Medication Summary

Glucocorticoid replacement is required in all forms of adrenal insufficiency (Addison disease). Mineralocorticoid replacement is required only in primary adrenal insufficiency, because aldosterone secretion is reduced in primary adrenal insufficiency but not in secondary (central) adrenal insufficiency. In acute adrenal crisis (eg, hypotension, hypoglycemia) use pharmacologic doses of glucocorticoids, which can be in the form of hydrocortisone, methylprednisolone, or dexamethasone.

Class Summary

Mineralocorticoids are used as replacement therapy in aldosterone deficiency and as prophylaxis against hyponatremia and hyperkalemia in patients with primary adrenal insufficiency (Addison disease).

Fludrocortisone

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Fludrocortisone is the drug of choice (DOC) for mineralocorticoid replacement therapy if the zona glomerulosa of the adrenal cortex does not produce aldosterone. This agent allows patients to achieve normal sodium homeostasis.

Fludrocortisone is available only in an oral (PO) formulation. If patient cannot tolerate PO, parenteral hydrocortisone can provide a mineralocorticoid effect. Infants may require sodium chloride supplements, because their diets often provide insufficient sodium.

Class Summary

Glucocorticoid agents give patients with adrenal insufficiency (Addison disease) the equivalent of the body's missing cortisol produced by the adrenal cortex under normal conditions and under stress. Dexamethasone and betamethasone cross the placenta to an appreciable degree; therefore, both agents should not be used in pregnant women unless they are specifically indicated (ie, to aid maturation of the fetal lung or to suppress fetal adrenal function).

Hydrocortisone (Alkindi Sprinkle, Cortef, SoluCortef)

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Hydrocortisone is the glucocorticoid drug of choice (DOC) because of its mineralocorticoid activity and glucocorticoid effects and its equivalency to the adrenal product (ie, cortisol). This agent has a short half-life; therefore, hydrocortisone does not inhibit growth in children to same degree as more potent, longer-acting synthetic glucocorticoid agents (eg, prednisone, methylprednisolone, dexamethasone). Because of short action, hydrocortisone must be administered orally (PO) twice or thrice daily (bid/tid). When administered intravenously, hydrocortisone is usually given every 6 hours.

In a healthy person, mean cortisol secretion is about 5-10 mg/m²/d. The aim of replacement therapy is to supply only as much as needed. The target level is best judged subjectively on basis of patient's own sense of well-being.

Dose requirements are greater PO than parenterally because some hydrocortisone is inactivated as it passes through liver. Equivalent low doses can be derived for prednisone, methylprednisolone, and dexamethasone (which have a minimum of about 4, 5, and 40-50 times the potency of hydrocortisone, respectively). An immediate-release oral granule product (Alkindi Sprinkle) is available in 0.5-mg, 1-mg, 2-mg, and 5-mg dosage sizes to assist with dosing in young children.

Dexamethasone (Baycadron)

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Dexamethasone provides glucocorticoid activity. At pharmacologic doses, this agent decreases inflammation by suppressing migration of polymorphonuclear leukocytes and by reducing capillary permeability. Dexamethasone and prednisone may be used for allergic and inflammatory conditions.

Methylprednisolone (Medrol, Solu-Medrol, Depo-Medrol)

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Methylprednisolone also provides glucocorticoid activity. At pharmacologic doses, this agent decreases inflammation by suppressing migration of polymorphonuclear leukocytes and by reversing increased capillary permeability.

Methylprednisolone is available in a liquid formulation, unlike hydrocortisone.

Prednisone

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Prednisone provides glucocorticoid activity. At pharmacologic doses, this agent decreases inflammation by suppressing migration of polymorphonuclear leukocytes and by reversing increased capillary permeability. Like methylprednisolone, prednisone is available in a liquid formulation.

