Adrenal Physiology Adrenal Physiology and Hypofunctioning and Hypofunctioning
StatesStates
Heidi Chamberlain Shea, MDHeidi Chamberlain Shea, MD
Endocrine Associates of Endocrine Associates of DallasDallas
Goals of DiscussionGoals of Discussion
Review Adrenal PhysiologyReview Adrenal Physiology Identify the clinical features of Identify the clinical features of
Adrenal InsufficiencyAdrenal Insufficiency Etiologies of Adrenal InsufficiencyEtiologies of Adrenal Insufficiency Understand testing of adrenal Understand testing of adrenal
functionfunction Treatment of Adrenal InsufficiencyTreatment of Adrenal Insufficiency
Adrenal DevelopmentAdrenal Development Derived Derived
– Neuroectodermal cells Neuroectodermal cells (medulla)(medulla)
– Mesenchymal cells Mesenchymal cells (cortex)(cortex)
Fetal adrenal is present Fetal adrenal is present by 2 months gestationby 2 months gestation– Mostly cortexMostly cortex– Glomerulosa and Glomerulosa and
fasiculata are present at fasiculata are present at birthbirth
– Reticularis develops Reticularis develops during first year of lifeduring first year of life
Adrenal AnatomyAdrenal Anatomy
Adult adrenalAdult adrenal– 2-3cm wide2-3cm wide– 1cm thick1cm thick– 4-6 grams 4-6 grams
LocatedLocated– Upper pole of Upper pole of
kidneyskidneys Vascular supplyVascular supply
– 12 small arteries 12 small arteries from aortafrom aorta
Adrenal PhysiologyAdrenal Physiology GlomerulosaGlomerulosa
– 15% of cortex15% of cortex– AldosteroneAldosterone
Renin-AngiotensinRenin-Angiotensin
FasciulataFasciulata– 75% of cortex75% of cortex– CortisolCortisol– DHEADHEA
ACTHACTH
ReticularisReticularis– Androgens and estrogensAndrogens and estrogens
ACTHACTH
MedullaMedulla– CatecholaminesCatecholamines
Congenital Adrenal Congenital Adrenal Hyperplasia Hyperplasia
Most adrenal Most adrenal biosynthetic defects biosynthetic defects result inresult in– Virilized femaleVirilized female– Normally virilized Normally virilized
malemale– DeficienciesDeficiencies
Mineralocorticoid Mineralocorticoid Glucocorticoid Glucocorticoid
– 21-OH deficiency21-OH deficiency– 11-OH deficiency11-OH deficiency
Congenital Adrenal HyperplasiaCongenital Adrenal Hyperplasia Deficiency of CYP 17Deficiency of CYP 17
– 1717αα- hydroxylase and - hydroxylase and 17-20 lyase deficiency17-20 lyase deficiency
– Rare causeRare cause– Diagnosed due to Diagnosed due to
delayed pubertal delayed pubertal developmentdevelopment
– 46xx46xx HypertensiveHypertensive +/- Hypokalemic+/- Hypokalemic Primary amenorrheaPrimary amenorrhea Absent secondary sex Absent secondary sex
characteristicscharacteristics
Congenital Adrenal HyperplasiaCongenital Adrenal Hyperplasia Deficiency of CYP 17Deficiency of CYP 17
– 46XY46XY Complete male Complete male
pseudohermaphroditispseudohermaphroditismm
Female external Female external genitaliagenitalia
Blind-ended vaginaBlind-ended vagina No mullerian No mullerian
structuresstructures Testes intra-abdominalTestes intra-abdominal
– Leydig cell Leydig cell hyperplasiahyperplasia
HypertensiveHypertensive +/- Hypokalemic+/- Hypokalemic
Cortisol sufficientCortisol sufficient– Tolerates general Tolerates general
anesthesia and anesthesia and surgerysurgery
TreatmentTreatment– Steroids to Steroids to
suppress excesssuppress excess– Gonadal Gonadal
replacementreplacement
Congenital Adrenal HyperplasiaCongenital Adrenal Hyperplasia
3 3 ββ-Hydroxysteroid -Hydroxysteroid DehydrogenaseDehydrogenase– Presents early infancyPresents early infancy– Adrenal insufficiencyAdrenal insufficiency– Females can be Females can be
virilized due to DHEAvirilized due to DHEA– Males Males
Normal genital Normal genital developmentdevelopment
HypospadiasHypospadias PseudohermaphroditisPseudohermaphroditis
mm
