Synopsis
Deliver physiological glucocorticoid replacement, teach proportionate stress dosing and create reliable oral, injectable and peri-procedural safeguards that prevent crisis without chronic overexposure.
- Physiological replacement aims to mimic the cortisol day: the largest hydrocortisone dose is generally taken on waking, with smaller later doses and avoidance of unnecessary late-evening exposure.
- NICE adult replacement options include hydrocortisone 15 to 25 mg daily in divided doses or prednisolone 3 to 5 mg daily when appropriate; individual clinical response and specialist review govern selection.
- For significant physiological stress, NICE advises at least 40 mg oral hydrocortisone daily in two to four divided doses or at least 10 mg prednisolone daily in one or two divided doses until the acute illness resolves.
Key red flags
Repeated vomiting, severe diarrhoea, inability to swallow, major trauma, collapse, confusion or shock makes oral absorption unsafe and requires emergency hydrocortisone plus urgent hospital assessment.
Investigation priorities
Determine actual daily glucocorticoid exposure and whether symptoms cluster around dose gaps.
Management branches
Stable primary, secondary or tertiary adrenal insufficiency outside acute physiological stress.
- Agree a total daily hydrocortisone or prednisolone regimen with endocrinology, giving the largest hydrocortisone component on waking and adapting clock time for shift workers.
- Review symptoms before and after doses, adherence, interacting medicines and metabolic/bone effects; change one variable at a time and document the maintenance schedule clearly.
Key medicines
Hydrocortisone maintenanceUsually 15 to 25 mg orally per day in two to four divided doses for adults under NICE guidance, tailored to the individual.
Hydrocortisone oral sick-day regimenAt least 40 mg orally daily in two to four divided doses during significant physiological stress, continued until the acute illness resolves.