO single dose early morning.
** 2.2  '<nowiki/>'''''Other Organ system involved 2''''''
'''Specific instructions: <br>
**: '''Note (1):'''
Monitoring: <br>
**: '''Note (2)''':
Based on the clinical picture
**: '''Note (3):'''  
Symptoms and signs that are suggestive of under-dosing: [[hypovolemia]], [[orthostatic hypotension]], [[hyperkalemia]], [[hyperuricemia]], increased plasma renin activity.<br>
*** 2.2.1 '''Adult'''
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]].
**** Parenteral regimen
*'''Mineralocorticoid replacement therapy'''
***** Preferred regimen (1): [[drug name]] 2 g IV q24h for 14 (14–21) days
**2.2 Pediatric
***** Alternative regimen (1): [[drug name]] 2 g IV q8h for 14 (14–21) days
***Preferred regimen: [[9 α-fludrocortisone]] 0.05-0.2 mg/day PO single dose early morning.
***** Alternative regimen (2): [[drug name]] 18–24 MU/day IV q4h for 14 (14–21) days
'''Specific instructions:'''<br>
**** Oral regimen
In newborns and children, higher dose upto 0.5mg of [[fludrocortisone]] maybe required because of lower mineralocorticoid sensitivity. <ref name="EspositoPasquali2018">{{cite journal|last1=Esposito|first1=Daniela|last2=Pasquali|first2=Daniela|last3=Johannsson|first3=Gudmundur|title=Primary Adrenal Insufficiency: Managing Mineralocorticoid Replacement Therapy|journal=The Journal of Clinical Endocrinology & Metabolism|volume=103|issue=2|year=2018|pages=376–387|issn=0021-972X|doi=10.1210/jc.2017-01928}}</ref>
***** Preferred regimen (1): [[drug name]] 500 mg PO q8h for 14 (14–21) days
***** Preferred regimen (2): [[drug name]] 100 mg PO q12h for 14 (14–21) days
***** Preferred regimen (3): [[drug name]] 500 mg PO q12h for 14 (14–21) days
***** Alternative regimen (1): [[drug name]] 500 mg PO q6h for 7–10 days 
***** Alternative regimen (2): [[drug name]] 500 mg PO q12h for 14–21 days
***** Alternative regimen (3):[[drug name]] 500 mg PO q6h for 14–21 days
*** 2.2.2 '''Pediatric'''
**** Parenteral regimen
***** Preferred regimen (1): [[drug name]] 50–75 mg/kg IV q24h for 14 (14–21) days (maximum, 2 g)
***** Alternative regimen (1): [[drug name]] 150–200 mg/kg/day IV q6–8h for 14 (14–21) days (maximum, 6 g per day)
***** Alternative regimen (2):  [[drug name]] 200,000–400,000 U/kg/day IV q4h for 14 (14–21) days (maximum, 18–24 million U per day)
**** Oral regimen
***** Preferred regimen (1): [[drug name]] 50 mg/kg/day PO q8h for 14 (14–21) days  (maximum, 500 mg per dose)
***** Preferred regimen (2): [[drug name]] 4 mg/kg/day PO q12h for 14 (14–21) days (maximum, 100 mg per dose)
***** Preferred regimen (3): [[drug name]] 30 mg/kg/day PO q12h for 14 (14–21) days  (maximum, 500 mg per dose)
***** Alternative regimen (1): [[drug name]] 10 mg/kg PO q6h 7–10 days  (maximum, 500 mg per day)
***** Alternative regimen (2): [[drug name]] 7.5 mg/kg PO q12h for 14–21 days  (maximum, 500 mg per dose)
***** Alternative regimen (3): [[drug name]] 12.5 mg/kg PO q6h for 14–21 days  (maximum,500 mg per dose)


