Mineralocorticoid replacement

Although controversial, consider giving DHEA 50 mg/day (in the morning) to female patients who do not experience an improvement in mood and well-being even with adequate glucocorticoid and mineralocorticoid replacement. 

Glucocorticoid replacement therapy is necessary for patients with adrenal insufficiency, and mineralocorticoid replacement therapy is required for those with Addison s disease. 

Counsel on dietary and pharmacologic therapy, including duration of treatment and potential adverse consequences of glucocorticoid and mineralocorticoid replacement. 

Give glucocorticoid and mineralocorticoid replacement to patients who undergo adrenalectomy (permanently in the case of bilateral adrenalectomy). 

Need for glucocorticoid and mineralocorticoid replacement after treatment, if appropriate. 

Mitotane—if well-tolerated, dose may be doubled on day 3 then, from day 5 onwards, may increase dose by 500 mg every 2-3 days until maximum tolerated dose (8-12 grams daily) has been reached glucocorticoid and mineralocorticoid replacement necessary to prevent adrenal insufficiency increased steroid doses may be needed at times of physiologic stress... 

The answer is e. (Katzung, p 672. Hardman, pp 1477—1978.) Fludrocortisone is a synthetic steroid compound that exhibits profound mineralo-corticoid activity and some glucocorticoid activity Electrolyte and water metabolisms are affected by the administration of this compound. Fludrocortisone promotes the reabsorption of Na and the urinary excretion of K and hydrogen ions in the collecting duct of the nephron. The drug is indicated for mineralocorticoid replacement therapy in primary" adrenal insufficiency... 

Treatment of secondary adrenal insufficiency is identical to primary disease treatment with the exception that mineralocorticoid replacement is usually not necessary. 

Keilholz U, Guthrie GP Jr. Adverse effect of phenytoin on mineralocorticoid replacement with fludrocortisone in adrenal insufficiency. Am J Med Sci 1986 291(4) 280-3. 

Drugs with mineralocorticoidlike activity (aldosterone agonists) are frequently administered as replacement therapy whenever the natural production of mineralo-corticoids is impaired. Mineralocorticoid replacement is usually required in patients with chronic adrenocortical insufficiency (Addison disease), following adrenalectomy, and in other forms of adrenal cortex hypofunction. These conditions usually require both mineralocorticoid and glucocorticoid replacement. 

Infants with salt-wasting CAH require mineralocorticoid replacement therapy, usually with fludrocortisone (9oc-fluorohydrocortisone). In addition, they require sodium chloride (1-2 g/day) since the sodium content of both breast milk and common infant formulas is only sufficient to meet the requirements of healthy infants (White and Speiser, 2000). Older children often acquire a taste for salty foods and do not require daily sodium chloride tablets. Plasma renin activity may be used to monitor mineralocorticoid and sodium replacement. 

Because most adrenal crises occur because of glucocorticoid dose reductions or lack of stress-related dose adjustments, patients receiving corticosteroid-replacement therapy should add 5 to 10 mg hydrocortisone (or equivalent) to their normal daily regimen shortly before strenuous activities such as exercise. During times of severe physical stress (e.g., febrile illnesses, after accidents), patients should be instructed to double their daily dose until recovery. Treatment of secondary adrenal insufficiency is identical to primary disease treatment with the exception that mineralocorticoid replacement is usually not necessary. 

Hydroxylase (nonvirilizing CAH) Hypertension usually present Low concentrations of cortisol and estrogens Mineralocorticoid replacement not necessary... 

Hydroxysteroid dehydrogenase (corticosterone methyloxidase deficiency) Hypotension Restricted to zona glomerulosa sole aldosterone defect hyponatremia, hyperkalemia, increased renin Mineralocorticoid replacement without glucocorticoid replacement... 

Fludrocortisone (e.g., Florinef) PO. Halogenated derivative with potent mineralocorticoid effects. Only oral mineralocorticoid replacement available. Inappropriate for use as an antiinflammatory agent. 

Keilholz U, Guthrie GP. Case report adverse effect of phen3 oin on mineralocorticoid replacement widi fludrocortisone in a enal insufficiency. AmJMedSci (1986) 291, 280-3. 

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