What is the maximum dose of hydrocortisone (cortisol) intravenous (IV)?

Maximum Intravenous Hydrocortisone Dosage

The maximum recommended dose of intravenous hydrocortisone is 400 mg per day for critical illness-related conditions such as septic shock, as established by the Society of Critical Care Medicine and European Society of Intensive Care Medicine guidelines. 1, 2

General Dosing Guidelines

• For septic shock not responsive to fluid and moderate to high-dose vasopressor therapy, the recommended dose is <400 mg/day for ≥3 days at full dose 1, 2
• The FDA label indicates that in certain overwhelming, acute, life-threatening situations, administration in dosages exceeding the usual dosages may be justified 3
• High dose corticosteroid therapy should generally not be continued beyond 48 to 72 hours unless clinically necessary 3
• Dosage requirements are variable and must be individualized based on the disease being treated and the patient's response 3

Condition-Specific Dosing

• For septic shock, the standard recommended dose is 200 mg per day, administered either as divided doses (50 mg every 6 hours) or as a continuous infusion 1, 2, 4
• For early moderate to severe Acute Respiratory Distress Syndrome (ARDS), IV methylprednisolone 1 mg/kg/day is preferred over hydrocortisone 2
• For perioperative management in patients with adrenal insufficiency, hydrocortisone 100 mg IV on induction, followed by continuous infusion of hydrocortisone 200 mg/24h is recommended 1, 2

Administration Methods

• For intravenous injection, the FDA recommends administering SOLU-CORTEF over a period of 30 seconds (e.g., 100 mg) to 10 minutes (e.g., 500 mg or more) 3
• For intravenous infusion, prepare solution by adding not more than 2 mL of Bacteriostatic Water for Injection to the vial; this solution may then be added to 100 to 1000 mL of appropriate IV fluid 3
• Continuous infusion is preferred over bolus administration for septic shock 4

Emerging Research on Dosing

• Recent research has explored whether lower doses (100 mg/day) might be sufficient and reduce steroid-associated complications like hyperglycemia 5
• A 2016 study found no significant differences in 28-day mortality between 200 mg/day and 300 mg/day regimens for septic shock treatment 6
• A 2024 review defined low-dose corticosteroids as ≤400 mg hydrocortisone equivalent daily for treatment of severe pulmonary infections 7

Monitoring and Adverse Effects

• Monitor for potential adverse effects including hyperglycemia, hypernatremia, secondary infections, and gastrointestinal bleeding 2, 4
• Regular blood pressure determinations and serum electrolyte monitoring are recommended, particularly when high doses are used 2
• When high dose hydrocortisone therapy must be continued beyond 48–72 hours, hypernatremia may occur, and it may be desirable to replace with methylprednisolone sodium succinate 3

Common Pitfalls to Avoid

• Using corticosteroids in sepsis without shock provides no benefit and is not recommended 2, 4
• Abrupt discontinuation of corticosteroids can lead to deterioration from a reconstituted inflammatory response; tapering is recommended 2
• Extending therapy beyond 7-10 days carries no additional benefit and increases toxicity 4

While the standard recommended dose is 200-300 mg/day for most critical conditions, the absolute maximum dose supported by guidelines is 400 mg/day, with the FDA acknowledging that higher doses may occasionally be justified in life-threatening situations 1, 2, 3.