Hydrocortisone Dosing and Administration
Standard Maintenance Dosing for Adrenal Insufficiency
For chronic adrenal insufficiency, prescribe hydrocortisone 15-25 mg daily divided into 2-3 doses, with the largest dose (10 mg) given upon awakening, followed by 5 mg at noon, and 2.5-5 mg at 4 PM. 1, 2
Weight-Based Dosing Approach
- Weight-adjusted dosing significantly reduces interpatient variability (from 31% to 7% in maximum cortisol concentration) compared to fixed dosing and should be the preferred method 3
- Administer doses before meals, as food delays hydrocortisone absorption 3
- Alternative two-dose regimen: 15 mg at 7 AM + 5 mg at noon, or 10 mg at 7 AM + 10 mg at noon 2
Monitoring
- Monitor clinically rather than with laboratory values, as no reliable biochemical markers exist for optimal replacement 2, 4
- A single serum cortisol measurement 4 hours after hydrocortisone administration predicts cortisol AUC (r² = 0.78) and can guide dosing adjustments 3
- Signs of over-replacement: weight gain, insomnia, peripheral edema 2
- Signs of under-replacement: lethargy, fatigue, weakness, nausea, vomiting, poor appetite, weight loss, increased pigmentation 2
Perioperative Management in Adults
For major surgery in patients with adrenal insufficiency, administer hydrocortisone 100 mg IV at induction, followed by continuous infusion of 200 mg over 24 hours. 5, 1
Major Surgery Protocol
- Give 100 mg IV bolus at induction 5, 1
- Continue 200 mg/24h as continuous IV infusion (preferred) or 50 mg IV/IM every 6 hours 5, 1
- Continuous infusion is superior to bolus dosing for maintaining cortisol in the physiological stress range 6
- Alternative: dexamethasone 6-8 mg IV provides adequate 24-hour coverage 1
- Continue IV hydrocortisone while nil by mouth or vomiting 1
- Once oral intake resumes: double usual oral dose for 48 hours after uncomplicated surgery, or up to one week after major surgery 1
Minor Surgery Protocol
- Give double the normal oral hydrocortisone dose pre-operatively 5
- Continue double dose for 24-48 hours postoperatively, then return to maintenance 5, 2
Chronic Steroid Therapy Considerations
- Patients on chronic steroids (≥20 mg/day prednisone equivalent for ≥3 weeks) should continue their usual regimen perioperatively 5
- If unexplained fluid-unresponsive hypotension occurs perioperatively, immediately give hydrocortisone 100 mg IV bolus for presumed adrenal crisis 5
- Evidence does not support routine "stress dose" steroids in patients with low probability of HPA axis suppression 5
Pediatric Dosing
Children with adrenal insufficiency require hydrocortisone 2 mg/kg IV at induction for any surgery under general anesthesia. 5, 1
Perioperative Pediatric Protocol
- Give 2 mg/kg IV at induction for both minor and major surgery 5, 1
- After major surgery: 2 mg/kg IV/IM every 4 hours, or continuous infusion if unstable 5, 1
- Once enteral intake established: double normal dose for 48 hours, then reduce to standard doses 5, 1
- Never fast a child with adrenal insufficiency for more than 6 hours 5, 1
- Monitor blood glucose hourly if fasting exceeds 4 hours and until enteral intake resumes 5, 1
Special Pediatric Consideration
- Children with both diabetes insipidus and adrenal insufficiency require strict fluid balance monitoring, as cortisol is necessary to excrete water loads 5, 1
- Inadequate cortisol replacement in these patients risks water intoxication and hyponatremia with significant morbidity 5, 1
Obstetric Management
During active labor, administer hydrocortisone 100 mg IV at onset (contractions every 5 minutes for one hour, or cervical dilation >4 cm), followed by continuous infusion of 200 mg/24h. 5, 1
Labor and Delivery Protocol
- Give 100 mg IV bolus at onset of active labor 5, 1
- Continue with either 200 mg/24h continuous infusion or 50 mg IM every 6 hours 5, 1
- Rapid taper over 1-3 days to regular replacement dose after uncomplicated delivery 5, 1, 2
Pregnancy Considerations
- Consider increasing maintenance dose by 20-40% in late pregnancy, as physiologic cortisol increases during this period 5, 1
Acute Adrenal Crisis
For acute adrenal crisis, immediately give hydrocortisone 100 mg IV bolus, followed by 50-100 mg IV/IM every 6 hours (or 200-300 mg/24h continuous infusion). 1
Crisis Management Protocol
- Do NOT delay treatment for diagnostic testing—draw blood for cortisol/ACTH, then treat immediately 1
- Simultaneously give rapid IV infusion of 0.9% saline (1 L over first hour) 1
- Continue IV saline at slower rate for 24-48 hours 1
- Taper parenteral glucocorticoids over 1-3 days to oral replacement once stable 1, 2
- Restart fludrocortisone when hydrocortisone dose falls below 50 mg/day 1
Septic Shock Management
Use hydrocortisone 200 mg/day as continuous infusion ONLY if adequate fluid resuscitation and vasopressors fail to restore hemodynamic stability in septic shock. 1
Septic Shock Protocol
- Administer as continuous infusion rather than bolus dosing 1
- Do NOT use ACTH stimulation test to determine who should receive hydrocortisone 1
- Taper hydrocortisone when vasopressors are no longer required 1
- Do NOT administer corticosteroids for sepsis without shock 1
IV Administration Details
For IV injection, administer 100 mg over 30 seconds to 500 mg over 10 minutes; for IV infusion, use continuous delivery of 200 mg over 24 hours. 7
Preparation and Administration
- Reconstitute with ≤2 mL Bacteriostatic Water for Injection 7
- For IV infusion, add reconstituted solution to 100-1000 mL of 5% dextrose in water or isotonic saline 7
- Solutions stable for at least 4 hours after reconstitution 7
- High-dose therapy should not continue beyond 48-72 hours due to risk of hypernatremia 7
- Initial dose range: 100-500 mg depending on disease severity; life-threatening situations may require doses in multiples of oral dosages 7
Oral Administration Details
Oral hydrocortisone dosing ranges from 20-240 mg daily depending on disease severity, with most maintenance regimens using 15-25 mg daily in divided doses. 8
Oral Dosing Principles
- Initial dosing: 20-240 mg/day depending on condition severity 8
- Maintain or adjust initial dose until satisfactory response noted 8
- Decrease dose in small decrements at appropriate intervals to find lowest effective maintenance dose 8
- If stopping after long-term therapy, withdraw gradually rather than abruptly 8
Multiple Sclerosis Specific Dosing
- For acute exacerbations: 800 mg hydrocortisone daily for one week, followed by 320 mg every other day for one month 7
- Alternatively: 200 mg prednisolone daily for one week, followed by 80 mg every other day for one month (20 mg hydrocortisone = 5 mg prednisolone) 8
Common Pitfalls and Patient Education
Critical Safety Points
- All patients require education on stress dosing for sick days (typically double or triple usual dose) 2
- Provide emergency injectable hydrocortisone and train a companion in its use 2
- Medical alert identification is mandatory to trigger stress-dose corticosteroids by emergency services 2
- HPA axis suppression may persist for months after discontinuation, requiring stress dosing during any stressful situation 2