Medication for Addison's & adrenal insufficiency If you have a diagnosis of Addison's disease or adrenal insufficiency, each day you will need to follow a time-critical medication regime to replace the life-essential steroid hormones that your adrenal glands are not able to produce, or not able to produce in sufficient quantities, due to your condition. Medication types, timings, doses and when to 'updose', can be confusing at times. We try to keep things as simple as possible and give you the information you need to make the right decisions for yourself, regarding your medication management. Why is medication needed? At a glance: types of Glucocorticoid (steroid hormone) medication Fludrocortisone DHEA - Dehydroepiandrosterone Longer-acting glucocorticoid medications and alternatives Free NHS Prescriptions (Medical Exemption Certificate) Sick Day Rules Adrenal Crisis Emergency Injection Kits FAQ Why is medication needed? People with Addison’s disease and adrenal insufficiency will need to take daily steroid medication at carefully timed intervals to keep their bodies alive and functioning well for the rest of their lives. This means they are steroid dependent. Their medication replaces steroid hormones such as cortisol, aldosterone and DHEA, which their adrenal glands can no longer make enough of. Learn more: What is Addison's disease and adrenal insufficiency. Cortisol production in the body Most people take their steroid replacement medication three times a day, with the largest dose first thing in the morning and then at five to six hourly intervals throughout the day. This is to replicate what happens in a healthy person's blood cortisol and the circadian rhythm. The red line on the graph shows cortisol levels in the body from ‘normally functioning’ adrenal glands. As you can see, there is a natural rise, first thing in the morning, starting at around 3am. The dotted purple lines show how spacing out hydrocortisone medication can try to replicate the ‘normal’ curve. Here we show a morning dose, a lunchtime dose and a smaller dose in the late afternoon. The regime in the graph is just one example - different people will be prescribed different doses and sometimes different types of glucocorticoid medication.As the graph shows, by 10pm levels of cortisol in the blood in people with healthy adrenal glands are very low, which links to the body preparing for sleep. The aim of the steroid replacement medication is to mirror the natural cortisol curve. At a Glance: Types of Glucocorticoid (steroid hormone) medication Hydrocortisone (15-25mg/day) This medication is chemically exactly the same as ‘natural’ cortisol. Most people are prescribed this as the first steroid replacement medicine to try, following diagnosis. It is taken in 2 or 3 divided doses. Prednisolone (3-5mg/day) Where conventional hydrocortisone treatment is not proving effective or where people are struggling with a 3x a day medication regime, low dose prednisolone may be prescribed. It is chemically similar to natural cortisol but lasts longer in the body. It is ‘stronger’ (more potent) than hydrocortisone. It is most often taken in a single dose on waking. Fludrocortisone (50-200mcg/day) - Addison's disease ONLY This is a mineralocorticoid and replaces the missing steroid hormone aldosterone. Aldosterone is an important hormone as it acts on your kidneys to tell them to keep salt in your body. Fludrocortisone is usually taken in one or two daily doses. It is longer-acting in the body in comparison to hydrocortisone. A higher dose (up to 500mcg) might be needed in children, younger adults, people who exercise vigorously or during the last trimester of pregnancy. Higher doses are sometimes necessary for those who live in warm countries, or when going through a heat wave, as people naturally lose more salt from their body through sweating. Increasing your salt intake through your diet during these times can mean you don't need to increase your dose. Normal dietary advice to avoid too much salt in your diet does not apply to people with primary adrenal insufficiency (Addison's disease). You can discuss this with your Endocrinologist based on your plasma renin blood results (the blood test used to monitor your fludrocortisone dose) as well as interpreting your personal symptoms. Fludrocortisone should be stored at room temperature (below 25°C), in a dry environment, to avoid degradation. Learn more about Fludrocortisone Why Salt? DHEA - Dehydroepiandrosterone (25-50mg/day) This medication is another hormone that is produced by the outer layer of the adrenal gland, the cortex. It influences stamina and libido and is a precursor hormone. Unlike glucocorticoid and mineralocorticoid replacement, DHEA supplementation is not considered essential for life and is therefore not routinely replaced in adrenal failure. As the Society for Endocrinology Consultation Reference Guide, a trial of DHEA 25-50 mg could be considered for women with low libido and persistent fatigue, following blood results and discussions with your endocrine team. There have also been findings showing positive effects of DHEA replacement on bone mineral density. More information on DHEA Longer-acting glucocorticoid medications and alternatives Not all medications work for everyone. Below are current alternatives which are considered in individual circumstances that warrant a different medication approach. Read more if you would like to discuss with your Endocrinologist or healthcare team. Many of our community have shared their experiences using the below alternatives on our online forum. Dual release