How long should a patient with hypothyroidism and adrenal insufficiency take hydrocortisone (cortisol replacement therapy)?

Duration of Hydrocortisone Therapy in Adrenal Insufficiency

Patients with confirmed adrenal insufficiency require lifelong hydrocortisone (or equivalent glucocorticoid) replacement therapy—this is not a temporary treatment. 1, 2

Lifelong Replacement is Mandatory

• Both primary adrenal insufficiency (Addison's disease) and secondary adrenal insufficiency from hypothalamic-pituitary disease require continuous, lifelong glucocorticoid replacement therapy. 1, 2
• The standard maintenance dose is hydrocortisone 15-25 mg daily in split doses, with the first dose immediately after waking and the last dose at least 6 hours before bedtime. 1
• Alternative regimens include cortisone acetate 18.75-31.25 mg daily (equivalent to 15-25 mg hydrocortisone) or prednisone 3-5 mg daily. 1, 2

Critical Distinction: Primary vs Secondary Adrenal Insufficiency

• Primary adrenal insufficiency requires both glucocorticoid AND mineralocorticoid (fludrocortisone 50-200 µg daily) replacement for life, since the adrenal glands cannot produce either hormone. 1, 2
• Secondary adrenal insufficiency requires only glucocorticoid replacement for life, as the renin-angiotensin-aldosterone system remains intact. 3

The Only Exception: Glucocorticoid-Induced Adrenal Insufficiency

• Iatrogenic secondary adrenal insufficiency from exogenous steroid use (≥20 mg/day prednisone or equivalent for ≥3 weeks) may be reversible after stopping the causative medication. 3, 4
• Recovery of the hypothalamic-pituitary-adrenal (HPA) axis should be assessed 3 months after switching to physiologic hydrocortisone maintenance therapy using ACTH stimulation testing. 3, 4
• If the cosyntropin stimulation test shows peak cortisol >550 nmol/L (>18-20 μg/dL), the HPA axis has recovered and glucocorticoids can be discontinued. 3
• However, approximately 39-48% of patients on chronic low-dose prednisolone develop persistent adrenal insufficiency requiring indefinite replacement. 4

Annual Monitoring Requirements

• Patients with primary adrenal insufficiency should be reviewed at least annually with assessment of health, well-being, weight, blood pressure, and serum electrolytes. 1
• Screen periodically for new autoimmune disorders, particularly hypothyroidism, as autoimmune adrenal insufficiency frequently coexists with other autoimmune conditions. 1, 3
• Monitor bone mineral density every 3-5 years to assess for complications of glucocorticoid therapy. 1

Critical Patient Education for Lifelong Management

• All patients must receive stress-dosing instructions: double or triple the daily dose during illness, fever, or physical stress. 3
• Patients must be prescribed an emergency injectable hydrocortisone 100 mg IM kit with self-injection training to prevent or treat adrenal crisis. 3, 2
• A medical alert bracelet or necklace indicating adrenal insufficiency is mandatory to trigger appropriate emergency treatment. 3, 2

Common Pitfall to Avoid

• Never attempt to discontinue hydrocortisone in patients with confirmed primary or secondary adrenal insufficiency from non-iatrogenic causes—these conditions are permanent and stopping replacement therapy will precipitate life-threatening adrenal crisis. 1, 3
• The only scenario where discontinuation is appropriate is glucocorticoid-induced adrenal insufficiency after documented HPA axis recovery on repeat testing. 3, 4