Treatment of chronic adrenal insufficiency

Treatment of chronic adrenal insufficiency is aimed, on the one hand, to eliminate the process that caused adrenal damage and, on the other hand, to replace the lack of hormones.

If a tuberculosis process in the adrenal gland is suspected, it is necessary to prescribe anti-tuberculosis drugs under the supervision of a phthisiatrician. Patients with an autoimmune lesion of the adrenal glands are treated with levomizol and thymosin, aimed at normalizing the deficit of T suppressors. At present, it is not widely used.

The recommended diet for hypocorticism should contain an increased number of calories, proteins, vitamins, table salt to 3-10 g / day.

Substitution therapy with synthetic hormones that possess glucocorticoid, mineralocorticoid and anabolic effects is vital for patients with chronic adrenal insufficiency and can not be canceled under any circumstances. Compensation of adrenal insufficiency depends not only on the amount of the drug administered, but also on various conditions associated with the functional state of the body. Synthetic analogues of hormones behave in the body not quite as natural. For example, it is known that a specific protein transcortin binds about 92% of cortisol and only 70% of its synthetic analogues. It is believed that the absorption of hormones in the gastrointestinal tract is almost complete, but with various violations of the function of the stomach and intestines, these conditions may be violated. For oral administration, synthetic analogs of glucocorticoid action are used: hydrocortisone, cortisone acetate, prednisolone, prednisone, metipred. Hydrocortisone is the only glucocorticoid that possesses the qualities of a natural hormone. Currently, it is registered in Russia under the name Cortef, is used in tablets of 5, 10 and 20 mg.

Treatment with cortisone began in the 30s of this century and, despite the appearance of many of its new analogues, has not lost its significance to the present day. Cortisone in the liver basically turns into cortisol and becomes physiologically active. The highest concentration of the drug in the blood is determined 1-2 hours after the administration, and after 8-10 hours it is almost not determined. More effective than Cortisone, 9a-fluorocortisol - after 30 minutes after taking it, the blood level increases significantly, reaching a maximum after 6-8 hours. Prednisolone is contained in the blood 12-36 h, and hydrocortisone, administered intramuscularly, is 4- 6 hours To compensate for chronic adrenal insufficiency, a combination of prednisolone and cortisone should be used. The dose of drugs depends on the severity of the disease and the degree of compensation.

With a mild degree of chronic adrenal insufficiency, it is recommended to perform cortisone treatment at a dose of 12.5-25 mg / day in one or two doses. If the dose is taken once, then in the morning after breakfast. Combination of treatment can be with the appointment of ascorbic acid 1-1.5 g / day during meals.

At an average severity of the disease, prednisolone is usually prescribed - 5-7.5 mg after breakfast, and in the afternoon - 25 mg cortisone acetate.

Patients with a severe course of chronic adrenal insufficiency, which is observed both with Addison's disease and after removal of the adrenal glands due to the Itenko-Cushing's disease and other diseases, sometimes it is necessary to prescribe glucocorticoids in three doses and necessarily combine them with Doxa preparations. For example, prednisolone is recommended in a dose of 5-7.5 mg in combination with 1 tablet of DOXA under the tongue after breakfast, cortisone - in doses of 25 mg after lunch and 12.5 mg after dinner. With low blood pressure and poor appetite, you can add 1 Doxa tablet to your appointments in the afternoon. It is believed that the given doses, although considered schematic, should compensate for adrenal insufficiency, if there are no reasons that require their increase. Objective exponential actions of glucocorticoids include weight gain, cessation of nausea and gastrointestinal disorders, reduction of pigmentation of skin and mucous membranes, improvement or restoration of tolerance to water.

Radioimmunological determination of ACTH, cortisol, aldosterone and renin activity in plasma is considered to be of little informative for a systematic evaluation of the effectiveness of Addison's disease replacement therapy.

