What is the typical dosage of hydrocortisone (cortisol) for various medical conditions?

Hydrocortisone Dosing for Various Medical Conditions

Maintenance Therapy for Adrenal Insufficiency

For primary adrenal insufficiency, hydrocortisone 15-25 mg daily in split doses (typically 10 mg morning, 5 mg afternoon, and 5 mg evening) is the recommended maintenance regimen, along with fludrocortisone 50-200 μg daily. 1

• Hydrocortisone is the preferred glucocorticoid for maintenance therapy over synthetic alternatives like prednisolone, which should only be used when hydrocortisone is not tolerated or compliance is problematic 2
• Weight-adjusted dosing significantly reduces interpatient variability in cortisol exposure compared to fixed dosing, decreasing variability in peak concentration from 31% to 7% 3
• For secondary adrenal insufficiency, use hydrocortisone 10-20 mg morning and 5-10 mg afternoon without fludrocortisone, as mineralocorticoid function remains intact 1
• Starting doses should be 15-20 mg for hydrocortisone divided into two or three doses, preferentially weight-adjusted 4

Adrenal Crisis Management

For suspected adrenal crisis, immediately administer hydrocortisone 100 mg IV or IM without waiting for diagnostic confirmation, followed by 100 mg every 6-8 hours until recovery. 1

• Concurrent IV isotonic sodium chloride solution is essential for volume resuscitation 1
• Treatment must not be delayed for diagnostic procedures when adrenal crisis is suspected 1
• Adrenal crises occur at a rate of 6-8 per 100 patient-years, with gastroenteritis and fever being the most common precipitants (30-50% of cases) 5, 6

Stress Dosing Algorithm

For minor illness (fever, cold): double the usual daily dose 1

For moderate illness (persistent vomiting, high fever): triple the usual daily dose or use 2-3 times maintenance dose 1

For severe illness, trauma, or inability to take oral medication: hydrocortisone 100 mg IV immediately, then 100 mg every 6-8 hours 1

• Patients working long shifts or experiencing morning nausea can wake earlier to take their first dose, then return to sleep 2
• The second dose should not be taken later than 4-6 hours before bedtime to avoid insomnia 2, 7

Perioperative Management

For major surgery, administer hydrocortisone 100 mg IV at induction, followed by continuous infusion of 200 mg over 24 hours. 5, 1

• Continue the 200 mg/24h infusion postoperatively while the patient is nil by mouth 1
• Once oral intake resumes after uncomplicated recovery, double the regular oral replacement dose for 48 hours (e.g., if usual dose was 10-5-5 mg, give 20-10-10 mg) 5
• After major surgery, continue doubled doses for up to one week before resuming maintenance dosing 5
• Patients on chronic exogenous steroids receiving prednisolone equivalent ≥5 mg for ≥4 weeks require perioperative coverage 1

Dosing Equivalence

20 mg hydrocortisone = 5 mg prednisolone = 4 mg prednisone 2, 8

• The FDA label indicates dosing ranges from 20-240 mg daily depending on the condition being treated, though these higher doses are for therapeutic (not replacement) purposes 8
• For multiple sclerosis acute exacerbations specifically, 200 mg prednisolone daily for one week (equivalent to 800 mg hydrocortisone) has been shown effective 8

Critical Monitoring and Safety Considerations

Clinical symptoms are the primary method for monitoring adequacy of replacement, not laboratory cortisol levels. 2, 7

• Signs of over-replacement: weight gain, insomnia, peripheral edema 2, 7
• Signs of under-replacement: lethargy, nausea, poor appetite, weight loss, increased pigmentation 2, 7
• Common pitfall: Do not compensate for inadequate mineralocorticoid replacement by increasing glucocorticoid doses, as this leads to glucocorticoid excess while still predisposing to adrenal crises 2
• Under-replacement of mineralocorticoids is common and may predispose to recurrent adrenal crises 2

Essential Patient Safety Measures

All patients must have a medical alert bracelet, explicit stress-dosing instructions, and emergency injectable hydrocortisone at home. 1

• Medication errors and omissions on hospital wards account for a significant proportion of adrenal crises, with 8.6% of patients reporting a previous crisis caused by insufficient glucocorticoid medication during inpatient stays 5
• Anticonvulsants, barbiturates, and antituberculosis medications increase hydrocortisone requirements 2, 7
• Grapefruit juice and licorice may decrease hydrocortisone requirements 2, 7