What is the dosing regimen for stress dosing of Solucortef (hydrocortisone) in adrenal insufficiency?

Stress Dosing of Solucortef (Hydrocortisone) in Adrenal Insufficiency

For adrenal insufficiency patients requiring stress dosing, administer hydrocortisone (Solucortef) 100 mg intravenously at the onset of stress, followed by continuous infusion of 200 mg over 24 hours or 50-100 mg every 6 hours until the patient can resume oral medication. 1

Stress Dosing Regimens Based on Stress Severity

Major Surgery/Severe Stress

• Initial dose: 100 mg IV hydrocortisone immediately before anesthesia/at onset of severe stress
• Maintenance:
  • Preferred method: Continuous IV infusion of 200 mg/24 hours 1, 2
  • Alternative: 50-100 mg IV/IM every 6 hours 1
• Duration: Continue until patient stabilizes, typically 24-72 hours 3
• Transition to oral: Double the usual oral replacement dose for 48 hours up to one week, then taper to maintenance dose 1

Moderate Surgery/Stress

• Initial dose: 100 mg IV hydrocortisone
• Maintenance: Double oral dose for 24-48 hours after procedure
• Transition: Return to normal dose once recovered 1

Minor Surgery/Stress

• Initial dose: Extra morning dose 1 hour prior to procedure
• Maintenance: Double oral dose for 24 hours
• Transition: Return to normal dose 1

Special Situations

Labor and Delivery

• 100 mg hydrocortisone IM at onset of active labor (contractions every 5 minutes or cervical dilation >4 cm)
• Follow with continuous infusion of 200 mg/24 hours or 50 mg IM every 6 hours
• Taper rapidly (1-3 days) to regular replacement dose after uncomplicated delivery 1

Pediatric Patients

• Initial dose: 2 mg/kg IV hydrocortisone at induction
• Maintenance:
  • 2 mg/kg every 4 hours IV/IM for major surgery, OR
  • Continuous hydrocortisone infusion if unstable or septic
• Transition: Double normal dose for 48 hours when enteral intake established 1

Administration Considerations

• IV administration: The preferred method for initial emergency use 3
• Preparation: Add no more than 2 mL of Bacteriostatic Water for Injection to one vial 3
• Incompatibilities: Do not dilute or mix with other solutions due to physical incompatibilities 3
• Continuous infusion: Provides the most stable cortisol levels, most closely mimicking the physiologic stress response 2

Monitoring and Precautions

• Monitor for signs of under-replacement: fatigue, nausea, vomiting, hypotension, fever
• Monitor for signs of over-replacement: hyperglycemia, hypertension, fluid retention
• Check blood glucose frequently, especially in pediatric patients 1
• Patients with diabetes insipidus and adrenal insufficiency require strict fluid balance monitoring to avoid hyponatremia 1

Common Pitfalls and Caveats

• Undertreatment: Failure to increase doses during stress is the most common cause of adrenal crisis 4
• Medication errors: Hospital medication errors are common causes of inadequate dosing during inpatient stays 1
• Patient dismissal: Healthcare staff may dismiss patient observations about warning signs of under-replacement 1
• Vomiting: Oral medication may not be absorbed during gastrointestinal illness, necessitating parenteral administration 1
• Dexamethasone: Not adequate for primary adrenal insufficiency as it lacks mineralocorticoid activity 1

Remember that adrenal crisis is a life-threatening emergency, and when in doubt about the need for glucocorticoids, they should be given as there are no long-term adverse consequences of short-term glucocorticoid administration 1.