What is the daily dose of hydrocortisone (cortisol replacement) needed for a patient (pt) with primary adrenal insufficiency who is dealing with pneumonia?

Hydrocortisone Dosing for Primary Adrenal Insufficiency with Pneumonia

For patients with primary adrenal insufficiency who develop pneumonia, the daily hydrocortisone dose should be doubled from the standard 15-25 mg/day to 30-50 mg/day and continued until recovery from the infection. 1

Standard Replacement Therapy vs. Stress Dosing

Standard Replacement Therapy

• Normal daily hydrocortisone dosage for primary adrenal insufficiency: 15-25 mg/day 2
• Typically administered in divided doses with 2/3 in the morning and 1/3 in the afternoon to mimic physiological cortisol rhythm 1
• Common regimens include:
  • Three doses: 10+5+2.5 mg or 15+5+5 mg (morning, noon, afternoon)
  • Two doses: 15+5 mg or 10+5 mg (morning, afternoon) 2

Stress Dosing for Pneumonia

Pneumonia represents a significant physiological stressor that requires increased glucocorticoid coverage to prevent adrenal crisis:

• Double the usual daily dose (30-50 mg/day) during the infection 1
• Continue this increased dosage until recovery from pneumonia (typically 2-3 days after clinical improvement) 1
• Monitor for signs of adrenal crisis despite increased dosing

Administration Considerations

• If the patient is able to take oral medications:

  • Provide the increased dose orally in the same divided schedule as their usual regimen
  • Consider three daily doses to provide more consistent coverage

• If the patient is unable to take oral medications or shows signs of adrenal crisis:

  • Administer hydrocortisone 100 mg IV immediately 1
  • Follow with 100-300 mg/day as continuous infusion or divided doses every 6 hours 1
  • Provide rapid IV isotonic saline administration 1
  • Monitor blood glucose regularly 1

Mineralocorticoid Considerations

• Continue regular fludrocortisone dosing (typically 0.05-0.2 mg/day) 2
• Fludrocortisone dose may need adjustment if the patient is receiving very high doses of hydrocortisone, as hydrocortisone itself has some mineralocorticoid activity at higher doses

Monitoring During Pneumonia

• Assess for signs of adequate replacement:

  • Blood pressure stability (avoid orthostatic hypotension)
  • Electrolyte balance (particularly sodium and potassium)
  • Resolution of fever and other infection symptoms
  • Energy levels and overall clinical status

• Watch for signs of under-replacement:

  • Fatigue, weakness
  • Nausea, vomiting
  • Hypotension
  • Electrolyte abnormalities (hyponatremia, hyperkalemia)

Important Caveats and Pitfalls

• Failure to increase glucocorticoid dosing during infection is a common cause of adrenal crisis 1
• Delayed recognition of adrenal crisis can be fatal - maintain high vigilance
• Patients should be educated about the importance of stress dosing during illness
• Ensure the patient has an emergency injection kit and knows when to use it 1
• The patient should wear a medical alert bracelet and carry a steroid card 1

Return to Maintenance Dosing

• Once the pneumonia has resolved and the patient is clinically stable:
  • Taper the dose back to the regular maintenance dose over several days
  • Do not abruptly reduce the dose to avoid precipitating adrenal insufficiency
  • Resume regular follow-up to assess replacement adequacy