From the Guidelines
For secondary adrenal insufficiency, hydrocortisone should typically be taken in divided doses with the largest dose (50-75% of total daily dose) in the morning upon waking, and the remaining dose in the early afternoon (around 2 PM), as recommended by the most recent guideline update 1. The standard total daily dose ranges from 15-25 mg, divided as 10-15 mg in the morning and 5-10 mg in the afternoon. This dosing schedule mimics the body's natural cortisol rhythm, with highest levels in the morning and declining throughout the day. Some key points to consider when taking hydrocortisone for secondary adrenal insufficiency include:
- Taking the medication with food can help reduce stomach irritation, as suggested by general clinical practice.
- It's crucial not to miss doses, as this could lead to an adrenal crisis, emphasizing the importance of adherence to the prescribed regimen.
- During times of illness, injury, or significant stress, the dose may need to be doubled or tripled temporarily (stress dosing), as outlined in the guideline update 1.
- Patients should wear a medical alert bracelet and carry an emergency injection kit with instructions, highlighting the need for preparedness in case of an emergency.
- Regular follow-up with an endocrinologist is necessary to adjust dosing as needed based on symptoms and occasional cortisol level monitoring, ensuring that the treatment plan is tailored to the individual's needs. The most recent and highest quality study, the 2021 ASCO guideline update 1, provides the basis for these recommendations, prioritizing morbidity, mortality, and quality of life as the primary outcomes.
From the Research
Timing of Hydrocortisone Intake for Secondary Adrenal Insufficiency
- The optimal timing for taking hydrocortisone in patients with secondary adrenal insufficiency is not explicitly stated in the provided studies.
- However, the studies suggest that the dosage and timing of hydrocortisone intake should be individualized to mimic the natural circadian rhythm of cortisol release 2, 3.
- A daily glucocorticoid replacement dose of 15 to 25 mg with a midpoint of 20 mg of hydrocortisone in divided doses is recommended for otherwise healthy individuals with adrenal insufficiency 2.
- The studies also emphasize the importance of stress adaptation and prevention of adrenal crises in patients with adrenal insufficiency 4, 5.
- The use of novel modified-release hydrocortisone formulations and subcutaneous formulations may offer improved therapeutic options for the treatment of adrenal insufficiency and prevention of adrenal crises 5.
Key Considerations
- The dosage and timing of hydrocortisone intake should be tailored to the individual patient's needs to minimize the risk of over- or under-treatment 2, 3.
- Patients with adrenal insufficiency should be educated and empowered to take control of their own medical management to prevent adrenal crises 4.
- The availability of various glucocorticoid formulations and access to expert centers may vary widely, and European Reference Networks on rare endocrine conditions aim to harmonize treatment and ensure access to specialized patient care 5.