What is the recommended tapering regimen for hydrocortisone (cortisol) after a stress dose has been administered?

From the Guidelines

The recommended tapering regimen for hydrocortisone after stress dosing typically involves a gradual reduction to the patient's maintenance dose over several days, with a tapering schedule of 5-7 days as suggested by the most recent guidelines 1. After the acute stress has resolved, reduce the stress dose (typically 50-100 mg every 6-8 hours) by approximately 50% per day until reaching the patient's usual maintenance dose. For example, if a patient received 100 mg every 8 hours during stress, taper to 50 mg every 8 hours on day 1, then 25 mg every 8 hours on day 2, and continue reducing until reaching their baseline dose (typically 15-30 mg total daily dose divided into 2-3 administrations). Some key points to consider when tapering hydrocortisone include:

• The tapering schedule should be individualized based on the patient's clinical condition, duration of stress dosing, and underlying adrenal function.
• Patients should be monitored for signs of adrenal insufficiency during tapering, including fatigue, weakness, nausea, hypotension, and electrolyte abnormalities.
• Tapering is necessary because exogenous glucocorticoids suppress the hypothalamic-pituitary-adrenal axis, and abrupt discontinuation can lead to adrenal crisis.
• Longer periods of stress dosing generally require more gradual tapering to allow the adrenal glands time to resume normal cortisol production, as noted in the guidelines for managing immune-related adverse events in patients treated with immune checkpoint inhibitor therapy 1. It's also important to note that the use of hydrocortisone allows for the recreation of the diurnal rhythm of cortisol, and typically, 2/3 of the dose is given in the morning and 1/3 in the early afternoon, as suggested by the guidelines 1.

From the Research

Hydrocortisone Tapering Regimen

The recommended tapering regimen for hydrocortisone after a stress dose has been administered is not explicitly stated in the provided studies. However, some studies provide guidance on the administration of hydrocortisone in patients with adrenal insufficiency.

• The study by 2 suggests that continuous intravenous hydrocortisone infusion is the most appropriate mode of administration in patients with adrenal insufficiency exposed to major stress, with a dose of 200 mg hydrocortisone over 24 hours, preceded by an initial bolus of 50-100 mg hydrocortisone.
• The study by 3 found that stress dose corticosteroid supplementation with 50 mg intravenous hydrocortisone every 6 hours improved ventilator weaning and clinical outcome in patients with adrenal insufficiency.
• The study by 4 recommends weight-adjusted hydrocortisone dosing, thrice daily before food, monitored with a single serum cortisol measurement using a nomogram, but this is for maintenance therapy rather than stress dose tapering.

Tapering Considerations

When tapering hydrocortisone after a stress dose, the following considerations should be taken into account:

• The study by 5 suggests that cortisol measurements should be used to assess the adequacy of hydrocortisone replacement therapy, and that dosing should be based on the individual's absorption and clearance of the drug.
• The study by 6 notes that the glucocorticoid dosage must be increased prophylactically in stressful situations and in febrile disorders to prevent an "adrenal crisis", but does not provide specific guidance on tapering.