The management of adrenal insufficiency in a hospital setting involves several key steps, including corticosteroid replacement, monitoring, patient education, and management of adrenal crisis.
Corticosteroid replacement
- Primary adrenal insufficiency: Corticosteroid therapy is recommended for all patients with confirmed primary adrenal insufficiency (PAI) . Hydrocortisone (15–25 mg/day PO, divided in two or three doses daily) or cortisone acetate (20–35 mg PO, divided in two or three doses daily) is suggested as initial therapy . Prednisolone (3–5 mg/day PO, divided in one or two doses daily) can be considered as an alternative, especially in patients with reduced compliance . Dexamethasone is the least preferred alternative and should only be given if no other corticosteroid is available
- Corticosteroid-induced adrenal insufficiency: Oral corticosteroids are recommended in case of minor stress and when there are no signs of hemodynamic instability or prolonged vomiting or diarrhea . Parenteral corticosteroids are recommended in case of moderate-to-major stress, procedures under general or regional anesthesia, procedures requiring prolonged avoidance or inability of oral intake, or when there are signs of hemodynamic instability or prolonged vomiting or diarrhea
Monitoring
- Corticosteroid replacement: Monitoring of corticosteroid replacement is recommended using clinical assessment including body weight, postural blood pressure, energy levels, and signs of frank corticosteroid excess
Patient education
- Stress dose corticosteroids: Patients should be educated regarding appropriate adjustment of corticosteroid dosing during stressful events and regarding adrenal crisis prevention strategies including parenteral self- or lay-administration of emergency corticosteroids
Management of adrenal crisis
- Primary adrenal insufficiency: Immediate therapy with stress-dose intravenous hydrocortisone is recommended in patients with symptoms of severe adrenal insufficiency or adrenal crisis, prior to results of diagnostic tests
- Corticosteroid-induced adrenal insufficiency: Adrenal crisis should be suspected in patients with current or recent corticosteroid use who have not undergone biochemical testing to rule out corticosteroid-induced adrenal insufficiency and present with hemodynamic instability, vomiting, or diarrhea. These patients should be treated with parenteral corticosteroids and fluid resuscitation
In conclusion, effective management of adrenal insufficiency in the hospital involves prompt recognition and treatment with appropriate corticosteroid replacement, careful monitoring of therapy, educating patients on stress dosing and emergency measures, and being prepared to manage adrenal crisis promptly to prevent serious complications.