Avoid Synthetic, Long-Acting Glucocorticoids in Children with PAI
STEP 1 — Gather Information
Confirm diagnosis of PAI in the child (via ACTH stimulation test or clinical/lab criteria) and assess need for glucocorticoid replacement therapy.
STEP 2 — Rule In / Rule Out
If the child has PAI and requires glucocorticoid replacement, rule out synthetic, long-acting glucocorticoids (prednisolone, dexamethasone) due to risks in pediatric PAI.
STEP 3 — Classify or Stratify
Classify glucocorticoid options: preferred short-acting agents (hydrocortisone, cortisone acetate) versus avoided long-acting agents (prednisolone, dexamethasone).
STEP 4 — Decide
Initiate glucocorticoid replacement with hydrocortisone (8 mg/m²/day in three or four divided doses) or cortisone acetate (20–35 mg/day in two or three divided doses); avoid prednisolone and dexamethasone entirely.
Clinical Guardrails / Mimics / Pitfalls
Do not use dexamethasone due to high risk of Cushingoid side effects and difficulty in dose titration. Avoid prednisolone in children with PAI as it is long-acting and may cause overexposure; if hydrocortisone is unavailable, prednisolone is a last-resort alternative only with extreme caution (per guideline 3.3), but dexamethasone remains least preferred.
Concrete Clinical Example
A 6-year-old girl with PAI (autoimmune etiology) is started on hydrocortisone 9 mg/m²/day in three divided doses (5 mg/m² morning, 2 mg/m² noon, 2 mg/m² evening) after confirming low cortisol and high ACTH. Prednisolone and dexamethasone are avoided per guideline 3.19.
Source: Diagnosis and Treatment of Primary Adrenal Insufficiency: An Endocrine Society Clinical Practice Guideline, Endocrine Society, 2016, DOI: 10.1210/jc.2015-1710