Treatment of Adrenal Insufficiency

The treatment of AI will include replacement of one or two missing hormones. The goal of treatment is to relieve the symptoms of  low cortisol and/or aldosterone.  It can be a balancing act to replace these at a level where you can live a “normal” life without developing signs of Cushings Syndrome (excessive weight gain from over replacement).

Treatment requires lifelong steroid replacement in PAI but may, under good medical care, be able to be stopped in SAI if it is from suppression (see info on weaning in Secondary). Finding the right dosing and schedule for your or your AI person is essential to reduce low symptoms while also reducing the chance of an Adrenal Crisis.  See notes on Emergency Injections at the bottom of this page.

Primary Adrenal Insufficiency (PAI)

Treatment of PAI requires a daily dose of a glucocorticoid (Hydrocortisone, Prednisone, Dexamethosone) and mineralocorticoid (Fludrocortisone) for life.

Androgen replacement (DHEA or Dehydroepiandrosterone) will occasionally be offered to women.  The goal of treatment in women is to stabilize hormone levels and relieve symptoms.  It has also been found to be useful for men.

The most severe symptoms of Adrenal Insufficiency should begin to reduce quickly after starting treatment, however it will not be until you have found the right balance that you will begin to feel like you can function again.

Secondary and Tertiary Adrenal Insufficiency

If you have Secondary and Tertiary AI you normally only require glucocorticoid (e.g., hydrocortisone) replacement.

Although with SAI you should not require mineralocorticoids (Fludro) or androgens (DHEA) replaced, there are exceptions depending on concomitant conditions.   Always ask your Dr to test to ensure you don’t need it.

Ask to be get checked for other hormone deficiencies and don’t just accept “you don’t need them” without evidence.

Replacement Medications

Glucocorticoids

Options available for replacing Cortisone are either Short Acting, or Long Acting.  Currently in New Zealand the two main options are Hydrocortisone, or Prednisone.  Your Dr should will work with you to determine the regimen that is most effective, convenient, and that has the least side effects.

First option in NZ is the short acting drug oral hydrocortisone.  this is similar to cortisol produced naturally in the body.   Although, depending on which books your Dr has read, you will be offered either 2 or 3 doses of Hydrocortisone a day, many find this is not a good option when trying to function.

the reason for the 2 – 3 is because Doctors believe that any more and the patient will not be compliant with taking more, and will therefore be at a higher risk of an Adrenal Crisis.

For proper cover, the minimum dose of Hydrocortisone taken should be 3 times a day with the largest dose taken in the early morning (normally on waking, and before getting out of bed) with a smaller dose being taken late-morning and again mid-afternoon.  This will mimic the very basic normal variation in blood cortisol levels.

Hydrocortisone is available in 5 and 20mg tablets in New Zealand so a variety of mixes of dose is available which makes working out the best schedule easier, which is an advantage over the longer acting glucocorticoid prednisone.

• A longer-acting glucocorticoid like prednisone is sometimes preferred because it can be taken once per day. Occasionally, a small additional dose is needed in the afternoon. However, it can be more difficult to adjust the dose of these longer-acting medications to avoid overtreatment.

• Monitoring during treatment – The development of weight gain or a puffy face is usually a sign of overtreatment, and the glucocorticoid dose is decreased as a result. Higher doses of glucocorticoids are of no benefit and may increase the risk of bone thinning (osteoporosis). A clinician will monitor closely for these complications.
• Dosing – The dose of any of glucocorticoids is tailored to the patient’s body weight and age; obese people may need a higher dose, while children and small adults may need a lower dose. Adjustments in dose are often necessary when starting treatment.

Mineralocorticoids

Aldosterone is replaced with an oral, synthetic mineralocorticoid called fludrocortisone, which is sold as Florinef in New Zealand.   Your dose will be adjusted to manage your blood pressure and electrolytes.

Getting the dose right means you should not have problems  with lightheadedness or dizziness when standing up.  If your dose is too high, you may notice swelling in the ankles.  If this is happening, talk to your Dr.  This can cause high blood pressure or low blood potassium levels.  If this is the case, your fludrocortisone dose may be decreased.

If you have high blood pressure but all other indications are that your fludrocortisone is at the correct dose then you should not have your dose reduced, but you should be treated for high BP as a separate issue.

DHEA

Androgen replacement is sometimes recommended for women with primary adrenal insufficiency.  Most studies on replacement of this are looking at women and state that there has been no real advantage in replacing it in men, but there is anecdotal evidence that for some men, it will make a difference.

One recommendation is to trial it for 3 months.

1.  You will notice an immediate difference, and want to stay on it.
2. You will not notice any real difference.
   1. If you don’t notice a difference in the 3 months, stop taking it.  You will either not notice, and therefore don’t need to start it again, or you will notice a difference and want to re start it.

A daily dose of dehydroepiandrosterone (DHEA) may improve libido and provide an improved overall sense of well-being. Before you start, have your DHEA levels checked by blood test.  And have your levels monitored as long as you are taking it.  The ideal is to be mid range for your age.  You are not aiming to be a body builder, just to function normally again.

DHEA is only available with a prescription, and made by a Compounding Pharmacy.  Take your prescription to your local Chemist and they should have a compounding pharmacy they use.  It is not subsidised in New Zealand so you will have to pay full price.  One Compounding Pharmacy we know of charges $60 for a 3 month supply of 25mg capsules.

Side Effects of DHEA:   There are potential side effects associated with taking DHEA that are related to elevated levels.  These include acne, facial hair, and occasionally a deepened voice.  Some of these will settle down once you are on a stable dose.  Have your levels tested to see if you are on to high a dose.

EMERGENCY INJECTION!

I have made this heading larger because it is that important.  There will be more covered in the Adrenal Crisis Page but do not EVER accept “You live close enough to a hospital so you don’t need an emergency injection” as an excuse for your Endo not giving it to you.  As a New Zealander you live in a country prone to flooding and earthquakes.  You might only live 10 minutes drive from a hospital.  But if the only road is cut of for ANY reason, that 10 minutes can take 10 hours.  You must ALWAYS have an up to date emergency injection kit on you.

Only 10 minutes from Hospital also makes the assumption you are not in the middle of the Desert Road in the middle of Winter, or stuck at Arthurs Pass, or even in Central Auckland in Peak hour traffic.

Unless you spend every minute of every day, at the doors of the hospital, you are ALWAYS more than 10 minutes from hospital.