Indications for Hydrocortisone
Hydrocortisone is indicated for adrenal insufficiency (primary and secondary), as stress-dose coverage during surgery or critical illness, and for various inflammatory and autoimmune conditions. 1
Primary Indications
Adrenal Insufficiency
- Replacement therapy for primary adrenal insufficiency (Addison's disease) at doses of 15-20 mg daily in divided doses 2
- Treatment of secondary adrenal insufficiency due to hypothalamic-pituitary disorders 1
- Management of congenital adrenal hyperplasia 1
Perioperative Management
- Stress-dose coverage for patients with known adrenal insufficiency undergoing surgery:
Critical Illness
- Management of septic shock with suspected relative adrenal insufficiency 2
- Stress-dose coverage for critically ill patients with known adrenal insufficiency 3
Inflammatory and Autoimmune Conditions
Respiratory Diseases
- Symptomatic sarcoidosis 1
- Loeffler's syndrome not manageable by other means 1
- Berylliosis 1
- Fulminating or disseminated pulmonary tuberculosis (with appropriate anti-TB therapy) 1
Rheumatic Disorders
Hematologic Disorders
- Idiopathic thrombocytopenic purpura in adults 1
- Secondary thrombocytopenia in adults 1
- Acquired (autoimmune) hemolytic anemia 1
- Erythroblastopenia and congenital hypoplastic anemia 1
Gastrointestinal Diseases
Neurological Conditions
- Acute exacerbations of multiple sclerosis 1
- Tuberculous meningitis with subarachnoid block (with appropriate anti-TB therapy) 1
Immune-Related Adverse Events
- Management of immune-related adverse events in patients treated with immune checkpoint inhibitors 2
Dosing Considerations
Physiological Replacement
- Daily total dose typically 15-20 mg in divided doses (2/3 in morning, 1/3 in afternoon) to mimic diurnal rhythm 2
- Weight-adjusted dosing reduces interpatient variability and improves therapeutic outcomes 4
- Timing: Administration before food improves absorption profile 4
Stress Dosing
- Continuous IV infusion (200 mg/24h) is the most effective method to maintain cortisol levels similar to physiologic stress response 3
- For major stress/surgery: Initial bolus of 50-100 mg followed by continuous infusion 3
- Double or triple maintenance doses for minor illness or procedures 2
Special Populations
Pediatric Patients
- Weight-based dosing: 2 mg/kg IV/IM at induction for surgery 2
- Continuous infusion based on weight:
- Up to 10 kg: 25 mg/24h
- 11-20 kg: 50 mg/24h
- Over 20 kg (prepubertal): 100 mg/24h
- Over 20 kg (pubertal): 150 mg/24h 2
Pregnancy
- Labor and vaginal delivery: 100 mg IV at onset of labor, followed by continuous infusion of 200 mg/24h 2
- Caesarean section: Same as major surgery protocol 2
Monitoring
- Serum cortisol measured 4 hours after oral hydrocortisone dose can predict total cortisol exposure 4
- Clinical signs of over-replacement: bruising, thin skin, edema, weight gain, hypertension, hyperglycemia 2
- Clinical signs of under-replacement: fatigue, nausea, hypotension, electrolyte abnormalities 2
Common Pitfalls and Caveats
- Conventional immediate-release hydrocortisone cannot provide physiological cortisol rhythm, leading to periods of over- and under-replacement 5
- Short half-life (approximately 1.5 hours) necessitates multiple daily dosing 6
- Food intake delays absorption, affecting peak levels - administration before meals is recommended 4
- Patients with primary adrenal insufficiency typically also require mineralocorticoid replacement (fludrocortisone) 2
- Patients on chronic glucocorticoid therapy (including inhaled) may have hypothalamic-pituitary-adrenal axis suppression requiring stress-dose coverage during illness or surgery 2