With an average and severe form of chronic adrenal insufficiency, in most patients with addison disease and in all after removal of the adrenal glands, drugs with a mineralocorticoid effect should be added to the drugs of glucocorticoid action. The daily requirement for deoxycorticosterone acetate is 5-10 mg. Doxas are available in various forms for oral and intramuscular administration. Doxas tablets of 5 mg are used sublingually. 0.5% Doxa oil solution is applied by 1 ml intramuscularly. Prolonged drug trimethyl acetate deoxycorticosterone is given intramuscularly by 1 ml once every 10-12 days. The most active synthetic mineralocorticoid is fludrocortisone acetate. In Poland, it is produced under the name cortinef, and in the UK - florinef. The drug in a dose of 0.05-0.1 mg is used as a support. During the period of decompensation of the disease, its dose increases by 2-3 times. The objective indicators of the action of mineralocorticoids include increased arterial pressure, normalization of the sodium / potassium ratio, an increase in the level of sodium in the plasma, and a reduction in the potassium content.

There are several important conditions for replacement therapy for chronic adrenal insufficiency. The dose and time of administration of drugs should be prescribed taking into account the production and daily rhythm of corticosteroid release in a healthy person: 2/3 of the daily dose is administered from 7-9 am in the morning and% in the afternoon; drugs are always prescribed after meals. The use of corticosteroids for years can lead to disorders of the gastrointestinal tract; at stresses, infections, operations, traumas, the dose of gluco- and mineralocorticoids increases 2-3 times in comparison with the maintenance dose.

In case of occurrence of gastrointestinal disorders in patients with chronic adrenal insufficiency, oral preparations are replaced by parenteral administration of hydrocortisone 50-100 mg 4-6 times a day and DOXA - 5-15 mg before the state is compensated.

It is necessary to dwell on the peculiarities of managing patients after removal of the adrenal glands in connection with the Itenko-Cushing disease. After removal of one adrenal hormone therapy is not appointed, since the remaining adrenal gland compensates the body's need for hormones. After removal of the second adrenal gland (stage II), immediately on day 1, patients receive 75-100 mg of water-soluble hydrocortisone intravenously. At the same time, intramuscular injections of hydrocortisone are prescribed according to the following scheme: 1-2 days - 50-75 mg every 3 hours, day 3 - 50 mg every 4-5 hours, 4-5th - 50 mg every 5 hours, 6-7th day - 50 mg in 8 hours, 9-10-e - 50 mg 2 times a day. As a rule, from the 8th to the 9th day, patients are gradually transferred to oral corticosteroids, and a fixed dose of drugs is established during the observation. Prescribed prednisolone 5-15 mg / day or 5 mg of the drug in the morning with 1 tablet of Dox, or 1 tablet of cortinef and 25 mg of cortisone in the afternoon. In the case of preservation in patients after removal of the adrenals of hypertension, the dose of substitution therapy is prescribed the same as without hypertension, and Doxa preparations are used. Substitution therapy with hormones is combined with antihypertensive drugs, preference is given to drugs rauwolfia. It should be noted that the addisonian crisis in patients with adrenal insufficiency and hypertension can occur against a background of high blood pressure. Under these conditions, patients should be treated to eliminate Addison's crisis.

After small surgical interventions, patients with chronic adrenal insufficiency (opening of abscesses, biopsy, extraction of teeth) are injected intramuscularly 3 times with 50 mg of hydrocortisone on the 1st day, 50 mg twice daily, and 3 times with 3 mg of hydrocortisone. On the 4th day the patient is transferred to the usual dose of corticosteroids in tablets.

