What is the recommended weaning schedule for patients on long-term hydrocortisone (cortisol) therapy?

Hydrocortisone Weaning Schedule for Long-Term Therapy

For patients on long-term hydrocortisone therapy, the recommended weaning schedule is to double the regular oral replacement dose for 48 hours after recovery from stress or surgery, and then gradually taper to maintenance dose over a period of up to one week, assuming uncomplicated recovery. 1

Principles of Hydrocortisone Weaning

Weaning from long-term hydrocortisone therapy must be done carefully to avoid precipitating adrenal crisis while minimizing exposure to excess glucocorticoids. The approach depends on:

1. The patient's underlying condition
2. Duration of previous therapy
3. Current physiological stress

Standard Maintenance Dosing

Before discussing weaning, it's important to understand typical maintenance dosing:

• Standard hydrocortisone replacement: 15-25 mg daily 2
• Typical regimens:
  • Three-dose regimen: 10 mg (morning) + 5 mg (noon) + 2.5-5 mg (afternoon) 2
  • Two-dose regimen: 15-20 mg (morning) + 5-10 mg (early afternoon) 2

Weaning Schedule After Surgery or Stress

Major Surgery

• Pre-operative: 100 mg hydrocortisone IM just before anesthesia
• Post-operative:
  • Continue 100 mg hydrocortisone IM every 6 hours until able to eat and drink
  • Then double oral maintenance dose for 48 hours
  • Taper to normal dose over up to one week 1

Minor Surgery

• Pre-operative: 100 mg hydrocortisone IM just before anesthesia
• Post-operative:
  • Double oral maintenance dose for 24 hours
  • Return to normal dose 1

Acute Illness

• Minor illness: Double or triple usual daily dose 2
• Moderate stress: Hydrocortisone 50-75 mg/day in divided doses 2
• Severe stress: Hydrocortisone 100 mg IV immediately followed by 100-300 mg/day as continuous infusion or divided doses every 6 hours 2

Weaning from Long-Term Therapeutic Doses

For patients who have been on long-term supraphysiologic doses of hydrocortisone for therapeutic purposes (rather than replacement):

1. Initial dose reduction should be determined by the underlying disease requirements
2. Once physiological doses are reached (approximately 15-25 mg/day), further reduction should be slower
3. When reaching 5 mg/day of prednisone equivalent (20 mg hydrocortisone), consider:
   • Testing adrenal function with morning cortisol levels
   • Substituting hydrocortisone for other glucocorticoids 3
   • Continuing hydrocortisone until ACTH and endogenous cortisol levels return to normal 4

Monitoring During Weaning

• Clinical assessment for symptoms of under-replacement: fatigue, nausea, poor appetite, weight loss, increased pigmentation 1
• Clinical assessment for symptoms of over-replacement: weight gain, insomnia, peripheral edema 1
• Monitor blood pressure, weight, and general energy levels 2
• Consider serum or salivary cortisol day curve monitoring in cases of suspected malabsorption 1

Special Considerations

Timing of Doses

• Waking up earlier to take the first dose may relieve morning nausea and vomiting 1
• For night shift workers, adjust dose schedule according to work pattern (e.g., 10 mg upon awakening before going to work) 1

Drug Interactions

Certain medications may affect hydrocortisone metabolism, requiring dose adjustments during weaning:

• Anti-epilepsy medications/barbiturates: May need higher hydrocortisone doses
• Antifungal drugs: May need dose adjustments
• Grapefruit juice/licorice: May need lower hydrocortisone doses 1

Patient Education During Weaning

All patients should receive education on:

• Recognizing symptoms of adrenal insufficiency
• Stress dosing for illness or procedures
• Carrying emergency hydrocortisone
• Wearing medical alert identification 2

Warning Signs to Monitor During Weaning

• Hypotension (especially orthostatic)
• Fatigue, weakness
• Nausea, vomiting, abdominal pain
• Confusion or altered mental status
• Hypoglycemia (particularly in children) 5

By following this structured weaning schedule and monitoring protocol, the risk of adrenal crisis can be minimized while successfully tapering patients off long-term hydrocortisone therapy.