How can I safely increase my cortisol levels?

Raising Cortisol Levels: Medical Management

If you have adrenal insufficiency, cortisol levels should be raised using hydrocortisone 15-25 mg daily in split doses, with the first dose immediately upon waking and the last dose at least 6 hours before bedtime. 1

Critical Context: When Raising Cortisol is Medically Indicated

Raising cortisol levels is only appropriate in diagnosed adrenal insufficiency—attempting to raise cortisol in healthy individuals is dangerous and contraindicated. 2

Diagnosis Requirements Before Treatment

• Morning serum cortisol <5 µg/dL with elevated ACTH confirms primary adrenal insufficiency 2
• Cortisol 5-10 µg/dL with low/normal ACTH suggests secondary or glucocorticoid-induced insufficiency 2
• Cosyntropin stimulation test (250 µg) with peak cortisol <500 nmol/L (18 µg/dL) at 60 minutes is diagnostic 1
• Some patients present with normal cortisol but elevated ACTH (>300 pg/mL)—this represents early Addison's disease requiring treatment 3

Standard Glucocorticoid Replacement Regimen

Primary Adrenal Insufficiency

• Hydrocortisone 15-25 mg daily in divided doses (typically 10 mg morning, 5 mg afternoon, 5 mg early evening) 1, 2
• Alternative: Cortisone acetate 18.75-31.25 mg daily 1
• Children: 6-10 mg/m² body surface area 1
• Add fludrocortisone 50-200 µg once daily for mineralocorticoid replacement 1, 2

Secondary/Glucocorticoid-Induced Insufficiency

• Hydrocortisone 15-25 mg daily or prednisone 3-5 mg daily 2
• No mineralocorticoid needed (aldosterone production preserved) 2

Stress Dosing: Critical for Preventing Adrenal Crisis

Minor Illness (fever, gastroenteritis)

• Double the usual oral hydrocortisone dose for 24-48 hours 1
• Continue until fully recovered 1

Major Surgery

• Hydrocortisone 100 mg IV/IM immediately before anesthesia 1
• Continue 100 mg every 6 hours (or 200 mg/24h continuous infusion) until able to eat 1, 4
• Then double oral dose for 48+ hours, taper to baseline 1
• Continuous IV infusion preceded by 50-100 mg bolus best mimics physiological stress response 4

Labor and Delivery

• Hydrocortisone 100 mg IV at onset of labor, then 200 mg/24h continuous infusion 1
• Alternative: 100 mg IM followed by 50 mg every 6 hours 1
• Double oral dose for 24-48 hours postpartum 1

Pregnancy Adjustments

• Increase hydrocortisone by 2.5-10 mg daily during third trimester 1
• Fludrocortisone dose often needs increase in late pregnancy 1

Intense Exercise

• Add 5 mg hydrocortisone before prolonged/unaccustomed exercise (e.g., marathon) 1
• Increase salt and fluid intake during intense activity 1

Adrenal Crisis Management: Life-Threatening Emergency

Immediate treatment without delay for diagnostic procedures: 1

• Hydrocortisone 100 mg IV or IM immediately 1, 2
• Repeat 100 mg every 6-8 hours until recovered 1
• 0.9% saline at 1 L/hour initially until hemodynamic improvement 1
• All patients must carry injectable hydrocortisone 100 mg for self/caregiver administration 1, 2

Important Monitoring and Safety Considerations

Drug Interactions to Avoid

• Liquorice and grapefruit juice potentiate mineralocorticoid effects—must avoid 1
• Diuretics, acetazolamide, NSAIDs, carbenoxolone interfere with fludrocortisone 1

Patient Education Essentials

• All patients must wear medical alert identification and carry steroid emergency card 1
• Provide supplies for self-injection of parenteral hydrocortisone 1
• Education on dose adjustments during illness is paramount to prevent adrenal crisis 5

Follow-up Requirements

• Annual review minimum: assess well-being, weight, blood pressure, serum electrolytes 1
• Monitor for new autoimmune disorders (especially hypothyroidism) 1
• Bone mineral density every 3-5 years to assess glucocorticoid complications 1

Common Pitfall: Excessive Dosing

The commonly used "low-dose" hydrocortisone of 50 mg every 6 hours (200 mg/day) during stress actually produces serum cortisol levels severalfold higher than physiological stress responses—use the lowest effective dose for shortest duration 6. Continuous infusion of 200 mg/24h preceded by bolus is superior to intermittent boluses for maintaining appropriate cortisol levels during major stress 4.