Replacement Therapy

Adrenal insufficiency may result from hypofunction of the adrenal cortex (primary adrenal insufficiency, Addison's disease) or from a malfunctioning of the hypothalamic-pituitary system (secondary adrenal insufficiency). In treating primary adrenal insufficiency, one should administer sufficient cortisol to diminish hy-perpigmentation and abolish postural hypotension; these are the cardinal signs of Addison's disease.

Although patients may require varying amounts of replacement steroid, 20 to 30 mg/day of cortisol supplemented with the mineralocorticoid 9-a-fluorocortisol (0.1 mg/day) is generally adequate. A doubling of the cortisol dose may be required during minor stresses or infections. In patients who require high-dose supplementation, prednisone can be substituted for cortisol to avoid fluid retention.

In the treatment of secondary adrenocortical insufficiency, lower doses of cortisol are generally effective, and fluid and electrolyte disturbances do not have to be considered, since patients with deficient corticotrophin secretion generally do not have abnormal function of the zona glomerulosa. Since cortisol replacement therapy is required for life, adequate assessment of patients is critical to avoid the serious long-term consequences of excessive or insufficient treatment. In many cases, the doses of glucocorticoid used in replacement therapy are probably too high. Patients should ideally be administered three or more doses daily. To limit the risk of osteoporosis, replacement therapy should be carefully assessed on an individual basis and overtreatment avoided.

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