Primary adrenal insufficiency (Addison’s disease)

15-30mg daily in 2 divided doses, the larger dose to be given in the morning and the smaller in the evening, mimicking the normal diurnal rhythm or cortisol secretion, the optimum dose is determined on the basis of clinical response.

50-300microgram once daily.

Prescribing Notes:

In secondary adrenal failure (hypopituitarism), hydrocortisone is given alone, there being no mineralocorticoid deficiency.
Patients deficient in glucocorticoids do not respond adequately to stress and should be advised to double the replacement dose of hydrocortisone for several days if significantly unwell.
More serious illnesses or gastro-intestinal disturbances necessitate prompt parenteral hydrocortisone.
Hydrocortisone (as sodium phosphate) 100mg/ml solution for intramuscular injection is provided to patients for self-administration for emergency use.
Patients should be given a steroid card and a steroid emergency card to carry, giving details of therapy including drug, dose and possible complications.

History Notes

16/02/2022

East Region Formulary content agreed.

Diagnostic (30-minute test), by intramuscular or intravenous injection, 250micrograms as a single dose.

Prescribing Notes:

Reference should be made to local clinical chemistry handbooks for interpretation of results.

History Notes

16/02/2022

East Region Formulary content agreed.

For dose, refer to BNF for Children and follow specialist advice.

Prednisolone may be used to provide longer steroid suppression overnight in congenital adrenal hyperplasia. Prednisolone oral solution is restricted to use in patients who are unable to swallow tablets. Standard Prednisolone 5mg tablets can be dispersed in water (off-label).

For dose, refer to BNF for Children and follow specialist advice.

Prescribing Notes:

In Addison’s disease (primary adrenal failure) hydrocortisone (glucocorticoid) and fludrocortisone (mineralocorticoid) are given.
In secondary adrenal failure (hypopituitarism), hydrocortisone is given alone, there being no mineralocorticoid deficiency.
Fludrocortisone tablets can be crushed and mixed with a small amount of soft food such as yogurt, honey or jam, swallowed straight away, without chewing. Fludrocortisone tablets may be halved and can be dispersed in water. See the Medicines for Children leaflet Fludrocortisone for hormone replacement.
Patients deficient in glucocorticoids do not respond adequately to stress and should be advised to double the replacement dose of hydrocortisone for several days if significantly unwell.
More serious illnesses necessitate prompt parenteral hydrocortisone. The replacement dose of hydrocortisone should be trebled or given by intramuscular injection if the patient is vomiting.
Hydrocortisone (as sodium phosphate) 100mg/ml solution for intramuscular injection is provided to patients for self-administration for emergency use. It is recommended that patients with adrenal insufficiency have their Emergency Care Summary updated with the following information:
- “Adrenal insufficiency: Serious injury, illness or vomiting can precipitate life threatening adrenal crisis. This patient has an adrenal emergency management plan and may require immediate administration of IV/IM hydrocortisone. Further information on the management of a potential adrenal crisis can be found on: https://www.speg.scot.nhs.uk/professional-pages/speg-guidelines”
For guidance on the clinical management of children and young people with known or suspected adrenal insufficiency see NHS Lothian University Hospitals Division – Children’s Services Endocrinology Guideline: Management of Known or Suspected Adrenal Insufficiency. Available on NHS Lothian intranet.
It is preferable to prescribe doses which can be given as a whole tablet or a measurable fraction of a tablet. Note that although there may be slight variations in the dose given on a day-to-day basis if approximated in this way, the potency of extemporaneously prepared suspensions may also vary.
In the case of hydrocortisone, smaller doses may be administered using the appropriate strength of Alkindi (hydrocortisone granules in capsules for opening) in line with the SMC restriction:(first-line treatment of infants and young children with adrenal insufficiency aged from birth to less than six years of age for whom hydrocortisone must otherwise be individually prepared by manipulation such as by compounding (or crushing) or by production of special solutions in order to produce age-appropriate doses). Note that patients may be on a combination of hydrocortisone tablets and Alkindi (e.g. for asymmetric dosing); hydrocortisone tablets will usually be required for sick day dosing.
When changing from unlicensed ‘special’ hydrocortisone formulations or hydrocortisone tablets to Alkindi advise the parent or carer to observe for potential symptoms of adrenal insufficiency (tiredness, floppiness, unstable temperature, headache and vomiting) in the first week. If this occurs advise patient or carer to seek immediate medical advice and give extra hydrocortisone doses if appropriate.
Doses should be titrated according to clinical and biochemical progress.
Neonates suffering congenital adrenal hyperplasia may be initiated on a higher dose of hydrocortisone, e.g. 2.5mg 2-3 times daily.
Children receiving corticosteroids should be given a steroid treatment card. The BSPED Paediatric Steroid Treatment Card is available at the Society for Endocrinology website.

History Notes

07/04/2025

Prednisolone 2mg tablets removed, ERWG March 25

29/02/2024

East Region Formulary content agreed.

For dose, refer to BNF for Children and follow specialist advice.

Prescribing Notes:

Reference should be made to local clinical chemistry handbooks for interpretation of results.
Refer to guidance in Scottish Paediatric Endocrine Group and British Society for Paediatric Endocrinology and Diabetes.

History Notes

29/02/2024

East Region Formulary content agreed.