From the Guidelines
The primary recommendation for adrenal support in individuals with deficient hormones is hormone replacement therapy, specifically with glucocorticoids like hydrocortisone or prednisone, with a typical regimen including hydrocortisone at 15-25 mg daily, divided into 2-3 doses, and mineralocorticoid replacement with fludrocortisone for complete adrenal insufficiency. For patients with adrenal insufficiency, the goal is to mimic the natural cortisol rhythm, with the largest dose taken in the morning 1.
- Hydrocortisone is the preferred glucocorticoid due to its ability to recreate the diurnal rhythm of cortisol, with 2/3 of the dose given in the morning and 1/3 in the early afternoon 1.
- The dose of hydrocortisone should be individualized based on clinical response and laboratory values, with a maximum of 30 mg daily for residual symptoms of adrenal insufficiency 1.
- Patients with complete adrenal insufficiency (Addison's disease) also require mineralocorticoid replacement with fludrocortisone, usually at 0.05-0.2 mg daily, with the dose adjusted based on volume status, sodium level, and renin response 1.
- Patients must carry emergency medication and wear medical identification, and should increase their dosage during illness, surgery, or significant stress, with regular monitoring by an endocrinologist to adjust dosing and prevent complications from either under or over-replacement 1.
- In the peri-operative period, patients with adrenal insufficiency require stress dose glucocorticoid cover, with recommended doses including hydrocortisone 100 mg intravenously at the start of surgery, followed by an infusion of 200 mg/24 h, and doubling of the regular oral replacement dose for 48 h or up to a week following major surgery 1.
From the FDA Drug Label
DOSAGE & ADMINISTRATION Dosage depends on the severity of the disease and the response of the patient. In Addison’s disease, the combination of fludrocortisone acetate tablets with a glucocorticoid such as hydrocortisone or cortisone provides substitution therapy approximating normal adrenal activity with minimal risks of unwanted effects.
The primary recommendation for adrenal support in individuals with deficient hormones is the combination of fludrocortisone acetate with a glucocorticoid such as hydrocortisone or cortisone, providing substitution therapy that approximates normal adrenal activity. The usual dose of fludrocortisone acetate is 0.1 mg daily. This combination is preferably administered in conjunction with cortisone (10 mg to 37.5 mg daily) or hydrocortisone (10 mg to 30 mg daily) in divided doses 2.
- Key points:
- Combination therapy with fludrocortisone acetate and a glucocorticoid
- Usual dose of fludrocortisone acetate: 0.1 mg daily
- Conjunction with cortisone or hydrocortisone in divided doses
- Dosage adjustment based on disease severity and patient response 2
From the Research
Adrenal Support Recommendations
The primary recommendation for adrenal support in individuals with deficient hormones is to regularly substitute with glucocorticoids, usually with hydrocortisone (15-25 mg/day) and with 9 alpha-fluor-hydrocortisone (0.05-0.2 mg/day) in addition in patients with primary adrenal disorder (Addison's disease) 3.
Key Considerations
- In stressful situations and in febrile disorders, the glucocorticoid dosage must be increased prophylactically to prevent an "adrenal crisis" 3, 4.
- Most women with adrenal insufficiency will profit from the additional substitution of dehydroepiandrosterone (DHEA) with regard to well-being and sexual function 3, 5.
- Patients with adrenal insufficiency are at risk of adrenal crisis, usually precipitated by major stress, such as severe infection or surgery, and early dose adjustments are required to cover the increased glucocorticoid demand in stress 5, 6.
Treatment Approaches
- Hydrocortisone and fludrocortisone are the preferred therapy for Addison's disease 6.
- Continuous intravenous hydrocortisone infusion should be favored over intermittent bolus administration in the prevention and treatment of adrenal crisis during major stress 4.
- The management and surveillance of therapy requires experience and several aspects need to be followed to prevent side effects which might occur due to overtreatment or undertreatment 6, 7.