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Primary Adrenal Insufficiency: Managing Mineralocorticoid Replacement Therapy.

Artikel i vetenskaplig tidskrift
Författare Daniela Esposito
Daniela Pasquali
Gudmundur Johannsson
Publicerad i The Journal of clinical endocrinology and metabolism
Volym 103
Nummer/häfte 2
ISSN 1945-7197
Publiceringsår 2018
Publicerad vid Institutionen för medicin, avdelningen för invärtesmedicin och klinisk nutrition
Språk en
Länkar dx.doi.org/10.1210/jc.2017-01928
www.ncbi.nlm.nih.gov/entrez/query.f...
Ämneskategorier Endokrinologi, Kardiovaskulär medicin

Sammanfattning

Mineralocorticoid (MC) replacement therapy in patients with primary adrenal insufficiency (PAI) was introduced more than 60 years ago. Still, there are limited data on how MC substitution should be optimized, since MC dosing regimens have only been systematically investigated in a few studies. We review the management of current standard MC replacement therapy in PAI and its plausible impact on outcome.Using PubMed, we conducted a systematic review of the literature from 1939 to 2017, with the following keywords: 'adrenal insufficiency', 'mineralocorticoid deficiency', 'aldosterone', 'cardiovascular disease', 'hypertension', and 'heart failure'.The current standard treatment consists of fludrocortisone (FC) given once daily in the morning, aiming at normotension, normokalemia, and plasma renin activity in the upper normal range. Available data suggest that patients with PAI may be under-replaced with FC as symptoms and signs indicating chronic MC under-replacement, such as salt craving and postural dizziness persist, in many treated PAI patients. Data acquired from large registry-based studies show that glucocorticoid doses for replacement in PAI are higher than those estimated from endogenous production. Glucocorticoid over-replacement may reduce the need of MC replacement but may also be a consequence of inadequate MC replacement.The commonly used MC replacement in PAI may not be adequate in some patients. Insufficient MC substitution may be responsible for poor cardiometabolic outcome and the failure to restore well-being adequately in patients with PAI. Well-designed studies oriented at optimizing MC replacement therapy are urgently needed.

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