What is the typical dose of hydrocortisone for various medical conditions?

Hydrocortisone Dosing for Various Medical Conditions

The typical dose of hydrocortisone varies significantly based on the condition being treated, with replacement therapy for adrenal insufficiency requiring 15-20 mg daily in divided doses, while stress dosing for surgery or acute illness requires substantially higher doses of 100-300 mg daily. 1, 2

Adrenal Insufficiency (Maintenance Therapy)

• For primary adrenal insufficiency (Addison's disease), the recommended replacement dose is 15-20 mg daily in divided doses to mimic the natural diurnal rhythm 1
• Typical dosing schedule involves dividing the total daily dose into 2-3 doses with the highest dose given in the morning 3
• Patients with primary adrenal insufficiency also require mineralocorticoid replacement with fludrocortisone 0.05-0.2 mg once daily 1, 4
• Starting doses should be weight-adjusted when possible, with a total daily dose of 15-20 mg for hydrocortisone or 20-30 mg for cortisone acetate 4

Stress Dosing for Surgery and Illness

• For major surgery in patients with adrenal insufficiency: 100 mg IV at induction followed by continuous infusion of 200 mg/24h 1
• For intermediate surgery: 100 mg IV at induction with subsequent dose adjustments 1
• For minor procedures: weight-based dosing (2 mg/kg IV/IM in children) 1
• For severe symptoms or adrenal crisis: 50-100 mg intravenously every 6-8 hours, with tapering to maintenance doses over 5-7 days 2
• During physiological stress, cortisol requirements increase up to five-fold (approximately 100 mg/day) compared to normal daily production of 20 mg 2

Pediatric Dosing

• For pediatric patients, weight-based dosing is recommended: 2 mg/kg IV/IM at induction for surgery 1
• Continuous infusion based on weight is recommended according to the following scale 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

Dosing for Specific Conditions

• For acute exacerbations of multiple sclerosis: 800 mg of hydrocortisone daily for a week followed by 320 mg every other day for one month 1, 5
• For septic shock with suspected relative adrenal insufficiency: high-dose therapy may be indicated 1
• For immune-related adverse events in patients treated with immune checkpoint inhibitors: dose varies based on severity 1

Pregnancy and Delivery

• For labor and vaginal delivery: 100 mg IV at onset of labor, followed by continuous infusion of 200 mg/24h 1
• For Caesarean section: follow the same protocol as for major surgery 1

Administration Considerations

• For IV administration, hydrocortisone can be given as an injection over 30 seconds (for 100 mg) to 10 minutes (for 500 mg or more) 6
• High-dose therapy should generally not continue beyond 48-72 hours unless clinically necessary 6
• For IV infusion, hydrocortisone can be added to 5% dextrose in water or isotonic saline solution 6

Monitoring and Pitfalls

• Signs of over-replacement include bruising, thin skin, edema, weight gain, hypertension, and hyperglycemia 1
• Signs of under-replacement include fatigue, nausea, hypotension, and electrolyte abnormalities 1
• Conventional twice-daily dosing often results in supraphysiological peaks (2 hours after morning dose) and unphysiological nadirs in the afternoon before the evening dose 7
• Morning cortisol levels are often low or negligible with twice-daily dosing, potentially increasing risk of early morning hypoglycemia 7
• All patients need education on stress dosing for sick days, use of emergency injectables, and medical alert identification 2

Important Considerations

• Dosage requirements are variable and must be individualized based on the disease being treated and the patient's response 6, 5
• When discontinuing long-term therapy, hydrocortisone should be withdrawn gradually rather than abruptly 6, 5
• Starting other hormone replacements before corticosteroids can precipitate adrenal crisis, as other hormones accelerate cortisol clearance 2
• Studies have shown that a standard oral dose of 20 mg hydrocortisone produces supraphysiological cortisol levels 8
• Synthetic glucocorticoids may have undesirable metabolic long-term effects, making them less suitable as first-line treatment 4