| name | enda-adult-glucocorticoid-dosing |
| description | Suggests using hydrocortisone 15–25 mg or cortisone acetate 20–35 mg daily in two or three divided oral doses for adult primary adrenal insufficiency (PAI) patients initiating glucocorticoid replacement. The highest dose is given upon awakening, with the second dose either early afternoon (≈2 h after lunch) or split into lunch and afternoon doses; consider total daily dose calculation based on chosen formulation and frequency. |
Prescribe Adult Glucocorticoid Replacement with Specific Dosing and Timing
STEP 1 — Gather Information
Confirm diagnosis of primary adrenal insufficiency (PAI) via ACTH stimulation test or morning cortisol/ACTH; assess need for glucocorticoid replacement, review current medications, pregnancy status, and presence of aldosterone deficiency requiring fludrocortisone. Action: If PAI confirmed and glucocorticoid replacement indicated, proceed to dose calculation.
STEP 2 — Rule In / Rule Out
Is the patient an adult with confirmed PAI requiring initiation of glucocorticoid replacement?
- Yes → Proceed to STEP 3.
- No → Consider alternative diagnosis or hold glucocorticoids; reassess need.
STEP 3 — Classify or Stratify
Choose glucocorticoid formulation and dosing frequency:
| Formulation | Total Daily Dose Range | Typical Split (2‑dose) | Typical Split (3‑dose) |
|---|
| Hydrocortisone | 15–25 mg | ⅔ morning, ⅓ early afternoon | ½ morning, ¼ early afternoon, ¼ late afternoon |
| Cortisone acetate | 20–35 mg | ⅔ morning, ⅓ early afternoon | ½ morning, ¼ early afternoon, ¼ late afternoon |
| Select based on patient preference, adherence, and availability. Action: Prescribe chosen total daily dose and divide as per selected schedule. | | | |
STEP 4 — Decide
Calculate individual doses: e.g., hydrocortisone 20 mg total → 10 mg morning, 5 mg early afternoon, 5 mg late afternoon (three‑dose) or 12 mg morning, 8 mg early afternoon (two‑dose). Write prescription with clear timing instructions. Action: Provide prescription and educate patient on dosing timing and stress‑dosing plan.
Clinical Guardrails / Mimics / Pitfalls
Avoid dexamethasone due to lack of mineralocorticoid activity and Cushingoid risk; do not give the largest dose in the evening to prevent insomnia; monitor for over‑replacement (weight gain, central obesity, hyperglycemia) and under‑replacement (fatigue, hypotension, hyperpigmentation, salt craving). Remember to assess and replace mineralocorticoid deficiency with fludrocortisone if aldosterone low; do not rely on ACTH levels for routine dose adjustment.
Concrete Clinical Example
A 48‑year‑man with newly diagnosed PAI (morning cortisol 80 nmol/L, ACTH 120 pmol/L) opts for hydrocortisone. Prescribed 20 mg daily: 10 mg upon awakening, 5 mg at 13:00 (≈2 h after lunch), 5 mg at 17:00. Instructed to double dose during febrile illness and carry emergency hydrocortisone kit.
Source: Diagnosis and Treatment of Primary Adrenal Insufficiency: An Endocrine Society Clinical Practice Guideline, Endocrine Society, 2016, doi:10.1210/jc.2015-1710
TODO: consider adding scripts/calc.py for the enda-adult-glucocorticoid-dosing calculator
