In a randomized crossover study, higher doses resulted in modestly higher blood pressure.
No universally accepted glucocorticoid replacement dose exists for patients with adrenal insufficiency. When hydrocortisone is used, divided doses often are given to mimic natural diurnal variation (higher dose early, lower dose later). In this double-blind crossover study, researchers compared the blood pressure effects of higher and lower hydrocortisone doses in 46 Dutch patients with secondary adrenal insufficiency. Each patient received courses of high-dose and low-dose hydrocortisone (10 weeks each, in random order), according to a dosing protocol. For example, a 70-kg patient received 15 mg daily during the low-dose phase (7.5 mg, 5.0 mg, and 2.5 mg before breakfast, lunch, and dinner, respectively), and twice these amounts during the high-dose phase.
Mean blood pressure was significantly higher at the end of the high-dose phase, compared with the low-dose phase (systolic/diastolic difference, 5/2 mm Hg). Plasma renin and aldosterone levels were lower with high-dose than with low-dose hydrocortisone, presumably reflecting hydrocortisone’s mineralocorticoid activity.
EDITOR DISCLOSURES AT TIME OF PUBLICATION
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Disclosures for Allan S. Brett, MD at time of publication Nothing to disclose
Filed under: adrenal crisis, Cushing's | Tagged: adrenal insufficiency, blood pressure, glucocorticoid, hydrocortisone |
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COMMENT
Although the higher blood pressure with high-dose hydrocortisone was modest, it conceivably could be consequential over many years of treatment. However, these researchers have published quality-of-life outcomes from this study elsewhere (Neuroendocrinology 2016; 103:771), and those outcomes generally were better with high-dose than with low-dose therapy. This study was too brief to be definitive, but it does highlight potential tradeoffs involved in glucocorticoid dosing for adrenal insufficiency. Whether the findings apply to patients with primary adrenal insufficiency is unclear.