From the Guidelines
The treatment for Addison's disease involves glucocorticoid replacement therapy, typically with hydrocortisone (HC) or cortisone acetate (CA), with the goal of mimicking the normal cortisol production pattern.
Treatment Regimens
- The preferred choice of glucocorticoid treatment is HC or CA, with no studies showing one to be superior to the other 1.
- HC is available in 20,10, and 2.5 mg tablets, while CA is available in 25 and 5 mg tablets.
- Both HC and CA are taken in two or three divided doses, with the first dose upon awakening and the last dose approximately 4–6 h before bedtime.
Dosing
- Standard dose regimens are:
- HC: 20 mg, 10 mg, 2.5 mg
- CA: 25 mg, 5 mg
- Monitoring of glucocorticoid replacement relies on clinical assessment, including symptoms and signs of over-replacement (weight gain, insomnia, peripheral oedema) and under-replacement (lethargy, nausea, poor appetite, weight loss, increased pigmentation) 1.
Special Considerations
- During surgery, dental procedures, delivery, and invasive procedures, patients with Addison's disease require additional glucocorticoid coverage, such as 100 mg hydrocortisone IM before the procedure and adjusted dosing post-procedure 1.
- In cases of suspected malabsorption, serum or salivary cortisol day curve monitoring may be useful to guide dosing 1.
From the Research
Treatment Overview
The treatment for Addison's disease typically involves replacing the deficient hormones with medication.
- Conventional steroid replacement consists of twice or three-times daily oral hydrocortisone and once-daily fludrocortisone 2, 3, 4.
- New treatment modalities such as modified-released hydrocortisone and continuous subcutaneous hydrocortisone infusion have been developed to simulate the physiological serum cortisol rhythm more closely 2, 3, 5.
Medication Dosage
- The starting dose of glucocorticoids should be 15 - 20 mg for hydrocortisone or 20 - 30 mg for cortisone acetate, divided into two or three doses, and preferentially weight-adjusted 3, 4.
- Mineralocorticoid replacement should be with fludrocortisone 0.05 - 0.20 mg once daily 3, 4.
- Replacement of dehydroepiandrosterone (DHEA) 20-50 mg has been advocated in adrenal failure, but the evidence for benefit is weak 4.
Novel Therapeutic Approaches
- Recent developments in treatment innovations for autoimmune Addison's disease include novel exogenous steroid formulations that mimic the physiological biorhythm of cortisol secretion 5.
- Immunomodulatory and regenerative medicine approaches have been explored to restore endogenous glucocorticoid production 5.
- Advances in the understanding of adrenocortical stem cell biology and adrenal plasticity may lead to new therapeutic approaches 5.
Patient Management
- Education of patients and healthcare professionals is essential to minimize the risk of a life-threatening adrenal crisis 6.
- Optimisation of pharmacological intervention and continued emphasis on education and empowerment of patients should underpin the management of individuals with autoimmune Addison's disease 6.