Hydrocortisone Tapering Protocol for Adrenal Insufficiency
For patients with adrenal insufficiency, hydrocortisone should be tapered over 1-3 days to the regular replacement dose following periods of stress dosing, with specific tapering schedules based on the clinical scenario and severity of the preceding condition. 1
Tapering Guidelines Based on Clinical Scenario
Post-Surgery Tapering
- For major surgery: Continue IV hydrocortisone 200 mg/24h while nil by mouth, then transition to double the usual oral dose for 48 hours when enteral intake is established, followed by tapering to maintenance dose over up to a week if recovery is uncomplicated 1
- For intermediate/body surface surgery: Double regular glucocorticoid dose for 48 hours, then return to usual treatment dose if recovery is uncomplicated 1
- For minor procedures requiring general anesthesia: Double normal hydrocortisone doses for 24 hours once enteral feeding is established, then return to normal dosing 1
Post-Delivery Tapering
- After labor and delivery: Rapidly taper hydrocortisone over 1-3 days to regular replacement dose after an uncomplicated delivery 1
- This typically follows initial stress dosing of hydrocortisone 100 mg IV at onset of labor with continuous infusion of 200 mg/24h or 50 mg IM every 6 hours 1
Post-Illness Tapering
- For moderate illness: Begin with 2-3 times maintenance dose, then taper to maintenance doses over 5-10 days as symptoms improve 2, 3
- For severe illness/adrenal crisis: After initial IV/IM hydrocortisone 100 mg followed by 100 mg every 6-8 hours, taper to maintenance dose once clinically stable 2, 4
Maintenance Dosing After Tapering
- Primary adrenal insufficiency: Hydrocortisone 15-25 mg daily in split doses (typically 2-3 doses) plus fludrocortisone 50-200 μg as a single daily dose 2, 4
- Secondary adrenal insufficiency: Hydrocortisone 10-20 mg morning and 5-10 mg afternoon, without fludrocortisone 2, 4
Special Considerations
- Pediatric patients: After major surgery, double usual oral doses of hydrocortisone for 48 hours and then reduce to normal doses over up to a week 1
- For patients on chronic exogenous steroids: Resume enteral glucocorticoid at double the pre-surgical therapeutic dose for 48 hours if recovery is uncomplicated, otherwise continue double oral dose for up to a week 1
Common Pitfalls in Tapering
- Tapering too quickly can precipitate adrenal crisis, especially after prolonged stress dosing 2, 5
- Inadequate tapering schedules may result in over- or under-treatment, with studies showing that 79%, 55%, and 45% of patients are improperly treated at morning, afternoon, and night, respectively 6
- Failure to monitor for signs of inadequate replacement during tapering (fatigue, nausea, hypotension, electrolyte abnormalities) 2, 7
- Not accounting for weight when determining maintenance dose, as body weight is the most important predictor of hydrocortisone clearance 8
Monitoring During Tapering
- Clinical assessment for symptoms of adrenal insufficiency (fatigue, weakness, nausea, vomiting, hypotension) 2, 9
- Blood pressure and electrolyte monitoring, particularly in primary adrenal insufficiency 4
- Serum cortisol measured 4 hours after hydrocortisone dose can predict cortisol AUC and help guide dosing adjustments 8