Adrenal insufficiency is treated by replacing the hormones your adrenal glands can no longer make in sufficient amounts. Most people take a daily oral glucocorticoid, typically hydrocortisone at 15 to 25 mg per day split into two or three doses. With the right medication regimen and a few key safety habits, most people with adrenal insufficiency live full, active lives.
Getting the Right Diagnosis First
Before treating adrenal insufficiency, you need a confirmed diagnosis. A morning blood draw showing cortisol below 3 micrograms per deciliter strongly suggests insufficiency, while levels above 18 generally rule it out. Values in between require a stimulation test: you receive a synthetic hormone that tells the adrenal glands to produce cortisol, and your blood is drawn 30 to 60 minutes later. A normal response is a cortisol level at or above 18 micrograms per deciliter. Anything below that confirms insufficiency.
Your doctor will also check whether the problem originates in the adrenal glands themselves (primary adrenal insufficiency, also called Addison’s disease) or in the pituitary gland, which sends signals to the adrenals (secondary adrenal insufficiency). This distinction matters because primary insufficiency usually requires an additional medication to replace a second hormone. A common cause of secondary insufficiency is long-term use of steroid medications like prednisone for conditions such as asthma or autoimmune diseases, which can suppress the adrenal glands if taken at doses above the body’s natural production for more than three to four weeks.
A Note on “Adrenal Fatigue”
“Adrenal fatigue” is not a recognized medical diagnosis. The term is widely used in wellness spaces to describe chronic tiredness, sleep problems, and difficulty recovering from illness, but cortisol testing in people with these symptoms often comes back completely normal. That doesn’t mean the fatigue isn’t real. It means the cause is something other than failing adrenal glands. If you suspect your adrenals are the problem, getting a proper stimulation test is the clearest way to know whether you need hormone replacement or whether your symptoms point to a different issue entirely.
Daily Glucocorticoid Replacement
The cornerstone of treatment is replacing cortisol, the stress hormone your adrenals aren’t producing enough of. The Endocrine Society recommends 15 to 25 mg of hydrocortisone daily, taken in divided doses to roughly mimic the body’s natural rhythm. A typical approach is a larger dose in the morning when cortisol would normally peak, with a smaller dose in the early afternoon. Some people take a third small dose later in the day if fatigue creeps in.
If splitting doses throughout the day is impractical, alternatives include prednisone (3 to 5 mg daily) or cortisone acetate (20 to 35 mg daily), also in divided doses. The choice often comes down to personal preference and how well you tolerate each option. Your doctor will fine-tune the dose over time, watching for signs of too much replacement (weight gain, high blood sugar, trouble sleeping) or too little (persistent fatigue, low blood pressure, nausea).
A newer option available in Europe is a modified-release hydrocortisone tablet taken once daily in the morning. It combines an immediate-release outer layer with a delayed-release core, delivering cortisol more steadily across the day. In clinical trials, people on this formulation lost an average of 2 kg over 24 weeks while those on conventional hydrocortisone gained nearly 2 kg, resulting in a 4 kg difference between groups. Blood sugar control and quality of life also improved. Importantly, the once-daily tablet delivers about 20% less bioavailable cortisol than the same milligram dose of standard hydrocortisone, which may explain some of those metabolic benefits.
Mineralocorticoid Replacement for Primary Insufficiency
If you have primary adrenal insufficiency, your adrenals likely aren’t producing enough aldosterone either. Aldosterone controls your body’s balance of sodium, potassium, and water. Without it, you lose too much salt in your urine, which drops blood pressure and can cause dizziness, dehydration, and dangerous electrolyte shifts.
The fix is fludrocortisone, a synthetic version of aldosterone, typically started at 50 to 100 micrograms per day in adults. Infants with primary insufficiency may also need direct sodium supplements during their first year. Unlike glucocorticoid dosing, which requires frequent adjustments, fludrocortisone doses tend to stay relatively stable. Your doctor will monitor blood pressure (both sitting and standing) and potassium levels to keep the dose dialed in. People with primary insufficiency should also avoid restricting salt intake, and some benefit from deliberately eating more sodium-rich foods.
Stress Dosing During Illness or Procedures
A healthy body ramps up cortisol production during physical stress. Yours can’t, so you need to increase your medication manually. The rules are straightforward:
- Fever of 100.4°F or higher: Take 20 mg hydrocortisone or 15 mg prednisone daily for three days or until the fever breaks.
- Diarrheal illness without fever: Double your normal dose for the duration of symptoms.
- Other illness that keeps you in bed: Double your normal dose until you feel well enough to resume normal activity.
- Minor procedures (colonoscopy, dental extraction, endoscopy without general anesthesia): Double your dose the day before, the day of, and the day after.
For major surgery under general anesthesia, your medical team will administer higher doses intravenously. The key is making sure every provider involved in your care knows about your adrenal insufficiency before any procedure.
Emergency Preparedness
An adrenal crisis happens when your body faces severe stress and cortisol drops dangerously low. It can cause fainting, vomiting, severe abdominal pain, and in extreme cases, shock. This is a medical emergency.
Everyone with adrenal insufficiency should carry an emergency injection kit. The kit contains a vial of injectable hydrocortisone (sold as Solu-Cortef), alcohol wipes, a syringe with needle, gauze, and a bandage. You give yourself the injection into the outer thigh if you have a serious injury, are vomiting and can’t keep oral medication down, feel faint, or are too sick to take your daily pills. Your doctor or pharmacist will walk you through exactly how to prepare and inject the medication, and it’s worth practicing the steps so they feel automatic in a crisis.
Wearing a medical alert bracelet or necklace is equally important. If you’re found unconscious, emergency responders need to know you have adrenal insufficiency and require immediate cortisol. The ID should list your condition, your daily medication, and an emergency contact.
Tapering Off Glucocorticoids Safely
If your adrenal insufficiency was caused by long-term steroid use for another condition, there’s a possibility your adrenal glands can recover once the steroid is no longer needed. The process is slow and must be done carefully. Your dose is gradually reduced until you reach a physiologic replacement level (roughly 4 to 6 mg of prednisone daily). From there, your doctor will either continue tapering in small increments while watching for symptoms of insufficiency, or check a morning cortisol level to see if your adrenals are waking back up.
Switching from a long-acting steroid like dexamethasone to a shorter-acting one like hydrocortisone or prednisone makes the taper smoother, since shorter-acting drugs clear your system faster and give the adrenal glands more opportunity to resume production. Recovery can take months, and some people’s adrenals never fully bounce back. During the taper, you still need stress dosing rules and an emergency kit.
Living Well Long-Term
The goal of replacement therapy is to use the lowest effective dose. Even at recommended replacement levels, long-term glucocorticoid use carries some risk of reduced bone density, weight gain, and changes in blood sugar. Regular monitoring, typically through annual checkups that include bone density scans and metabolic panels, helps catch problems early.
Day-to-day management becomes routine for most people. You take your medication on a consistent schedule, carry your emergency kit, wear your medical ID, and adjust doses when you’re sick or stressed. Exercise is safe and encouraged, though you may need a small extra dose before unusually intense physical activity. Travel requires planning: pack extra medication, carry a letter from your doctor explaining your condition and the need for syringes, and account for time zone changes when scheduling doses.
The condition is lifelong for most people with primary insufficiency and for many with secondary insufficiency. But with reliable hormone replacement and the habit of adjusting doses when your body needs more, the vast majority of people maintain normal energy, activity levels, and quality of life.