What is the appropriate hydrocortisone (cortisol replacement therapy) dosing for a 41-year-old female patient with Addison's disease (adrenal insufficiency)?

From the Guidelines

For a 41-year-old female with Addison's disease, I recommend oral hydrocortisone at a total daily dose of 15-25 mg divided into 2-3 doses, as this regimen is supported by the most recent and highest quality study 1. A typical regimen would be 10-15 mg in the morning upon waking, 5 mg in the early afternoon (around 2 PM), and optionally 5 mg in the early evening (before 6 PM) to mimic the natural cortisol rhythm. The morning dose should be the largest, comprising about 50-60% of the total daily dose. The patient should take medication with food to improve absorption and reduce gastrointestinal side effects. She should wear a medical alert bracelet and carry an emergency hydrocortisone injection kit (typically 100 mg for self-administration) for adrenal crisis situations. During times of illness, injury, or significant stress, the dose should be doubled or tripled temporarily (stress dosing) as suggested by 1. For surgical procedures, dental work, or other major stressors, additional parenteral hydrocortisone may be required. Regular monitoring with an endocrinologist is essential to adjust dosing based on symptoms and to check for signs of over-replacement (weight gain, hypertension, glucose intolerance) or under-replacement (fatigue, nausea, hypotension) as recommended by 1 and 1. This regimen aims to replace the physiologic cortisol that the adrenal glands cannot produce due to primary adrenal insufficiency while minimizing side effects from excessive glucocorticoid exposure. Some key points to consider in the management of Addison's disease include:

• Education on stress dosing for sick days, use of emergency injectables, and when to seek medical attention for impending adrenal crisis 1
• The importance of endocrinology consultation for planning before surgery or high-stress treatments 1
• The potential need for fludrocortisone replacement, especially in primary adrenal insufficiency 1

From the Research

Hydrocortisone Dosing for Addison's Disease

The appropriate hydrocortisone dosing for a 41-year-old female patient with Addison's disease can be determined based on the following evidence:

• A daily dose of approximately 10 mg/m(2) body surface area/day restores the circadian variation and normal levels of salivary cortisol in most patients, as shown in a study on continuous subcutaneous hydrocortisone infusion 2.
• Current recommended daily starting dose for hydrocortisone is 20 mg, divided into two or preferably three doses 3.
• Starting doses of glucocorticoids should be 15 - 20 mg for hydrocortisone, divided into two or three doses, and preferentially weight-adjusted 4.
• A daily dose of 15-25 mg of hydrocortisone is recommended, with the lowest possible dose identified according to clinical and biochemical parameters to minimize long-term complications 5.

Key Considerations

• The dosing regimen should aim to restore the normal diurnal cortisol rhythm and minimize long-term complications such as osteoporosis and cardiovascular and metabolic alterations.
• Patients should be educated to adjust their hydrocortisone dose in response to fever, infections, vomiting, diarrhea, or acute hypotension.
• The use of timed-release hydrocortisone tablets and continuous subcutaneous hydrocortisone infusion are promising new treatment modalities that may improve outcomes for patients with Addison's disease 2, 4.