What dose of steroids, specifically hydrocortisone (cortisol), is given to an inpatient with Addison's disease?

Steroid Dosing for Inpatients with Addison's Disease

For inpatients with Addison's disease, hydrocortisone should be administered at 100 mg intravenously at admission, followed by continuous infusion of 200 mg/24 hours or 50 mg every 6 hours intramuscularly while the patient is unable to take oral medication. 1

Initial Inpatient Management

• For hospitalized patients with Addison's disease, hydrocortisone 100 mg should be administered intravenously immediately upon admission 1
• This should be followed by a continuous infusion of hydrocortisone at 200 mg/24 hours 1
• If continuous infusion is not feasible, hydrocortisone 50 mg every 6 hours by intramuscular injection can be used as an alternative 1

Transitioning to Oral Therapy

• Once the patient can take oral medications, transition to double the usual maintenance oral hydrocortisone dose for 48 hours 1
• For major surgery or complicated recovery, this doubled dose may need to be continued for up to a week 1
• Standard maintenance therapy is typically 15-20 mg of hydrocortisone daily in divided doses to mimic diurnal rhythm 2, 3

Special Considerations

Surgical Patients

• For inpatients undergoing surgery, hydrocortisone 100 mg IV should be given at induction 1
• Post-operatively, continue hydrocortisone 200 mg/24 hours by IV infusion until able to take oral medication 1
• For major surgery with long recovery time, double the oral dose for at least 48 hours after resuming oral intake, then taper to normal dose 1

Acute Adrenal Crisis

• For patients presenting with adrenal crisis, immediate administration of hydrocortisone 100 mg IV is critical 1, 4
• This should be accompanied by rapid intravenous administration of 0.9% saline (1 L over an hour) 1, 4
• Continue parenteral glucocorticoids for 24-48 hours, then taper over 1-3 days to oral therapy as the patient's condition permits 1

Pediatric Patients

• For children, weight-based dosing should be used: 2 mg/kg IV/IM at induction for surgery 1
• Continuous infusion rates for children 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 1, 2

Pitfalls and Caveats

• Dexamethasone is not appropriate as glucocorticoid treatment in patients with primary adrenal insufficiency as it has no mineralocorticoid activity 1
• Patients with primary adrenal insufficiency (Addison's disease) typically also require mineralocorticoid replacement (fludrocortisone) once they resume oral intake 2, 3
• Infections are major precipitating causes of adrenal crisis and may require prolonged stress-dose coverage 4
• Hydrocortisone dosage requirements are variable and must be individualized based on the patient's clinical response 5
• Failure to provide adequate glucocorticoid coverage during hospitalization can lead to adrenal crisis, which has a significant mortality rate of approximately 0.5/100 patient years 4

Monitoring

• Monitor for signs of under-replacement: hypotension, nausea, vomiting, abdominal pain, fatigue, electrolyte abnormalities (hyponatremia, hyperkalemia) 1, 2
• Watch for signs of over-replacement: hyperglycemia, hypertension, fluid retention, excessive weight gain 2
• For prolonged high-dose hydrocortisone therapy (beyond 48-72 hours), be aware of potential hypernatremia 5