Glucocorticoid Replacement for Secondary Adrenal Insufficiency

Introduction to Replacement Therapy

The American College of Endocrinology recommends a maintenance dose of 4-5 mg prednisolone daily for secondary adrenal insufficiency, preferably given as a single morning dose or split as 3 mg morning and 1-2 mg at 2 pm 1

A divided-dose regimen of 3 mg prednisolone upon awakening + 1-2 mg at 2 pm can be used for patients with symptoms, with approximately two-thirds of the total dose given in the morning 1
The afternoon dose should never be taken later than 4-6 hours before bedtime to avoid sleep disruption 1

The Endocrine Society recommends doubling the usual dose for minor illness, 20 mg prednisolone daily for moderate illness, and IV hydrocortisone 100 mg for severe illness/surgery 2, 3, 6

Clinical assessment is the primary monitoring method, with signs of under-replacement including lethargy, nausea, and weight loss, and signs of over-replacement including weight gain, insomnia, and peripheral edema 1, 4, 6
The American College of Endocrinology warns against confusing maintenance with stress dosing, as the "10 mg morning and 5 mg afternoon" regimen is a stress-dose protocol that can lead to iatrogenic Cushing's syndrome over time 1