Is a patient with adrenal insufficiency on chronic prednisone (corticosteroid) therapy, presenting with low cortisol levels and labile blood pressure, likely to benefit from transitioning to hydrocortisone (corticosteroid)?

From the Guidelines

Transitioning from prednisone to hydrocortisone may be beneficial for a patient with adrenal insufficiency presenting with low cortisol levels and labile blood pressure, as hydrocortisone more closely mimics the body's natural cortisol rhythm and has more mineralocorticoid activity. According to the most recent and highest quality study, a typical starting regimen would be hydrocortisone 15-20 mg in the morning and 5-10 mg in the afternoon, totaling 20-30 mg daily 1. When transitioning, calculate the prednisone-to-hydrocortisone conversion (approximately 1:4 ratio) and consider a gradual switch to monitor for signs of adrenal insufficiency, such as changes in blood pressure, electrolytes, and symptoms 1. The patient should also be educated on stress dosing during illness or procedures, typically doubling or tripling their usual dose for short periods of increased physiological stress 1. It is essential to note that the measured cortisol level only reflects the patient's natural cortisol production and does not capture the glucocorticoid effect from the prednisone, making it expected and not concerning in this context [@Example@]. Primary and secondary adrenal insufficiency can be distinguished by the relationship between ACTH and cortisol, and if the ACTH is low with low cortisol, management is as per hypophysitis 1. Overall, the goal is to stabilize blood pressure and improve the patient's quality of life while minimizing the risk of adrenal insufficiency and other complications. Key considerations include:

• Monitoring blood pressure, electrolytes, and symptoms during the transition
• Educating the patient on stress dosing and emergency procedures
• Gradually switching from prednisone to hydrocortisone to minimize the risk of adrenal insufficiency
• Considering the patient's individual needs and medical history when determining the optimal treatment regimen.

From the Research

Adrenal Insufficiency and Corticosteroid Therapy

• Adrenal insufficiency is a rare disease with increasing prevalence, often caused by autoimmune adrenalitis or pituitary tumors and their treatment 2.
• Patients with adrenal insufficiency are at risk of adrenal crisis, usually precipitated by major stress, and require careful dose adjustments and education to avoid this life-threatening emergency 2, 3.

Hydrocortisone Replacement Therapy

• Hydrocortisone is commonly used for glucocorticoid replacement therapy in patients with adrenal insufficiency, with a typical dose of 15-25 mg/day in divided doses 2.
• The pharmacokinetics of hydrocortisone require 2-3 daily doses, including a morning intake of 2/3 or half of the daily dose, to mimic the natural circadian rhythm of cortisol release 3.
• Studies have shown that hydrocortisone replacement therapy can improve clinical symptoms and health-related quality of life in patients with primary adrenal insufficiency, although the optimal dosing regimen is still debated 4, 5.

Transitioning from Prednisone to Hydrocortisone

• There is limited direct evidence on the benefits of transitioning from prednisone to hydrocortisone in patients with adrenal insufficiency.
• However, studies suggest that hydrocortisone may provide a more physiological cortisol profile and reduce the risk of over-replacement and cardiovascular complications compared to other glucocorticoids 4, 6.
• Patients with adrenal insufficiency on chronic prednisone therapy presenting with low cortisol levels and labile blood pressure may benefit from transitioning to hydrocortisone, but individualized dose adjustments and monitoring are crucial to avoid adverse effects 2, 3, 6.