From the Guidelines
The treatment for low cortisol (hypocortisolism) primarily involves hormone replacement therapy with glucocorticoids, with oral hydrocortisone being the preferred initial treatment, typically given at a total daily dose of 15-20 mg divided into 2-3 doses, as recommended by the most recent guidelines 1. The standard treatment regimen includes initiating replacement therapy with hydrocortisone (15-20 mg in divided doses) and titrating to a maximum of 30 mg daily total dose for residual symptoms of adrenal insufficiency, with the largest dose in the morning to mimic the body's natural cortisol rhythm.
- Key considerations in the management of hypocortisolism include:
- Distinguishing between primary and secondary adrenal insufficiency based on the relationship between ACTH and cortisol levels 1
- Using hydrocortisone to recreate the diurnal rhythm of cortisol, with 2/3 of the dose given in the morning and 1/3 in the early afternoon
- Considering mineralocorticoid replacement with fludrocortisone (starting dose 0.05-0.1 mg/d) for patients with severe adrenal insufficiency, adjusting based on volume status, sodium level, and renin response
- Educating patients on stress dosing, emergency injectables, and the importance of carrying a medical alert bracelet or necklace for adrenal insufficiency
- Regular monitoring through clinical assessment and occasional blood tests to optimize therapy and prevent life-threatening adrenal crisis. The most critical aspect of treatment is to ensure that patients receive adequate hormone replacement therapy to prevent adrenal crisis, with dose adjustments necessary during illness, surgery, or stress, typically doubling or tripling the usual dose, as outlined in the guidelines 1.
From the FDA Drug Label
To avoid drug-induced adrenal insufficiency, supportive dosage may be required in times of stress (such as trauma, surgery, or severe illness) both during treatment with fludrocortisone acetate and for a year afterwards Since mineralocorticoid secretion may be impaired, salt and/or a mineralocorticoid should be administered concurrently.
The treatment for low cortisol (hypocortisolism) involves supportive dosage of corticosteroids, such as hydrocortisone or fludrocortisone, to avoid drug-induced adrenal insufficiency.
- Key points:
- Supportive dosage may be required in times of stress.
- Salt and/or a mineralocorticoid should be administered concurrently if mineralocorticoid secretion is impaired.
- The lowest possible dose of corticosteroid should be used to control the condition under treatment.
- A gradual reduction in dosage should be made when possible 2, 3.
From the Research
Treatment for Low Cortisol (Hypocortisolism)
- The treatment for low cortisol, also known as hypocortisolism, typically involves hormone replacement therapy with hydrocortisone 4, 5.
- In cases of adrenal crisis, immediate parenteral hydrocortisone (100 mg bolus) and subsequent continuous infusion until the underlying precipitating cause is cured and/or when regular supplementation can be continued is recommended 5.
- Patients with known adrenal insufficiency should receive verbal and written instructions on how to deal with physical and severe psychic stress, and should be taught how to use an emergency injection of hydrocortisone 6.
- Chronic hormone replacement therapy with hydrocortisone and fludrocortisone may be initiated after stabilization of the patient 4.
Diagnosis of Adrenal Insufficiency
- The normal cortisol response 30 or 60 minutes after cosyntropin (ACTH[1-24]) is considered to be ≥18 μg/dL (500 nmol/L), but newer specific cortisol assays may have lower thresholds for a normal response 7.
- New cortisol cutoffs for adrenocorticotropic hormone (ACTH) stimulation testing with newer specific cortisol assays have been proposed, ranging from 14 to 15 μg/dL depending on the assay used 7.