Can present in Can present in pubertypuberty– HyperandrogenemiHyperandrogenemi
aa HirsuitismHirsuitism OligomenorrheaOligomenorrhea
TreatmentTreatment– Cortisol Cortisol
replacementreplacement
Congenital Adrenal HyperplasiaCongenital Adrenal Hyperplasia Congenital Lipoid Congenital Lipoid
Adrenal HyperplasiaAdrenal Hyperplasia StAR DeficiencyStAR Deficiency
– Transports cholesterol Transports cholesterol to inner mitochondrial to inner mitochondrial membranemembrane
Rarest formRarest form Autosomal recessiveAutosomal recessive All adrenal steroids All adrenal steroids
are deficientare deficient Present with adrenal Present with adrenal
insufficiencyinsufficiency Typically fatal infancyTypically fatal infancy MalesMales
– Female external Female external genitaliagenitalia
Renin and AldosteroneRenin and Aldosterone ReninRenin
– Enzyme released from the Enzyme released from the kidneys (macula densa)kidneys (macula densa)
– Activates Angiotensinogen Activates Angiotensinogen Angiotensin 1 Angiotensin 1 Angiotensin 2Angiotensin 2
– Increased secretionIncreased secretion Low blood pressureLow blood pressure Low sodiumLow sodium High potassiumHigh potassium Upright postureUpright posture
AldosteroneAldosterone– Sodium homeostasisSodium homeostasis– Regulates arterial Regulates arterial
pressurepressure– RegulatedRegulated
Angiotensin 2Angiotensin 2
– Increases Increases Renal sodium retentionRenal sodium retention Renal potassium Renal potassium
excretionexcretion
– Low AldosteroneLow Aldosterone Adrenal insufficiencyAdrenal insufficiency
– High reninHigh renin HyperkalemiaHyperkalemia
Renin and AldosteroneRenin and Aldosterone
Mineralocorticoid DeficiencyMineralocorticoid Deficiency Hyporeninemic Hyporeninemic
HypoaldosteronismHypoaldosteronism– Impaired renin Impaired renin
releaserelease– 50-70 years50-70 years– Chronic Chronic
assymptomatic assymptomatic hyperkalemiahyperkalemia
– Mild-moderate renal Mild-moderate renal insufficiencyinsufficiency
– Muscle weaknessMuscle weakness– Cardiac arrhythmiasCardiac arrhythmias
Mineralocorticoid DeficiencyMineralocorticoid Deficiency
50% of patients with 50% of patients with Diabetes Diabetes
Type IV RTAType IV RTA– Metabolic acidosisMetabolic acidosis– Decreased renal Decreased renal
ammoniagenesisammoniagenesis– Decreased H ion Decreased H ion
secretionsecretion– Decreased bicarbonate Decreased bicarbonate
resorbtionresorbtion
Other diseasesOther diseases– SLESLE– Multiple myelomaMultiple myeloma– Renal amyloidosisRenal amyloidosis– CirrhosisCirrhosis– Sickle CellSickle Cell– AIDSAIDS– POEMSPOEMS
Transient with drugsTransient with drugs– NSAIDNSAID– Cyclosporin ACyclosporin A– Mitomycin CMitomycin C– CosyntropinCosyntropin
Mineralocorticoid DeficiencyMineralocorticoid DeficiencyPrimary HypoaldosteronismPrimary Hypoaldosteronism
Aldosterone synthase Aldosterone synthase deficiency (CYP11B2)deficiency (CYP11B2)– Autosomal recessiveAutosomal recessive– Diagnosed in infancyDiagnosed in infancy
Recurrent dehydrationRecurrent dehydration Failure to thriveFailure to thrive Salt wastingSalt wasting
TreatmentTreatment– FlorinefFlorinef
AcquiredAcquired– Heparin Heparin
Suppresses Suppresses aldosteronealdosterone
Increase in reninIncrease in renin Healthy person, Healthy person,
asymptomaticasymptomatic Critically ill, can be Critically ill, can be
symptomaticsymptomatic
Mineralocorticoid DeficiencyMineralocorticoid DeficiencyPrimary HypoaldosteronismPrimary Hypoaldosteronism
PseudohypoaldosteronisPseudohypoaldosteronismm– Salt wasting syndromeSalt wasting syndrome– InfancyInfancy– Renal tubular insensitivity Renal tubular insensitivity
to mineralocorticoidsto mineralocorticoids– Autosomal DominantAutosomal Dominant
Resistance to aldosterone Resistance to aldosterone at the renal tubuleat the renal tubule
