Treatment of Adrenal Insufficiency

Glucocorticoid Replacement Therapy

The American College of Endocrinology recommends that most patients with primary adrenal insufficiency should receive 15-25 mg of hydrocortisone daily in split doses 1
The first dose of hydrocortisone should be taken immediately after waking, and the last dose not less than 6 hours before bedtime to mimic the natural circadian rhythm, as suggested by the Endocrine Society 1
The lowest dose of hydrocortisone compatible with health and a sense of well-being should be used to minimize side effects, according to the American Association of Clinical Endocrinologists 1
For children, hydrocortisone dosing should be 6-10 mg per m² of body surface area, as recommended by the Pediatric Endocrine Society 1

Most patients with primary adrenal insufficiency should take 50-200 μg fludrocortisone as a single daily dose in the morning, as suggested by the American College of Endocrinology 1
Dose adjustments of fludrocortisone should be based on blood pressure measurements, serum electrolytes, and clinical symptoms, according to the Endocrine Society 3, 4

Adrenal crisis should be treated immediately with intravenous or intramuscular hydrocortisone, 100 mg followed by 100 mg every 6-8 hours until recovered, as recommended by the American College of Emergency Physicians 1, 4
Isotonic sodium chloride solution should be administered at an initial rate of 1 L/hour until hemodynamic improvement, as suggested by the Society of Critical Care Medicine 1, 4

All patients should wear Medic Alert identification jewelry and carry a steroid/alert card, as recommended by the American College of Endocrinology 1
Patients should receive sufficient education to manage daily medications and situations of minor to moderate concurrent illnesses, according to the Endocrine Society 1

Patients should be reviewed at least annually, with assessment of health and well-being, measurement of weight, blood pressure, and serum electrolytes, as suggested by the American Association of Clinical Endocrinologists 1
Assessment for the complications of glucocorticoid therapy should include monitoring of bone mineral density every 3-5 years, as recommended by the Endocrine Society 1

Delaying treatment in suspected acute adrenal insufficiency while waiting for test results is a common pitfall, as warned by the American College of Emergency Physicians 5
Failing to adjust glucocorticoid doses during periods of illness, surgery, or other stressors is a common mistake, according to the Society of Critical Care Medicine 1