The management of patients with secondary adrenal insufficiency

The term secondary adrenal insufficiency (SAI) refers to the clinical syndrome of glucocorticoid deficiency due to anatomical or functional disorders of the upper level of the hypothalamus-pituitary-adrenal (HPA) axis. An increasing incidence of SAI is being observed, mainly because of the widespread therapeutic use of glucocorticoids which suppress the HPA axis. Diagnosis of SAI is achieved mainly by dynamic tests, but is difficult and often uncertain, due to the broad escalation observed in HPA axis dysfunction, which results in major diagnostic problems and therapeutic dilemmas. This is a review of the management of patients suspected of having SAI due to space occupying lesions of the hypothalamus-pituitary region. Special attention is given to the diagnostic difficulties before, but mainly after, surgical intervention, and the need for constructive cooperation between neurosurgeons and endocrinologists is emphasized. For this purpose a diagnostic approach is proposed based on a specific protocol aimed at the lege-artis management of these patients before, during and particularly after surgery. The review also deals with the prevention of possible SAI manifestations caused by glucocorticoid withdrawal, with a description of two specific withdrawal protocols, and refers to the glucocorticoid withdrawal syndrome, which is often confused with SAI. It focuses finally on the appropriate management of patients with SAI in the event of acute illness or surgery or during pregnancy.