What is the recommended dose of hydrocortisone (corticosteroid) for an adult patient?

Hydrocortisone Dosing for Adult Patients

The recommended maintenance dose of hydrocortisone for adult patients with adrenal insufficiency is 15-25 mg/day divided into 2-3 doses, with the highest dose given in the morning to mimic the natural cortisol rhythm. 1

Standard Maintenance Dosing

Hydrocortisone replacement therapy for adults with adrenal insufficiency should follow these principles:

• Daily maintenance dose: 15-25 mg/day total
• Dosing schedule: Divided into 2-3 doses per day
• Timing distribution:
  • 50-60% of total daily dose in the morning (upon waking)
  • 25-30% in early afternoon (around noon)
  • 15-20% in late afternoon/early evening (before 6 PM) if using three daily doses

This dosing regimen aims to mimic the natural cortisol circadian rhythm, with higher levels in the morning and lower levels in the evening.

Stress Dosing Protocol

Hydrocortisone doses must be adjusted during periods of stress:

• Minor illness/stress (fever, cold): Double or triple the usual daily dose 1
• Moderate stress (infection requiring antibiotics): 50-75 mg/day in divided doses 1
• Severe stress/adrenal crisis (severe illness, surgery, trauma): 100 mg IV immediately followed by 200-300 mg/day as continuous infusion or divided doses every 6 hours 1, 2

Perioperative Dosing

For patients undergoing surgery:

• Induction: 100 mg IV bolus at induction of anesthesia 2, 1
• Maintenance: Continuous infusion of 200 mg/24h or 50 mg every 6 hours IM 2
• Post-operative: Double the maintenance dose for 48 hours if recovery is uncomplicated, or up to a week following major surgery 2, 1

Special Considerations

Primary vs. Secondary Adrenal Insufficiency

• Primary adrenal insufficiency: Requires both glucocorticoid (hydrocortisone) and mineralocorticoid (fludrocortisone) replacement 1
• Secondary adrenal insufficiency: Requires glucocorticoid replacement only 1

Monitoring Therapy

• Monitor for signs of under-replacement: fatigue, nausea, weight loss, hypotension
• Monitor for signs of over-replacement: weight gain, insomnia, edema, hypertension, hyperglycemia
• No established biomarker exists for optimal cortisol activity 3

Common Pitfalls

1. Inadequate stress dosing: Failure to increase dose during illness or stress is dangerous and can lead to adrenal crisis
2. Evening dosing: Administering hydrocortisone too late in the day can cause insomnia and disrupt sleep patterns
3. Improper distribution: Giving equal doses throughout the day rather than following the natural cortisol rhythm
4. Monitoring challenges: Relying solely on serum cortisol levels without considering clinical symptoms

Administration Considerations

For IV administration during emergencies:

• 100 mg can be administered over 30 seconds
• 500 mg or more should be administered over 10 minutes 4
• High-dose therapy should generally not continue beyond 48-72 hours unless clinically necessary 4

The pharmacokinetics of oral immediate-release hydrocortisone make it impossible to fully mimic the natural cortisol rhythm 3, which is why multiple daily doses are required. Newer dual-release formulations may provide better metabolic outcomes over conventional hydrocortisone dosing 5.

Patient education about stress dosing is crucial for preventing adrenal crisis, and clear written instructions for emergency situations should be provided to all patients with adrenal insufficiency 1.