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

Treatment for Low Cortisol Levels (Hypocortisolism)

The treatment for hypocortisolism (low cortisol levels) consists primarily of hydrocortisone replacement at 15-20 mg daily in divided doses, with the morning dose being 10-15 mg (2/3 of total dose) and the afternoon dose being 5-10 mg (1/3 of total dose). 1

Diagnosis Before Treatment

Before initiating treatment, proper diagnosis is essential:

• Hypocortisolism should be confirmed with laboratory testing:
  • ACTH stimulation test (gold standard): A delta total serum cortisol of <9 μg/dL after ACTH administration or random total cortisol <10 μg/dL indicates adrenal insufficiency 2
  • Measure 21-hydroxylase autoantibodies to check for primary adrenal insufficiency 1
  • Low-normal or subnormal plasma cortisol plus elevated ACTH indicates primary adrenal insufficiency (Addison's disease) 2
  • Low-normal cortisol with low ACTH suggests secondary hypocortisolism 2

Treatment Protocol

For Primary Adrenal Insufficiency:

• Glucocorticoid replacement:

  • Hydrocortisone 15-20 mg total daily dose in divided doses 1
  • Morning dose: 10-15 mg (2/3 of total dose)
  • Afternoon dose: 5-10 mg (1/3 of total dose)

• Mineralocorticoid replacement:

  • Fludrocortisone 0.05-0.1 mg daily 1
  • Encourage salt and salty foods consumption
  • Avoid licorice and grapefruit juice (can interfere with treatment) 1

For Secondary Adrenal Insufficiency:

• Glucocorticoid replacement only:
  • Hydrocortisone 15-20 mg daily in divided doses 1
  • Mineralocorticoid replacement is not necessary 3

Dose Adjustments for Special Situations

Stress Dosing:

• Mild illness (fever, minor infection):

  • Double or triple the daily hydrocortisone dose 1

• Moderate symptoms:

  • Increase to 2-3 times maintenance dose (30-50 mg total hydrocortisone or prednisone 20 mg daily)
  • Taper back to maintenance over 5-10 days 1

• Severe illness or adrenal crisis:

  • Immediate IV hydrocortisone 100 mg or dexamethasone 4 mg
  • At least 2L of normal saline IV 1

Pregnancy:

• Hydrocortisone requirements may increase, particularly in the third trimester
• Parenteral hydrocortisone should be planned for during delivery 1

Patient Education and Safety Measures

• Provide a medical alert bracelet/necklace and steroid card with emergency instructions 1
• Educate on stress dosing and when to seek emergency care
• Teach self-administration of injectable hydrocortisone for emergencies 1

Monitoring and Follow-up

• Review patients at least annually:

  • Assess weight, blood pressure, and serum electrolytes
  • Monitor for development of autoimmune disorders, particularly hypothyroidism 1

• Bone mineral density assessment every 3-5 years

• Consider calcium and vitamin D supplementation 1

• Titrate hydrocortisone to the lowest effective dose that maintains well-being

• Adjust based on clinical symptoms rather than laboratory values alone 1

Important Cautions and Pitfalls

• Drug-induced secondary adrenal insufficiency requires gradual dose reduction when discontinuing treatment 4
• Avoid abrupt discontinuation of glucocorticoid therapy, which can precipitate adrenal crisis 5
• Patients with comorbidities such as asthma and diabetes have a higher risk of adrenal crisis 1
• Long-term use of hydrocortisone at doses ≥20 mg can lead to secondary adrenal insufficiency 1
• Monitor for side effects of glucocorticoid therapy, including hypertension, hyperglycemia, and osteoporosis 5, 4
• Patients on immunosuppressant doses should avoid exposure to chickenpox or measles 4

By following this treatment protocol and monitoring plan, patients with hypocortisolism can achieve adequate cortisol replacement while minimizing the risk of complications from both under-replacement and over-replacement.