What is the role of glucocorticoids in the treatment of acute pediatric adrenal insufficiency (Addison disease)?

Updated: Dec 07, 2018
  • Author: Kimberly Tafuri, DO; Chief Editor: Sasigarn A Bowden, MD  more...
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Answer

After intravenous fluids are provided, administer stress doses of glucocorticoid. The recommended stress dosage of hydrocortisone is an initial dose of 50-100 mg/m2 given intravenously, followed by 50-100 mg/m2/d divided in 4 intravenous doses. Hydrocortisone may be given intramuscularly if intravenous access is unavailable. However, intramuscular administration works slowly. Comparable stress doses of methylprednisolone are 10-15 mg/m2 and dexamethasone 1-1.5 mg/m2.

Dexamethasone is preferable for patients with suspected but unproved adrenal insufficiency (Addison disease), because the physician can simultaneously treat the patient while performing a diagnostic cosyntropin stimulation test. Methylprednisolone and dexamethasone have negligible mineralocorticoid effects. Large doses of hydrocortisone (ie, even double or triple the stress doses previously mentioned) are preferred if the patient is hypovolemic, hyponatremic, or hyperkalemic, due to the mineralocorticoid effects of hydrocortisone (lacking in prednisone or dexamethasone).

A study by Quinkler et al found that patients with adrenal insufficiency (Addison disease) who received prednisolone have significantly higher mean low-density lipoprotein cholesterol levels than do those being treated with hydrocortisone (3.9 vs 3.2 mmol/L, respectively). In addition, research suggests that prednisolone is associated with decreased bone mineral density in adrenal insufficiency. [55, 56]

No parenteral form of a mineralocorticoid is currently available in the United States. However, if the patient has good gastrointestinal function, fludrocortisone 0.1-0.2 mg may be orally administered.

Iatrogenic adrenal insufficiency due to glucocorticoid therapy can be prevented by giving the patient dosages below his or her physiologic requirements. Treatment with alternate-day oral prednisone, or with topical or inhaled glucocorticoids, can reduce the risk of iatrogenic adrenal insufficiency.


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