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Adrenal Insufficiency: Changing Concepts in Management

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Prof (Dr) Paul M Stewart UK    27 November 2019

  • Morbidity and increased mortality in patients with adrenal insufficiency is unacceptable. Management of adrenal crisis is currently inadequate.
  • Morbidity is related, in part, to excessive daily doses of glucocorticoids.
  • Glucocorticoid replacement in the treatment of adrenal insufficiency – Current practice: According to a survey of current practice in glucocorticoid replacement therapy in patients with adrenal insufficiency, glucocorticoid replacement therapy consisted primarily of hydrocortisone.
  • Patients with adrenal insufficiency are not sufficiently equipped with emergency kits. Recent studies show that subcutaneous administration of drug is effective and patient acceptance is high.
  • Subcutaneous administration of 100 mg hydrocortisone shows excellent pharmacokinetics for emergency use; it has a good safety profile and is preferred by patients over intramuscular injection (Hahner S, et al. Eur J Endocrinol. 2013;169(2):147-54).
  • Adrenal suppression after glucocorticoid treatment is dose- and duration-dependant. Suppression of the adrenal response is common after short-term, high-dose glucocorticoid treatment (Henzen C, et al. Lancet. 2000;355(9203):542-5).
  • Evidence suggests that circadian rhythm is important. There are deleterious consequences of ‘late pm’ excess. Elevated evening levels of cortisol are associated with glucose intolerance, abdominal obesity, coronary atherosclerosis, insomnia and reduced sleep quality.
  • Management of adrenal suppression is challenging and more studies are required.

Newer preparations mimicking physiology are highly desirable. Endocrinologists need to take ownership of iatrogenic adrenal insufficiency.

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