What is the protocol for titrating hydrocortisone (cortisol replacement therapy) after adrenalectomy (surgical removal of the adrenal gland)?

From the Guidelines

Hydrocortisone titration after adrenalectomy should start with 100 mg intravenously at the start of surgery, followed by an infusion of 200 mg/24 h, and then transition to oral hydrocortisone, doubling the regular oral replacement dose for 48 h, and for up to a week following major surgery before resuming the maintenance dose. This approach is based on the most recent guidelines from the Association of Anaesthetists, the Royal College of Physicians, and the Society for Endocrinology UK, as outlined in the study by Woodcock et al. 1. The guidelines emphasize the importance of stress dosing during the peri-operative period to prevent adrenal crisis, which can be life-threatening.

Key Considerations

• The initial dose of hydrocortisone should be administered intravenously at the start of surgery, followed by a continuous infusion to maintain adequate cortisol levels during the stress of surgery.
• The dose should be adjusted based on the patient's response to surgery and their overall health status, with the goal of preventing adrenal crisis while minimizing the risk of excessive glucocorticoid exposure.
• Patients should be educated about stress dosing and how to manage their glucocorticoid replacement therapy during periods of illness or stress, as outlined in the guidelines 1.
• The maintenance dose of hydrocortisone should be individualized based on the patient's needs, with typical doses ranging from 15-25 mg daily, as recommended in the guidelines 1.

Monitoring and Adjustments

• Patients should be closely monitored for signs of adrenal insufficiency or excess, including fatigue, nausea, hypotension, electrolyte abnormalities, hypertension, hyperglycemia, and edema.
• The dose of hydrocortisone should be adjusted based on the patient's response to treatment, with the goal of achieving a stable and asymptomatic state.
• The guidelines recommend collaborating with the patient's endocrinologist to ensure optimal management of their glucocorticoid replacement therapy, as emphasized in the study by Woodcock et al. 1.

From the FDA Drug Label

The initial dosage of hydrocortisone tablets may vary from 20 mg to 240 mg of hydrocortisone per day depending on the specific disease entity being treated. After a favorable response is noted, the proper maintenance dosage should be determined by decreasing the initial drug dosage in small decrements at appropriate time intervals until the lowest dosage which will maintain an adequate clinical response is reached. If after long-term therapy the drug is to be stopped, it is recommended that it be withdrawn gradually, rather than abruptly

The protocol for titrating hydrocortisone after adrenalectomy is to:

• Start with an initial dosage of 20-240 mg per day
• Adjust the dosage based on the patient's response
• Gradually decrease the dosage in small increments until the lowest effective dose is reached
• Monitor the patient closely for changes in clinical status and adjust the dosage as needed 2
• When stopping therapy, withdraw the drug gradually rather than abruptly

From the Research

Titrating Hydrocortisone after Adrenalectomy

• The protocol for titrating hydrocortisone (cortisol replacement therapy) after adrenalectomy is not straightforward and may vary depending on the individual patient's needs 3, 4, 5, 6, 7.
• According to a study published in 2016, the recommended protocol for maintenance therapy is 15-25 mg of hydrocortisone, divided into two or three separate doses 5.
• However, another study published in 2020 suggests that lower doses of hydrocortisone can be safely administered to patients with adrenal insufficiency undergoing major surgery, and that the current practice of administering excessive glucocorticoid supplementation during stress may be unnecessary 4.
• A study published in 2017 compared the efficacy and safety of hydrocortisone and prednisone in glucocorticoid replacement therapy post-adrenalectomy for Cushing's syndrome, and found that both groups had similar baseline responses to adrenalectomy, but hydrocortisone showed advantages over prednisone in improving liver function 7.
• The use of cosyntropin stimulation testing on postoperative day 1 can help identify patients who require glucocorticoid replacement therapy after adrenalectomy for hypercortisolism, and can prevent unnecessary replacement in some patients 6.
• Factors such as age, body mass index, and adrenal nodule size may also influence the need for glucocorticoid replacement therapy after adrenalectomy 6.
• It is essential to monitor patients closely and adjust the dosage of hydrocortisone accordingly to avoid adrenal insufficiency and other complications 3, 4, 5, 6, 7.