From the Guidelines
In primary adrenal insufficiency, both hydrocortisone and fludrocortisone should be given together to replace both glucocorticoid and mineralocorticoid production. When considering a glucocorticoid for a patient already on fludrocortisone, hydrocortisone is a good option due to its balanced glucocorticoid and mild mineralocorticoid effects, as suggested by the consensus statement on the diagnosis, treatment, and follow-up of patients with primary adrenal insufficiency 1. The typical dose regimen for hydrocortisone is 15-25 mg daily, divided into 2-3 doses with the largest dose in the morning. Some key points to consider when prescribing glucocorticoids for primary adrenal insufficiency include:
- Hydrocortisone has a dose range of 15-25 mg day−1, with typical dose regimens including three doses (07:00,12:00,16:00 1 h) or two doses (07:00,12:00 1 h) 1
- Alternative glucocorticoids like prednisolone may be considered in cases of compliance problems or marked fluctuations of energy, but should only be used if hydrocortisone or cortisone acetate is not tolerated, as stated in the consensus statement 1
- Patients on fludrocortisone should continue to receive this medication to replace aldosterone, while also receiving a glucocorticoid like hydrocortisone to replace cortisol. It is essential to educate patients about stress dosing during illness or surgery, typically doubling or tripling their glucocorticoid dose, and to ensure they carry an emergency injection kit and medical alert identification. Regular monitoring of blood pressure, electrolytes, and symptoms helps ensure adequate replacement therapy is maintained.
From the FDA Drug Label
DOSAGE & ADMINISTRATION ... In Addison’s disease, the combination of fludrocortisone acetate tablets with a glucocorticoid such as hydrocortisone or cortisone provides substitution therapy approximating normal adrenal activity with minimal risks of unwanted effects. Fludrocortisone acetate tablets are preferably administered in conjunction with cortisone (10 mg to 37. 5 mg daily in divided doses) or hydrocortisone (10 mg to 30 mg daily in divided doses).
- Yes, in primary adrenal insufficiency, both hydrocortisone and fludrocortisone would be given.
- A good glucocorticoid option if the patient is on fludrocortisone is hydrocortisone or cortisone 2.
From the Research
Treatment of Primary Adrenal Insufficiency
- In primary adrenal insufficiency, both hydrocortisone and fludrocortisone are typically administered as part of the treatment regimen 3, 4.
- The recommended protocol for maintenance therapy is 15-25 mg of hydrocortisone, divided into two or three separate doses, and fludrocortisone 0.05-0.2 mg/day 3.
- Hydrocortisone is a commonly used glucocorticoid for replacement therapy in patients with adrenal insufficiency, including those on fludrocortisone 3, 5, 6.
Glucocorticoid Replacement Therapy
- Glucocorticoid replacement therapy is the main therapeutic approach in all forms of adrenal insufficiency 3, 5, 6.
- The goal of glucocorticoid replacement therapy is to replicate the natural circadian rhythm of cortisol release and provide individualized cortisol exposure 5.
- Different glucocorticoid formulations are available, including short-acting, intermediate, long-acting, and novel modified-release hydrocortisone, as well as subcutaneous formulations 6.
Management of Adrenal Crisis
- Adrenal crisis is a life-threatening complication of glucocorticoid and mineralocorticoid under-replacement, which may be prevented by educational programs towards the adrenal insufficient patient 7.
- Patients with adrenal insufficiency should be educated about stress dosing and equipped with a steroid card and glucocorticoid preparation for parenteral emergency administration 4.