How to give orally dosage in secondary adrenal insufficiency
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Oral Dosing in Secondary Adrenal Insufficiency
Key Principle
In secondary adrenal insufficiency (SAI), ACTH production is deficient (pituitary/hypothalamic cause), so only glucocorticoid replacement is required - mineralocorticoid (aldosterone) control remains intact via the renin-angiotensin system. No fludrocortisone is needed. A liberal salt diet is encouraged.
First-Line Drug: Hydrocortisone (Cortisol)
Hydrocortisone is preferred because it mirrors the body's natural cortisol, has a shorter biological half-life, and provides some mineralocorticoid activity.
| Source | Daily Oral Dose | Regimen |
|---|---|---|
| Tintinalli's Emergency Medicine | 20 mg/day | Split doses |
| Rosen's Emergency Medicine | 15-25 mg/day | 2-3 divided doses |
| Textbook of Family Medicine | 20-30 mg/day | 2 doses: 2/3 in morning, 1/3 in early afternoon/evening |
| Harriet Lane (pediatric) | 6-18 mg/m²/day | Divided TID |
Standard adult regimen:
- Morning dose: ~15-20 mg (two-thirds of total)
- Afternoon/early evening dose: ~5-10 mg (one-third of total)
- This mimics the normal diurnal cortisol rhythm (peak in early morning)
The goal is the smallest dose that relieves symptoms, to minimize side effects like weight gain and osteoporosis. - Textbook of Family Medicine, p. 1030
Alternative: Prednisolone or Prednisone
If hydrocortisone is not available or not tolerated:
- Prednisolone equivalent: ~20 mg/day hydrocortisone is roughly equivalent to 5-7.5 mg/day prednisone, given in 1-2 doses
- Prednisone 5 mg morning + 2.5 mg evening is a typical alternate regimen
- Dexamethasone is NOT recommended for maintenance - dose titration is difficult and cushingoid effects can be pronounced
Stress Dosing (Sick Day Rules)
Patients must increase their dose during physiological stress:
| Stress Level | Action |
|---|---|
| Minor illness / fever | Double or triple the daily dose for 24-48 hours |
| Significant illness/injury | Triple the maintenance dose |
| Vomiting (cannot take oral) | Switch to IM/IV hydrocortisone; patient should carry emergency ampoules |
| Adrenal crisis | IV hydrocortisone 100 mg bolus, then 100 mg q6-8h |
Steroid Potency Reference (Harriet Lane)
| Steroid | Glucocorticoid Potency (vs. cortisol) |
|---|---|
| Hydrocortisone | 1 |
| Cortisone acetate | 0.8 |
| Prednisone / Prednisolone | 4 |
| Methylprednisolone | 5 |
| Dexamethasone | 30 |
Practical Points
- No mineralocorticoid (fludrocortisone) needed in SAI - this distinguishes it from primary adrenal insufficiency
- Give 2/3 of the dose in the morning and 1/3 in the early afternoon - mimics physiologic diurnal rhythm
- Do NOT give a late evening dose - it can suppress overnight cortisol recovery and cause insomnia
- Clinical evaluation (symptoms of fatigue, weight, BP, electrolytes) is the primary guide to dosing adequacy; there is no reliable lab marker for oral glucocorticoid adequacy
- All patients should carry a medical alert card/bracelet and emergency injectable hydrocortisone for situations where oral dosing fails (e.g., vomiting)
Sources: Tintinalli's Emergency Medicine; Rosen's Emergency Medicine; Textbook of Family Medicine 9e; Barash Clinical Anesthesia 9e; Harriet Lane Handbook 23e
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