Dermatologic Aspects of Addison Disease Treatment & Management

Updated: Jul 18, 2017
  • Author: Elizabeth A Liotta, MD; Chief Editor: William D James, MD  more...
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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. [11, 12]

Admit patients with any of the systemic manifestations of Addison disease to the hospital. Immediately treat patients with acute adrenal insufficiency with glucocorticoid replacement. Hydrocortisone can be administered both as a bolus and as an infusion. Treat hypovolemia and hyponatremia with intravenous fluid and sodium replacement until the patient's condition is stable and he or she can tolerate oral fluids. Consider treating the patient on an outpatient basis once the symptoms of adrenal insufficiency improve enough to enable oral replacement therapy.

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Consultations

The need for consultation depends on the cause of the adrenal insufficiency and may involve the following specialists:

  • Endocrinologist

  • Rheumatologist

  • Infectious diseases specialist

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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.

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Activity

No restrictions on activity are required; however, inform patients about salt loss during vigorous exercise.

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Complications

Pay attention to potential drug interactions. Concomitant use of rifampin, phenytoin, or barbiturates increases the metabolism of replaced hormones; therefore, the patient's hormone levels may decrease to subtherapeutic levels.

Excessive sodium loss may result from the use of diuretics.

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Prevention

Avoid the use of diuretics to prevent excessive sodium loss.

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Long-Term Monitoring

Monitoring glucocorticoid and mineralocorticoid replacement therapy is perhaps more of an art than a science. The ideal dose of glucocorticoids in replacement therapy adequately supplements the adrenal insufficiency while minimizing any adverse effects. If the dose of the replacement glucocorticoids is too low, adrenal insufficiency continues. In children, nocturnal hypoglycemia may result in seizures. Overdoses of replacement glucocorticoids result in many undesired adverse effects, including weight gain and osteoporosis. Correct dosing may be guided by monitoring urine cortisol levels.

Monitor mineralocorticoid replacement by observing the patient's blood pressure levels, which are low when doses of the mineralocorticoid are too low. Monitor serum potassium levels to ensure resolution of the initial hyperkalemia. Plasma renin concentrations may be monitored as well. An overdose of fludrocortisone is difficult to assess, but overdoses may result in hypokalemia and increased atrial natriuretic peptide levels.

Exact dosing of both glucocorticoid and mineralocorticoid replacement is elusive.

Recognize and manage cases of adrenal crisis. Eight percent of diagnosed patients require hospital therapy annually for adrenal crisis. Gastric infection and fever are the most frequent precipitating causes of adrenal crisis. Other physical and mental stress, surgery, and pregnancy can less frequently induce a crisis.

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