From the Guidelines
For a 41-year-old female with Addison's disease weighing 60.3 kg, I recommend oral hydrocortisone at a total daily dose of 15-20 mg divided into 2-3 doses, with the largest dose given in the morning, as suggested by the most recent guideline update 1. This dosing regimen is based on the latest evidence from the Journal of Clinical Oncology, which provides guidance on the management of immune-related adverse events, including adrenal insufficiency.
Key Considerations
- The patient should be educated on steroid stress dosing, emergency injections, and the importance of wearing a medical alert bracelet or necklace 1.
- The dosing regimen should be adjusted to mimic the natural cortisol rhythm, with higher levels in the morning and lower levels in the evening.
- Regular monitoring with an endocrinologist is essential to adjust dosing based on clinical response, avoiding symptoms of both under-replacement (fatigue, nausea, hypotension) and over-replacement (weight gain, insomnia, hypertension) 1.
Dosing Regimen
- A typical regimen would be 10-15 mg upon waking, 5 mg at midday, and 5 mg in the early evening (before 6 PM).
- During times of illness, injury, or significant stress, the dose should be doubled or tripled (sick day rules) 1.
- For minor illness with fever, double the usual dose for the duration of illness.
- For severe illness, vomiting, or inability to take oral medication, seek immediate medical attention for parenteral hydrocortisone.
Additional Recommendations
- The patient should carry an emergency hydrocortisone injection kit containing 100 mg hydrocortisone for adrenal crisis.
- Fludrocortisone may also be required, with a starting dose of 0.05-0.1 mg/d, adjusted based on volume status, sodium level, and renin response 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, weighing 60.3 kilograms, can be determined based on the following guidelines:
- Starting doses of glucocorticoids should be 15 - 20 mg for hydrocortisone or 20 - 30 mg for cortisone acetate, divided into two or three doses, and preferentially weight-adjusted 2
- Current recommended daily starting dose for hydrocortisone is 20 mg, divided into two or preferably three doses 3
- Maintenance therapy includes substitution of glucocorticoid and mineralocorticoid steroids, using divided and lower total dosages of glucocorticoids than previously used 4
- AAD requires life-long substitutive therapy with two-three daily doses of hydrocortisone (HC) (15-25 mg/day) 5
Key Considerations
- The lowest possible HC dose must be identified according to clinical and biochemical parameters to minimize long-term complications 5
- Patients must be educated to double-triple HC dose in the case of fever or infections and to switch to parenteral HC in the case of vomiting, diarrhoea or acute hypotension 5
- New treatment modalities such as modified-released hydrocortisone and continuous subcutaneous hydrocortisone infusion have recently been developed, offering the potential for closer simulation of the physiological serum cortisol rhythm 6