Our Chair of Trustees at the ADSHG, Dominic Hargreaves, shares his experience of changing from hydrocortisone to prednisolone as his glucocorticoid replacement medication.

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In sharing this story, I think it is important to start with some background. I was diagnosed with Addison’s disease in 2004 and have been on a constant dose of hydrocortisone ever since, 10mg on waking, 10mg at 1130hrs and 5mg at 17:30- 18:00 hrs. In addition, I take 200mg of Fludrocortisone daily, and recently, as I have got older, a variety of medications to manage hypertension.

I was actively involved in the ADSHG when first diagnosed, whilst on my journey to becoming an expert patient. I have been a Trustee for the charity since 2019 and Chairman of Trustees since 2022. As a result of my exposure to the charity, I routinely met with a lot of the leading lights of the UK endocrine medics, and I am very immersed in Addison's disease and adrenal insufficiency from a patient perspective.      

In the last few years, I have found that I have been waking very early in the morning with joint pain, which resolved itself within 20 minutes of taking hydrocortisone and muscle aches/stiffness during the day. I had put a lot of these aches and pains down to the wide range of musculoskeletal injuries that I had sustained during my military and rugby careers. With hindsight, these musculoskeletal aches and pains were similar to the ones that I encountered on the route to diagnosis. It was getting to the point where I was taking significant doses (Naproxen 500mg, with gastro-resistant capsules) of anti-inflammatory medications two or four times a week to cope with the pain. 

Over the twenty-plus + years that I have had Addison’s disease, I have conducted various trials which have involved adjusting my medication, working with the GP and Endocrinologist who look after me. To date, these trails have been linked to:

• Management of nausea and blood electrolyte and creatine levels (2004) – which resulted in my starting a 100mg fludrocortisone dose.
• Management of nausea and blood electrolyte and creatine levels (2012) – which resulted in me increasing my fludrocortisone dose to 200 mg. This trial elevated my blood pressure, but generally, I felt a lot better on the higher dose. We agreed that the blood pressure increase would be managed when the hypertension became a concern.
• Management of blood pressure (2024) – my hypertension had now become an issue, and it was agreed to try reducing my fludrocortisone dose to see what impact that would have on my hypertension and blood quality. This trial was very short; severe nausea returned within 72 hours of starting the trial, to the extent I considered not going to work. I reverted to my normal 200 mg dose and was then prescribed tablets for hypertension.   

Before starting any of these trials, I have sought agreement with both my GP and Endocrinologist, and made both aware of the start dates of each trial. Each of the trials has required me to be tested before starting the trial, and afterwards (blood tests and blood pressure testing), I have always reported back on the outcome of the trial to both parties.   

Prednisolone Trial 

All of a sudden, I realised I was a creature of habit, and I had been very psychologically comfortable on Hydrocortisone. I then started some research on Prednisolone before the prescription arrived in the post.  My concerns initially were:

• What is the correct dose for prednisolone?
• How long does it take to become effective in the morning?
• How would I manage the transition from one medication to the other?
• How do I adjust my medication for travel?

The Living with Addison’s Disease book contained two tables of interest. 

The first table is about the respective dosing of cortisol replacement tablets:

Drug	Equivalent Dose	Split into daily doses
Hydrocortisone	20mg	2 or 3 doses
Prednisolone	5mg	1(or 2)
Dexamethasone	0.75mg	1 or 2
Cortisone acetate	25mg	2 or 3

A second table contains dose regimes (limited extract):

Job	Weight (kg)	Hydrocortisone Dose
Journalist	49	10mg,  5mg
Nurse	59	10mg, 2.5mg, 2.5mg, 2.5mg
Postman	65	10mg, 10mg, 2.5mg
IT Tech	78	10mg, 5mg, 5mg
Builder	105	10mg, 10mg, 5mg

Physiologically, as a larger active man, I have coped with 25mg (10mg, 10mg and 5mg) of hydrocortisone for twenty + years, which matched the second table. Historically, I tended to under-medicate and not take the 5mg evening dose, unless I was staying out late or was fatigued, etc. Recently, I have found the evening dose of 5mg was more important to try and manage late-night pain. I frequently surge my medication using the sick day rules (two or three days per month), a habit I wasn’t aware of until I took part in the VIStAA study, led by Lisa Shepherd.

I was therefore nervous about taking the initial prescribed dose of 3mg of Prednisolone. On the first two days of the trial, I was struggling with postural drop by 3 o’clock in the afternoon (literally, I would sit down and fall asleep) and took 10mg of Hydrocortisone on each occasion to recover. Rather than cancel the trial, I took the decision to increase my daily dose to 4mg Prednisolone on waking and see what the effect would be. On the 4mg dose, I felt I was bumping on the bottom of my cortisol dose by mid to late afternoon (but no postural droop symptoms), and I topped up with 5mg of hydrocortisone at 1800hrs each day.  

Read more: cortisol replacement medication

After two weeks on this dose regime, I have found I have no joint pain on waking or leg muscular stiffness during the day. This change alone was a significant upturn in my quality of life. The lack of pain also meant that I was sleeping through the night and not waking up craving Hydrocortisone, another bonus.            

In the third week of this routine, I was exposed to flu-like symptoms in the office and added 25mg of hydrocortisone, under sick day rules, over the top of my Prednisolone for four days until fully recovered.  

I then had to fly to the US for a work trip for a week, and unsure how to manage the time zone shift, jet lag and long working days etc, on Prednisolone, I reverted back to Hydrocortisone. Interestingly, joint pain in the morning and leg stiffness returned within a week of being back on Hydrocortisone.