What is the treatment plan for Addison's disease?

Treatment Plan for Addison's Disease

The standard treatment for Addison's disease consists of glucocorticoid replacement with hydrocortisone 15-25 mg daily in divided doses, combined with mineralocorticoid replacement using fludrocortisone 0.1 mg daily. 1, 2

Core Replacement Therapy

Glucocorticoid Replacement

• First-line therapy: Hydrocortisone 15-25 mg daily in divided doses
  • Typical dosing schedule: 2-3 doses per day to mimic physiological cortisol rhythm
  • Morning dose should be highest (typically 50-60% of total daily dose)
  • Alternative regimens: Prednisone 5-7.5 mg daily 1

Mineralocorticoid Replacement

• Standard therapy: Fludrocortisone 0.1 mg daily
  • Dosage range: 0.05-0.2 mg daily
  • Administered once daily (morning)
  • Adjust based on blood pressure, serum electrolytes, and salt cravings 3, 2

Monitoring Treatment Efficacy

• Blood pressure measurements
• Serum electrolytes (sodium, potassium)
• Weight changes
• Salt cravings
• General well-being and energy levels
• Annual follow-up should include:
  • Assessment of overall well-being
  • Weight and blood pressure measurement
  • Serum electrolyte testing
  • Screening for other autoimmune disorders
  • Bone mineral density assessment every 3-5 years 1

Stress Dosing Protocol

During periods of stress, illness, or procedures, glucocorticoid doses must be increased to prevent adrenal crisis:

Minor Illness/Stress

• Double or triple usual daily hydrocortisone dose 1

Moderate Stress

• Hydrocortisone 50-75 mg/day in divided doses 1

Severe Stress/Surgery/Medical Procedures

• Major surgery: 100 mg hydrocortisone IM before anesthesia, then 100 mg IM every 6 hours until able to take oral medications
• Labor and delivery: 100 mg hydrocortisone IM at onset of labor, then double oral dose for 24-48 hours after delivery
• Minor surgery/dental procedures: 100 mg hydrocortisone IM before procedure, then double oral dose for 24 hours 3

Adrenal Crisis Management

Adrenal crisis is a life-threatening emergency requiring immediate treatment:

1. Immediate IV administration of 100 mg hydrocortisone
2. Rapid infusion of 0.9% saline (1L over first hour)
3. Continue IV hydrocortisone 100-300 mg/day as continuous infusion or divided doses every 6 hours
4. Continue IV fluids (3-4L isotonic saline)
5. Treat precipitating conditions
6. Taper parenteral glucocorticoids over 1-3 days as condition improves 3

Patient Education (Essential Component)

All patients must be educated on:

• Recognizing early symptoms of adrenal crisis
• Wearing medical alert identification
• Carrying a steroid alert card
• Having an emergency hydrocortisone injection kit
• When and how to adjust medication during illness or stress 1

Special Considerations

Pregnancy

• Monitor salt cravings, blood pressure, and serum electrolytes
• During delivery: 100 mg hydrocortisone IM bolus, repeated every 6 hours if necessary
• Postpartum: Double oral dose for 24-48 hours 3

Physical Activity

• Regular, accustomed activity: No dose adjustment needed
• Intense/prolonged exercise: Increase hydrocortisone and salt intake
• Marathon or similar events: Extra 5 mg hydrocortisone before the event 3

Additional Therapies

• DHEA supplementation (25-50 mg daily) may be considered for patients with persistent symptoms despite adequate primary replacement therapy 1

Common Pitfalls to Avoid

1. Underdosing during stress: Failure to increase glucocorticoid doses during illness or stress is the most common cause of adrenal crisis
2. Overdosing during routine care: Excessive glucocorticoid replacement can lead to metabolic syndrome, osteoporosis, and shortened lifespan 4
3. Inadequate patient education: Patients must understand when and how to adjust their medication
4. Missing mineralocorticoid replacement: Essential for patients with primary adrenal insufficiency to prevent electrolyte imbalances
5. Delayed treatment of adrenal crisis: Treatment should never be delayed for diagnostic procedures 3