Hydrocortisone Dosing for Adrenal Insufficiency
For adults with adrenal insufficiency, the recommended daily maintenance dose of hydrocortisone is 15-25 mg divided into multiple doses to mimic the natural diurnal rhythm. 1, 2
Maintenance Therapy for Adults
- Standard daily dosing for primary adrenal insufficiency is 15-25 mg of hydrocortisone in split doses, with the first dose immediately after waking and the last dose not less than 6 hours before bedtime 3
- Typical dosing schedule is 10 mg in the morning, 5 mg at noon, and 5 mg in the late afternoon (around 4:30 PM) to best mimic physiological cortisol secretion 4
- The lowest dose compatible with health and a sense of well-being should be used 3
- Patients with primary adrenal insufficiency also require mineralocorticoid replacement with fludrocortisone 50-200 μg daily as a single dose 3, 1
Pediatric Dosing
- For children with adrenal insufficiency, hydrocortisone should be dosed at 6-10 mg/m² of body surface area per day 3
- Weight-based dosing for pediatric patients undergoing procedures 1:
- 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
Stress Dosing for Surgery/Procedures
For major surgery under general or regional anesthesia 3:
- Hydrocortisone 100 mg IV at induction
- Followed by continuous infusion of 200 mg/24h
- Once oral intake is possible, double the usual oral dose for 48 hours or up to a week for major surgery
For minor procedures requiring general anesthesia 3:
- Adults: Hydrocortisone 100 mg IV at induction
- Children: Hydrocortisone 2 mg/kg IV/IM at induction
For minor procedures not requiring general anesthesia 3:
- Double the morning dose of hydrocortisone given pre-operatively
Adrenal Crisis Management
- Adrenal crisis should be treated immediately with IV or IM hydrocortisone, 100 mg followed by 100 mg every 6-8 hours until recovered 3, 5
- Alternatively, after the initial 100 mg bolus, a continuous infusion of 200 mg over 24 hours can be administered 3, 5
- Isotonic (0.9%) sodium chloride solution should be administered at an initial rate of 1 L/h until hemodynamic improvement 3, 5
Special Considerations
- During pregnancy, small adjustments to hydrocortisone and fludrocortisone doses may be needed, particularly during the last trimester 3
- For labor and delivery, hydrocortisone 100 mg IV at onset of labor, followed by continuous infusion of 200 mg/24h is recommended 3, 1
- For patients with known adrenal insufficiency who develop intercurrent illness, the hydrocortisone dose should be doubled during febrile illness or other significant stressors 6
Common Pitfalls
- Underdosing during stress can lead to adrenal crisis, which has a mortality rate of approximately 0.5/100 patient-years 5
- Overdosing can lead to Cushingoid features including weight gain, hypertension, hyperglycemia, and osteoporosis 1, 7
- Studies show that with standard oral replacement regimens, 79% of patients are either over- or under-treated based on plasma cortisol measurements 4
- All patients should carry an emergency card and be provided with an emergency kit for parenteral hydrocortisone self-administration 5
Monitoring
- Patients with adrenal insufficiency should be reviewed at least annually 3
- Assessment should include health and well-being, weight, blood pressure, and serum electrolytes 3
- Clinical signs of under-replacement include fatigue, nausea, hypotension, and electrolyte abnormalities 1
- Clinical signs of over-replacement include bruising, thin skin, edema, weight gain, and hypertension 1