– Autosomal RecessiveAutosomal Recessive SevereSevere Also affects sweat and Also affects sweat and
salivary glandssalivary glands ColonColon
Features of Features of hypoaldosteronismhypoaldosteronism– HyopnatremiaHyopnatremia– HyperkalemiaHyperkalemia– Hyper-reninemiaHyper-reninemia– Increased aldosterone Increased aldosterone
levelslevels Many kindreds Many kindreds
– Homozygous mutation Homozygous mutation in amiloride-sensitive in amiloride-sensitive epithelial sodium epithelial sodium channelchannel
TreatmentTreatment– NaClNaCl– KK++ binding resins binding resins
(+) POSTERIORPITUITARYANTERIOR
PITUITARY
(-)
CRH
HYPOTHALAMUS
HYPOTHALAMIC-PITUITARY
PORTAL SYSTEM
ACTH
CORTISOLAdrenal Fasiculata
(-)
Adrenal PhysiologyAdrenal Physiology
ACTH and cortisolACTH and cortisol– Pulsatile secretionPulsatile secretion– Highest in AM at Highest in AM at
wakeningwakening– Lowest late afternoon Lowest late afternoon
and eveningand evening– Nadir is 1-2 hrs after the Nadir is 1-2 hrs after the
start of sleepstart of sleep– CircadianCircadian
Blind patientBlind patient Reverts to a 24.5-25hrReverts to a 24.5-25hr
– DHEA and DHEA and Androstenedione Androstenedione regulated by ACTHregulated by ACTH
Increase in response Increase in response to stressto stress– HypoglycemiaHypoglycemia– SurgerySurgery– IllnessIllness– HypotensionHypotension– SmokingSmoking– Cold exposureCold exposure
Blunted responseBlunted response– Chronic illnessChronic illness
Circulation of Cortisol and Circulation of Cortisol and Adrenal AndrogensAdrenal Androgens
Secreted unboundSecreted unbound In circulation bind In circulation bind
to plasma proteinsto plasma proteins Unbound is activeUnbound is active CortisolCortisol
– Free (10%)Free (10%)– Corticosteroid-Corticosteroid-
binding globulin binding globulin (CBG) (75%)(CBG) (75%)
– AlbuminAlbumin
AndrogensAndrogens– AlbuminAlbumin– TestosteroneTestosterone
Sex Hormone Sex Hormone binding (SHBG)binding (SHBG)
Cortisol EffectsCortisol Effects
Connective TissueConnective Tissue– Inhibit fibroblastsInhibit fibroblasts– Loss of collagenLoss of collagen– Thinning of skinThinning of skin
BoneBone– Inhibit bone Inhibit bone
formationformation– Stimulate bone Stimulate bone
resorptionresorption– Potentiate actions of Potentiate actions of
PTHPTH Increased resorptionIncreased resorption
Calcium Calcium metabolismmetabolism– Decrease intestinal Decrease intestinal
calcium absorptioncalcium absorption– Stimulates renal 1Stimulates renal 1αα--
hydroxylasehydroxylase Increases 1,25 OH Increases 1,25 OH
vitamin D synthesisvitamin D synthesis
– Increased calciuriaIncreased calciuria– Increased Increased
phosphaturiaphosphaturia
Cortisol EffectsCortisol Effects
GrowthGrowth– Accelerate development Accelerate development
of fetal tissuesof fetal tissues Lung maturityLung maturity
– Inhibit linear growthInhibit linear growth Decreased growth Decreased growth
hormonehormone ErythrocytesErythrocytes
– Minimal effectMinimal effect LeukocytesLeukocytes
– Increase PMN by Increase PMN by increasing release from increasing release from bone marrowbone marrow
– Decreases lymphocytes, Decreases lymphocytes, monocytes and monocytes and eosinophilseosinophils
ImmunologicImmunologic– Inhibit Inhibit
prostaglandin prostaglandin synthesissynthesis Phospholipase APhospholipase A22
– Decreases IL-1Decreases IL-1 IL-1 stimulates CRH IL-1 stimulates CRH
and ACTHand ACTH
– Impairs AB Impairs AB production and production and clearanceclearance
Cortisol EffectsCortisol Effects
CardiovascularCardiovascular– Increase COIncrease CO– Increase peripheral Increase peripheral
vascular tonevascular tone– HypertensionHypertension
Renal functionRenal function– Mineralocorticoid Mineralocorticoid
