What are the maintenance steroids for adrenal insufficiency (Addison's disease)?

From the Guidelines

Patients with adrenal insufficiency should be treated with oral hydrocortisone 15-25 mg daily divided into 2-3 doses, with the morning dose being higher to mimic the natural cortisol peak, as recommended by the most recent and highest quality study 1. The dose regimen can be individualized, with options including hydrocortisone, cortisone acetate, or prednisolone, as outlined in the consensus statement on the diagnosis, treatment, and follow-up of patients with primary adrenal insufficiency 1. Some key points to consider when managing adrenal insufficiency include:

• Using hydrocortisone to recreate the diurnal rhythm of cortisol, with 2/3 of the dose given in the morning and 1/3 in the early afternoon 1
• Monitoring for signs of over-replacement, such as weight gain, hypertension, and edema, and under-replacement, such as fatigue, hypotension, and electrolyte abnormalities 1
• Educating patients on stress dosing, emergency injectables, and when to seek medical attention for impending adrenal crisis 1
• Providing patients with a medical alert bracelet or necklace and an emergency injection kit containing hydrocortisone for severe illness when oral medication cannot be taken 1
• Regular follow-up every 6-12 months to assess adequacy of replacement and monitor for complications of both the disease and treatment 1

From the FDA Drug Label

DOSAGE & ADMINISTRATION Dosage depends on the severity of the disease and the response of the patient. 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. The usual dose is 0.1 mg of fludrocortisone acetate tablets daily, although dosage ranging from 0.1 mg three times a week to 0. 2 mg daily has been employed.

The maintenance steroid for adrenal insufficiency is fludrocortisone in combination with a glucocorticoid such as hydrocortisone or cortisone.

• The usual dose of fludrocortisone is 0.1 mg daily.
• The dose of glucocorticoid is:

• 10 mg to 37.5 mg daily of cortisone in divided doses.
• 10 mg to 30 mg daily of hydrocortisone in divided doses 2.

From the Research

Adrenal Insufficiency Maintenance Steroids

• The current standard treatment regimen for adrenal insufficiency (AI) involves twice- or thrice-daily dosing with a glucocorticoid, most commonly oral hydrocortisone 3.
• The daily glucocorticoid replacement dose recommended by The Endocrine Society Guidelines is 15 to 25 mg with a midpoint of 20 mg of hydrocortisone (HC) in divided doses in otherwise healthy individuals with AI 4.
• However, a daily glucocorticoid replacement dose of 4.3 to 26 mg/d HC with a midpoint of 15 mg/d is predicted from current measurements of daily cortisol production rates and oral HC bioavailability, suggesting that the higher HC doses recommended in the current guidelines may result in glucocorticoid overtreatment of some AI patients 4.
• The use of prednisolone and dual-release hydrocortisone may provide a smoother glucocorticoid profile of cortisol than standard oral multidose regimens of hydrocortisone and cortisone acetate, with potential reductions in total steroid exposure 5.
• Modern hydrocortisone replacement regimens in adrenal insufficiency patients may be associated with an increased risk of adrenal crisis, highlighting the need for further investigation into the optimal dosing regimens 6.
• In hospitalized patients, hydrocortisone is the preferred choice of steroid for most relative adrenal insufficiency patients, with fludrocortisone added on a case-by-case basis in refractory shock 7.

Key Considerations

• The importance of individualizing glucocorticoid replacement doses to minimize the risk of over- or under-treatment 3, 4.
• The need for further research into the optimal dosing regimens and treatment strategies for adrenal insufficiency 4, 5, 6.
• The potential benefits and risks of using different glucocorticoids, such as prednisolone and dual-release hydrocortisone, in the treatment of adrenal insufficiency 5.