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Addison Disease: Treatment & Medication
Updated: Jan 21, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Medical Care
- Promptly treat patients in whom acute adrenal insufficiency is suspected; follow up with a workup for adrenal insufficiency.
- In Addison disease, the adequate replacement of glucocorticoids and mineralocorticoids is the primary goal.
- Studies show that dehydroepiandrosterone therapy improves the patient's quality of life.10,11
Consultations
The need for consultation depends on the cause of the adrenal insufficiency and may involve the following specialists:
- Endocrinologist
- Rheumatologist
- Infectious diseases specialist
Diet
- Advise patients not to restrict salt in their diets.
- In patients with concurrent primary hypertension, salt intake may be restricted instead of discontinuing mineralocorticoid replacement.
- Advise patients who live in warm climates to increase their salt intake because of their increased loss of salt as a result of sweating.
Activity
- No restrictions on activity are required.
- Inform patients about salt loss during vigorous exercise.
Medication
With optimum dosing (which is often a challenge), the glucocorticoids are adequately replaced with minimal adverse effects. Underdosing of glucocorticoids results in continued adrenal insufficiency. In children, nocturnal hypoglycemia can result in seizures. Overdosing of glucocorticoids results in weight gain, increased blood pressure, and osteoporosis. The effects of steroid replacement are assessed with clinical examination.
The resolution of symptoms and the correction of electrolyte abnormalities are the customary signals in determining the adequacy of replacement. In patients at risk for osteoporosis, monitor serum and urine cortisol levels; this method appears to be the best available assessment of steroid dosing.
The titration of mineralocorticoid replacement is achieved by monitoring electrolyte levels and plasma rennin concentrations and by evaluating clinical findings such as dizziness or weight gain. Weakness, decreased diastolic blood pressure, low serum sodium levels, and increased plasma rennin concentrations occur with an underdosing of fludrocortisone. Overdosing is difficult to determine. Decreased serum potassium levels may be seen. Increased levels of atrial natriuretic peptide have been proposed to be more accurate in determining an overdose.12
Corticosteroids
These agents are used to restore corticosteroid levels. Some cases of multifocal disseminated lipoatrophy as a result of IV corticosteroid administration have been reported in these patients with adrenal insufficiency.13
Cortisone (Cortone)
DOC for patients with adrenocortical insufficiency.
Adult
25-300 mg/d PO/IM divided q12-24h; taper to physiologic replacement
Alternatively, 12-15 mg/m2/d PO, divided two-thirds am and one-third pm
Pediatric
0.5-0.75 mg/kg/d PO/IM or 20-25 mg/m2/d divided q8h
Alternative IM administration: 0.25-0.35 mg/kg/d IM qd or 12.5 mg/m2/d IM
Estrogen coadministration may increase corticosteroid levels; may increase digitalis toxicity secondary to hypokalemia; concomitant administration with bisphosphonates associated with increased incidence of osteonecrosis; concomitant administration with fluoroquinolones may increase risk of tendon rupture, especially in elderly persons
Documented hypersensitivity; viral, fungal, or tubercular skin lesions; infections (except during replacement therapy)
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Positive evidence of human fetal risk exists, but benefits from use in pregnant women may be acceptable despite risk (eg, if drug needed in life-threatening situation or for serious disease for which safer drugs cannot be used or are ineffective); caution in hyperthyroidism, cirrhosis, nonspecific ulcerative colitis, osteoporosis, peptic ulcer disease, diabetes, and myasthenia gravis
Hydrocortisone (Hydrocortone, Cortef)
DOC because of mineralocorticoid activity and glucocorticoid effects. Some cases of multifocal disseminated lipoatrophy as a result of IV corticosteroid administration have been reported in these patients with adrenal insufficiency.
Adult
100 mg IV bolus followed by continuous infusion of 100 mg q8h for 24-48 h
Once condition stable, initiate 50 mg q8h PO for 48 h; may taper to 30-50 mg/d in divided doses
Chronic dosing should approximate physiologic replacement.
Pediatric
<12 years: 1-2 mg/kg IV bolus followed by 25-150 mg/d divided q6-8h
>12 years: 1-2 mg/kg IV bolus followed by 150-250 mg/d divided q6-8h
Corticosteroid clearance may decrease with estrogens; may increase digitalis toxicity secondary to hypokalemia; concomitant administration with bisphosphonates associated with increased incidence of osteonecrosis; concomitant administration with fluoroquinolones may increase risk of tendon rupture, especially in elderly persons
Documented hypersensitivity; viral, fungal, or tubercular skin infections
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Positive evidence of human fetal risk exists, but benefits from use in pregnant women may be acceptable despite risk (eg, if drug needed in life-threatening situation or for serious disease for which safer drugs cannot be used or are ineffective); caution in hyperthyroidism, osteoporosis, peptic ulcer disease, cirrhosis, nonspecific ulcerative colitis, diabetes, and myasthenia gravis
Fludrocortisone (Florinef)
Used for partial replacement therapy in primary and secondary adrenocortical insufficiency.
Adult
0.1-0.2 mg PO 3 times/wk
Pediatric
Infants: 0.1 to 0.2 mg/d PO
Children: 0.05 to 0.1 mg/d PO
Antagonizes effects of anticholinergics; rifampin, hydantoins, and barbiturates decrease effects; decreases salicylate levels; concomitant administration with bisphosphonates associated with increased incidence of osteonecrosis; concomitant administration with fluoroquinolones may increase risk of tendon rupture, especially in elderly persons
Documented hypersensitivity; systemic fungal infections
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Positive evidence of human fetal risk exists, but benefits from use in pregnant women may be acceptable despite risk (eg, if drug needed in life-threatening situation or for serious disease for which safer drugs cannot be used or are ineffective); caution in Addison disease, potassium loss, and sodium retention
Dexamethasone (Decadron, Baldex, Dexone)
DOC for patients with adrenocortical insufficiency.
Adult
0.25-0.75 mg PO qhs
Pediatric
Not established
Effects decrease with coadministration of barbiturates, phenytoin, and rifampin; decreases effect of salicylates and vaccines used for immunization; concomitant administration with bisphosphonates associated with increased incidence of osteonecrosis; concomitant administration with fluoroquinolones may increase risk of tendon rupture, especially in elderly persons
Documented hypersensitivity; active bacterial or fungal infection
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Increases risk of multiple complications (eg, severe infections); monitor adrenal insufficiency when tapering; abrupt discontinuation may cause adrenal crisis; hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression, and infections are possible complications
More on Addison Disease |
| Overview: Addison Disease |
| Differential Diagnoses & Workup: Addison Disease |
 Treatment & Medication: Addison Disease |
| Follow-up: Addison Disease |
| Multimedia: Addison Disease |
| References |
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References
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Further Reading
Keywords
Addison disease, Addison's disease, primary adrenal insufficiency, chronic adrenal insufficiency, hypoadrenalism, polyglandular autoimmune diseases, polyglandular autoimmune disease I, PGAD I, polyglandular autoimmune disease II, PGAD II, Schmidt syndrome, addisonian crisis, adrenocorticotropic hormone, ACTH, corticotropin, melanocyte-stimulating hormone, MSH
