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].