Approach Considerations
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. Consult an endocrinologist if adrenal insufficiency is suspected.
Patients with suspected adrenal crisis should undergo immediate treatment with a parenteral injection of 100 mg (50 mg/m2 for young children) hydrocortisone, after which, appropriate fluid resuscitation should be administered, as well as 200 mg (50-100 mg/m2 for children) of hydrocortisone/24 hours (by way of continuous IV therapy or 6-hourly injection). If hydrocortisone is unavailable, prednisolone may be used. Dexamethasone is least-preferred, as its onset of action is slow. [47]
After results for the patient's electrolyte, blood sugar, cortisol, and adrenocorticotropic hormone (ACTH) concentrations are obtained, administer glucocorticoids if adrenal insufficiency is suspected. If a cosyntropin stimulation test is chosen, a single dose of dexamethasone may be administered without interfering with the measurement of the cortisol response to cosyntropin.
No surgical management is needed in most cases.
Supplementation of patients with primary adrenal insufficiency with dehydroepiandrosterone has not proven to be beneficial. [58, 59]
Do not forget that chronic infections, such as tuberculosis (TB) and human immunodeficiency virus (HIV) infection, can impair adrenal function. The possibility of central adrenal insufficiency must be investigated, identified, and treated in all patients who have undergone pituitary surgery, irradiation, or prolonged treatment with glucocorticoids.
Management of Acute Adrenal Insufficiency
Patients with adrenal insufficiency (Addison disease) are generally hypovolemic and may be hypoglycemic, hyponatremic, or hyperkalemic. Initial therapy consists of intravenously administered saline and dextrose. Potassium is generally not needed in acute situations, especially in patients with primary adrenal insufficiency, who are often hyperkalemic.
Fluid resuscitation
In a hypotensive patient, rapidly administer isotonic sodium chloride solution (eg, 450 mL/m2 or 20 mL/kg bolus) over the first hour. If the patient remains hypotensive, a second 20-mL/kg bolus of isotonic sodium chloride solution may be given. Follow this with the typical continuous infusion of 3200 mL/m2/d or 200 mL per 100 calories of estimated energy expenditure at rest to restore intravascular volume.
Correction of hypoglycemia
Dextrose must be provided. If the patient is hypoglycemic, 2 mL/kg of 25% dextrose in water (D25W) or 4 mL/kg 10% dextrose in water (D10W) should correct hypoglycemia. Provide 5% dextrose in water (D5W) to prevent initial or further hypoglycemia.
Glucocorticoid administration
After intravenous fluids are provided, administer stress doses of glucocorticoid. The recommended stress dosage of hydrocortisone is an initial dose of 50-100 mg/m2 given intravenously, followed by 50-100 mg/m2/d divided in 4 intravenous doses. Hydrocortisone may be given intramuscularly if intravenous access is unavailable. However, intramuscular administration works slowly. Comparable stress doses of methylprednisolone are 10-15 mg/m2 and dexamethasone 1-1.5 mg/m2.
Dexamethasone is preferable for patients with suspected but unproved adrenal insufficiency (Addison disease), because the physician can simultaneously treat the patient while performing a diagnostic cosyntropin stimulation test. Methylprednisolone and dexamethasone have negligible mineralocorticoid effects. Large doses of hydrocortisone (ie, even double or triple the stress doses previously mentioned) are preferred if the patient is hypovolemic, hyponatremic, or hyperkalemic, due to the mineralocorticoid effects of hydrocortisone (lacking in prednisone or dexamethasone).
A study by Quinkler et al found that patients with adrenal insufficiency (Addison disease) who received prednisolone have significantly higher mean low-density lipoprotein cholesterol levels than do those being treated with hydrocortisone (3.9 vs 3.2 mmol/L, respectively). In addition, research suggests that prednisolone is associated with decreased bone mineral density in adrenal insufficiency. [60, 61]
No parenteral form of a mineralocorticoid is currently available in the United States. However, if the patient has good gastrointestinal function, fludrocortisone 0.1-0.2 mg may be orally administered.
Iatrogenic adrenal insufficiency due to glucocorticoid therapy can be prevented by giving the patient dosages below his or her physiologic requirements. Treatment with alternate-day oral prednisone, or with topical or inhaled glucocorticoids, can reduce the risk of iatrogenic adrenal insufficiency.
Perioperative Considerations
If a patient with adrenal insufficiency (Addison disease) requires surgery, treat him or her with stress doses of glucocorticoids (eg, hydrocortisone 50-100 mg/m2 given intramuscularly or intravenously when the patient is being transported to the operating room or in advance of the planned surgery). Fludrocortisone may be withheld on the day of surgery and while the patient is receiving stress doses of hydrocortisone.
Intraoperative period
During surgery, administer additional doses by giving either a hydrocortisone infusion at a dosage of 2-4 mg/m2/h or additional intravenous boluses of 10-25 mg/m2 every 6 hours throughout the procedure. Note that these dosage recommendations are empiric, not evidence based.
Postoperative period
After surgery, continue the administration of hydrocortisone in the immediate postoperative period.
On the second and third postoperative days, the dosage of hydrocortisone can be decreased by 50% each day to a minimum of the patient's usual daily requirement if the patient is recovering well and has no complications.
By the fourth postoperative day, the usual daily dosage of steroids may be resumed if the patient is recovering satisfactorily. If complications occur, stress doses of glucocorticoids must be continued.
If the patient is unable to take oral fludrocortisone in the postoperative period, stress doses of hydrocortisone may be continued for a prolonged period to provide adequate mineralocorticoid activity.
