What is the treatment for adrenal cortisol insufficiency?

Treatment of Adrenal Cortisol Insufficiency

The standard treatment for adrenal cortisol insufficiency consists of glucocorticoid replacement with hydrocortisone 10-30 mg daily in divided doses (or equivalent prednisone 5-10 mg daily), plus mineralocorticoid replacement with fludrocortisone 0.05-0.3 mg daily for patients with primary adrenal insufficiency. 1, 2, 3

Maintenance Therapy

Glucocorticoid Replacement

• Primary agent: Hydrocortisone 15-25 mg daily, divided into 2-3 doses 3
  • Typical dosing schedule: 10 mg in morning + 5 mg at noon + 5 mg in afternoon (1630h) 4
  • Morning dose should be highest to mimic natural cortisol rhythm
• Alternative: Prednisone 3-5 mg daily 3

Mineralocorticoid Replacement

• Fludrocortisone 0.05-0.2 mg once daily 2, 5
• Required only for primary adrenal insufficiency (Addison's disease) 3
• Not needed for secondary adrenal insufficiency (pituitary/hypothalamic causes)

Adrenal Crisis Management

Immediate Treatment

1. Hydrocortisone 100 mg IV bolus immediately 1
2. Follow with either:
   • 50-100 mg IV every 6 hours OR
   • 200 mg/day as continuous infusion 1, 6
3. Fluid resuscitation: Normal saline 10-20 ml/kg (maximum 1,000 ml) 1

Dosing by Weight (for children)

Weight	Induction Dose	Maintenance Dose
Up to 10 kg	2 mg/kg IV	25 mg/24h
11-20 kg	2 mg/kg IV	50 mg/24h
Over 20 kg (prepubertal)	2 mg/kg IV	100 mg/24h
Over 20 kg (pubertal)	2 mg/kg IV	150 mg/24h

Stress Dosing for Illness or Surgery

• Minor illness: Double or triple maintenance oral glucocorticoid dose 1
• Major stress/surgery: Hydrocortisone 50-100 mg IV every 6-8 hours 1
• Continuous IV infusion: Most effective method for maintaining appropriate cortisol levels during major stress 6
  • 200 mg hydrocortisone over 24 hours with initial 50-100 mg bolus
• Taper: Return to maintenance dose over 5-10 days once stress resolves 1

Patient Education - Critical Components

• Stress dosing instructions during illness
• Use of emergency injectable steroids
• When to seek medical attention for impending adrenal crisis
• Importance of medical alert bracelet/card 1

Monitoring and Complications

• Monitor for common side effects:
  • Lipodystrophy
  • Hypertension
  • Cardiovascular disease
  • Osteoporosis
  • Metabolic disorders 1

Important Clinical Considerations

• Medications that induce CYP3A4 may increase hydrocortisone metabolism, requiring higher doses 1
• Recent etomidate administration can suppress cortisol production 1
• Conventional immediate-release hydrocortisone tablets create non-physiological peaks and troughs 5, 7
• Continuous subcutaneous hydrocortisone infusion and timed-release formulations are promising newer treatment modalities 5
• Studies show that approximately 50-80% of patients are over- or under-treated with conventional dosing regimens 4

Differentiating Primary vs Secondary Adrenal Insufficiency

Type	ACTH Level	Cortisol Level	Electrolytes	Mineralocorticoid Need
Primary	High	Low	↓Na, ↑K	Yes (fludrocortisone)
Secondary	Low	Low	Generally normal	No