What is the recommended dosing of hydrocortisone (cortisol) for sepsis in adults?

From the Guidelines

For adults with septic shock, hydrocortisone is recommended at a dose of 200 mg per day, as a continuous infusion, for patients who remain hypotensive despite adequate fluid resuscitation and vasopressor therapy. This recommendation is based on the latest guidelines from the Surviving Sepsis Campaign, which suggests using IV hydrocortisone at a dose of 200 mg per day for patients with septic shock that is not responsive to fluid and vasopressor therapy 1. The use of hydrocortisone in septic shock is supported by evidence from multiple studies, including a Cochrane systematic review of 33 RCTs, which showed that corticosteroids significantly reduced the risk of death at 28 days compared with placebo 1. The recommended dose and duration of treatment are also supported by guidelines from the Society of Critical Care Medicine and the European Society of Intensive Care Medicine, which suggest using IV hydrocortisone <400 mg/day for ≥3 days at full dose in patients with septic shock that is not responsive to fluid and moderate- to high-dose vasopressor therapy 1.

Some key points to consider when using hydrocortisone in septic shock include:

• Hydrocortisone should be considered for patients who remain hypotensive despite adequate fluid resuscitation and vasopressor therapy
• The preferred regimen is often a continuous infusion of 200 mg per day
• A gradual taper is not necessary for short-course therapy
• Monitor for potential adverse effects including hyperglycemia, which may require insulin therapy, and secondary infections
• Some clinicians add fludrocortisone 50 mcg orally once daily to the regimen for additional mineralocorticoid effect, though this is not universally practiced 1.

It's worth noting that the evidence for the use of hydrocortisone in septic shock is not universally agreed upon, and some studies have shown mixed results. However, based on the current evidence and guidelines, the recommended dose of 200 mg per day as a continuous infusion is the most appropriate choice for adults with septic shock.

From the FDA Drug Label

In certain overwhelming, acute, life-threatening situations, administration in dosages exceeding the usual dosages may be justified and may be in multiples of the oral dosages. The initial dose of SOLU-CORTEF Sterile Powder is 100 mg to 500 mg, depending on the specific disease entity being treated This dose may be repeated at intervals of 2,4, or 6 hours as indicated by the patient's response and clinical condition

The recommended dosing of hydrocortisone for sepsis in adults is 100 mg to 500 mg initially, and this dose may be repeated at intervals of 2,4, or 6 hours as needed, depending on the patient's response and clinical condition 2.

From the Research

Recommended Dosing of Hydrocortisone for Sepsis in Adults

The recommended dosing of hydrocortisone (cortisol) for sepsis in adults is a topic of ongoing research and debate.

• According to the study 3, long course low-dose hydrocortisone treatment (about 200-300mg per day) for approximately 7 days may be a viable management option for patients with sepsis.
• The study 4 found no significant differences in 28-day mortality between two low-dose hydrocortisone regimens: a 50-mg intravenous bolus every 6 hours during 7 days (200-mg group) and a 100-mg initial bolus followed by a continuous infusion of 300mg daily for 5 days (300-mg group).
• Another study 5 compared the clinical outcomes of minimized hydrocortisone dose of 100mg/day to the currently recommended dose of 200mg/day and found that the lower dose was associated with a lower hyperglycemic rate and shorter time to shock reversal.
• The study 6 suggests that intravenous hydrocortisone should be started immediately after a 250 microg corticotropin test, at a dose of 200-300 mg per day, and continued at full doses for 7 days if adrenal insufficiency is confirmed.
• The study 7 found that hydrocortisone therapy in patients with severe sepsis without shock did not reduce the risk of septic shock within 14 days, and does not support the use of hydrocortisone in these patients 7.

Key Considerations

• The optimal dosing and duration of hydrocortisone treatment for sepsis in adults may depend on various factors, including the severity of sepsis, the presence of adrenal insufficiency, and the patient's individual response to treatment.
• The use of hydrocortisone in sepsis should be guided by the latest clinical practice guidelines and evidence-based recommendations, taking into account the potential benefits and risks of treatment 3, 6.