Understanding Addison’s Disease

Addison’s disease, also known as primary adrenal insufficiency, occurs when the adrenal glands do not produce enough of the essential hormones cortisol and aldosterone. Cortisol plays a critical role in regulating metabolism, blood sugar, and immune responses, while aldosterone helps balance salt and water in the body, maintaining blood pressure.

Because hormone production is permanently reduced or lost, Addison’s disease requires lifelong treatment. The cornerstone of therapy is hormone replacement, ensuring the body receives the hormones it can no longer produce. Additional medications, lifestyle adjustments, and emergency preparedness are also part of comprehensive care.

Goals of Treatment

The primary objectives of treating Addison’s disease are:

  • Restoring hormonal balance: Replacing cortisol and aldosterone at levels similar to natural production.

  • Preventing adrenal crisis: Reducing risk of life-threatening emergencies.

  • Maintaining quality of life: Helping patients live normal, active lives.

  • Supporting long-term health: Preventing complications like chronic fatigue, low blood pressure, and electrolyte imbalance.

Treatment is highly individualized, with doses adjusted based on symptoms, stress levels, and lifestyle.

Glucocorticoid Replacement

The most important part of Addison’s treatment is glucocorticoid replacement therapy. This provides synthetic forms of cortisol to regulate metabolism, immune response, and stress adaptation.

Common medications include:

  • Hydrocortisone: The most commonly prescribed glucocorticoid, given in two or three doses daily to mimic natural cortisol rhythm.

  • Prednisone or prednisolone: Longer-acting alternatives, sometimes preferred for convenience.

  • Dexamethasone: Potent and long-lasting, used less often due to higher risk of side effects.

Key considerations:

  • Doses must be carefully balanced to avoid underdosing (leading to fatigue, nausea, or adrenal crisis) or overdosing (causing weight gain, insomnia, or osteoporosis).

  • During illness, injury, or stress, doses often need temporary adjustment (“stress dosing”).

Mineralocorticoid Replacement

Many patients also require mineralocorticoid replacement to restore aldosterone function, which maintains sodium and potassium balance.

  • Fludrocortisone acetate is the standard treatment.

  • It helps regulate blood pressure, electrolyte levels, and hydration.

  • Patients are often advised to consume a moderate salt-rich diet alongside fludrocortisone.

Without mineralocorticoid replacement, patients risk severe dehydration, low blood pressure, and dangerous electrolyte imbalances.

Managing Stress Dosing

Because the adrenal glands normally release extra cortisol during stress, Addison’s patients must compensate with stress dosing.

  • Mild stress (fever, infection): Doubling oral glucocorticoid doses.

  • Severe stress (surgery, trauma, hospitalization): Intravenous or intramuscular hydrocortisone injections.

  • Adrenal crisis prevention: Patients should always carry an emergency hydrocortisone injection kit.

Stress dosing is life-saving, and patient education is critical to avoid adrenal crisis during emergencies.

Emergency Management of Adrenal Crisis

Adrenal crisis is a medical emergency that can occur if hormone replacement is interrupted or stress dosing is not administered. Symptoms include severe vomiting, dehydration, low blood pressure, shock, and confusion.

Emergency treatment includes:

  • Intravenous hydrocortisone immediately.

  • IV fluids with electrolytes to restore circulation.

  • Treatment of underlying cause (infection, injury, or withdrawal from steroids).

Every Addison’s patient should wear a medical alert bracelet and carry emergency identification for prompt treatment.

DHEA Supplementation

Some patients, particularly women, may benefit from dehydroepiandrosterone (DHEA) supplementation.

  • DHEA is a weak androgen hormone produced by the adrenal glands.

  • Supplementation may improve mood, energy, and sexual well-being.

  • Evidence is mixed, so it is not routinely prescribed for all patients.

This option is usually considered when patients report persistent fatigue or reduced quality of life despite optimal hormone replacement.

Lifestyle Adjustments

Medications alone are not enough—patients must adopt supportive lifestyle strategies:

  • Balanced nutrition: Adequate salt and hydration are especially important.

  • Regular medical follow-ups: Monitoring hormone levels and adjusting medications.

  • Consistent sleep and stress management: Cortisol deficiency makes stress harder to handle.

  • Avoiding abrupt steroid withdrawal: Hormone replacement should never be stopped suddenly.

Education plays a central role, empowering patients to manage their condition daily.

Monitoring and Long-Term Care

Treatment is lifelong, and ongoing monitoring ensures effectiveness. Regular evaluations may include:

  • Electrolyte testing (sodium, potassium).

  • Blood pressure checks.

  • Weight monitoring to track fluid balance.

  • Bone density scans if long-term glucocorticoid doses are high.

Endocrinologists often work closely with patients to fine-tune therapy, adapting doses during illness, pregnancy, or major life events.

Future Therapies

Research is underway to improve Addison’s treatment beyond current medications:

  • Modified-release hydrocortisone: Designed to better mimic natural circadian cortisol rhythms.

  • Continuous infusion pumps: Deliver steady cortisol, reducing fluctuations.

  • Gene and stem cell therapies: Long-term possibilities for restoring adrenal function.

While not yet widely available, these emerging therapies hold promise for reducing reliance on lifelong oral medication.

Living With Addison’s Disease

With proper treatment and education, people with Addison’s disease can live full, healthy lives. Key practices include:

  • Taking medications consistently.

  • Adjusting doses appropriately during stress.

  • Recognizing early signs of adrenal crisis.

  • Keeping medical identification and emergency kits accessible.

Though Addison’s disease requires constant management, modern therapies allow patients to maintain energy, stability, and well-being.