Steroid Dosing for Adrenal Suppression
For adrenal suppression, hydrocortisone 15-25 mg daily in divided doses (or equivalent prednisone 5-10 mg daily) is the recommended dosing regimen. 1
Recommended Glucocorticoid Dosing Regimens
Hydrocortisone (First-Line Option)
- Total daily dose: 15-25 mg/day 2, 1
- Typical dosing schedule:
- Three doses: 10 mg (7:00 AM) + 5 mg (12:00 PM) + 2.5 mg (4:00 PM)
- Alternative schedules: 15 mg + 5 mg + 5 mg; 10 mg + 5 mg + 5 mg; 10 mg + 5 mg + 2.5 mg 2
- Two-dose regimen: 15 mg + 5 mg; 10 mg + 10 mg; or 10 mg + 5 mg 2
Cortisone Acetate (Alternative)
- Total daily dose: 25-37.5 mg/day 2
- Typical dosing schedule:
Prednisolone (Limited Use)
- Total daily dose: 4-5 mg/day 2, 1
- Dosing options:
- Single dose: 4-5 mg at 7:00 AM
- Two doses: 3 mg (7:00 AM) + 1-2 mg (2:00 PM) 2
- Note: Should only be considered in cases of compliance problems, marked fluctuations of energy, or when hydrocortisone/cortisone acetate is not tolerated 2
Dosing Considerations and Adjustments
Special Populations
- Night shift workers: Adjust schedule according to work pattern (e.g., 10 mg upon awakening before going to work) 2
- Pregnancy: May need to increase hydrocortisone dose by 2.5-10 mg daily in the third trimester 1
- Morning symptoms: For patients with morning nausea/vomiting, taking the first dose earlier and going back to sleep may help 2
Drug Interactions Requiring Dose Adjustments
- Medications requiring increased steroid dose:
- Anti-epilepsy medications/barbiturates
- Antituberculosis drugs
- Etomidate
- Topiramate 2
- Substances requiring decreased steroid dose:
- Grapefruit juice
- Licorice 2
Monitoring and Dose Adjustment
Clinical Assessment
- Signs of over-replacement: Weight gain, insomnia, peripheral edema 2
- Signs of under-replacement: Lethargy, nausea, poor appetite, weight loss, increased pigmentation 2
- Fine-tuning indicators: General energy levels, mental concentration, daytime somnolence, pigmentation changes 2
Laboratory Monitoring
- In cases of suspected malabsorption, serum or salivary cortisol day curve monitoring may guide dosing 2
- Most useful measurements: Morning post-dose peak level and trough pre-dose levels 2
Adrenal Crisis Prevention
During infections or other stressors, the maintenance dose of hydrocortisone should be increased 2-3 times to prevent adrenal crisis 1, 3
Important Cautions
- Avoid dexamethasone for regular replacement therapy 2
- Modified-release hydrocortisone (Plenadren) allows once-daily dosing but its role is still being evaluated 2
- Physiologic adrenal suppression can occur as early as 1-2 weeks after treatment with topical corticosteroids, but this rarely leads to clinical symptoms 4
- Pathologic adrenal suppression typically requires prolonged use of high-dose steroids 4
This dosing regimen aims to mimic the natural diurnal rhythm of cortisol release, with higher doses in the morning and lower doses later in the day, to minimize the risk of adverse effects while providing adequate adrenal suppression.