Glucocorticoid replacement is needed in primary and secondary adrenal insufficiency. Cortisol (hydrocortisone) is the most physiologically appropriate drug; prednisolone has little mineralocorticoid activity, and cortisone acetate suffers variable absorption and hepatic conversion to cortisol.1 Patients with primary adrenal insufficiency usually need additional mineralocorticoid replacement with fludrocortisone once a day. Patients with secondary adrenal failure (ACTH deficiency due to pituitary/hypothalamic disease) still produce aldosterone and so do not need fludrocortisone.
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