AI and Stressed, Ill, or Pregnant Patients
An important physiologic response to stress is an increase in adrenocorticotropic hormone (ACTH)-mediated cortisol production. Patients with adrenal insufficiency (AI) (Addison disease) are unable to mount this response, regardless of the reason, and they must be given stress doses of glucocorticoid.
When a febrile illness occurs or when a patient requires a surgical or stressful procedure, triple the glucocorticoid dosage. If a patient is vomiting or listless, administer parenteral glucocorticoid (hydrocortisone 50-100 mg/m2 given intramuscularly or intravenously or equivalent methylprednisolone 10-15 mg/m2 or dexamethasone 1-1.5 mg/m2). Repeat the dose every 6-8 hours until patient recovers, because hydrocortisone succinate has a short duration of action.
Injectable glucocorticoid must be provided to all patients with adrenal insufficiency. The patient and caretaker must be instructed in its administration, the indications for its use and the lifesaving importance of its administration.
Mineralocorticoid therapy does not need to be tripled during periods of illness or physical stress.
Glucocorticoid or mineralocorticoid replacement is not contraindicated when needed. This therapy is involved in few drug-drug interactions.
Pregnant women
Preferred glucocorticoids during pregnancy are hydrocortisone or prednisone, because the placenta inactivates them and thereby prevents exposing the fetus to excess glucocorticoids. Therefore, dosage requirements may increase during pregnancy.
In contrast, dexamethasone and betamethasone readily cross the placenta and can suppress fetal adrenal function.
Because cortisol from the adrenal cortex stimulates phenylethanolamine N -methyltransferase, the last step in epinephrine synthesis, in the adrenal medulla, patients with cortisol deficiency have deficient epinephrine responses to stress, a condition not amenable to replacement therapy. [62, 63]
Long-Term Monitoring
In a child with adrenal insufficiency (Addison disease), long-term glucocorticoid replacement must be balanced between the need to prevent symptoms of adrenal insufficiency and the need to allow the child to grow at a normal rate, because excess replacement with glucocorticoid diminishes growth velocity.
Hydrocortisone is available in 5-mg, 10-mg, and 20-mg tablets. This agent is recommended for long-term therapy because of its relatively low potency, which eases the titration of appropriate doses.
In a large patient, prednisone or dexamethasone may be substituted; however, individual sensitivity to these drugs widely varies. Estimated equivalencies are as follows: [64]
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1 mg of prednisone = typically given as 4-6 mg of hydrocortisone, but may be up to 15 mg
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1 mg of dexamethasone = 20-25 mg of hydrocortisone but was previously thought to be up to 100 mg
Patients with primary adrenal insufficiency who also have mineralocorticoid deficiency require fludrocortisone at 0.1-0.2 mg/d. Infants with primary adrenal insufficiency usually require sodium chloride supplementation, the usual dosage being 2-4 g/d (4 g = 1 teaspoon). Older children generally do not need sodium chloride supplements, since they can access salt to meet their requirements. [10]
If the patient's adrenal insufficiency has an autoimmune etiology, monitor patients for the development of associated autoimmune phenomena, such as hypoparathyroidism, hypogonadism, vitiligo, pernicious anemia, thyroid dysfunction, and diabetes mellitus.
Glucocorticoid dosing
Individualize the maintenance dosage for each patient. The range for hydrocortisone is 7-20 mg/m2/d given orally in 2 or 3 divided doses.
Monitor the adequacy of dosing in patients with adrenal insufficiency who receive long-term glucocorticoid therapy, and adjust the dose of glucocorticoid for each patient on the basis of clinical criteria (eg, absence of symptoms of glucocorticoid deficiency, excessive weight gain and normal growth). Too little glucocorticoid causes symptoms of adrenal insufficiency. Too much glucocorticoid causes excessive weight gain, cushingoid features, hypertension, hyperglycemia, cataracts, and growth failure. In children, growth failure is a sensitive indicator of exposure to excessive glucocorticoids.
In the authors' experience, plasma adrenocorticotropic hormone (ACTH) concentrations provide little guidance for adjusting doses of glucocorticoids. Growth pattern and symptoms of salt craving, blood pressure, plasma renin activity, and electrolytes help in adjusting doses of fludrocortisone.
Caloric and activity monitoring
The patient's caloric intake may need to be monitored. Restrict the patient's caloric intake if excess weight gain occurs and reevaluate the glucocorticoid dose, because excess glucocorticoid administration stimulates appetite.
Although no activity restrictions are necessary after adequate replacement therapy is started, provide patients who exercise in warm climates with sufficient sodium chloride to prevent hyponatremia. Stress doses of glucocorticoids are generally not needed for exercise.
It is advisable for patients with adrenal insufficiency to wear a medical alert bracelet or necklace. [10]
Diet
Patients should eat an unrestricted diet. Those with primary adrenal insufficiency (Addison disease) should have ample access to salt because of the salt wasting that occurs if their condition is untreated. Infants with primary adrenal insufficiency often need 2-4 g of sodium chloride per day.
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Regulation of the adrenal cortex. ACTH = adrenocorticotropic hormone; CRF = corticotropin-releasing factor; neg. = negative.
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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.
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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.
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Left photograph shows vitiligo in a patient with autoimmune adrenalitis. Right photograph shows an area of hyperpigmentation surrounding the vitiligo.
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Left photomicrograph shows autoimmune adrenalitis. Right photomicrograph shows tuberculous adrenalitis. Note the caseous granuloma.
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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.
