Treatment for Hypocortisolism (Low Cortisol Levels)

Diagnostic Considerations

The Endocrine Society indicates that low cortisol with low ACTH suggests secondary adrenal insufficiency, while low cortisol with high ACTH suggests primary adrenal insufficiency 1
Morning ACTH and cortisol levels, along with basic metabolic panel to check for electrolyte abnormalities, are essential for diagnosis, as recommended by clinical guidelines 1
Consider MRI of the brain with pituitary/sellar cuts in patients with multiple endocrine abnormalities or new severe headaches to identify potential causes of secondary adrenal insufficiency, according to clinical guidelines 1

The American College of Clinical Endocrinologists recommends initiating replacement therapy with hydrocortisone 15-20 mg in divided doses (2/3 morning, 1/3 afternoon) for mild symptoms 2
For primary adrenal insufficiency, the Endocrine Society suggests adding fludrocortisone (0.05-0.1 mg/day) to replace mineralocorticoid function 2
The American College of Clinical Endocrinologists recommends reducing maintenance dosing if signs of iatrogenic Cushing's syndrome develop (bruising, thin skin, edema, weight gain, hypertension, hyperglycemia) 2
Consider higher initial dosing: hydrocortisone 30-50 mg total dose or prednisone 20 mg daily for moderate symptoms, as recommended by the American College of Clinical Endocrinologists 2

The Endocrine Society prefers hydrocortisone over long-acting steroids like prednisone as it better recreates the diurnal rhythm of cortisol 2
Hydrocortisone 20 mg is equivalent to prednisone 5 mg, according to the American College of Clinical Endocrinologists 2
When both glucocorticoid and thyroid replacement are needed, always start glucocorticoids first to prevent precipitating adrenal crisis, as recommended by the Endocrine Society 1

All patients need education on stress dosing for sick days (doubling or tripling doses), as recommended by the American College of Clinical Endocrinologists and the Endocrine Society 2, 1
Provide emergency injectable hydrocortisone and instructions for use, according to the American College of Clinical Endocrinologists 2
Recommend medical alert bracelet for adrenal insufficiency, as suggested by the American College of Clinical Endocrinologists and the Endocrine Society 2, 1

In patients with multiple hormone deficiencies, testosterone or estrogen replacement may be needed after cortisol replacement is established, according to the Endocrine Society 3, 1
DHEA replacement may be considered in women with low libido and/or energy who are otherwise well-replaced with cortisol, as recommended by the American College of Clinical Endocrinologists and the Endocrine Society 2, 3

In critical illness or adrenal crisis, administer hydrocortisone 100 mg IV bolus immediately, followed by either continuous infusion of 200 mg over 24 hours or 50 mg IV/IM every 6 hours, as recommended by the Anaesthesia society 4, 5

For surgery under general anesthesia, administer hydrocortisone 100 mg IV at induction, followed by either 200 mg/24 hours as continuous infusion or 50 mg IV/IM every 6 hours, as recommended by the Anaesthesia society 4, 5
After uncomplicated surgery, double the regular oral replacement dose for 48 hours, extending up to one week for major surgery before resuming maintenance dosing, as recommended by the Anaesthesia society 4

In pediatric patients, administer 2 mg/kg IV hydrocortisone at induction for surgery, followed by 2 mg/kg every 4 hours postoperatively or continuous infusion for major procedures, as recommended by the Anaesthesia society 5
No child with adrenal insufficiency should be fasted for more than 6 hours, as recommended by the Anaesthesia society 5