ADRENAL HORMONE REPLACEMENT
Most Common Symptoms of Adrenal Hormone Replacement Excess and Deficiency
A Quick Reference by Paul Margulies, M.D.
Updated 9/30/21
Most common symptoms of glucocorticoid (cortisol) excess:
Weight gain
Fatigue
Easy bruising
Muscle weakness
Redness in the face
Pink stretch marks
Mood swings
Inappropriate hunger
Most common symptoms of glucocorticoid (cortisol) deficiency:
Severe fatigue
Weakness
Weight loss
Hyperpigmentation
Nausea
Loss of appetite
Most common symptoms of mineralocorticoid (fludrocortisone acetate) deficiency:
Reduced blood pressure
Nausea (sometimes to the point of vomiting)
Dizziness (sometimes to the point of passing out)
Salt craving
Muscle cramps
Most common symptoms of mineralocorticoid (fludrocortisone acetate) excess:
Hypertension
Ankle swelling
Exertion headache
The Hypothalamic-Pituitary-Adrenal Connection
A defect at any point along the hypothalamic-pituitary-adrenal (HPA)-axis could disrupt normal physiologic glucocorticoid levels. Administration of exogenous glucocorticoids leads to suppression of cortisol production by the adrenal cortex.
HPA-axis suppression is a well-known adverse effect of glucocorticoid therapy; however, considerable controversy exists over the dose and duration of glucocorticoid therapy required to suppress the HPA-axis.
Some of the many factors that influence HPA-axis suppression include time of day that the doses are administered, route of administration, dose and duration of therapy, and duration of action of the agent used.
Reference: Helfer EL, Rose LI. Corticosteroids and adrenal suppression: characterizing and avoiding the problem. Drugs. 1989;38(5):838-845
Normal Cortisol Secretion
Hormone production by the adrenal gland is influenced by many factors. Normal cortisol production follows a diurnal cycle. Levels peak in the early morning hours (6 am–8 am) and decline throughout the day with a second, lower peak in the late afternoon (4 pm–6 pm).
In an adult who is not experiencing stress, the average amount of cortisol secreted by the adrenal gland is equivalent to 5 mg of prednisone.
Reference: Katzung BG. Basic and Clinical Pharmacology. 6th ed. East Norwalk: Appleton & Lange;1995:590-607
Further Resources
Protocols
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In treating adrenal insufficiency, NADF would like to stress its position that all hydrocortisone and fludrocortisone acetate dosing should be personalized, with the following dosage ranges:
Hydrocortisone 15 mg to 40 mg
average dose 20 to 30 mg
PLEASE NOTE: Hydrocortisone dosing should be given in divided doses, with most on awakening and the remainder in one or two doses at midday or afternoon, to mimic the normal daily cycle.
Fludrocortisone Acetate 0 to 0.4 mg
average dose 0.05 to 0.2 mg
To manage Addison's Disease (adrenal insufficiency), patients should learn how to adjust cortisol hormone replacement medication (Cortef®/hydrocortisone/cortisone acetate/prednisone) to their situation's need (with their physician’s oversight).
The current philosophy is to stay as low as possible with cortisol hormone replacement dose, BUT STILL FEEL COMFORTABLE, while keeping oneself out of adrenal crisis.
Ingesting more glucocorticoid then your body needs can cause cataracts, glaucoma, osteoporosis and reactive diabetes.
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Steroid coverage for adult adrenal insufficient patients needing surgery is infusing 200 mg hydrocortisone over 24 hours after an initial bolus of 50‐100 mg, then taper or resume the normal dosage depending on the surgery. If major surgery is performed, a slow taper is used; if minor, resumption to normal dose within a day is fine. If the surgery itself is very minor, like an outpatient biopsy, just using a double oral dose of hydrocortisone may be sufficient coverage.
DOWNLOAD THE SURGERY PROTOCOL FOR ADULT ADRENAL INSUFFICIENT PATIENTS PDF »
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Patients who rely on daily oral hydrocortisone replacement often need additional oral hydrocortisone to mimic the body’s natural stress response. Stress-dose hydrocortisone may be needed in emergencies or before surgery and must be given intramuscularly (IM), subcutaneously (SC), or intravenously (IV) if vomiting or diarrhea is present to prevent death from adrenal crisis.
Causes and symptoms of a potential adrenal crisis can vary among people; please consult your endocrinologist for specific recommendations for your care and go to the nearest emergency department if crisis symptoms are evident.
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Children who rely on daily oral hydrocortisone replacement often need additional oral hydrocortisone to mimic the body’s natural stress response. Stress-dose hydrocortisone may be needed in emergencies or before surgery and must be given intramuscularly (IM), subcutaneously (SC), or intravenously (IV) if vomiting or diarrhea is present to prevent death from adrenal crisis.
Causes and symptoms of a potential adrenal crisis can vary among people; please consult the endocrinologist for specific recommendations for your care and go to the emergency room if crisis symptoms are evident.