Treatment of Adrenal Insufficiency

Maintenance Therapy

The American College of Endocrinology recommends hydrocortisone as the preferred glucocorticoid for replacement therapy, typically administered in a total daily dose of 15-25 mg divided into 2-3 doses 1
Common dosing schedules include three daily doses: 10 mg in the morning, 5 mg at midday, and 2.5 mg in the afternoon, as suggested by the Endocrine Society 1
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, according to the American Association of Clinical Endocrinologists 1
Fludrocortisone (50-200 μg once daily) is required for patients with primary adrenal insufficiency, as recommended by the European Society of Endocrinology 1

Adrenal crisis requires immediate treatment without delay for diagnostic procedures, and includes hydrocortisone 100 mg IV bolus followed by 100-300 mg/day as continuous infusion or divided IV/IM doses every 6 hours, as stated by the Journal of Internal Medicine 2, 3
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, is recommended by the American Heart Association 3
Parenteral glucocorticoids should be tapered over 1-3 days to oral maintenance therapy as the patient's condition improves, according to the Endocrine Society 3

All patients should wear medical alert identification jewelry, and need comprehensive education on increasing steroid doses during intercurrent illnesses, vomiting, injuries, or other stressors, as recommended by the American College of Endocrinology 1, 3
Common precipitating factors for adrenal crisis include gastrointestinal illness with vomiting/diarrhea, infections, surgical procedures, injuries, and severe allergic reactions, according to the European Society of Endocrinology 1

Annual follow-up should include assessment of symptoms, weight, and blood pressure, as well as laboratory tests: serum sodium, potassium, glucose, HbA1c, and complete blood count, as recommended by the American Association of Clinical Endocrinologists 1
Screening for associated autoimmune conditions, particularly thyroid dysfunction (TSH, FT4, TPO-Ab), is suggested by the Journal of Internal Medicine 3

Regular, accustomed physical activity generally doesn't require dose adjustment, but for intense or prolonged exercise, an increase in hydrocortisone and salt intake may be necessary, according to the American College of Sports Medicine 4
During delivery, a bolus parenteral dose of 100 mg of hydrocortisone should be given and repeated if necessary every 6 hours, as recommended by the American College of Obstetricians and Gynecologists 4