What is the recommended dose of steroids, such as hydrocortisone (corticosteroid), for the management of adrenal insufficiency?

Steroid Dosing in Adrenal Insufficiency

For chronic maintenance therapy of adrenal insufficiency, use hydrocortisone 15-25 mg daily in divided doses (typically 10-20 mg morning, 5-10 mg early afternoon) for primary adrenal insufficiency, plus fludrocortisone 0.05-0.2 mg daily; for secondary adrenal insufficiency, use hydrocortisone alone at 10-20 mg morning and 5-10 mg afternoon without mineralocorticoid replacement. 1, 2, 3

Maintenance Dosing by Type

Primary Adrenal Insufficiency (Addison's Disease)

• Hydrocortisone 15-25 mg daily in split doses (e.g., 10-20 mg upon waking, 5-10 mg in early afternoon) 1, 2, 4
• Fludrocortisone 50-200 μg (0.05-0.2 mg) once daily for mineralocorticoid replacement 1, 2, 3
• The FDA label specifies that 0.1 mg daily is the usual dose, with a range of 0.1 mg three times weekly to 0.2 mg daily 3
• Fludrocortisone should be titrated to maintain normotension, normokalemia, and plasma renin activity in the upper normal range 5

Secondary Adrenal Insufficiency

• Hydrocortisone 10-20 mg in the morning and 5-10 mg in the afternoon 1, 2
• No fludrocortisone required as aldosterone production is preserved 1, 2

Stress Dosing Guidelines

Minor Illness (Fever, Cold, Minor Infection)

• Double the usual daily dose during the illness 2
• Return to maintenance dose once recovered 2

Moderate Illness

• Triple the usual daily dose or use 2-3 times maintenance dose 2
• Taper to maintenance over 5-10 days as symptoms improve 6, 2

Severe Illness, Trauma, or Adrenal Crisis

• Immediate hydrocortisone 100 mg IV or IM bolus, do not delay for diagnostic testing 6, 2
• Follow with hydrocortisone 100 mg IV every 6-8 hours (total 400 mg/24h) OR continuous IV infusion of 200 mg/24h until stabilized 2, 7
• Administer at least 2 liters IV isotonic saline for volume resuscitation 2
• The most recent high-quality evidence from 2020 demonstrates that continuous IV infusion of 200 mg hydrocortisone over 24 hours, preceded by a 50-100 mg bolus, best maintains cortisol concentrations in the physiological stress range compared to intermittent bolus dosing 7

Perioperative Steroid Coverage

Major Surgery (General or Regional Anesthesia)

• Intraoperative: Hydrocortisone 100 mg IV at induction, followed immediately by continuous infusion of 200 mg/24h 6
• Postoperative: Continue hydrocortisone 200 mg/24h IV infusion while nil by mouth (alternatively, 50 mg IM every 6 hours) 6
• Transition to oral: Once enteral intake established, double the usual oral dose for 48 hours if recovery is uncomplicated, or up to one week for complicated recovery 6, 1
• Alternative: Dexamethasone 6-8 mg IV provides 24-hour coverage 6

Intermediate/Body Surface Surgery

• Intraoperative: Hydrocortisone 100 mg IV at induction, followed by continuous infusion of 200 mg/24h 6
• Postoperative: Double regular glucocorticoid dose for 48 hours, then return to usual dose if uncomplicated 6, 1

Labor and Vaginal Delivery

• Hydrocortisone 100 mg IV at onset of labor, followed by continuous infusion of 200 mg/24h 6
• Alternative: Hydrocortisone 100 mg IM followed by 50 mg IM every 6 hours 6
• Rapid taper over 1-3 days to regular replacement dose after uncomplicated delivery 1

Critical Pitfalls to Avoid

Dosing Errors

• Never use oral hydrocortisone during acute crisis or when patient is vomiting - always use IV or IM routes 2
• Do not use dexamethasone if ACTH stimulation testing is planned - it does not interfere with cortisol assays, unlike hydrocortisone 6
• Avoid underdosing during stress - this is the most common cause of preventable adrenal crisis 2, 5

Monitoring Inadequacy

• Watch for signs of overdosing: easy bruising, thin skin, edema, weight gain, hypertension, hyperglycemia 8
• Watch for signs of underdosing: fatigue, nausea, hypotension, hyponatremia, hyperkalemia 8
• In primary adrenal insufficiency, monitor blood pressure and electrolytes to guide fludrocortisone dosing 1

Patient Education Gaps

• All patients must have a medical alert bracelet identifying adrenal insufficiency 6
• Patients need explicit stress-dosing instructions and emergency injectable hydrocortisone at home 2, 5
• Endocrine consultation is required before any surgery for stress-dose planning 6

Special Considerations

Patients on Chronic Exogenous Steroids

• Those receiving prednisolone equivalent ≥5 mg for ≥4 weeks require perioperative coverage as outlined above 6, 8
• Resume enteral glucocorticoid at double the pre-surgical therapeutic dose for 48 hours if recovery is uncomplicated 6, 1

Distinguishing Primary vs Secondary Adrenal Insufficiency

• Primary: High ACTH with low cortisol, requires both glucocorticoid and mineralocorticoid replacement 6, 2
• Secondary: Low ACTH with low cortisol, requires only glucocorticoid replacement 6, 2
• This distinction is critical as fludrocortisone is unnecessary and potentially harmful in secondary adrenal insufficiency 2