What is the treatment for cortisol deficiency?

From the Guidelines

The treatment for cortisol deficiency involves hormone replacement therapy with glucocorticoids, primarily hydrocortisone, given in divided doses of 15-20 mg total daily, with a larger portion in the morning and smaller doses in the afternoon, as recommended by the most recent guidelines 1. The primary goal of treatment is to mimic the body's natural cortisol rhythm and prevent life-threatening adrenal crisis.

• The medication regimen typically includes:
  • Hydrocortisone (oral) in divided doses, with a larger portion in the morning (e.g., 10-15 mg) and smaller doses in the afternoon (5-10 mg)
  • Alternative medications, such as prednisone (3-5 mg daily) or dexamethasone (0.25-0.75 mg daily), although dexamethasone is not recommended for primary adrenal insufficiency due to its lack of mineralocorticoid activity 1
• Patients with adrenal crisis require immediate treatment with intravenous hydrocortisone (100 mg bolus, followed by 200 mg over 24 hours) along with fluid resuscitation using normal saline, as outlined in the guidelines for managing acute adrenal insufficiency 1
• All patients with cortisol deficiency should carry an emergency injection kit containing hydrocortisone and wear a medical alert bracelet, and receive education on stress dosing, emergency injections, and when to seek medical attention for impending adrenal crisis 1
• Dose adjustments are necessary during times of illness, surgery, or significant stress, typically doubling or tripling the usual dose, and regular monitoring through clinical assessment and occasional blood tests helps optimize therapy 1

From the FDA Drug Label

ACTIONS Naturally occurring glucocorticoids (hydrocortisone and cortisone), which also have salt-retaining properties, are used as replacement therapy in adrenocortical deficiency states. INDICATIONS & USAGE Fludrocortisone acetate tablets, 0.1 mg are indicated as partial replacement therapy for primary and secondary adrenocortical insufficiency in Addison’s disease and for the treatment of salt-losing adrenogenital syndrome.

The treatment for cortisol deficiency includes replacement therapy with glucocorticoids such as hydrocortisone 2 or fludrocortisone 3.

• Hydrocortisone is used as replacement therapy in adrenocortical deficiency states.
• Fludrocortisone is used as partial replacement therapy for primary and secondary adrenocortical insufficiency in Addison’s disease.

From the Research

Treatment for Cortisol Deficiency

The treatment for cortisol deficiency, also known as adrenal insufficiency, typically involves replacement therapy with hydrocortisone, a synthetic form of cortisol. The goal of treatment is to replicate the natural circadian rhythm of cortisol release and provide individualized cortisol exposure.

Hydrocortisone Replacement Regimens

• Traditional regimens involve twice- or thrice-daily dosing with oral hydrocortisone, with the highest dose given in the morning 4, 5.
• Weight-related dosing regimens have been developed to reduce interpatient variability in cortisol levels and minimize overexposure to cortisol 6.
• Circadian hydrocortisone therapy, which imitates the physiological cortisol rhythm, has been investigated as a potential improvement over traditional regimens 5.
• Delayed and sustained release oral formulations of hydrocortisone are being developed to provide a more practical and effective solution for patients with adrenal insufficiency 5.

Monitoring and Dose Titration

• Monitoring treatment and dose titration is crucial to ensure that patients receive the optimal dose of hydrocortisone.
• Serum cortisol levels can be measured to assess the effectiveness of treatment and adjust the dose as needed 4, 6.
• Clinical symptoms, such as fatigue and depression, can also be used to monitor treatment and adjust the dose 4.

Special Considerations

• Patients with adrenal insufficiency require increased hydrocortisone cover during major stress to avoid a life-threatening adrenal crisis 7.
• Continuous intravenous hydrocortisone infusion may be necessary in certain situations, such as major trauma or sepsis, to maintain cortisol concentrations in the required range 7.
• Individualized treatment plans are necessary to ensure that patients receive the optimal dose of hydrocortisone and minimize the risk of adverse events 8.