Thread by @mendesthiagob

❗️Chronic Adrenal insufficiency treatment has several options

Follow the 🧵 for more information about these options.

#Endotips #MedTwitter

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First and foremost:

- Primary adrenal insufficiency (adrenal lesion): CORTICOSTEROID and MINERALOCORTICOID are needed;

- Secondary adrenal insufficiency (ACTH impairment): CORTICOSTEROID only is needed.

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Let's start with the MINERALOCORTICOID:
- Natural mineralocorticoid: aldosterone
- Replacement: fludrocortisone (usually 100 mcg/day)

- Goal: avoid both hypotension and hyperkalemia. Plasma renin activity (PRA) at the upper level of normal.
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CORTICOSTEROID:
- Natural corticosteroid: cortisol

- Replacement: hydrocortisone OR cortisone acetate OR prednisone OR prednisolone OR dexamethasone.
- Goal: mimic the endogenous hormone secretion to prevent AI symptoms (nausea, abdominal pain, fatigue...) and AI crisis.

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❗️There is no head-to-head trial comparing different corticosteroid replacements.

Let's split them into 2 categories:
- Short-acting (few hours): hydrocortisone, cortisone acetate.

- Long-acting (up to 24h or more): prednisone, prednisolone, dexamethasone.

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Most experts recommend using a short-acting corticosteroid as it better mimics the physiologic secretion of cortisol (⬆️ in the morning).

Most experts recommend 2 or 3 doses of short-acting corticosteroids over the day - morning/lunch or morning/lunch/evening.

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Long-acting corticosteroids may be preferred for those who don't like multiple dose schedules.

The theoretical problem with long-acting corticosteroids is overtreatment (Cushing's syndrome).

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What about the dose?

Start with 5 mg of prednisone/day equivalent.

For a table of equivalent, there are several sources, such as the table in the link.

europepmc.org/articles/PMC55…

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Monitoring: mainly symptoms/signs assessing for both AI and Cushing's syndrome.
ACTH is less useful but indicates too much corticosteroid if suppressed.

✅ Do not forget to duplicate the corticosteroid dose (2 pills) in case of stress (any acute illness at home).

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✅ Do not forget to give stress corticosteroid dose in case of trauma, surgery, or hospitalization - there are several different regimens, consult your hospital guideline.

That's it, folks! Feel free to add more!

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