7
Treatment
Treatment of Primary Adrenal Insufficiency in Adults
Î In patients with severe adrenal insufficiency symptoms or adrenal
crisis, ES recommends IMMEDIATE therapy with IV hydrocortisone at
an appropriate stress dose prior to the availability of the results of
diagnostic tests. (1|⊕⊕⊕
)
Glucocorticoid Replacement Regimen
Î ES recommends glucocorticoid therapy in all patients with confirmed
PAI. (1|⊕⊕⊕⊕)
Î ES suggests using hydrocortisone (15–25 mg) or cortisone acetate
(20–35 mg) in two or three divided oral doses per day. The highest
dose should be given in the morning at awakening, the next either in
the early afternoon (2 h after lunch—two-dose regimen) or at lunch
and afternoon (three dose regimen). Higher frequency regimens and
size-based dosing may be beneficial in individual cases. (2|⊕⊕
)
Î As an alternative to hydrocortisone, ES suggests using prednisolone
(3–5 mg/d), administered orally once or twice daily, especially in
patients with reduced compliance. (2|⊕
)
Î ES suggests against using dexamethasone for the treatment of PAI
because of risk of Cushingoid side effects due to difficulties in dose
titration. (2|⊕⊕
)
Î ES suggests monitoring glucocorticoid replacement using clinical
assessment including body weight, postural blood pressure, energy
levels, signs of frank glucocorticoid excess. (2|⊕⊕⊕
)
Î ES suggests against hormonal monitoring of glucocorticoid replacement
and to adjust treatment only based on clinical response. (2|⊕⊕⊕
)
Mineralocorticoid Replacement in PAI
Î ES recommends that all patients with confirmed aldosterone
deficiency receive mineralocorticoid replacement with fludrocortisone
(starting dose, 50–100 μg in adults) and not restrict their salt intake.
(1|⊕⊕⊕⊕)
Î ES recommends monitoring mineralocorticoid replacement primarily
based on clinical assessment (salt craving, postural hypotension, or
edema), and blood electrolyte measurements. (1|⊕⊕⊕
)
Î In patients who develop hypertension while receiving fludrocortisone,
ES suggests reducing the dose of fludrocortisone. (2|⊕
)
Î If blood pressure remains uncontrolled, ES suggests initiating
antihypertensive treatment and continuing fludrocortisone. (2|⊕
)