hydrocortisone (Plenadren, Duocort - more information and personal experiences discussed on our online forum) Delayed release hydrocortisone Efmody® (development name: Chronocort®) Hydrocortisone infusion pump For more detailed information on cortisol replacement medication, including doses, times of day to take your medication, and which medication is right for you, visit our cortisol replacement page. Cortisol Replacement Medication The amount and type of medication varies a lot from patient to patient and depends upon the type of adrenal insufficiency they have been diagnosed with and their individual needs (other conditions, body size, age, level of activity etc). Together with their endocrinologist, they should work out a medication schedule that suits them. Your endocrinologist will have a reasonable idea of a good starting dose for you, and then your medication can be fine-tuned over a few weeks and months to get you feeling as good as possible. This might involve taking your medication at slightly different times of day, as well as changing the dose. Don't be disheartened if you find it takes several months or longer to find what works for you. Even once you are established on a regime of medication that suits you, it is possible for this to change over time. You will need to be seen regularly (normally once or twice each year) by your endocrinology team to keep an eye on how you feel. As your replacement medication dose is individual to you, and you will learn to listen to your body, giving your body what it needs each day, as you do with food and water. Free NHS prescriptions - Medical Exemption Certificate People with Addison's and adrenal insufficiency are entitled to free prescriptions on the NHS, so you won’t need to pay for medications. In England, you'll need a prescription exemption certificate to claim your free prescription unless you're 60 or over. Prescriptions are free for everybody in Scotland, Wales and Northern Ireland. You can find out if you're entitled to free NHS prescriptions using their eligibility quick and easy online eligibility checker Sick Day Rules When the body experiences illness, injury and physical or psychological trauma, it needs more cortisol than usual. As a result, you will need to take extra medication on top of your usual daily dose to meet the increased cortisol need. This extra medication is known as ‘stress dosing’ or ‘updosing’. You will also need to take extra if you are not able to take, or are not absorbing your usual daily dose due to vomiting or diarrhoea. In cases of vomiting or shock, people with Addison’s and adrenal insufficiency can experience a sudden drop in blood pressure and if you do not take enough extra medication, you may experience a life-threatening emergency called an adrenal crisis. The Sick Day Rules are a set of guidelines that have been developed by clinicians to help keep you safe and reduce the chances of an adrenal crisis. As everyone’s medication needs are different, they are guidance rather than concrete rules. Always listen to your body and understand that minor ailments (e.g. colds and flu) can have a potentially serious effect on anyone with a steroid-dependent adrenal condition. It's important to recognise the early symptoms of a bug or cold and adjust your steroid replacement medication accordingly. Sick Day Rules Adrenal Crisis Without sufficient steroid hormone replacement, all patients with adrenal insufficiency are at risk of a life-threatening emergency called an adrenal crisis. They have to follow a strict medication regime, taking glucocorticoid treatment at carefully timed intervals every day to replace what their body can’t produce. An adrenal crisis is experienced when the body’s need for cortisol outstrips the ability of the adrenal glands to produce it. We look later at the potential triggers of adrenal crisis. It requires time-critical and life-saving medical treatment. This takes the form of an emergency injection of hydrocortisone, either self-administered, or administered by someone close by, or a medical professional. This needs to be followed up by a hospital visit for intravenous fluids. Adrenal Crisis Management Emergency Injection Kits The NICE Guidelines for the Identification and Management of Adrenal Insufficiency suggest that everyone with Addison's disease (primary adrenal insufficiency) and secondary insufficiency (due to a problem with the pituitary gland) should be prescribed a minimum of 2 emergency injection kits. People with tertiary adrenal insufficiency and a history of adrenal crisis should also be considered for an emergency injection kit. There are two types of hydrocortisone injection medication available. Therefore a kit is prescribed as 3-5 vials of either: Hydrocortisone Sodium Phosphate (100mg) – 1ml liquid ampoule OR Hydrocortisone Sodium Succinate 100mg powder / Hydrocortisone 100mg Powder for Solution, for injection or infusion – 1 x 2ml vial with dilutant (5ml or 10ml water) The kit(s) should also contain 2 x intramuscular (IM) needles and 2 x 2ml syringes, and written instructions in an easy-to-understand format, on how to prepare and give the injection, and dispose of needles and syringes. You can find out more about what goes into a kit and how to get one below. Emergency hydrocortisone injection kit FAQs on Medication Explore the answers to some of the most frequently asked questions we get asked about medication. FAQs Whether you're newly diagnosed or have lived with the condition for years - please join our community and support our cause! 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