receptorsreceptors Na retentionNa retention Hypokalemia Hypokalemia HTNHTN
– Glucocorticoid receptorsGlucocorticoid receptors Increased GFRIncreased GFR
Nervous systemNervous system– Enters the brainEnters the brain– EuphoriaEuphoria– Irritability, depression Irritability, depression
and emotional labilityand emotional lability– Hyperkinetic or manic Hyperkinetic or manic
behaviorbehavior– Overt psychosisOvert psychosis– Increased appetiteIncreased appetite– Impaired memory or Impaired memory or
concentrationconcentration– Decreased libidoDecreased libido– InsomniaInsomnia
Decreased REM and Decreased REM and increased Stage II increased Stage II sleepsleep
Cortisol EffectsCortisol EffectsMetabolismMetabolism
GlycogenGlycogen– Activates glycogen Activates glycogen
production\production\– Deactivates Deactivates
glycogen glycogen breakdownbreakdown
GlucoseGlucose– Increase hepatic Increase hepatic
glucose productionglucose production– Inhibits peripheral Inhibits peripheral
tissue utilization of tissue utilization of glucoseglucose
LipidsLipids– Activate lipolysis in Activate lipolysis in
adipose tissueadipose tissue– Redistributes body Redistributes body
fat fat Sparing of the Sparing of the
extremitiesextremities
Adrenal InsufficiencyAdrenal Insufficiency
IncidenceIncidence– 6 cases per 1 million 6 cases per 1 million
adults/yearadults/year PrevalencePrevalence
– 40-110 cases per 1 40-110 cases per 1 million adultsmillion adults
More common in More common in femalesfemales– 2.6:12.6:1
Diagnosed in the 3-5Diagnosed in the 3-5thth decadesdecades
Adrenal InsufficiencyAdrenal InsufficiencyPresentationPresentation
Signs and Signs and symptomssymptoms– Rate and degree of Rate and degree of
loss of adrenal loss of adrenal functionfunction
– Degree of Degree of physiologic stressphysiologic stress
– PrimaryPrimary Mineralocorticoid Mineralocorticoid
deficiencydeficiency
– Secondary/TertiarySecondary/Tertiary Mineralocorticoid Mineralocorticoid
sufficientsufficient
Adrenal InsufficiencyAdrenal InsufficiencyPresentationPresentation
DehydrationDehydration Hypotension/shockHypotension/shock
– SyncopeSyncope Abdominal painAbdominal pain
– Recurrent and unexplainedRecurrent and unexplained Mental status changesMental status changes Nausea and vomitingNausea and vomiting Weight lossWeight loss FatigueFatigue HyperpigmentationHyperpigmentation VitiligoVitiligo
Adrenal CrisisAdrenal CrisisPresentationPresentation
Unexplained Unexplained hypoglycemiahypoglycemia
HyponatremiaHyponatremia HyperkalemiaHyperkalemia HypercalcemiaHypercalcemia EosinophiliaEosinophilia Other autoimmune Other autoimmune
deficienciesdeficiencies– HypothyroidHypothyroid– HypogonadalHypogonadal
Adrenal CrisisAdrenal CrisisPopulations at RiskPopulations at Risk
Secondary adrenal Secondary adrenal insufficiencyinsufficiency– Exogenous steroid Exogenous steroid
useuse Joint injections Joint injections Herbals from MexicoHerbals from Mexico High dose inhaled High dose inhaled
steroidssteroids
Congenital Adrenal Congenital Adrenal HyperplasiaHyperplasia
Primary Adrenal InsufficiencyPrimary Adrenal InsufficiencyEtiologyEtiology
Autoimmune adrenalitisAutoimmune adrenalitis– 70% of cases70% of cases– Polyendocrinopathy-candidiasis-Polyendocrinopathy-candidiasis-
ectodermal dystrophy (APECED)- PGA Iectodermal dystrophy (APECED)- PGA I Autosomal recessive disorderAutosomal recessive disorder Mutation in zinc finger proteinMutation in zinc finger protein Adrenal failure, hypoparathyroidism, Adrenal failure, hypoparathyroidism,
mucocutaneous candidiasis, dental enamel mucocutaneous candidiasis, dental enamel hypoplasia, dystrophy of the nailshypoplasia, dystrophy of the nails
Primary Adrenal InsufficiencyPrimary Adrenal InsufficiencyEtiologyEtiology
