What is the recommended corticosteroid (corticosteroid) regimen for treating adrenal insufficiency?

Corticosteroid Regimen for Adrenal Insufficiency

Maintenance Therapy

For primary adrenal insufficiency, use hydrocortisone 15-25 mg daily in divided doses (typically two-thirds in the morning and one-third in early afternoon) plus fludrocortisone 0.05-0.1 mg daily; for secondary adrenal insufficiency, use hydrocortisone alone without mineralocorticoid replacement. 1, 2

Glucocorticoid Replacement

• Hydrocortisone is the preferred glucocorticoid because it allows recreation of the diurnal cortisol rhythm and has a short half-life 1
• Typical dosing: 15-20 mg daily split into 2-3 doses (e.g., 10 mg morning, 5 mg early afternoon, 5 mg late afternoon if needed) 1, 2
• The standard equivalency is: 20 mg hydrocortisone = 5 mg prednisone 1, 3
• Long-acting steroids like prednisone carry risk of over-replacement but can be used if adherence to short-acting regimens is problematic 1

Mineralocorticoid Replacement (Primary AI Only)

• Fludrocortisone 0.05-0.1 mg daily as a single morning dose for patients with primary adrenal insufficiency 1, 2
• Titrate based on volume status, serum sodium, potassium, and renin levels (target upper half of reference range) 1, 3
• Not required in secondary adrenal insufficiency as aldosterone secretion remains intact 1, 2

Stress Dosing for Illness

Minor Illness (Fever, Cold, Minor Infection)

• Double the usual daily hydrocortisone dose until recovery 2
• Continue doubled dose for 24-48 hours after symptoms resolve 1

Moderate Illness (Persistent Vomiting, Moderate Infection)

• Triple the usual daily dose or use 2-3 times maintenance (e.g., hydrocortisone 30-50 mg total daily or prednisone 20 mg daily) 1, 2
• Initiate fludrocortisone 0.05-0.1 mg daily if not already taking 1
• Decrease to maintenance doses after 2 days if improving 1

Severe Illness or Adrenal Crisis

• Immediate IV or IM hydrocortisone 100 mg bolus without delay for diagnostic testing 1, 2
• Follow with hydrocortisone 100 mg IV every 6-8 hours (or continuous infusion of 200 mg/24 hours) 1, 2
• Administer at least 1-2 liters of 0.9% normal saline rapidly to correct hypovolemia 1
• Taper stress-dose steroids down to oral maintenance over 5-7 days once stabilized 1

Perioperative Management

Major Surgery

• Hydrocortisone 100 mg IV at induction, followed immediately by continuous infusion of 200 mg/24 hours 1, 2
• Alternative: Hydrocortisone 50 mg IV/IM every 6 hours if continuous infusion impractical 1
• Continue 200 mg/24 hours while NPO or unable to tolerate oral intake 1, 3
• Once tolerating oral intake: double the usual oral dose for 48 hours, then taper to maintenance if recovery uncomplicated 1, 3
• For complicated recovery or prolonged surgery: continue doubled dose for up to one week 1

Minor Surgery/Procedures

• Hydrocortisone 100 mg IV/IM just before procedure 1
• Double oral dose for 24 hours postoperatively, then return to normal 1

Labor and Vaginal Delivery

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

Critical Patient Education Requirements

All patients must receive education on stress dosing, possess emergency injectable hydrocortisone at home, and wear a medical alert bracelet or necklace. 1, 2

Essential Education Components

• How to double or triple doses during illness 1, 2
• When to use emergency injectable hydrocortisone (100 mg IM) 2
• Recognition of adrenal crisis symptoms: severe weakness, confusion, abdominal pain, vomiting, hypotension 1
• Never abruptly stop glucocorticoids 3
• Seek immediate medical attention for persistent vomiting or inability to take oral medications 1

Common Pitfalls to Avoid

• Never use dexamethasone for long-term replacement in primary adrenal insufficiency as it lacks mineralocorticoid activity 1, 3
• Do not delay treatment of suspected adrenal crisis for diagnostic testing—draw blood for cortisol and ACTH, then treat immediately 1, 2
• Do not initiate thyroid hormone replacement before adrenal replacement in hypopituitarism, as this can precipitate adrenal crisis 1
• Avoid using prednisone as first-line due to inability to mimic diurnal rhythm and higher risk of over-replacement 1
• Patients on chronic steroids (prednisolone ≥5 mg for ≥4 weeks) require perioperative stress dosing even without diagnosed adrenal insufficiency 1, 2

Monitoring and Follow-up

• Annual assessment of health status, weight, blood pressure, and serum electrolytes 2
• Monitor for signs of under-replacement: fatigue, nausea, hypotension, hyponatremia, hyperkalemia 3
• Monitor for signs of over-replacement: weight gain, hypertension, hyperglycemia, bruising, thin skin 3
• Check morning ACTH and cortisol levels if adjusting doses or assessing adequacy of replacement 2
• Screen for development of new autoimmune disorders in primary adrenal insufficiency 2