Glucocorticoids

Indications

Adrenal insufficiency.

Formulations and Dosage

  • Oral hydrocortisone: 10 mg in the morning and 5 mg in the afternoon.
  • Prednisone: 5 mg per day.
  • The second dose of hydrocortisone is best taken in the early afternoon. Taking it near bedtime may cause insomnia.
  • Hydrocortisone is preferred over prednisone because it stays intravascularly which reduces soft tissue exposure to steroids and minimizes the risk of Cushingoid features.

Monitoring and Adjustment

  • Monitoring and dose adjustment is mainly based on symptoms (e.g., dizziness, appetite, change in weight).
  • Serum cortisol level are not helpful in monitoring response to therapy.
  • ACTH and renin levels are not helpful in monitoring the response to therapy in patients with secondary adrenal insufficiency (i.e., all patients with a pituitary/hypothalamic cause of adrenal insufficiency).

Counseling

  • During illness (e.g., fever), patients should double their dose for 3 days and make sure that they have an adequate oral intake.
  • Patients with vomiting who are unable to keep their oral steroids down should present to the emergency department for intravenous steroid therapy.
  • Patients undergoing surgery will need coverage with stress doses of steroids and should inform their surgeon/anesthesist that they use steroids.
  • In case of emergency, such as trauma, patients need to receive intravenous stress doses of glucocorticoids. Patients should consider using a medical alert bracelet to make sure first responders are aware of their condition and requirement.
  • Patients traveling/camping in remote areas with poor access to healthcare need to make sure they have plenty of pills and should consider carrying a dose of steroids that can be used subcutaneously/intramuscularly in case of emergency (e.g., intramuscular dexamethasone 4 mg/mL inject 1 mL im = 4 mg, in case of emergency and seek immediate medical help).

Notes

  • Patients with secondary adrenal insufficiency are expected to have an intact renin-angiotensin-aldosterone system. However, in those with significant orthostatic hypotension, treatment with fludrocortisone may help reduce the symptoms and spare them from exposure to higher doses of glucocorticoid they might otherwise need to control the symptoms.