How should I wean a patient off hydrocortisone (cortisol) 100mg every 8 hours (q8h)?

Hydrocortisone Weaning Protocol After High-Dose Therapy

For a patient on hydrocortisone 100mg every 8 hours, you should taper the dose over 5-7 days, transitioning to a maintenance physiologic dose of 15-20mg daily in divided doses. 1

Understanding the Context

High-dose hydrocortisone (100mg q8h) is typically used in specific clinical scenarios:

• Major surgery or post-operative stress
• Adrenal crisis
• Severe inflammatory conditions

The weaning process is critical because:

• Abrupt discontinuation can lead to adrenal crisis
• Prolonged high-dose therapy increases risk of adverse effects
• The hypothalamic-pituitary-adrenal axis needs time to recover

Step-by-Step Weaning Protocol

Days 1-2:

• Reduce from 100mg q8h to 50mg q6h (200mg/day)
• This provides a gradual initial reduction while maintaining adequate coverage

Days 3-4:

• Reduce to 25mg q6h (100mg/day)
• Monitor for signs of adrenal insufficiency (fatigue, nausea, hypotension)

Days 5-6:

• Transition to oral maintenance therapy:
  • Morning: 10mg
  • Midday: 5mg
  • Evening: 5mg
  • Total: 20mg/day (physiologic replacement)

Day 7 and beyond:

• Continue maintenance dose of 15-20mg daily in divided doses
• Typically 10mg on waking, 5mg at midday, and 5mg in early evening 1

Monitoring During Weaning

• Blood pressure: Watch for orthostatic hypotension
• Electrolytes: Monitor for hyponatremia or hyperkalemia
• Symptoms: Assess for fatigue, nausea, dizziness, or abdominal pain
• Morning cortisol levels: Consider checking if uncertain about adrenal recovery

Special Considerations

If patient has known adrenal insufficiency:

• Never completely discontinue; maintain physiologic replacement
• Educate on stress dosing for illness (double or triple maintenance dose)
• Provide medical alert identification 1

If patient was on high-dose therapy for surgery:

• If recovery is uncomplicated, double the maintenance dose for 48 hours, then return to normal maintenance 1
• For major surgery with prolonged recovery, continue double doses for up to a week 1

If patient shows signs of adrenal insufficiency during taper:

• Return to previous dose step
• Slow the taper (extend each step by 1-2 days)
• Consider endocrinology consultation

Common Pitfalls to Avoid

1. Tapering too quickly, risking adrenal crisis
2. Failing to account for the patient's underlying condition
3. Not providing clear instructions about stress dosing
4. Stopping hydrocortisone completely if the patient has adrenal insufficiency
5. Using single daily dosing (fails to mimic physiologic cortisol rhythm) 2

The goal of weaning is to return to physiologic cortisol levels while avoiding both adrenal insufficiency and prolonged exposure to supraphysiologic doses. Weight-based dosing may further optimize therapy for long-term maintenance 3.