In patients with chronic adrenal insufficiency, surgical interventions are routinely scheduled intramuscularly on the eve of the operation, 50 mg hydrocortisone every 8 hours. Intramuscularly 75 mg hydrocortisone is administered intramuscularly on the day of surgery and 75-100 mg of water-soluble hydrocortisone in physiological saline or 5% glucose solution. In the 1-2 days after the operation, hydrocortisone is administered intramuscularly at 50-75 mg every 6 hours. On the 3-4th day - 50 mg every 8 hours, and on the 5th-6th day - 50 mg 2 times per day and perorally administered prednisolone 5-10 mg per day. On the 7th day, intramuscularly inject 50 mg of hydrocortisone and 5 mg 2-3 times per day of prednisolone. From the 8th day the patients are transferred to the usual oral replacement therapy with corticosteroids, respectively, a fixed dose, individual for each patient. In addition, during the first 3-4 days patients receive 5-10 mg of Doxa in the form of a single intramuscular injection. In the postoperative period, careful monitoring of the patient's condition is necessary. To do this, you should measure blood pressure every hour. In case of signs of adrenal insufficiency, it is urgent to start additional intravenous injection of water-soluble hydrocortisone at the rate of 75 mg for 1-1.5 hours. The amount of hormones administered should be large, and the duration of their application may vary depending on the patient's condition, severity of surgery, complications .

In the case of emergency surgery, 75-100 ml of hydrocortisone is administered intramuscularly immediately before the operation, later on according to the scheme given.

In the treatment of chronic adrenal insufficiency, symptoms of an overdose of both gluco- and mineralocorticoid drugs may occur. This is evidenced by a rapid increase in body weight, headaches, the appearance of muscle weakness, increased blood pressure, fluid retention, facial swelling, decreased potassium levels in the plasma, and an increase in sodium content. The dose of drugs administered should be reduced by at least 2 times. Elimination of symptoms of an overdose occurs slowly within 4-8 weeks. The maintenance dose should be reduced after the elimination of drug hypercorticism.

This phenomenon is often found in the appointment of glucocorticosteroids in an increased dose. Adherence to therapy with Doxa drugs can reduce the dose of glucocorticoid hormones and get compensation for adrenal insufficiency.

In conclusion, it is necessary to consider the peculiarities of substitution therapy in patients with chronic adrenal insufficiency in pregnancy, when combined with diabetes mellitus, diseases of the thyroid and parathyroid glands. The dose of substitution therapy during pregnancy remains the same, a small increase is required after the 3rd month. All patients before hospital are hospitalized. When giving birth, hormones are administered under the same conditions as in planned operations. When the combination of chronic adrenal insufficiency and diabetes mellitus is recommended, first compensate for adrenal insufficiency, and then increase the dose of insulin. In patients with a combination of chronic adrenal insufficiency and hypothyroidism or thyrotoxicosis, full compensation of adrenal insufficiency is first achieved, and then either a thyroxine or antithyroid therapy is added. The same conditions are met if hypoparathyroidism is present. Patients with chronic adrenal insufficiency should be on dispensary supervision and be provided with corticosteroid preparations for free.

Forecast

The use of synthetic hormones for replacement therapy for chronic adrenal insufficiency has opened up wide opportunities for the treatment of this disease and prolonging the life of patients.

The prognosis of the disease depends on the presence of active tuberculosis in other organs (miliary, renal, pulmonary) and the sensitivity of the patient to antibacterial therapy.

With an autoimmune lesion of the adrenal glands, the future of the patient depends on the combined damage of other endocrine glands, for example, in the development of diabetes mellitus.

The condition and life of the patient are due to the correct selection of the dose of drugs, their combination, accuracy of reception and self-control.

A major danger is associated diseases, complicating the course of chronic adrenal insufficiency. Proper tactics for intercurrent diseases and surgical interventions, as well as for the management of labor, can prevent the development of the crisis and its consequences.

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Disability 

Transfer of the patient to easy work, deprived of heavy physical exertion, night shifts, and normalized working day help to maintain work capacity.

Prevention of chronic adrenal insufficiency is reduced to measures to reduce the incidence of tuberculosis and autoimmune diseases. These issues are related to social and environmental problems.

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