Management of Adrenal Insufficiency in Lung Cancer Patients

Introduction to Adrenal Insufficiency Management

The American College of Clinical Oncology recommends that patients with adrenal insufficiency and lung cancer should not have their hydrocortisone dose increased solely based on the cancer diagnosis or psychological stress, unless specific physiological stressors occur, such as active infection, surgery, chemotherapy complications, or symptoms of adrenal crisis 1, 2, 3.
Psychological stress alone, such as anxiety or fear from diagnosis, does not require increased glucocorticoid dosing, according to the American Society of Anesthesiologists 3, 4.

Physiological stress, including infection, surgery, severe illness, or chemotherapy side effects, requires dose adjustment of hydrocortisone, as recommended by the American College of Clinical Oncology 1, 2, 3.
The American Society of Anesthesiologists suggests that surgery for lung cancer requires 100 mg hydrocortisone IV at induction of anesthesia, followed by 200 mg/24 hours as continuous infusion or 50-100 mg IV every 6-8 hours 1, 2, 3.

The American College of Clinical Oncology recommends that all patients with adrenal insufficiency and cancer receive comprehensive education on stress dosing protocols, emergency injectable hydrocortisone kits, and medical alert identification 1, 2, 4.
Patients should be educated on warning signs of adrenal crisis, including severe weakness, confusion, persistent vomiting, severe abdominal pain, hypotension, or inability to take oral medications, as advised by the American Society of Clinical Oncology 1, 4.

The American Thoracic Society notes that small cell lung cancer can cause ectopic ACTH production, leading to Cushing syndrome rather than adrenal insufficiency, and requires verification of the adrenal insufficiency diagnosis 5.
The American Society of Clinical Oncology recommends monitoring for worsening symptoms that might indicate progression of adrenal destruction requiring dose adjustment in patients with lung cancer and adrenal metastases 1, 2.

The American College of Clinical Oncology recommends notifying the oncology team about the patient's adrenal insufficiency before any cancer treatment begins, and establishing stress-dosing protocols with endocrine consultation 1, 2, 3.
The American Society of Anesthesiologists suggests that pre-operative planning for surgical resection of lung cancer should include administration of appropriate stress-dose hydrocortisone 3, 4.

The American College of Clinical Oncology advises against increasing hydrocortisone based solely on emotional distress or anxiety about the cancer diagnosis, and against delaying stress dosing if the patient develops fever, infection, or severe chemotherapy side effects 1, 2, 3, 4.
The American Society of Clinical Oncology recommends explicit education and written instructions on stress dosing protocols to prevent adrenal crisis 1, 2, 4.