From the Guidelines
Low cortisol, also known as adrenal insufficiency, should be treated with cortisol replacement therapy, most commonly with hydrocortisone (15-25 mg daily divided into 2-3 doses), with the largest dose taken in the morning to mimic natural cortisol rhythm, as recommended by the most recent guidelines 1.
Treatment Overview
The treatment of adrenal insufficiency involves replacing the deficient hormones, typically with hydrocortisone and fludrocortisone if aldosterone is also deficient.
- Hydrocortisone is usually given in a dose of 15-25 mg daily, divided into 2-3 doses, with the largest dose taken in the morning.
- Fludrocortisone is typically given in a dose of 0.05-0.2 mg daily.
Key Considerations
- Patients with adrenal insufficiency should wear a medical alert bracelet and carry an emergency injection kit containing hydrocortisone (100 mg) for crisis situations.
- During illness, injury, or significant stress, patients need to double or triple their usual dose ("stress dosing") to prevent adrenal crisis, as advised in the guidelines 1.
- The condition can be primary (from adrenal gland damage) or secondary (from pituitary gland problems affecting ACTH production), and requires lifelong management with regular medical follow-up to adjust medication doses as needed.
Education and Support
- All patients need education on stress dosing for sick days, use of emergency injectables, when to seek medical attention for impending adrenal crisis, and a medical alert bracelet or necklace for adrenal insufficiency to trigger stress dose corticosteroids by emergency medical personnel, as emphasized in the guidelines 1.
- Early endocrinology consultation is appropriate for patients with adrenal insufficiency, as recommended in the guidelines 1.
From the Research
Low Cortisol Levels
- Low cortisol levels can be an indication of adrenal insufficiency, a life-threatening condition that requires lifelong glucocorticoid substitution therapy 2.
- Adrenal insufficiency can be primary or secondary, and the number of individuals with this condition in Europe is estimated to be 20-50/100,000 2.
- The daily glucocorticoid replacement dose for adrenal insufficiency is recommended to be 15 to 25 mg with a midpoint of 20 mg of hydrocortisone, but some studies suggest that lower doses may be more effective and reduce the risk of long-term adverse outcomes 3.
Diagnosis and Treatment
- A single measurement of serum cortisol can be used to investigate suspected adrenal insufficiency, with morning and afternoon thresholds of <275 nmol/L and <250 nmol/L, respectively, identifying subnormal-stimulated cortisol with high sensitivity 4.
- Novel strategies to replicate the physiological cortisol rhythm using hydrocortisone infusion pumps and oral modified release hydrocortisone have been developed and shown to offer benefits to patients with adrenal insufficiency 5.
- Patients with adrenal insufficiency who are susceptible to adrenal crisis have been found to have differences in cortisol and cortisone excretion, as well as in pharmacodynamics, compared to those who do not experience an adrenal crisis 6.
Management and Prevention
- The management of adrenal insufficiency requires a comprehensive approach, including glucocorticoid replacement therapy, stress adaptation, and prevention of adrenal crises 2.
- The use of novel glucocorticoid formulations and treatment regimens, such as hydrocortisone infusion pumps and oral modified release hydrocortisone, may improve patient outcomes and reduce the risk of long-term adverse effects 5.
- Further research is needed to determine the optimal daily glucocorticoid replacement dose and to develop more effective treatment strategies for adrenal insufficiency 3, 5, 6.