What is the treatment for hypocortisolism (low cortisol levels)?

Treatment for Hypocortisolism (Low Cortisol Levels)

The treatment for hypocortisolism requires hormone replacement therapy with hydrocortisone at 15-20 mg daily in divided doses, with additional fludrocortisone for primary adrenal insufficiency. 1

Distinguishing Primary vs. Secondary Hypocortisolism

Before initiating treatment, it's essential to determine the type of hypocortisolism:

• Primary adrenal insufficiency: Low cortisol WITH high ACTH
• Secondary adrenal insufficiency: Low cortisol WITH low/normal ACTH 2

This distinction is crucial as it determines whether mineralocorticoid replacement (fludrocortisone) is needed.

Treatment Algorithm

For Primary Adrenal Insufficiency:

1. Glucocorticoid replacement:

   • Hydrocortisone 15-20 mg total daily dose in divided doses (typically 2/3 in morning, 1/3 in early afternoon) 1
   • Maximum of 30 mg daily for residual symptoms 1

2. Mineralocorticoid replacement:

   • Fludrocortisone 0.05-0.1 mg daily 1
   • Adjust based on volume status, sodium level, and renin response (target upper half of reference range) 1

For Secondary Adrenal Insufficiency:

1. Glucocorticoid replacement only:
   • Hydrocortisone 15-20 mg daily in divided doses 2
   • No mineralocorticoid replacement needed 2

For Moderate Symptoms (Grade 2):

• Outpatient corticosteroid treatment at 2-3 times maintenance dose (hydrocortisone 30-50 mg total or prednisone 20 mg daily) 1
• Decrease to maintenance doses after symptoms improve (typically after 2 days) 1

For Severe Symptoms/Adrenal Crisis (Grade 3-4):

• Immediate IV hydrocortisone 50-100 mg every 6-8 hours 1
• IV normal saline (at least 2L) 1
• Taper to oral maintenance doses over 5-7 days 1

Medication Considerations

Hydrocortisone is preferred over prednisone or dexamethasone because:

• Shorter half-life allows better mimicry of natural cortisol rhythm
• Allows for more precise titration
• Better matches physiologic cortisol patterns 2

If hydrocortisone cannot be used, prednisone may be substituted (5 mg prednisone ≈ 20 mg hydrocortisone) 1

Patient Education (Critical)

All patients must receive:

1. Medical alert bracelet/necklace for adrenal insufficiency 1, 2
2. Education on stress dosing:
   • Double or triple dose during illness, fever, or significant stress
   • Injectable hydrocortisone for emergency use 2
3. When to seek medical attention for impending adrenal crisis 1

Monitoring

• Regular blood pressure measurements
• Periodic electrolyte checks (sodium, potassium)
• Weight monitoring
• Assessment for symptoms of under-replacement (fatigue, nausea, hypotension) or over-replacement (weight gain, hypertension, edema, hyperglycemia) 1, 2

Common Pitfalls

• Tapering too rapidly: Can precipitate adrenal crisis 2
• Inadequate stress dosing: Failure to increase dose during illness or surgery can be life-threatening 3, 4
• Overlooking secondary hormone deficiencies: Always evaluate for other pituitary hormone deficiencies in secondary hypoadrenalism 2
• Using long-acting glucocorticoids: These don't mimic natural cortisol patterns as well 2

Special Considerations

• Endocrine consultation should be obtained early in management 1
• Endocrine consultation is mandatory before surgery or high-stress treatments 1
• Patients on chronic corticosteroids for other conditions may develop secondary adrenal insufficiency and require similar management during stress 3

Remember that untreated hypocortisolism can be fatal, especially during stress, so prompt diagnosis and appropriate treatment are essential.