Questions

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Media Gallery

Regulation of the adrenal cortex. ACTH = adrenocorticotropic hormone; CRF = corticotropin-releasing factor; neg. = negative.
Left photograph shows hyperpigmentation on the dorsum of a patient's hand before the treatment of primary adrenal insufficiency. Right photograph shows normal pigmentation after treatment.
Left photograph shows a patient with Addison disease who has prominent pigmentation in areas not exposed to the sun, such as the palmar creases. Right photograph shows normal pigmentation after treatment.
Left photograph shows vitiligo in a patient with autoimmune adrenalitis. Right photograph shows an area of hyperpigmentation surrounding the vitiligo.
Left photomicrograph shows autoimmune adrenalitis. Right photomicrograph shows tuberculous adrenalitis. Note the caseous granuloma.
Computed tomography scan shows enlarged adrenal glands in a patient with early active autoimmune adrenalitis. Patients with chronic disease present with the opposite picture of hypotrophic adrenals.

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Author

Kimberly Tafuri, DO Assistant Professor, Department of Pediatrics, Division of Pediatric Endocrinology, Stony Brook Children's Hospital

Kimberly Tafuri, DO is a member of the following medical societies: American Academy of Pediatrics, Endocrine Society, Pediatric Endocrine Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Barry B Bercu, MD Professor, Departments of Pediatrics, Molecular Pharmacology and Physiology, University of South Florida College of Medicine, All Children's Hospital

Barry B Bercu, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Clinical Endocrinologists, American Medical Association, American Pediatric Society, Association of Clinical Scientists, Endocrine Society, Florida Medical Association, Pediatric Endocrine Society, Society for Pediatric Research, Southern Society for Pediatric Research, Society for the Study of Reproduction, American Federation for Clinical Research, Pituitary Society

Disclosure: Nothing to disclose.

Chief Editor

Sasigarn A Bowden, MD, FAAP Professor of Pediatrics, Section of Pediatric Endocrinology, Metabolism and Diabetes, Department of Pediatrics, Ohio State University College of Medicine; Pediatric Endocrinologist, Division of Endocrinology, Nationwide Children’s Hospital; Affiliate Faculty/Principal Investigator, Center for Clinical Translational Research, Research Institute at Nationwide Children’s Hospital

Sasigarn A Bowden, MD, FAAP is a member of the following medical societies: American Society for Bone and Mineral Research, Central Ohio Pediatric Society, Endocrine Society, International Society for Pediatric and Adolescent Diabetes, Pediatric Endocrine Society, Society for Pediatric Research

Disclosure: Nothing to disclose.

Additional Contributors

Karl S Roth, MD Retired Professor and Chair, Department of Pediatrics, Creighton University School of Medicine

Karl S Roth, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American College of Nutrition, American Pediatric Society, American Society for Nutrition, American Society of Nephrology, Association of American Medical Colleges, Medical Society of Virginia, New York Academy of Sciences, Sigma Xi, The Scientific Research Honor Society, Society for Pediatric Research, Southern Society for Pediatric Research

Disclosure: Nothing to disclose.

Phyllis W Speiser, MD Chief, Division of Pediatric Endocrinology, Steven and Alexandra Cohen Children's Medical Center of New York; Professor of Pediatrics, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell

Phyllis W Speiser, MD is a member of the following medical societies: American Association of Clinical Endocrinologists, Endocrine Society, Pediatric Endocrine Society, Society for Pediatric Research

Disclosure: Nothing to disclose.

Thomas A Wilson, MD Professor of Clinical Pediatrics, Chief and Program Director, Division of Pediatric Endocrinology, Department of Pediatrics, The School of Medicine at Stony Brook University Medical Center

Thomas A Wilson, MD is a member of the following medical societies: Endocrine Society, Pediatric Endocrine Society, Phi Beta Kappa

Disclosure: Nothing to disclose.

Sections Pediatric Adrenal Insufficiency (Addison Disease)
Overview
Presentation
DDx
Workup
Treatment
Medication
Questions & Answers
Media Gallery
References

Pediatric Adrenal Insufficiency (Addison Disease) Medication

Medication Summary

Mineralocorticoids