What is the recommended protocol for tapering hydrocortisone (cortisol replacement therapy)?

How to Taper Hydrocortisone

After stress-dose hydrocortisone, taper by reducing to double the usual maintenance dose for 24-48 hours, then return to standard physiologic replacement of 15-25 mg daily divided into 2-3 doses. 1, 2

Post-Acute Illness or Adrenal Crisis Tapering

For patients recovering from adrenal crisis or acute illness requiring stress doses, reduce to double the usual oral maintenance dose for 24-48 hours, then return to normal maintenance dosing. 1, 2 This rapid taper over 1-3 days is appropriate when recovery is uncomplicated. 3

Post-Surgical Tapering Protocol

After Major Surgery

• Continue hydrocortisone 100 mg IV/IM every 6 hours (or 200 mg/24h continuous infusion) until the patient can eat and drink. 3, 2
• Once enteral intake is established, give double the normal oral dose for 48 hours. 3
• If recovery is prolonged or complicated, continue double oral dosing for up to one week before tapering to maintenance. 3, 2
• Then reduce to standard maintenance dosing of 15-25 mg daily. 2

After Minor Surgery

• Give double the normal oral dose for 24-48 hours postoperatively. 3
• Return to normal daily dosing once stable. 3

Post-Delivery Tapering

• After uncomplicated vaginal delivery or cesarean section, perform rapid tapering over 1-3 days from stress-dose hydrocortisone (200 mg/24h infusion or 50 mg IM every 6 hours) back to regular replacement dose. 3

Pediatric Tapering

For children after major surgery, once enteral intake is established, give double the normal dose of hydrocortisone for 48 hours, then reduce to standard doses once stability is achieved. 3 After minor surgery or procedures under general anesthesia, give double the normal oral doses, then switch to normal daily dosing. 3

Tapering from Immune-Related Adverse Events

• When tapering from high-dose prednisone (1-2 mg/kg/day) for Grade 2 adrenal insufficiency, taper stress-dose corticosteroids down to maintenance over 5-10 days. 2
• For Grade 3-4 adrenal insufficiency, taper stress-dose corticosteroids down to maintenance over 7-14 days after discharge. 2
• Target physiologic maintenance equivalent to hydrocortisone 15-20 mg daily in divided doses. 2

Standard Maintenance Dosing After Taper

The goal maintenance dose is 15-25 mg hydrocortisone daily, divided into 2-3 doses, with the largest dose given upon awakening. 2, 4

Three-Dose Regimen (Preferred)

• 10 mg at 07:00 + 5 mg at 12:00 + 2.5-5 mg at 16:00. 2
• This mimics physiologic cortisol rhythm better than twice-daily dosing. 5, 6

Two-Dose Regimen (Alternative)

• 15 mg at 07:00 + 5 mg at 12:00, or 10 mg at 07:00 + 10 mg at 12:00. 2

Doses should be taken before food to optimize absorption, as food delays hydrocortisone absorption. 6

Monitoring During Tapering

Clinical Assessment

Monitor for signs of adrenal insufficiency during tapering: fatigue, weakness, nausea, vomiting, abdominal pain, hypotension, and electrolyte disturbances. 1, 2 Clinical assessment is the primary monitoring tool, as there are no reliable biochemical markers for optimal glucocorticoid replacement. 2

Practical Monitoring Approach

• Question patients about daily energy levels, "get up and go," mental concentration, and daytime somnolence. 2
• Ask about low points or dips in energy during the day. 2
• Inquire about bedtime and ease of falling asleep. 2
• Watch for signs of over-replacement: weight gain, insomnia, and peripheral edema. 2

Laboratory Monitoring

• A single serum cortisol measurement 4 hours after hydrocortisone dose can predict cortisol AUC (r² = 0.78). 6
• Assess weight, blood pressure, and serum electrolytes at least annually. 7

Critical Pitfalls to Avoid

Tapering too rapidly can precipitate adrenal crisis, which is life-threatening. 1, 2 The 2020 UK guidelines emphasize that abrupt cessation should never occur; gradual reduction over several days is mandatory to avoid hemodynamic and immunologic rebound effects. 1

Failure to increase doses during intercurrent illness or stress during or after tapering leads to adrenal insufficiency. 1, 2 Even after successful taper to maintenance, patients must double their dose for 24-48 hours during minor illness. 7, 2

Never stop corticosteroids before thyroid hormone replacement in patients with multiple hormone deficiencies, as this can precipitate adrenal crisis. 2 Always start corticosteroids first when planning hormone replacement therapy for multiple deficiencies. 7

Patient Education Requirements

All patients require education on stress dosing for sick days, use of emergency steroid injectables, and when to seek medical attention for impending adrenal crisis. 2 Provide emergency injectable hydrocortisone and train a companion in its use. 2

Medical alert identification for adrenal insufficiency is mandatory to trigger stress-dose corticosteroids by emergency medical services. 2 This is essential even after successful taper to maintenance dosing. 2

Special Tapering Considerations

Septic Shock Context

• For patients treated with hydrocortisone for septic shock, taper when vasopressors are no longer required. 1
• Tapering over several days rather than abrupt cessation avoids hemodynamic rebound. 1
• During "low-dose" hydrocortisone therapy (100 mg bolus, 10 mg/h), plasma cortisol levels decline despite constant dosing, requiring monitoring during taper. 8

Prolonged Glucocorticoid Therapy

• HPA axis suppression may persist for months after discontinuation of therapy. 2
• Hormone therapy should be reinstituted during any stressful situation occurring during that period. 2
• For patients on glucocorticoid therapy longer than 1 month who undergo surgery, perioperative management with adequate glucocorticoid replacement is required. 2

Weight-Based Dosing

Weight-adjusted hydrocortisone dosing decreases interpatient variability and reduces overexposure compared to fixed dosing. 6 Body weight is the most important predictor of hydrocortisone clearance. 6