Autoimmune adrenalitisAutoimmune adrenalitis– Polyglandular autoimmune IIPolyglandular autoimmune II
Primary adrenal insufficiency, Autoimmune Primary adrenal insufficiency, Autoimmune thyroid disease (hypo and hyper), Type I thyroid disease (hypo and hyper), Type I Diabetes, hypogonadismDiabetes, hypogonadism
InfectiousInfectious– TuberculosisTuberculosis
5% of cases5% of cases Rifampin will increase cortisol metabolism-Rifampin will increase cortisol metabolism-
higher dose neededhigher dose needed
– HistoplasmosisHistoplasmosis Ketoconazole inhibits steroid synthesisKetoconazole inhibits steroid synthesis
Primary Adrenal InsufficiencyPrimary Adrenal InsufficiencyEtiologyEtiology
Bilateral adrenal hemorrhageBilateral adrenal hemorrhage– Ill patients on anticoagulantsIll patients on anticoagulants– CoagulopathiesCoagulopathies– HeparinHeparin
Thrombosis and thrombocytopeniaThrombosis and thrombocytopenia
– Primary antiphospholipid antibody Primary antiphospholipid antibody syndromesyndrome
Primary Adrenal InsufficiencyPrimary Adrenal InsufficiencyEtiologyEtiology
Adrenoleukodystrophy and Adrenoleukodystrophy and adrenomyeloneuropathyadrenomyeloneuropathy– X-linkedX-linked– Defect in Defect in ββ-oxidation-oxidation– Mutations in gene encoding a peroxisomal Mutations in gene encoding a peroxisomal
membrane protein of the ABC superfamily of membrane protein of the ABC superfamily of membrane transportersmembrane transporters
– Demyelination of central and peripheral Demyelination of central and peripheral nervous systemnervous system
– High levels of High levels of very long chain fatty acidsvery long chain fatty acids (VLCFA)(VLCFA)
Primary Adrenal InsufficiencyPrimary Adrenal InsufficiencyEtiologyEtiology
Familial glucocorticoid Familial glucocorticoid DeficiencyDeficiency– Autosomal recessiveAutosomal recessive– ACTH resistanceACTH resistance
High plasma ACTH High plasma ACTH concentrationsconcentrations
– Cortisol and androgen Cortisol and androgen deficiencydeficiency
– Aldosterone is normalAldosterone is normal– Presents in childhoodPresents in childhood
HyperpigmentationHyperpigmentation Muscle weaknessMuscle weakness Hypoglycemia and seizuresHypoglycemia and seizures Low epinephrineLow epinephrine
Primary Adrenal InsufficiencyPrimary Adrenal InsufficiencyEtiologyEtiology
HIV/AIDSHIV/AIDS– Adrenal necrosisAdrenal necrosis
Infiltrative etiologiesInfiltrative etiologies– CMV or TBCMV or TB
Bilateral metastatic infiltrationBilateral metastatic infiltration– Breast cancer Breast cancer – Bronchogenic carcinomaBronchogenic carcinoma– Renal malignanciesRenal malignancies
Primary Adrenal InsufficiencyPrimary Adrenal InsufficiencyEtiologyEtiology
Drugs that inhibit Drugs that inhibit cortisol synthesiscortisol synthesis– AminoglutethimideAminoglutethimide– EtomidateEtomidate– KetoconazoleKetoconazole– MetyraponeMetyrapone– SuraminSuramin– MitotaneMitotane
Accelerate cortisol Accelerate cortisol metabolismmetabolism– PhenytoinPhenytoin– BarbituatesBarbituates– RifampinRifampin
Secondary Adrenal Secondary Adrenal InsufficiencyInsufficiency
EtiologyEtiology Glucocorticoid useGlucocorticoid use PituitaryPituitary
– TumorsTumors– HemorrhageHemorrhage
Pituitary necrosis Pituitary necrosis (Sheehan Syndrome)(Sheehan Syndrome)
– Metastatic Metastatic malignanciesmalignancies
– Lymphocytic Lymphocytic hypophysitishypophysitis
– SarcoidosisSarcoidosis– Histiocytosis XHistiocytosis X
Developmental Developmental abnormalitiesabnormalities– Pit-1Pit-1– Prop-1Prop-1– Septo-optic Septo-optic
dysplasiadysplasia
Adrenal InsufficiencyAdrenal InsufficiencyDiagnosisDiagnosis
Always test for thyroid Always test for thyroid sufficiencysufficiency
Insulin Hypoglycemia Insulin Hypoglycemia testtest– Tests anterior pituitary Tests anterior pituitary
