Adrenal Insufficiency Treatment Guidelines

Maintenance Therapy

The primary treatment for adrenal insufficiency consists of glucocorticoid replacement (hydrocortisone 15-25 mg daily in divided doses) and mineralocorticoid replacement (fludrocortisone 50-200 μg daily) for patients with primary adrenal insufficiency 1
Hydrocortisone is the preferred glucocorticoid for replacement therapy, typically administered in a total daily dose of 15-25 mg divided into multiple doses (usually 2-3 times daily) 1
Common dosing schedules include: Three doses: 10 mg + 5 mg + 2.5 mg (morning, midday, afternoon) 2
Cortisone acetate can be used as an alternative at 18.75-31.25 mg daily in divided doses 3
The first dose should be taken immediately upon waking, and the last dose should be taken at least 6 hours before bedtime to avoid sleep disturbances 3
Fludrocortisone (50-200 μg once daily) is required for patients with primary adrenal insufficiency 2
Higher doses (up to 500 μg daily) may be needed in children, younger adults, or during the last trimester of pregnancy 2
Patients should be advised to consume salt and salty foods without restriction 2

Adrenal crisis requires immediate treatment with: Hydrocortisone 100 mg IV bolus followed by 100-300 mg/day as continuous infusion or divided IV/IM doses every 6 hours 5, 4
Rapid IV administration of isotonic saline (0.9%) at an initial rate of 1 L/hour, followed by 3-4 L over 24 hours with frequent hemodynamic monitoring 5, 4
Parenteral glucocorticoids should be tapered over 1-3 days to oral maintenance therapy as the patient's condition improves 1
During minor illnesses with fever, the usual glucocorticoid dose should be doubled or tripled 5, 4
Major surgery requires 100 mg hydrocortisone IM before anesthesia, followed by 100 mg IM every 6 hours until able to take oral medications 6
Minor surgery requires 100 mg hydrocortisone IM before anesthesia, then double oral dose for 24 hours 6

All patients should wear medical alert identification jewelry 3
Patient education should emphasize the importance of increasing steroid doses during intercurrent illnesses, vomiting, injuries, or other stressors 4
Common precipitating factors for adrenal crisis include: Gastrointestinal illness with vomiting/diarrhea 5, Infections 5, Surgical procedures 6, Injuries 5, Severe allergic reactions 5

Annual follow-up should include: Assessment of symptoms, weight, and blood pressure 1, 4
Laboratory tests should include: serum sodium, potassium, glucose, HbA1c, and complete blood count 7
Screening for associated autoimmune conditions, particularly thyroid dysfunction (TSH, FT4, TPO-Ab) should be performed 7
Evaluation of vitamin B12 levels to screen for autoimmune gastritis should be performed 7
Signs of inadequate replacement include: Weight loss 4, Fatigue 5, Postural hypotension 4, Salt craving 2, Hyperpigmentation (in primary adrenal insufficiency) 4
Signs of excessive replacement include weight gain, hypertension, and edema 4

Under-replacement with mineralocorticoids is common and can predispose patients to recurrent adrenal crises 2
Medications that can affect glucocorticoid metabolism (requiring dose adjustments) include: Anti-epileptic drugs and barbiturates (may increase hydrocortisone requirements) 2, Antifungal drugs (may affect metabolism) 2, Grapefruit juice and licorice (may decrease hydrocortisone requirements) 2
Essential hypertension in patients with adrenal insufficiency should be treated with vasodilators rather than by stopping mineralocorticoid replacement 2