Adrenal hormone replacement therapy in adults with adrenal insufficiency

This algorithm summarizes our suggested approach to adrenal hormone replacement in adults with chronic adrenal insufficiency. To minimize adverse effects, all doses should be individualized to provide the lowest dose that relieves symptoms. Dose adjustments may be required for drug interactions. When initiating or changing drug therapy, use of a drug interactions database, such as Lexicomp drug interactions, is advised. This algorithm is intended for use with additional UpToDate content. For additional details, including the evidence supporting this approach, refer to UpToDate topics on the treatment of chronic adrenal insufficiency in adults.

DHEA: dehydroepiandrosterone; DHEAS: dehydroepiandrosterone sulfate.

* Aldosterone and renin levels should be measured prior to initiating mineralocorticoid replacement therapy as rare patients with primary adrenal insufficiency can have mild mineralocorticoid deficiency that does not require treatment.

¶ In central (ie, secondary or tertiary) adrenal insufficiency, mineralocorticoid replacement is not needed at the time of diagnosis. In rare patients with longstanding disease, mineralocorticoid replacement may become necessary.

Δ Initiation of thyroid or growth hormone replacement before glucocorticoid replacement can precipitate adrenal crisis.

◊ Glucocorticoid replacement regimens are titrated on the basis of clinical signs and symptoms of inadequate (eg, fatigue, nausea, weight loss, weakness, hypotension) or excessive (eg, weight gain, edema, hypertension) glucocorticoid exposure. The adequacy of mineralocorticoid replacement is determined by both clinical and biochemical assessments and requires routine measurement of serum potassium, sodium, and creatinine levels and plasma renin activity. Monitoring and optimization of glucocorticoid and mineralocorticoid regimens are reviewed in detail in other UpToDate content.

§ The principal signs of excessive androgen replacement include hirsutism, sweating, odor, oily skin, and acne. DHEA has a long half-life and may be taken every second or third day if needed to minimize side effects. Some females have therapeutic benefit with DHEAS levels below the middle of the reference range, but higher levels should be avoided. The DHEA dose should not exceed 50 mg daily. DHEA is available in the United States and some other countries as a nonprescription dietary supplement, and these products are not well regulated for potency or purity.

¥ To mimic endogenous cortisol production, short-acting glucocorticoid regimens are given in decreasing, divided doses throughout the day, and the last dose is given no later than 4 to 6 hours before bedtime. For example, in a typical twice-daily regimen with hydrocortisone or cortisone acetate, approximately two-thirds of the total daily dose is taken in the morning and one-third in the afternoon. When prednisolone is taken in divided doses, approximately 70 to 80% of the total daily dose is taken in the morning and the remainder at bedtime.

Graphic 142464 Version 5.0

خرید پکیج

Adrenal hormone replacement therapy in adults with adrenal insufficiency