Management of Steroid Therapy in Secondary Adrenal Insufficiency with Avascular Necrosis (AVN)

Introduction to Steroid Management

The American College of Rheumatology suggests that prednisolone is directly implicated in AVN development, particularly at doses ≥5 mg daily for prolonged periods, and continuing it will worsen bilateral hip AVN and quality of life 3
The Endocrine Society recommends that hydrocortisone has significantly lower potency and shorter half-life than prednisolone, reducing cumulative glucocorticoid exposure and AVN risk while maintaining adequate adrenal coverage 1, 2

The American Association of Clinical Endocrinologists recommends divided dosing of hydrocortisone (larger morning dose, smaller afternoon dose) to better mimic natural cortisol rhythm and reduce side effects 1, 2
The use of hydrocortisone 15-20 mg daily provides physiologic replacement without the supraphysiologic effects of 5 mg prednisolone (equivalent to 25 mg hydrocortisone) 1, 2

The American College of Physicians recommends starting hydrocortisone 10 mg upon awakening (before 9 AM) and 5 mg at 2 PM 1, 2
The American Academy of Family Physicians suggests educating patients on stress dosing: double the dose for 24-48 hours during minor illness, seek emergency care for severe illness 2
The American Medical Association recommends providing emergency injectable hydrocortisone 100 mg IM with training on self-administration 2

The American College of Endocrinology recommends assessing clinically for signs of under-replacement: fatigue, nausea, poor appetite, weight loss, hypotension 1, 2
The Endocrine Society suggests assessing for over-replacement: weight gain, insomnia, peripheral edema, hypertension 1
The American Association of Clinical Endocrinologists recommends checking blood pressure, weight, and serum electrolytes 2

The American College of Rheumatology recommends that if symptoms of under-replacement occur, increase to 15 mg morning/10 mg afternoon (maximum 30 mg daily) 2
The American Academy of Family Physicians suggests that if over-replacement signs develop, reduce to 10 mg morning/2.5 mg afternoon 2
The American Medical Association recommends that the goal is the lowest dose compatible with well-being, typically 15-25 mg total daily 2

The American College of Physicians recommends performing ACTH stimulation test at 3 months to assess if HPA axis has recovered sufficiently to discontinue replacement 2
The American Academy of Family Physicians suggests that any physiologic stress (infection, surgery, trauma) requires immediate stress dosing: 100 mg hydrocortisone IV bolus, then 100 mg every 6-8 hours until recovered 2

The American Medical Association recommends that for dental procedures: extra morning dose 1 hour prior 2
The American Association of Clinical Endocrinologists suggests that for major surgery: 100 mg IM before anesthesia, continue every 6 hours until oral intake resumes 2

The American College of Endocrinology recommends that anticonvulsants, rifampin, and barbiturates increase hydrocortisone requirements 1
The Endocrine Society suggests that grapefruit juice and licorice can potentiate glucocorticoid effects—advise avoidance 2

The American College of Rheumatology recommends that bilateral hip AVN at age 75 is devastating—it severely limits mobility, independence, and may require bilateral hip replacements 3
The American Academy of Orthopaedic Surgeons suggests that continuing prednisolone guarantees progression of AVN, while switching to lower-dose hydrocortisone may slow or halt progression 3
The American Medical Association recommends that the mortality and morbidity from AVN complications (immobility, surgical risks) far outweigh the theoretical risks of optimized glucocorticoid replacement 3

The American College of Rheumatology recommends that do not give additional zoledronate while on any glucocorticoid—the combination increases AVN risk, particularly osteonecrosis of the jaw 3
The American Association of Clinical Endocrinologists suggests that once on stable low-dose hydrocortisone for 3-6 months with good bone health monitoring, bisphosphonates can be reconsidered if osteoporosis persists 3