Managing HPA suppression
Patients diagnosed with cortisol insufficiency require physiological
glucocorticoid replacement with hydrocortisone 15-20 mg/day or
prednisolone 4-5 mg/day. For some patients, very slow weaning of
treatment from these doses over many months may allow full recovery of
the HPA axis and eventual cessation of exogenous glucocorticoids. For
other patients, recovery does not occur, and lifelong glucocorticoid
replacement is required.
Patients with cortisol insufficiency are at risk of an adrenal crisis,
particularly in times of intercurrent illness such as infection, trauma
or surgery. They should be warned of the risk and advised to increase
(double or treble) their glucocorticoid dose to a minimum of 40 mg
hydrocortisone or prednisolone 10 mg if this occurs. Patients should be
signposted to ‘sick day rules guidance’, such as that provided by the
Addison’s self-help group to help them with this [31].