Adrenal Insufficiency

Non-acute treatment of Adrenal Insufficiency.

The normal physiology: On average we make ~10mg/m2 per day of cortisol. The peak or cortisol surge occurs b/w 6am and 8am. The nadir, which occurs at night, is usually ~5mcg/dL and the peak of the surge is ~25mcg/dL. Stress from a surgery in an adrenally competent patient might raise their serum cortisol as high as 50-60mcg/dL.

Usual treatment regimens include ~15-25mg/day of hydrocortisone

There’s no difference in quality of life or outcomes between twice daily and three times daily dosing.

Marilyn and Ellen pointed out that we also make lifestyle adjustments for these patients including med-alert wrist bracelets and adjustments based on their lifestyle (for example, for athletic activity).

Steroids in acute illness of adrenal insufficiency: Patients with adrenal insufficiency can't generate increase steroids in the face of stressors...their dependent upon their medication dose. Without savvy titration of their meds, they can experience varying degres of adrenal crisis (primary adrenal insufficiency worse than secondary or tertiary but it's possible in any of these). We discussed today that the commonly cited evidence for use of steroids in sesptic shock in the ICU (the Corticus and French Trials) likely doesn’t inform our decision-making much as these patients weren’t adrenally insufficient prior to their illness and our patient’s aren’t as sick as the patients in these trials. Adrenally insufficient patients require adjustments in their daily steroid dose based on the acuity of their illness (or the kind of surgery they are undergoing). Marilyn reminded us of a good rule of thumb for mild illness like URI’s which is the “3x3 rule”. Increase the steroids three fold for three days. Other groups have recommended an adjustment algorithm like the following:

Condition	Hydrocortisone
Physiologic daily dosing	15-25 mg PO in three divided doses at 8:00 AM (7.5-12.5 mg), 12:00 noon (5.0-7.5 mg), and 6:00 PM (2.5-5.0 mg)
Minor stress (symptoms of a cold or mild influenza)	30-50 mg/d PO in three divided doses
Moderate stress (UTI, minor/moderate surgical procedure [such as cataract surgery])	45-75 mg/d PO or IV in three or four divided doses; can use prednisone or dexamethasone instead
Severe stress (major surgical procedure, such as cardiac surgery, hip replacement), sepsis without shock	100-150 mg/d IV in four divided doses
Septic shock	150-200 mg/d IV in four divided doses

(Andy Copland MD, 6/6/11)