What is the typical dosage of hydrocortisone (corticosteroid) for a patient?

Hydrocortisone Dosage for Patients

Standard Maintenance Dosing for Adrenal Insufficiency

For chronic replacement therapy in primary adrenal insufficiency, initiate hydrocortisone 15-25 mg daily in divided doses, with most patients requiring 15-20 mg daily. 1

Specific Dosing Regimens

• Divide the total daily dose into 2-3 administrations, with the largest dose given immediately upon waking 1
• Typical three-dose regimen: 10 mg at 0700h + 5 mg at 1200h + 2.5-5 mg at 1600h (±1 hour) 1
• Alternative two-dose regimen: 15 mg at 0700h + 5 mg at 1200h (±1 hour) for patients with compliance issues 1
• The last dose should be taken at least 6 hours before bedtime to avoid disrupting sleep 1
• Titrate to a maximum of 30 mg daily for residual symptoms of adrenal insufficiency 1

The goal is to use the lowest dose compatible with health and sense of well-being, as over-replacement increases risk of iatrogenic Cushing's syndrome (bruising, thin skin, edema, weight gain, hypertension, hyperglycemia) 1

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Stress Dosing for Acute Illness or Surgery

Severe Stress (Grade 3-4 symptoms, adrenal crisis, major surgery)

Administer hydrocortisone 50-100 mg IV bolus immediately, followed by continuous infusion of 200 mg over 24 hours. 1, 2, 3

• Alternative if continuous infusion unavailable: Hydrocortisone 50 mg IV/IM every 6 hours 1, 3
• Taper stress-dose steroids down to oral maintenance over 5-7 days after stabilization 1, 2, 3
• Once tolerating oral intake: Resume oral hydrocortisone at double the maintenance dose for 48 hours (or up to 1 week following major surgery), then return to maintenance 1, 3

This high dosing replicates the physiologic stress response, where cortisol production increases five-fold to approximately 100 mg/day during major stress 1, 2, 3

Moderate Stress (Grade 2 symptoms, moderate illness)

Initiate outpatient hydrocortisone at 2-3 times maintenance dose (30-50 mg total daily dose) 1

• Decrease to maintenance doses after 2 days if symptoms resolve 1
• Add fludrocortisone 0.05-0.1 mg daily for primary adrenal insufficiency 1

Minor Stress (Febrile illness, minor procedures)

Double the regular oral maintenance dose for the duration of illness 2, 3

• Continue doubled dose for 24-48 hours after symptom resolution 1

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Special Clinical Contexts

Perioperative Management

For surgery under general or regional anesthesia: Hydrocortisone 100 mg IV at induction, followed immediately by continuous infusion of 200 mg over 24 hours 1

For labor and vaginal delivery: Hydrocortisone 100 mg IV at onset of active labor, followed by continuous infusion of 200 mg over 24 hours 1

Immune Checkpoint Inhibitor-Related Adrenal Insufficiency

Grade 1 (asymptomatic/mild): Hydrocortisone 15-20 mg in divided doses, titrate to maximum 30 mg daily 1

Grade 2 (moderate): Hydrocortisone 30-50 mg total dose initially, decrease to maintenance after 2 days 1

Grade 3-4 (severe): Hydrocortisone 50-100 mg IV every 6-8 hours, taper over 5-7 days 1

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Mineralocorticoid Co-Administration

Most patients with primary adrenal insufficiency require fludrocortisone 0.05-0.1 mg daily in addition to hydrocortisone 1

• Adjust based on volume status, sodium level, and renin (target upper half of reference range) 1
• Higher doses (up to 200 µg daily) may be needed in children, younger adults, or during pregnancy 1
• Secondary adrenal insufficiency (pituitary/hypothalamic causes) does not require fludrocortisone, as aldosterone production remains intact 1

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Critical Pitfalls to Avoid

Never delay treatment while awaiting diagnostic confirmation in suspected adrenal crisis—treat immediately with IV hydrocortisone 1, 3

Always start corticosteroids BEFORE other hormone replacements (thyroid, testosterone, estrogen), as these accelerate cortisol clearance and can precipitate adrenal crisis 2, 3

Avoid long-acting steroids like dexamethasone for chronic replacement, as they carry risk of over-replacement and lack mineralocorticoid activity 1, 3

Avoid abrupt discontinuation after long-term therapy—taper gradually 4

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Patient Education Requirements

All patients must receive:

• Emergency hydrocortisone injection kit (100 mg) for self-administration 1, 2, 3
• Medical alert bracelet/necklace and steroid emergency card 1, 2, 3
• Education on stress dosing for sick days and recognition of adrenal crisis 1, 2

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Steroid Equivalencies

Hydrocortisone 20 mg = Prednisone 5 mg = Dexamethasone 0.75 mg 1, 2, 3

Only hydrocortisone provides mineralocorticoid activity at physiologic doses, making it the preferred agent for chronic replacement 3

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Monitoring and Dose Adjustment

Monitoring is largely clinical, based on symptoms of under-replacement (fatigue, salt craving, orthostatic hypotension) versus over-replacement (weight gain, hypertension, hyperglycemia, bruising) 1

Reduce maintenance dosing if signs of iatrogenic Cushing's syndrome develop 1

Certain medications require dose adjustments: Anti-epileptics, barbiturates, antituberculosis drugs, and etomidate may increase hydrocortisone requirements, while grapefruit juice and liquorice may decrease requirements 1