functionfunction– Insulin 0.15U/kg/bodyInsulin 0.15U/kg/body– Cortisol and growth Cortisol and growth
hormone drawn at hormone drawn at baselinebaseline
– Repeat when glucose Repeat when glucose <35 mg/dl<35 mg/dl
ContraindicatedContraindicated– Elderly, CAD, seizuresElderly, CAD, seizures
Adrenal InsufficiencyAdrenal InsufficiencyDiagnosisDiagnosis
Overnight Metyrapone Overnight Metyrapone testingtesting– Tests for secondary or Tests for secondary or
tertiary abnormalitiestertiary abnormalities– Blocks 11Blocks 11ββ--
deoxycortisol to cortisoldeoxycortisol to cortisol– Can initiate adrenal Can initiate adrenal
crisiscrisis– Useful in determining Useful in determining
return of function from return of function from steroid suppressionsteroid suppression
Normal resultNormal result– Increased ACTHIncreased ACTH– Increased 11Increased 11ββ--
deoxycortisoldeoxycortisol Metyrapone is difficult Metyrapone is difficult
to obtainto obtain
Adrenal InsufficiencyAdrenal InsufficiencyDiagnosisDiagnosis
Secondary causeSecondary cause– Normal renin-Normal renin-
angiotensin systemangiotensin system Normal kalemiaNormal kalemia No hyperpigmentation No hyperpigmentation
Baseline critical Baseline critical samplessamples– Hypoglycemia or Hypoglycemia or
hypotensionhypotension– Metabolic panel, CBC, Metabolic panel, CBC,
Cortisol, ACTHCortisol, ACTH– Thyroid function studiesThyroid function studies
High dose- High dose- – 250 mcg ACTH250 mcg ACTH– Evaluates primary Evaluates primary
diseasedisease– Critically ill Critically ill – Inpatient settingInpatient setting
Low doseLow dose– 1 mcg ACTH1 mcg ACTH– Evaluates primary Evaluates primary
Secondary if long Secondary if long standingstanding
Outpatient settingOutpatient setting Evaluating for return of Evaluating for return of
adrenal functionadrenal function
SteroidsSteroidsPotencyPotency
SteroidSteroid Anti-Anti-InflammatorInflammator
y Actiony Action
HPA HPA SuppressioSuppressio
nn
Salt Salt RetentioRetentio
nn
CortisolCortisol 11 11 11
PrednisolonePrednisolone 33 44 0.740.74
MethylprednisoloMethylprednisolonene
6.26.2 44 0.50.5
DexamethasoneDexamethasone 2626 1717 00
FludrocortisoneFludrocortisone 1212 1212 125125
Adrenal CrisisAdrenal CrisisInpatient TreatmentInpatient Treatment
Fluid resuscitationFluid resuscitation– Saline and dextroseSaline and dextrose
Hydrocortisone Hydrocortisone (Solucortef)(Solucortef)– 100 mg IV bolus 100 mg IV bolus
then 100mg IV then 100mg IV Q6hrsQ6hrs
Once stableOnce stable Wean hydrocortisoneWean hydrocortisone
– 50 mg IV Q6-8hrs50 mg IV Q6-8hrs– Taper and transition Taper and transition
to oral therapyto oral therapy If primaryIf primary
– Once saline Once saline heplockedheplocked
– Start Florinef Start Florinef (fludrocortisone 0.1 (fludrocortisone 0.1 mg PO QD)mg PO QD)
Outpatient TreatmentOutpatient Treatment CortisolCortisol
– HydrocortisoneHydrocortisone 10mg AM and 5 mg PM10mg AM and 5 mg PM 6-8 mg/m6-8 mg/m22/day/day Stress dosingStress dosing
– Fever, illness, surgeryFever, illness, surgery– 20 mg/m20 mg/m22/day/day– Double or triple daily Double or triple daily
dosedose– 100 mg x1 then 25-50 100 mg x1 then 25-50
mg Q6-8hrsmg Q6-8hrs
All adrenal insufficient All adrenal insufficient patients need a patients need a medic alert braceletmedic alert bracelet
Outpatient TreatmentOutpatient Treatment
Alternative glucocorticoid Alternative glucocorticoid replacementreplacement– Dexamethasone 0.5 mg (0.25-0.75) per Dexamethasone 0.5 mg (0.25-0.75) per
dayday– Prednisone 5 mg (2.5-7.5) per dayPrednisone 5 mg (2.5-7.5) per day
Florinef dosingFlorinef dosing– Usual production 100mcg per dayUsual production 100mcg per day– 0.05-0.2 mg (50-200mcg) per day0.05-0.2 mg (50-200mcg) per day
Questions?Questions?