Adrenal insufficiency is treated with daily hormone replacement medications that substitute for what your adrenal glands can no longer produce on their own. The core of treatment is a glucocorticoid taken every day, with additional medications and adjustments depending on whether you have primary or secondary adrenal insufficiency. Beyond the daily pills, living safely with this condition means knowing how to adjust your dose during illness, carrying emergency supplies, and wearing medical identification.
Daily Glucocorticoid Replacement
The foundation of treatment is replacing cortisol, the stress hormone your adrenal glands normally make throughout the day. Three glucocorticoid medications are commonly used: hydrocortisone, prednisone, and dexamethasone. They all do the same basic job but differ in how long they last in your body, which affects how often you take them.
Hydrocortisone is the most commonly prescribed because it closely mimics your body’s natural cortisol rhythm. It’s typically taken first thing in the morning, with a second or third smaller dose in the late afternoon or around dinner. This split dosing pattern tries to replicate the way healthy adrenal glands release more cortisol in the morning and taper off through the day. Prednisone lasts longer and can be taken once daily, either at bedtime or in the morning. Dexamethasone is the longest-acting option and is usually taken once at bedtime.
Your doctor will start you at a dose and fine-tune it over time based on how you feel and your lab results. The goal is to find the lowest dose that controls your symptoms without tipping into over-replacement. Getting this balance right matters a lot, because too much glucocorticoid over months and years can lead to central weight gain, high blood pressure, insulin resistance, weakened bones, and increased infection risk. These are essentially the same problems seen in Cushing’s syndrome, where the body has too much cortisol. Too little replacement, on the other hand, leaves you fatigued, lightheaded, and vulnerable to adrenal crisis.
Mineralocorticoid Replacement for Primary AI
If you have primary adrenal insufficiency (Addison’s disease), your adrenal glands also can’t make aldosterone, the hormone that regulates sodium, potassium, and blood pressure. To replace it, you’ll take fludrocortisone, typically 0.05 to 0.2 mg once daily in the morning. Most people start at 0.05 to 0.1 mg, and the dose gets adjusted in small increments of 0.025 to 0.05 mg.
Your doctor monitors whether your fludrocortisone dose is right by checking your blood pressure, potassium levels, and a blood marker called plasma renin. They’ll also ask about specific symptoms. Salt cravings, dizziness when standing, weight loss, and dehydration suggest you need more. High blood pressure, rapid weight gain, and low potassium suggest you’re getting too much. After any dose change, it takes at least one to two weeks before lab tests will reflect the adjustment.
If you have secondary adrenal insufficiency, where the problem originates in the pituitary gland rather than the adrenal glands themselves, you do not need fludrocortisone. Your adrenal glands are still intact and continue producing aldosterone on their own, since aldosterone production is controlled by a separate system.
Dietary Sodium and Hydration
People with Addison’s disease who have low aldosterone levels often benefit from a higher-sodium diet. Because aldosterone normally helps your kidneys retain salt, its absence means you lose more sodium in your urine. A dietitian can help you figure out how much additional sodium you need and the best food sources. This is less of a concern for people with secondary adrenal insufficiency, since their aldosterone function remains intact.
Staying well hydrated is also important, especially during hot weather or exercise, when your body loses extra fluid and salt through sweat. Dehydration can lower blood pressure further and increase your risk of feeling faint or triggering a crisis.
Sick Day Rules
One of the most critical things to learn after diagnosis is how to adjust your medication when your body is under physical stress. Illness, injury, and procedures all increase your body’s cortisol demand, and since your adrenal glands can’t ramp up production on their own, you need to manually increase your dose. These adjustments are called “sick day rules,” and getting them right can prevent a life-threatening adrenal crisis.
For fever above 37.5°C (99.5°F) or an active infection like a chest or urinary tract infection, the standard approach is to double your usual hydrocortisone dose for as long as the fever lasts. If you take prednisone instead, you increase to 10 mg daily.
Vomiting and diarrhea require a different approach because your body may not absorb oral medication properly. Take an additional 20 mg of hydrocortisone (or 5 mg prednisone, or 0.75 mg dexamethasone) immediately after each vomiting or diarrhea episode. If you can’t keep anything down, you may need an emergency injection.
For minor procedures like a tooth extraction, double your oral dose for 24 hours and take the increased dose about an hour before the procedure. Major dental surgery follows the same doubling rule for 24 hours after the procedure, then you return to your normal dose. For any surgery under general anesthesia, your medical team will manage stress dosing with intravenous glucocorticoids during and after the operation.
Emergency Preparedness
Adrenal crisis is the most dangerous complication of adrenal insufficiency. It can happen when your body faces severe stress, like a bad stomach virus, a car accident, or surgery, without enough cortisol to cope. Symptoms include severe weakness, confusion, vomiting, abdominal pain, and dangerously low blood pressure. Without treatment, it can be fatal.
Everyone with adrenal insufficiency should carry an emergency injection kit. The kit contains an intramuscular hydrocortisone injection (100 mg), along with needles, syringes, and written instructions for preparation and administration. Two formulations exist: one comes ready to use, and another is a powder that needs to be mixed with liquid before injecting. You and someone close to you should practice the steps so you can act quickly if you’re too sick to reach a hospital.
Medical alert identification is equally important. Guidelines recommend wearing a bracelet or necklace inscribed with clear emergency instructions, such as: “Adrenal insufficiency. Give IM 100 mg hydrocortisone.” In an emergency where you can’t speak for yourself, this tells paramedics exactly what you need. Carrying a steroid emergency card in your wallet provides additional detail for first responders.
Glucocorticoid-Induced Adrenal Insufficiency
If your adrenal insufficiency was caused by taking steroid medications (like prednisone for asthma or an autoimmune condition), treatment follows a slightly different path. You still need glucocorticoid coverage during the recovery period while your adrenal glands wake back up, but you do not need fludrocortisone, since your adrenals were never damaged and can still produce aldosterone.
Current Endocrine Society guidelines from 2024 recommend oral glucocorticoids for minor stress events when you’re otherwise stable, and injectable glucocorticoids for moderate to major stress, procedures under general anesthesia, or situations involving prolonged vomiting, diarrhea, or low blood pressure. If you were on a short course of steroids lasting less than three to four weeks, the risk of lasting adrenal suppression is low, and you can typically stop without a prolonged taper.
Long-Term Monitoring
Treatment for adrenal insufficiency is lifelong in most cases, and your medication needs will shift over time. Weight changes, aging, new medications, and changes in activity level can all affect how much glucocorticoid you need. Periodic lab work and symptom check-ins help your doctor keep your doses dialed in.
Because even appropriate-dose glucocorticoid replacement carries some long-term risk to bone density, your doctor may periodically screen for osteoporosis, especially if you’re postmenopausal or have other risk factors. Monitoring blood sugar and cholesterol is also reasonable, given the metabolic effects of chronic glucocorticoid use. The overarching principle is to use the lowest effective dose that keeps you feeling well and protects you during physical stress.