Addison’s disease is treated with daily hormone replacement pills that substitute for the cortisol and aldosterone your adrenal glands can no longer produce. Most people take two medications, one replacing each hormone, and adjust their doses during illness, surgery, or pregnancy. With the right regimen, people with Addison’s disease can expect a normal, active life, but understanding how to manage the treatment day to day is essential.
Daily Glucocorticoid Replacement
The cornerstone of treatment is replacing cortisol, the stress hormone your adrenals would normally release. The standard medication is hydrocortisone, taken at a total daily dose of 15 to 25 mg split into two or three doses throughout the day. The largest dose is taken first thing in the morning, because that’s when your body would naturally produce the most cortisol. A second dose follows in the early afternoon, and if you’re on a three-dose schedule, a smaller third dose is taken later in the afternoon.
An alternative is cortisone acetate at 20 to 35 mg per day, split the same way. For people who struggle with taking pills multiple times a day, prednisolone (3 to 5 mg daily, once or twice) can be used instead. Dexamethasone is generally avoided because its potency makes it too easy to accidentally take too much, leading to side effects like weight gain, high blood sugar, and thinning skin.
One limitation of current treatment is that swallowing a pill doesn’t perfectly replicate how your body would release cortisol naturally. Healthy adrenal glands produce cortisol in rhythmic pulses and ramp up production before you even wake up. Oral pills miss that pre-awakening surge and create brief spikes of higher-than-normal levels after each dose. This mismatch is one reason some people with Addison’s still experience fatigue or brain fog despite treatment. Researchers are working on modified-release formulations, but for now, timing your doses consistently is the best tool you have.
Mineralocorticoid Replacement
Most people with Addison’s disease also lose the ability to produce aldosterone, the hormone that regulates salt, potassium, and blood pressure. This is replaced with fludrocortisone, typically started at 50 to 100 micrograms per day as a single morning pill. Without it, your body dumps too much sodium in urine, which drops blood pressure and raises potassium to potentially dangerous levels.
Unlike the general population, people on fludrocortisone should not restrict their salt intake. In fact, a higher sodium diet is often recommended. Your doctor or a dietitian can help you figure out how much extra salt you need based on your symptoms and lab results. If you notice salt cravings, lightheadedness when standing, or unusually low energy, your fludrocortisone dose may need adjustment.
How Treatment Is Monitored
There’s no single blood test that tells you your glucocorticoid dose is perfect. Instead, doctors rely on clinical signs: your body weight, energy levels, blood pressure (especially when you stand up), and overall well-being. Too little hydrocortisone causes fatigue, nausea, and weight loss. Too much causes weight gain, insomnia, and elevated blood sugar.
For fludrocortisone, monitoring is a bit more nuanced. Doctors check blood pressure, potassium levels, and sometimes a blood marker called plasma renin, which reflects your blood volume status. Renin appears to be more sensitive to dose changes than blood pressure or electrolytes alone, making it a useful signal that your mineralocorticoid dose is too high or too low. Swollen ankles suggest too much fludrocortisone, while dizziness on standing and salt cravings suggest too little.
Sick Day Rules
When your body is healthy, 15 to 25 mg of hydrocortisone covers your daily needs. But illness, fever, and injury all increase cortisol demand significantly. A healthy person’s adrenal glands would automatically ramp up production. Yours can’t, so you have to do it manually.
The general approach is to double or triple your oral hydrocortisone dose during moderate illness like a fever, flu, or infection that keeps you in bed. If you’re vomiting and can’t keep pills down, you need an emergency injection (more on that below). Once you’re recovering and eating normally, you taper back to your usual dose over a day or two. These “sick day rules” should be discussed with your endocrinologist so you have a clear, personalized plan before you actually get sick.
Emergency Preparedness for Adrenal Crisis
Adrenal crisis is the most dangerous complication of Addison’s disease. It happens when your body faces severe physical stress, such as major infection, surgery, or trauma, without enough cortisol to respond. Symptoms include severe weakness, vomiting, abdominal pain, confusion, and dangerously low blood pressure. Without treatment, it can be fatal.
Emergency treatment involves an injection of 100 mg hydrocortisone (into a muscle or vein), followed by rapid fluid replacement and continued high-dose hydrocortisone at about 200 mg over 24 hours until recovery. For children, the dose is weight-based: 25 mg for infants under one year, 50 mg for children aged one to five, and 100 mg for those over six.
Every person with Addison’s disease should carry three things at all times: a steroid emergency card, a medical alert bracelet or necklace, and an injectable hydrocortisone kit. The emergency kit is for situations where you can’t take oral medication, whether from vomiting, loss of consciousness, or a serious accident. Make sure someone close to you, a partner, family member, or coworker, knows how to give the injection.
Surgery and Medical Procedures
Any surgery, even a minor one, increases your body’s cortisol needs. If you have Addison’s disease and are scheduled for a procedure, your medical team will plan supplemental steroid coverage. The approach depends on the level of surgical stress. For minor procedures, continuing your normal oral dose may be enough with a small intravenous boost. For major surgery, protocols typically call for 100 to 200 mg of hydrocortisone per day given intravenously, tapered back to your normal oral dose once you’re eating and recovering, usually within a few days.
The trend in recent years has been toward lower supplemental doses and shorter tapers than were used in the past, since excessively high steroid doses carry their own risks, including impaired wound healing and elevated blood sugar. The key is making sure your surgeon and anesthesiologist know about your Addison’s disease well before the day of surgery.
DHEA for Women
Some women with Addison’s disease experience low libido, depressive symptoms, or persistent low energy even when their hydrocortisone and fludrocortisone doses are well optimized. This can be related to loss of DHEA, a precursor hormone that the adrenal glands normally produce in significant amounts. A trial of DHEA replacement is sometimes recommended in these cases.
The typical approach is a six-month trial. If you notice a meaningful improvement in energy, mood, or sexual function during that time, continuing makes sense. If not, the supplement is stopped. DHEA is not routinely recommended for all patients, only for women with specific symptoms that haven’t responded to standard replacement.
Managing Addison’s Disease During Pregnancy
Pregnancy is very possible with Addison’s disease, but it requires closer monitoring and dose adjustments. Hydrocortisone is the preferred glucocorticoid during pregnancy because other options like dexamethasone cross the placenta and can affect the baby. Fludrocortisone is continued as usual.
As pregnancy progresses, cortisol demand rises. Doses typically increase in the third trimester, sometimes substantially. One published regimen used a total of 35 mg of hydrocortisone per day in the third trimester, compared to the usual 15 to 25 mg. During active labor, stress-dose steroids are given intravenously, similar to what’s used during major surgery, at around 100 mg of hydrocortisone three times daily. After delivery, the dose is tapered over several days back to the pre-pregnancy regimen.
Treatment in Children
Children with Addison’s disease are treated with the same medications as adults, but doses are calculated differently. Hydrocortisone is dosed based on body surface area, starting at about 8 mg per square meter per day, divided into three or four doses. This is adjusted as the child grows and based on how they’re responding clinically. Over-replacement is a particular concern in children because excess glucocorticoids can slow growth.
Children with aldosterone deficiency take fludrocortisone at a starting dose of 100 micrograms per day. Infants have an additional requirement: sodium chloride supplements from birth through the first 12 months, because breast milk and formula alone may not provide enough sodium to compensate for their salt-wasting.