Adrenal Insufficiency instructions for Stress Dosing

The adrenal glands normally produce 3 different hormones – cortisol, aldosterone, and DHEA (Dehydroepiandrosterone). 

Cortisol helps the body deal with stress and is involved in the regulation of metabolism, blood pressure, and the immune system.  Aldosterone plays a vital role in controlling blood pressure and in maintaining normal blood electrolyte levels.  

DHEA is an androgen, a testosterone-like product. Cortisol and aldosterone are vital for the body and the sustenance of life. During periods of stress or emergencies, the adrenal glands increase the production of these hormones, which enable our bodies to deal with emergencies.

If you have adrenal insufficiency, your adrenal glands cannot make cortisol and aldosterone, and you will have to take replacement doses of these hormones to remain healthy. If you are ill, have an accident, or are under other emergent situations, you will have to adjust the dose of these hormones. The dose of the replacement hormone for cortisol (hydrocortisone, prednisone, methylprednisolone, or dexamethasone) will need to be increased. Not increasing the dose may result in weakness, dizziness, loss of appetite, nausea, vomiting, and low blood pressure. The potassium and acid levels in your blood may increase causing breathing and heart problems and may be fatal if not corrected. This condition is called an ‘adrenal crisis’ and can be prevented if a ‘sick day plan’ is followed. 

Examples of stressful episodes which require adjustment in the doses of hydrocortisone include:

• • Infections (fever greater than 100°F, sinusitis, urinary tract infection, flu, etc.) 
• • Trauma (accidents, fractures, etc.) 
• • Surgery 
• • Major dental procedures 
• • Endoscopies
• • Cardiac procedures
• • Severe emotional stress (in some patients only).

As an example, a typical dose of hydrocortisone is 15 mg in the morning and 5 mg in the afternoon. During illness, you will need to increase the dose of hydrocortisone to 30 or 45 mg in the morning and 10 or 15 mg in the afternoon. You should consult your physician regarding your exact needed dose depending on the situation. 

If you are unable to eat or keep your medications down, you may need to take an emergency injection of hydrocortisone, or a related compound called dexamethasone. If you do not have access to the injectable preparation of hydrocortisone or dexamethasone, you may need to go to the emergency room to get an intravenous dose of hydrocortisone and intravenous fluids for dehydration. As soon as your illness is over and the symptoms have resolved (e.g., resolution of fever, diarrhea, vomiting), you can resume your normal dose of hydrocortisone.  

Please note that fludrocortisone (one of the preparations of aldosterone) typically does not need to be increased under stressful circumstances. However, if you are going to be in hot temperatures for extended periods of time and have a risk of developing dehydration, you may need to temporarily increase the dose of fludrocortisone. It is recommended that you consult with your physician for dose adjustments. 

Adjusting your medication dose for illnesses and other difficult situations is called ‘stress dose adjustment.’ In consultation with your physician, you should have a plan for such circumstances. It is important that high doses of hydrocortisone or other cortisol replacement medications not be taken for extended periods of time to avoid side effects such as weight gain, type 2 diabetes, osteoporosis, and cardiovascular disease.