==References==
==References==

Revision as of 20:03, 5 November 2020

Adrenal insufficiency Microchapters

Home

Patient Information

Overview

Historical Perspective

Classification

Pathophysiology

Causes

Differentiating Xyz from other Diseases

Epidemiology and Demographics

Risk Factors

Screening

Natural History, Complications and Prognosis

Diagnosis

Diagnostic Study of Choice

History and Symptoms

Physical Examination

Laboratory Findings

Electrocardiogram

X-ray

Echocardiography and Ultrasound

CT scan

MRI

Other Imaging Findings

Other Diagnostic Studies

Treatment

Medical Therapy

Interventions

Surgery

Primary Prevention

Secondary Prevention

Cost-Effectiveness of Therapy

Future or Investigational Therapies

Case Studies

Case #1

Adrenal insufficiency medical therapy On the Web

Most recent articles

Most cited articles

Review articles

CME Programs

Powerpoint slides

Images

American Roentgen Ray Society Images of Adrenal insufficiency medical therapy

All Images
X-rays
Echo & Ultrasound
CT Images
MRI

Ongoing Trials at Clinical Trials.gov

US National Guidelines Clearinghouse

NICE Guidance

FDA on Adrenal insufficiency medical therapy

CDC on Adrenal insufficiency medical therapy

Adrenal insufficiency medical therapy in the news

Blogs on Adrenal insufficiency medical therapy

Directions to Hospitals Treating Psoriasis

Risk calculators and risk factors for Adrenal insufficiency medical therapy

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

Overview

There is no treatment for [disease name]; the mainstay of therapy is supportive care.

OR

Supportive therapy for [disease name] includes [therapy 1], [therapy 2], and [therapy 3].

OR

The majority of cases of [disease name] are self-limited and require only supportive care.

OR

[Disease name] is a medical emergency and requires prompt treatment.

OR

The mainstay of treatment for [disease name] is [therapy].

OR   The optimal therapy for [malignancy name] depends on the stage at diagnosis.

OR

[Therapy] is recommended among all patients who develop [disease name].

OR

Pharmacologic medical therapy is recommended among patients with [disease subclass 1], [disease subclass 2], and [disease subclass 3].

OR

Pharmacologic medical therapies for [disease name] include (either) [therapy 1], [therapy 2], and/or [therapy 3].

OR

Empiric therapy for [disease name] depends on [disease factor 1] and [disease factor 2].

OR

Patients with [disease subclass 1] are treated with [therapy 1], whereas patients with [disease subclass 2] are treated with [therapy 2].

Medical 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

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

Specific instructions:
In newborns and children, higher dose upto 0.5mg of fludrocortisone maybe required because of lower mineralocorticoid sensitivity. [4]

References

  1. ↑ Bornstein, Stefan R.; Allolio, Bruno; Arlt, Wiebke; Barthel, Andreas; Don-Wauchope, Andrew; Hammer, Gary D.; Husebye, Eystein S.; Merke, Deborah P.; Murad, M. Hassan; Stratakis, Constantine A.; Torpy, David J. (2016). "Diagnosis and Treatment of Primary Adrenal Insufficiency: An Endocrine Society Clinical Practice Guideline". The Journal of Clinical Endocrinology & Metabolism. 101 (2): 364–389. doi:10.1210/jc.2015-1710. ISSN 0021-972X.
  2. ↑ Oprea, Alina; Bonnet, Nicolas C. G.; Pollé, Olivier; Lysy, Philippe A. (2019). "Novel insights into glucocorticoid replacement therapy for pediatric and adult adrenal insufficiency". Therapeutic Advances in Endocrinology and Metabolism. 10: 204201881882129. doi:10.1177/2042018818821294. ISSN 2042-0188.
  3. ↑ https://www.elsevier.es/index.php?p=revista&pRevista=pdf-simple&pii=S2173509314700698
  4. ↑ Esposito, Daniela; Pasquali, Daniela; Johannsson, Gudmundur (2018). "Primary Adrenal Insufficiency: Managing Mineralocorticoid Replacement Therapy". The Journal of Clinical Endocrinology & Metabolism. 103 (2): 376–387. doi:10.1210/jc.2017-01928. ISSN 0021-972X.

Template:WH Template:WS

Retrieved from "https://www.wikidoc.org/index.php?title=Adrenal_insufficiency_medical_therapy&oldid=1674089"