What is the recommended dosage and administration of hydrocortisone for various medical conditions?

Hydrocortisone Dosage and Administration Guidelines for Various Medical Conditions

Hydrocortisone dosing should be tailored based on the specific medical condition, with perioperative dosing requiring 100 mg IV at induction followed by continuous infusion of 200 mg/24h for adults undergoing surgery. 1

Adrenal Insufficiency (Standard Replacement)

Oral Replacement

• Initial dosage: 20-240 mg daily, depending on disease severity 2
• Typical maintenance: Weight-based dosing recommended to reduce interpatient variability 3
  • Usually administered in 2-3 divided doses with largest dose in morning to mimic circadian rhythm
  • Thrice daily dosing before food provides better pharmacokinetic profile 3

Monitoring

• Serum cortisol measured 4 hours after dose can predict cortisol exposure 3
• Clinical symptoms and signs should guide dose adjustments

Perioperative Management

Adults with Primary/Secondary Adrenal Insufficiency

• Major surgery:
  • 100 mg IV hydrocortisone at induction
  • Followed by continuous infusion of 200 mg/24h
  • Post-op: Continue 200 mg/24h IV while NPO or switch to 50 mg every 6h IM 1
  • When oral intake resumes: Double usual oral dose for 48h or up to 1 week for major surgery 1

Adults on Chronic Steroid Therapy (≥5 mg prednisolone for ≥4 weeks)

• Major surgery: Same as above
• Intermediate surgery: 100 mg IV at induction, then double regular dose for 48h 1
• Bowel procedures: Continue normal dose; use IV equivalent if prolonged NPO 1

Children with Adrenal Insufficiency

• Major surgery:

  • Hydrocortisone 2 mg/kg at induction
  • Followed by continuous IV infusion based on weight:
    • Up to 10 kg: 25 mg/24h
    • 11-20 kg: 50 mg/24h
    • Over 20 kg (prepubertal): 100 mg/24h
    • Over 20 kg (pubertal): 150 mg/24h 1
  • Post-op: Double usual oral doses for 48h

• Minor procedures with general anesthesia:

  • Hydrocortisone 2 mg/kg IV/IM at induction
  • Double normal doses for 24h when oral intake resumes 1

Septic Shock Management

Adults

• Dosage: 200 mg/day in four divided doses or continuous infusion of 240 mg/day (10 mg/hr) for ≥7 days 4
• Indicated for vasopressor-dependent septic shock

Children

• Dosage range: 1-2 mg/kg/day for stress coverage up to 50 mg/kg/day titrated to reverse shock 1
• Consider in children with fluid-refractory, catecholamine-resistant shock with suspected adrenal insufficiency 1

IV Administration Guidelines

• IV push: Administer over 30 seconds (100 mg) to 10 minutes (500 mg or more) 5
• IV infusion: Can be added to 100-1000 mL of 5% dextrose or isotonic saline 5
• High-dose therapy: Generally not continued beyond 48-72 hours unless clinically indicated 5

Important Clinical Considerations

• Weaning: Gradual tapering rather than abrupt discontinuation is recommended 5, 2
• Food interactions: Food delays absorption; administer before meals for optimal absorption 3
• Monitoring: No established biomarker exists for cortisol activity; clinical response remains important 6

Special Situations

• Multiple sclerosis exacerbations: 800 mg/day for one week, then 320 mg every other day for one month 5
• Labor and delivery: 100 mg IV at onset, followed by continuous infusion of 200 mg/24h or 100 mg IM followed by 50 mg every 6h IM 1

Pitfalls to Avoid

• Abrupt discontinuation: Can precipitate adrenal crisis; always taper gradually
• Fixed dosing: Weight-adjusted dosing reduces interpatient variability in cortisol exposure 3
• Hypernatremia: May occur when high-dose therapy continues beyond 48-72 hours 5
• Undertreatment: Insufficient dosing during stress can lead to adrenal crisis
• Overtreatment: Excessive long-term dosing can cause cushingoid features and metabolic complications

Remember that hydrocortisone dosing must be individualized based on the specific condition being treated and patient response, with careful monitoring for both under-replacement and over-replacement.